SURGEON GENERAL'S OFFICE
LIBRARY.
Section ~
 No. 113,
W.D.S.G.O.
Wi.;..i/
l < m

£  t*  f
• m  ^
  • • v.
>j ^Wj
- * ^-*»
i^i
 

«:~ t ^ * ; # / A <m> ^ 5* /•:
*•- 4.'- c *s < e -*^ -** % »WJ * T & ✓ ♦ IIP*? -..'%


j J,; S ^ £■ >)''..& c -* ,- » . * >^ > t i * » ,
 
 
THE                 '^
PRINCIPLE*. AND PRACTICE
                                 s-6
SUEGEET,
EMBRACING
MINOR  AND OPERATIVE SURGERY
A BIBLIOGRAPHICAL INDEX OF AMERICAN SURGICAL

    WRITERS FROM THE YEAR 1783 TO 1860.
grrangri* fjar % m ai %tntentif
ILLUSTRATED BY 400 WOOD-CUTS, AND NEARLY

     1000 ENGRAVINGS ON STEEL.
             BY



   HENRY H.^SMITH, M.D.,

PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC.

     IN TWO VOLUMES.


SENLt . .
iS'VJPj J
"/^.v^ ,  '
VOL. II.
      PHILADELPHIA:


J. B. LIPPINCOTT & CO.


          1863. 
  wo
5t5
P
      Entered, according to Act of Congress, in the year 1863, by
               HENRY  H.  SMITH,  M.D.,
In the Clerk's Office of the District Court of the United States for the Eastern
                  District of Pennsylvania. 
CONTENTS
VOLUME   II.
Regional Disorders and Operations
    Introductory Remarks
VAliE
 49
                            PART XII.

          Disorders and Operations on the Head and Face.

                            CHAPTER I.

                disorders and operations on  the head.

Section I.—Surgical anatomy of the head......51
        Plate V.—Instruments employed in trephining and other opera-
            tions on the bones........52
Section II.—Disorders and operations upon the head    ....   54
    \ 1. Operations upon the scalp.......54
        Plate V[.—Operations upon the scalp and skull     ...   56
    \ 2. Operations upon the bones of the  cranium   ....     60
        Plate VII.—A view of the structure of the head and of the oper-
            ation of trephining........64
                           CHAPTER II.

          disorders  and operations  connected with the face.

Section I.—Surgical anatomy of the face
    \ 1. Anatomy of the appendages of the eye
    § 2. Anatomy of the lachrymal apparatus
        Plate VIII.—Eye instruments .
Section II.—Disorders of the appendages of the eye  .
    \ 1. Blows upon the eye.....
    I 2. Foreign bodies in the eye     .    .    .   .
    § 3. Wounds of the eyelids     ....
    | 4. Tumors of the eyelids.....
71
72
73
74
75
75
75
76
76
( xxxi) 
xxxii
CONTENTS OF VOL. II.
PAGE
     § 5.  Hordeolum..........."
     § 6.  Ophthalmia tarsi.........77
     g 7.  Trichiasis...........'8
     g 8.  Encanthus..........79
     g 9.  Epicanthus...........79
   g 10.  Ankylo-blepharon.........79
   \ 11.  Sym-blepharon..........79
         Plate IX.—Operations upon the eyelids      ....      80
   g 12.  Ptosis........         ...   81
   g 13.  Lagophthalmus.........82
   g 14.  Blepharoplasty........              82
   § 15.  Ectropion..........83
   g 16.  Entropion...........85
        Plate X.—Operations for the relief of affections of the eyelids     86
Section III.—Disorders of, and operations on, the lachrymal apparatus  .    88
        Plate XL—Operations  performed for  the  obstruction of the
            lachrymal passages........90
                             CHAPTER III.

                       disorders  of the eyeball.

Section I.—Anatomy of the eyeball.......92
Section II.—Disorders of  the coats  of the eyeball.....94
    g 1.  Conjunctivitis..........94
    g 2.  Pterygium...........97
    g 3.  Sclerotitis..........97
    g 4.  Corneitis..........         98
    g 5.  Staphyloma    .         ........99
    g 6.  Iritis..........             99
    g 7.  Choroiditis and retinitis                    s                  101
Section III.—Operations on the exterior of the eyeball  ....  104
    g 1.  Strabismus........              105
        Plate XII.—Operations practiced on the eyeball    .    .     .  106
    g 2. Extirpation  of the eyeball......         109
    g 3. Tumors in the orbit.......            HO
Section IV.—Disorders of, and operations on, the interior of the eyeball   110
    § 1.  Cataract......,                       -qq
        Plate XIII.—Eye instruments.....           H4
        Plate XIV.—Operation of couching cataract     .     .         120
        Plate XV.—Operations for extracting cataract and the forma-
            tion of artificial pupil    ....                  122
    g 2. Dislocation of the lens     .                                   ^03
    g 3. Formation of an artificial pupil     ....              123
    g 4. Insertion of  artificial eyes  ....                     127 
CONTENTS OF VOL. II.
xxxiii
                             CHAPTER IV.

                     plastic  operations on the face.
                                                                     PAGE
Section I.—Metoplasty, or restoration of the integuments on the forehead.  128
         Plate  XVI.—Metoplasty and rhinoplasty, or plastic operations
             on the forehead and nose.......130
Section II.—Anatomy of the external nose......131
Section III.—Operations upon the external nose.....131
     g 1.  Rhinoplasty..........132
     g 2.  Indian  or Brahmin method of rhinoplasty.....133
         Plate XVII.—Rhinoplastic and cheiloplastic operations    .     136
         Plate XVIII.—Rhinoplastic operations.....140


                             CHAPTER V.

          disorders of, and  operations on, the nasal cavities.

Section I.—Anatomy..........142
Section II. Diseases of the nasal cavities......143
     g 1.  Ozaena...........143
     g 2.  Rhinolithes...........144
     g 3.  Foreign bodies in the nostril.......144
     g 4.  Abscess of the septum narium.......144
Section III.—Operation on the nasal cavities.....145
     g 1.  Arrest  of hemorrhage from the  nostril.....145
     g 2.  Polypi in  the nostrils........145
        Plate XIX.—Anatomy of the internal nose, with the operations
             for nasal polypi.........146


                             CHAPTER  VI.

          disorders of, and  operations on, the lips  and mouth.

Section'L—Anatomy of the external portion of the mouth   .    .    .  151
Section II.—Operations on the lips.......152
    g 1. Simple  hare-lip..........152
        Plate XX.—Operations practiced on the lips and mouth    .     154
    g 2. Double  hare-lip..........155
    g 3. Cancer  of the lip.........156
    g 4. Enlargement of the mouth........156
    g 5. Cheiloplasty..........157
        Plate XXI.—The operations of  cheiloplasty and genioplasty   .   158
    g 6. Genioplasty..........160
    g 7. Removal of tumors from the  cheeks......161
    g 8. Salivary fistula.........161
    g 9. Division of tile masseter muscle  for immobility of the lower jaw,
          false anchylosis.........162 
XXXIV
CONTENTS OF  VOL. II.
                            CHAPTER VII.

                operations  practiced within the mouth.
                                                                     PAGE
Section I.—Anatomy..........163
Section II.—Operations upon the tongue.......165
    g 1. Cancer of the tongue........165
        Plate XXII.—Operations practiced on the tongue and tonsils  .   166
    g 2. Hypertrophy of the tongue.......167
Section III.—Operations on the uvula and pharynx      ....   168
    g 1. Excision of the uvula.......•     168
    g 2. Excision of the tonsils........169

                           CHAPTER VIII.
            DISORDERS OF, AND OPERATIONS ON, THE UPPER JAW.
Section I.—Anatomy of the parts concerned  .     .     .    .     .     .  171
Section II.—Disorders of  the upper jaw    ......     171
    g 1. Affections of the antrum Highmorianum.....171
        Plate XXIII.—Instruments employed on the jaws and ear   .    172
Section III.—Resection of the upper jaw-bone     .....   174
        Plate XXIV.—A view of the anatomy of the side of the face,
            and of some of the operations practiced on it .    .     .     176
Section IV.—Resection of both superior maxillae.....179
        Plate XXV.—Resections of the upper and lower jaw  .     .     180
Section V.—Resection of  the inferior maxilla......182
    g 1. Resection  of one  side of the inferior maxilla ....     183
    g 2. Resection  of the inferior maxilla entire, or nearly so .    .     .   185

                            CHAPTER IX.
                      operations on the palate.
Section I.—Staphyloraphy    .......            187
        Plate XXVL—A view of the instruments employed in  opera-
            tions upon the throat, and especially  in staphyloraphy   .     188
        Plate XXVIL—A front view of the operation of staphyloraphy   190
Section II.—Staphyloplasty......                 iqo

                            CHAPTER  X.
                         disorders of the ear.
Section I.—Anatomy of the ear......              -jos
        Plate XXVIII.—Operations upon the ear     .    .    .        193
Section II.—Disorders of,  and operations on, the external ear   .     .     199
                                                                     199
                                                                     200
                                                                     203
                                                                     205
  1. Otoplasty
g 2. Foreign bodies in the meatus auditorius externus
g 3. Polypi in the meatus externus
g 4. External otitis
g 5. Myringitis and injuries of the membrana tympani    .            207 
CONTENTS OF  VOL. II.
XXXV
                                                                    PAGE
Section III.—Disorders of the internal ear......210
    g 1. Internal otitis..........210
    g 2. Chronic otitis..........213
    § 3. Otorrhcea...........213
Section IV.—Deafness.........215
    § 1. Deafness from excess of wax.......216
    g 2. Deafness from dryness of the ear......217
    g 3. Catarrhal deafness.........219
    g 4. Nervous  deafness.........220
    g 5. Deafness from subacute and chronic myringitis  .    .     .    .221
    g 6. Perforation of the membrane of the tympanum    .     .    .    223
    g 7. Catheterism of the Eustachian tube......224
American papers on the surgical disorders of the head and face  .    .    227
                             PART XIII.

         Disorders of, and Operations on, the Neck and Trunk.

                             CHAPTER I.

                     surgical anatomy of the neck.

Section I.—The supra-hyoid or glosso-hyoid region of the neck    .     .  240
Section II.—The parotid region........241
         Plate XXIX.—The surgical anatomy of the neck   .    .     .  242
Section III.—The laryngo-tracheal and supra-sternal  regions    .     .    243
Section IV.—The supra clavicular region......245
         Plate XXX.—Instruments employed upon the oesophagus and
            trachea..........246


                             CHAPTER II.

     diseases of, and operations on, the neck ABOVE THE OS HYOIDES.

Section I.—Of the diseases of the parotid gland.....248
    g 1.  Extirpation of the parotid gland......249
    g 2.  Relief of enlargement of the parotid gland by obstructing the cir-
          culation  ...........254
Section II.—Operations practiced on the submaxillary gland    .     .    254


                            CHAPTER III.

  DISEASES OF, AND OPERATIONS PERFORMED ON, THE  LARYNX AND TRACHEA.

Section I.—Surgical anatomy of the larynx and trachea ....  255
        Plate XXXI.—A view of the operations performed on the trachea  256 
xxxvi
CONTENTS OF VOL.  II.
PAGE
Section II.—Disorders of, and operations on, the larynx    .    .     .     257
    g 1. Cauterization of the larynx.......L^°
    g 2. (Edema of the glottis........259
    g 3. Polypi in the larynx.........2gl
    g 4. Tracheotomy..........262
                            CHAPTER IV.

                  DISORDERS OF THE THROAT AND NECK.

Section I.—Anatomy of the throat........274
Section II.—Disorders of the throat.......274
    g 1. Foreign bodies in the pharynx.......274
Section III.—Disorders of the neck.......276
    g 1. Disorders of the muscles of the neck......276
    g 2. Hydrocele of the neck........277


                            CHAPTER  V.

             OPERATIONS UPON  THE PHARYNX AND OESOPHAGUS.

Section I.—Surgical anatomy of the pharynx and oesophagus .    .     .   277
    g 1. Of the pharynx.........278
    g 2. Of the oesophagus.........278
Section II.—Operations upon the pharynx......278
    g 1. Hypertrophy of the follicles of the pharynx     ....   279
    g 2. Tumors in the pharynx........279
    g 3. Retro-pharyngeal abscess........280
Section III.—Operations upon the oesophagus.....280
    g 1. Removal of foreign substances from the oesophagus  .    .     .   281
        Plate  XXXII.—Operations practiced  on the oesophagus and
            larynx..........282
    g 2. Poisons in the  stomach......    .     .   283
    g 3. Extraction of noxious substances from the stomach, through the
          oesophagus..........287
    g 4. Stricture of the oesophagus.......288
          I. Dilatation of the stricture......289
         II. Application of caustic.......290
        III. (Esophagotomy........290


                            CHAPTER VI.

    OPERATIONS DEMANDED FOR THE RELIEF OF DEFORMITIES  IN  THE  NECK.

Section I.—Deformities from burns......         293
        Plate XXXIIL—Operations practiced on the neck .    .     .   294
Section II.—Torticollis, or wry-neck......         295 
CONTENTS OF VOL. II.
xxxvii
                            CHAPTER VII.

           operations for the removal of tumors of the neck.
                                                                     PAGE
Section I.—The ordinary position of tumors.....297
Section II.—Operations for the removal of tumors of the neck    .     .  298
        Plate XXXIV.—Appearance and position of some of the tumors
             seen about the neck    ........  300
    g 1. Removal of large adenoma in lymphatic glands of the neck   .    301
    g 2. Extirpation of a large malignant tumor of the neck   .    .     .  302
Section III.—Bronchocele, or goitre.......305
    g 1. Bronchocele, or goitre........305
Section IV.—Hydrocele of the neck.......309


                            CHAPTER VIII.

                THE LIGATION OF  THE ARTERIES OF THE  NECK.

Section I.—Anatomy of the blood-vessels of the neck   ....  310
Section II.—Rules to be observed in the ligation of all arteries  .     .    312
        Plate XXXV.—Instruments employed in the ligation of arteries,
             wry-neck, oedema of the glottis, and hernia   .    .     .    314
Section III—Ligation of the carotid arteries......315
    g 1. Ligation of the primitive carotid artery.....316
    g 2. Effects resulting from ligation of  the carotid    ....  317
    g 3. Statistics of the operation of ligating the carotid artery     .    319
      4. Ligation of the lingual and facial arteries  .....  319
        Plate XXXVI.—Operations upon the neck  ....    320
           I. Ligation of the lingual artery......321
         II. Ligation of the facial artery......321


                             CHAPTER IX.

           ligation of the innominata and subclavian arteries.

Section I—Surgical anatomy of the  innominata and subclavian arteries .  322
    g 1. Anatomical relations of the innominata.....322
    g 2. Anatomical relations of the subclavian artery   ....  322
Section II.—Ligation of the innominata artery.....323
Section III.—Ligation of the subclavian artery.....325
        Plate XXXVII.—Operations practiced on the lower portion of
             the neck..........326
    g 1. Ligation of the subclavian artery on the first rib               328
    g 2. Ligation of the artery between the scaleni muscles .    .     .    329
    g 3. Ligation of the subclavian  artery within the scaleni muscles    .  329
    g 4. Ligation of the left subclavian artery within the scaleni muscles  329
    g 5. Statistics of the operation of ligation of the subclavian artery  .  331
    g 6. Anatomical phenomena consequent on  the ligation of the  sub-
           clavian artery.........331 
xxxviii
CONTENTS OF VOL. II.
      CHAPTER X.

OPERATIONS UPON  THE CHEST.
PAGE
 Section I.—Surgical anatomy of the chest......333
     g 1. Surgical anatomy of the portion of the chest about the clavicle   333
 Section II.—Resections of the clavicle......334
     g 1. Resection of the entire clavicle.......334
     g 2. Resection of a portion of the clavicle.....338
 Section III.—Resection of the scapula.......339
     g 1. Resection of the entire body of the scapula  ....    339
     g 2. Resection of the acromion process of the scapula    .     .    .  340
 Section IV.—Operations on the parts  about the clavicle    .     .    .    341
     g 1. Ligation of the axillary artery beneath the clavicle   .     .    .  341


                            CHAPTER XL

           OPERATIONS UPON THE  MAMMARY GLAND OF THE FEMALE.

 Section I.—Extirpation or amputation of the mammary gland      .    .   342
        Plats XXXVIII.—Operations practiced on the chest   .    .     344
 Section II.—Removal of  tumors of the chest......350
     g 1. Congenital encysted tumor on the right side of the chest success-
          fully treated by a  seton     .......     350

                            CHAPTER XII.

           OPERATIONS PRACTICED ON THE WALLS OF THE THORAX.

Section I.—Surgical anatomy of the thorax......351
Section II.—Operations on the chest......         352
     g 1. Resection of the ribs........       352
     g 2. Paracentesis thoracis, or thoracentesis   ....         353
     g 3. Effusions into the pericardium.....            357
American papers on the disorders of, and operations on, the neck and trunk   358
                             PART XIV.

           Disorders of, and Operations on, the Abdomen.

                             CHAPTER I.
Section I—Paracentesis abdominis    ....                   3"1
Section II.—Hepatic abscesses     ....'.                 3-U
        Plate XXXIX.—Operations practiced on the abdomen          374
Section III.—Hydatids of the liver . 
CONTENTS OF VOL. II.
xxxix
                                                                      PAGE
Section IV.—Gastrotomy or enterotomy......376
    g 1.  Gastrotomy..........377
    g 2.  Enterotomy..........378
Section V.—Gastric and intestinal fistulse......380
                             CHAPTER  II.

                        WOUNDS OF  THE ABDOMEN.

Section I.—AVounds which cause protrusion  or strangulation of the intes-
               tines or omentum........382
Section II.—AA'ounds of the intestines   .......383
    g 1. Sutures employed in longitudinal wounds of the intestine    .     384
    g 2. Suture of transverse wounds.......385
        Plate XL.—Sutures of the intestines—artificial anus   .    .     386
                             CHAPTER III.

                                OF HERNIjE.

Section I.—General pathology of herniae......389
         Plate XLI.—Surgical anatomy of the parts concerned in herniae  392
Section II.—Strangulated herniae.......•     395
         Plate XLII.—A view of some of the parts concerned in  inguinal
             and femoral herniae........396
Section III.—Treatment of herniae.......398
     g 1.  Reduction of herniae.........398
     g 2.  Palliative treatment of reducible herniae.....400


                             CHAPTER IV.

                     ON THE  RADICAL CURE OF HERNLSJ.

Section I.—Observations on the result of the operations for  the radical
               cure of inguinal herniae......406


                              CHAPTER V.

                      STRANGULATED  INGUINAL HERNIA.

Section I.—Surgical relations of inguinal herniae.....409
         Plate XLIII.—Surgical relations  of  the parts concerned in her-
             niae  ...........410
Section II.—Treatment of  strangulated inguinal herniae  ....  413
     g 1.  Taxis in reducible or strangulated  herniae    ....     413
     g 2.  Operation  of herniotomy in strangulated inguinal herniae  .     .  415
        Plate XLIV.—A view of the operations performed for  inguinal
             herniae..........418
     g 3.  Statistics...........421 
xl
CONTENTS  OF VOL. II.
                             CHAPTER VI.

                       femoral or crural hernia.
                                                                       PAGE
Section I.—Anatomical relations of femoral herniae   ....     422
Section II.—Treatment of reducible and strangulated femoral herniae   .   424
    g 1. Taxis and the application of a truss in femoral herniae   .     .     424
    g 2. Herniotomy in strangulated femoral herniae     ....   425
        Plate XLV.—Parts concerned in the operation for femoral herniae   426
    g 3. Statistics of the operation of herniotomy in strangulated femoral
            herniae..........428

                            CHAPTER VII.

                        UMBILICAL  HEENIjE.

Section I.—Surgical anatomy......'        .     429
Section II.—Treatment of umbilical herniae......430
    g 1. Of the palliative treatment of umbilical herniae    .     .     .     430
    g 2. The radical cure of umbilical herniae......431
    g 3. Herniotomy in strangulated umbilical herniae ....     432
    g 4. Frequency of the forms of herniae......433

                            CHAPTER VIII.

                          ARTIFICIAL ANUS.

Section I.—Artificial anus resulting from  mortified intestine     .     .     433
        Plate XLVI.—A view of the operation for the formation of an
            artificial anus    .........   436
    g 1. Statistics of artificial anus.......437
Section II.—Formation of an artificial anus   ......   438
    g 1. Formation  of an artificial anus at the groin   ....     439
    g 2. Formation of  an artificial anus in the lumbar region  .     .     .   440
    g 3. Statistics of the operation   .......     441

                             CHAPTER IX.

                     LIGATION of the iliac  arteries.
Section I.—Surgical anatomy.......             442
Section II.—Operations upon the iliac arteries   ....          442
    g 1. Ligation of the external Iliac artery......443
    g 2. Statistics of the application of a ligature to the external iliac artery   445
        Plate XLVIL—A^iew of the parts concerned in the operation of
            ligating the iliac arteries.....               44^
Section III.—Ligation of the primitive iliac artery ...             447
    \ 1. Surgical anatomy.....                        , ,7
    g 2. Operation of ligating the primitive iliac artery  .    .     .     .447
    g 3. Statistics of ligation of primitive iliac   ...               449
    g 4. Ligation of the internal iliac artery   ...                 449 
CONTENTS OF  VOL. II.
xli
                            CHAPTER X.

                  OPERATIONS  PRACTICED ON THE BACK.
                                .                                   PAGE
Section I.—Superficial tumors of the back......452
Section II.—Tumors of the spinal canal, or spina bifida ....  453
    g 1. Operations for the cure of spina bifida   .    ...    .     .    453
        Plate XLVIII.—External characters of tumors of the neck and
            back...........454
American papers on the disorders of, and operations on, the abdomen  .    458
PART XV.
Disorders  of,  and Operations on,  the G-enito-TJrinary
                 Organs  and Rectum.

                      CHAPTER  I.

      disorders of the  male genito-urinary organs.
the penis
Section I.—Surgical anatomy of the male organs
    g 1. The penis......
    g 2. The urethra.....
    g 3. The testicles.....
Section II.—Operations on the penis
    g 1. Phymosis......
    g 2. Paraphymosis ....
        Plate XLIX.—Operations practiced on
    g 3. Division of the fraenura  .
    g 4. Amputation of the penis
Section III.—Operations on the urethra
    g 1. Catheterism........
        Plate L.—Instruments for operations on the urethra
Section IV.—Strictures of the urethra......
        Plate LI.—Operations practiced on the urethra
Section V.—Puncture of the bladder......
    g 1. Fistula in perineo........
    g 2. Hypospadias and epispadias......
Section VI.—Affections of the spermatic cord   ....
        Plate LII.—Operations practiced on the testicle and cord
Section VII.—Operations on the scrotum.....
465
465
466
467
467
467
469
470
471
471
472
473
474
477
484
487
489
491
492
494
496 
xlii
CONTENTS OF VOL.  II.
      CHAPTER II.

AFFECTIONS OF THE TESTICLE.
Section I.—Hydrocele
    g 1. Castration
497
501
                            CHAPTER III.

                        STONE and gravel.

Section I.—Gravel..........502
    g 1. Uric acid and the urates........5°3
    g 2. Sediments of the urates........505
    g 3. Of the phosphates.........506
    g 4. Oxalate of lime.........509
    g 5. Cystine...........51°
    g 6. Uric oxide..........^11
Section II.—Calculus, or stone.........511
                            CHAPTER IV.

        OPERATIONS FOR THE  REMOVAL OF STONE  FROM THE BLADDER.

Section I.—Surgical anatomy  of the male perineum   ....     517
        Plate LIII.—Instruments employed in lithotomy    .    .    .   518
Section II.—Operation of perineal lithotomy.....519
    g 1. Preparatory steps.........519
    g 2. Constitutional treatment ........     521
    g 3. Local preparatory means........   521
Section III.—The lateral operation......    .     522
    g 1. Instruments that may be wanted during the operation    .    .   522
    g 2. Lateral operation  with the cutting gorget    ....     523
        Plate LlAr.—Lateral operation for lithotomy  ....   524
    g 3. Operation with the single lithotome cache of  Frere Cosme   .     526
Section IV.—The bilateral operation.......527
        Plate LV.—The operation of lithotomy as performed in the bilat-
            eral section, with the lithotome cache of  Dupuytren     .     528
Section V.—The median operation........531
    g 1. Lithectasy..........532
    g 2. Recto-vesical lithotomy.......       532
Section VI.—Of the supra-pubic operation......533
     g 1. The quadrilateral operation......       534
Section V1L—General remarks on perineal lithotomy ....     534
    g 1.  Extraction of the stone.....                534
     g 2.  Accidents connected with lithotomy     ....         536
Section VIII.—After-treatment in perineal lithotomy     .    .     .    .537
     g 1.  Putting to bed.......              537 
CONTENTS OF VOL. II.
xliii
                                                                     PAGE
         Plate LVI.—Instruments employed in the operations of lithot-
             omy and lithotripsy........538
     g 2. Treatment of the wound........539
     g 3. Constitutional treatment  %........539
 Section IX.—General  estimate of the value of the different methods of
             operating for lithotomy   .......    540


                              CHAPTER V.

            LITHOTRIPSY, OR CRUSHING OF STONE IN THE BLADDER.

 Section I.—Preliminary treatment necessary in lithotripsy   .    .     .  543
 Section II.—Operation of lithotripsy.......543
         Plate LVII.—Operations for the  removal of stone from the
             bladder..........  544
 Section III.—Cases adapted to the operation of lithotripsy .     .     .    546
 Section IV.—Litholiby..........547


                             CHAPTER VI.

   DISORDERS OF, AND OPERATIONS  ON, THE FEMALE  GENITO-URINARY ORGANS.

 Section I.—Surgical anatomy of the female perineum ....    548
 Section II.—Disorders of the  external organs......549
     g 1. Eczema of  the vulva........549
         Plate LVIII.—Instruments employed in operations upon the
             vagina and rectum........550
     g 2. Occlusion of the vulva........551
     g 3. Inflammation of the hymen and enlarged follicles    .    .     .  551
     g 4. Hypertrophy of the clitoris.......551
     § 5. Polypi of the urethra.........552
     g 6. Catheterism..........552
     g 7. Imperforate hymen.........552
     g 8. Occlusion of the vagina........552
         Plate  LIX.—Operations performed  upon the  female  genito-
             urinary organs.........554
Section III.—Laceration of the perineum......555


                            CHAPTER VII.

                    OPERATIONS FOR VAGINAL FISTULA.

Section I.—Vesico-vaginal fistula.......559
    g 1.  Palliative treatment.........560
    g 2.  Operations for vesico-vaginal fistulae.....560
        Plate LX.—Operations performed on the female genito-urinary
            organs...........562
Section II.—Vesico-uterine fistula.......566 
xliv
CONTENTS OF VOL. II.
                                                                      PAGE
 Section IIT.—Recto-vaginal fistulae........567
 Section IV.—Stone in the female bladder......568
     g 1. Vaginal lithotomy.........569
     g 2. Lithectasy in the female........569
     g 3. Lithotripsy in the female........570


                           CHAPTER VIII.

                        DISORDERS OF THE UTERUS.  ,

 Section I.—Displacements of the uterus......573
 Section II.—Puncture of  the uterus.......575
 Section III—Polypi of the uterus.......575
 Section IV.—Amputation of the neck of the uterus    ....   577
 Section V.—Extirpation of the womb.......578
 Section VI.—Extirpation of the ovary, or ovariotomy  ....   578
     g 1. The major operation........579
         Plate LXI.—Operations practiced on the female genito-urinary
             organs...........580
         Plate LXII.—Operations  practiced upon the uterus through
             the abdomen.........584
 Section VII.—On the Caesarean operation......585


                            CHAPTER  IX.

         DISORDERS OF, AND OPERATIONS PRACTICED ON, THE RECTUM.

 Section I.—Surgical anatomy of the rectum......586
 Section II.—Disorders of the anus.....              587
    g 1.  Eczema of the anus.......            588
 Section III.—Disorders of the rectum.......539
    g 1.  Removal of foreign bodies......            590
    g 2.  Encysted rectum.......              590
    g 3.  Fissure of the anus......                 gg-^
    g 4.  Imperforate anus   .    .     ...    .     .                   591
        Plate LXIIL—Operations practiced on the rectum  .    .    .592
    g 5.  Prolapsus ani......                        gQo
    g 6.  Hemorrhoids, or piles......                 cog
        Plate LXIV.—Operations for fistula in ano  .     .     .    .    604
    g 7.  Fistula in ano.....                           fin-
    g 8. Stricture of the rectum  ....                        607
American papers on the disorders of, and operations on,'the genito-urinary
            organs and rectum    ...                           ana 
CONTENTS OF VOL. II.                     xlv
                             PART XVI.

          Disorders  of, and Operations on,  the Extremities.

             GENERAL OPERATIONS ON THE  EXTREMITIES.


                             CHAPTER I.

                                club-foot.

Section I.—Pes equinua.........
     g 1.  Phalangeal variety of pes equinus.....
Section II.—Pes calcaneus........
Section III.—Varus.........
Section IV.—Valgus.........
Section V.—Pes talus, or plantaris......
Section VI.—Treatment of  all the varieties of club-foot  .


                             CHAPTER II.

               ligation  of  the  arteries of the extremities.

Section I.—Ligation of the axillary artery in  the axilla    .     .    .    633
     g 1.  Anatomical relations of the axillary  artery     ....  633
     g 2.  Ligation of the axillary artery......633
         Plate LXV.—Ligation of the arteries of the upper extremity  .  634
Section II.—Ligation of the brachial artery.....636
     § 1.  Anatomical relations of the  brachial  artery     ....  636
     g 2.  Ligation of the brachial artery at the middle of the arm     .    636
     g 3.  Ligation of the  brachial artery near the elbow  ....  637
         Plate LXVI.—Ligation of  the arteries  of the upper extremity   638
Section III.—Ligation of the radial artery......639
     g 1.  Anatomical relations of the  radial artery.....639
     g 2.  Ligation of the radial artery.......639
Section IAr.—Ligation of the ulnar artery......640
     g 1.  Anatomical relations of the  ulnar artery      ....    640
     g 2.  Ligation of the ulnar artery.......640


                            CHAPTER III.

            ligation of  the arteries of the lower extremity.

Section I.—Ligation of the femoral artery......641
     g 1. Anatomical relations of the  femoral artery.....641
        Plate LXVII.—Ligation of the arteries of the lower extremity  642
     g 2.  Ligation of the femoral artery......643
     VOL. II.—2
625
627
628
629
630
630
630 
xlvi
CONTENTS  OF  VOL. II.
Section II.—Ligation of the popliteal artery   .
    g 1.  Anatomical relations of the popliteal artery  .
    g 2.  Ligation of the popliteal artery.....
Section III.—Ligation of the posterior  tibial artery   .
    g 1.  Anatomical relations of the posterior tibial artery   .
    g 2.  Ligation of the posterior tibial  artery
        Plate LXVIIT.—Ligation of the arteries of the leg .
Section IAr.—Ligation of the anterior tibial artery
    g 1.  Anatomical relations of the anterior tibial artery
    g 2.  Operations for the ligation of the anterior tibial artery

                            CHAPTER IV.
            OPERATIONS ON  THE BONES  OF THE UPPER EXTREMITY.
Section I.—Resections in general........649
Section II.—Resection of the bones of the upper extremities    .     .    651
    g 1.  Resection of the shoulder-joint.......651
        Plate LXIX.—Resection of the bones of the upper extremity   652
    g 2.  Resection for false joint in the humerus.....653
    g 3.  Resection of the elbow-joint.......654
    g 4.  Resection of the bones of the forearm and hand   .     .         655


                             CHAPTER V.
           OPERATIONS ON THE  BONES OF THE LOWER EXTREMITY.
Section I.—Resection of the femur........657
        Plate LXX.—Resection of the bones of the lower extremities   658
    g 1.  Resection of the head of the femur......659
    g 2.  Resection  of the femur for anchylosis, and  formation of a  new
            joint at the hip.........659
Section IT.—Resection of the knee-joint......659
    g 1.  Removal of a portion of the patella, condyles, and articulating
            surfaces of the tibia........661
    g 2.  Resection of the bones of the leg......663
    g 3.  Resection of the fibula........664
Section III.—Resection of the ankle.......664
    g 1.  Resection of the inferior extremity of the tibia  and fibula .     .  664
    g 2.  Resection of the astragalus......         665
    g 3.  Resection of the os calcis.......       665
    § 4.  Resection of the metatarsal bones and phalanges  ...    666

                             CHAPTER VI.

                    general  remarks  on amputations.
Section  I.—Cases for amputation   ....
    g 1.  Gunshot wounds   ....
         Plate LXXL—Instruments for amputation, etc.
    g 2.  Railroad accidents ....
    g 3.  The period for amputating  ....
644
644
644
645
645
645
646
648
648
648
667
667
668
669
670 
CONTENTS OF VOL. II.
xlvii
                                                                    PAGE
Section II.—Points for the performance of amputation     .    .     .    673
    g 1. The place of election.........673
Section III.—The different varieties of amputation    ....    674
    g 1. The circular operation........674
    g 2. The oval method.........675
    g 3. The flap operation.........675
    § 4. Estimate of the different kinds of amputation     .    .     .    676
Section IV.—General measures requisite in amputation  ....  677
    g 1. Preparatory measures........678
    g 2. Duties of assistants.........  678
    g 3. After-treatment.........679
    g 4. Accidents that may occur either during or after amputation    .  680
                            CHAPTER VII.

                  amputations of the upper extremity.

Section I.—Amputation at the shoulder-joiut.....682
    g 1. Amputation at the shoulder-joint......682
        Plate LXXII.—Amputation of the arm     ....    684
Section II.—Amputation of the arm.......686
        Plate LXXIII.—Amputation  at the elbow-joint  .     .     .    688
Section III.—Amputation at the elbow-joint......689
        Plate LXXIV.—Amputation  of the hand    ....    690
Section IV.—Amputation of the forearm......691
        Plate LXXV.—Amputation of the fingers   ....    692
Section V.—Amputation of the fingers.......693
                           CHAPTER  VIII.                           ,

                  amputations of the lower extremity.

Section I.—Amputation at the hip-joint......693
    g 1.  Surgical anatomy of the hip-joint......694
    g 2.  Amputation at the hip-joint.......694
         Plate LXXVI.—Amputation at the hip-joint       .    .    .696
         Plate LXXVII.—Amputations of the thigh ....     698
    g 3.  Statistics of amputation at the hip-joint.....699
Section II.—Amputation of the thigh.......699
    g 1.  Circular operation of Alanson.......700
    g 2.  Flap operation.........700
    g 3.  Statistics of amputation of the thigh......702
Section III.—Amputation at the knee-joint ......     702
    g 1.  Statistics of amputation at the knee-joint.....703
Section  IV.—Amputation of the leg.......705
    g 1.  Circular amputation of the leg.......705
         Plate LXXVIIL—Amputations  of the leg  .     .     .    .     706
    g 2.  Flap operation on the leg........707
    g 3.  Oval method..........708 
xlviii
CONTENTS OF  VOL. II.
Section V.—Amputation at the ankle-joint    ....
Section VI.—Amputation of the foot at the tarsus
        Plate LXXIX.—Amputations of the foot .
Section VII.—Amputation of the toes......
Section VIII.—Organic changes resulting from amputations  .
        Plate LXXX —Amputation of the toes
Section IX.—Substitutes for the natural limb ....
American papers on disorders of, and operations on. the extremities
Alphabetical  Ltst of American Surgeons..... 
THE  PRINCIPLES
AND
PRACTICE   OF   SURGERY.
REGIONAL DISORDERS AND  OPERATIONS.
                    INTRODUCTORY REMARKS.

  In the consideration of the Principles and Practice of Surgery, as hitherto
presented, attention has been mainly directed to the disorders noted in con-
nection with the different tissues of the body, without  any special reference
to their relative positions to  each other.  By this means the subject has been
studied in detail mainly as it related to the efforts of nature, aided by art, in
the process of repair, or in such modifications of disordered nutrition as
constituted the special diseases of each tissue.
  In the present volume the subject of Regional Disorders and the oper-
ations demanded for their relief, will be investigated, rather in reference to
the anatomical relations of the varied parts that compose the region under
discussion, than in view of the pathological changes created by disease—omit-
ting in this consideration such general characteristics as  have been already
alluded to.  Thus, under the regional  division  of the Head, Neck,  Chest,
etc., there will be given  such an account of special disorders and operations
as are  mainly seen in these portions of the body, while, at  the same time,
attention can be readily  given to the influence of such structures and organs
as are  met with in the  region  under examination.   When operations  are
performed  on regions, as the eyes, ears, nose, etc., it  is  also desirable that
     vol. il—4                                          ( 49 ) 
50
PRINCIPLES AND  PRACTICE OF  SURGERY.
the surgeon  should have a clear recollection of the anatomical  relations
of the parts  operated.  Hence the  account of each operation will be pre-
ceded  by a topographical description of the anatomy of  the  structures
liable to be involved in the operator's proceedings.   In the prosecution of
this plan, the subject will be presented in  the usual topographical order of
the anatomist, and studied, first, as  limited to the region of the Head and
Face, then of the Neck, Chest, Abdomen, and Genito-urinary Organs, reserv-
ing for the Extremities, the varied operations of the ligation of arteries, am-
putation, resections, etc, 
PART   XII.
DISORDERS  AND  OPERATIONS  ON THE  HEAD
                      AND  FACE.
  As the disorders and operations  connected with  the  Head  and Face
embrace two distinct regions not specially bearing on each other, they may
be advantageously studied separately.
                          CHAPTER I.

            DISORDERS  AND OPERATIONS ON THE  HEAD.

  The regional disorders specially requiring  operative treatment, in con-
nection  with  the Head, may be studied  as limited  to the scalp, or as in-
volving  the bones  of the cranium.  The surgical disorders of the Scalp,
under this arrangement, will embrace the  various forms of tumors met with
in this structure, as well  as the injuries  and diseases of its  blood-vessels.
Those involving the Cranium will  be  referred  to as due to fracture and
tumors,  or other disorders of the bones  of the  skull.   Before examining
the peculiarities of either class, attention  should be given to the surgical
relations of the constituent parts of the head as a region.
                            SECTION I.

                  SURGICAL  ANATOMY OF THE  HEAD.

  The Head, as a Surgical  Region, is divided into  two parts:  one, the
Cranium, being all  that portion of the bony structure occupied by the
Brain ; the other, the Face, being the  region bounded above by the super-
ciliae,  and below by  the base  of the inferior  maxilla.   In the cavity of
the cranium, anatomists recognize two distinct portions:  one, the superior,
which is designated as the Vault; the  other, the inferior, usually called the
Base.   With the Base of the cranium a surgeon has but little to do, it being
so situated and connected with vital parts of the nervous system as to forbid,
as a general rule, the application of instruments to it, except in its lateral
                                                         (51) 
                            PLATE  V.

       INSTRUMENTS  EMPLOYED  IN  TREPHINING  AND OTHER
                     OPERATIONS  ON  THE  BONES.

  Fig. 1. The Circular Saw of Martin, of Paris.   1.  The handle.   2. The shaft.
3.  The double joint.  4. The saw.  This  most  useful instrument consists of a
shaft to which circular  as well  as  mushroom-shaped saws or circular gouges
may be  adapted  by a screw. These saws may  be made to revolve rapidly  by
means  of the brace, Fig. 2.  In consequence of the double joint at 3, the saw
can be  kept in motion, no matter what may be the relative position of  the shaft
to which the brace is attached, except when the two are at a right angle.  This
saw is to be employed by the surgeon  holding the handle,  1, while the assistant
turns the brace, Fig. 2,  when attached to the shaft at 2.  I have used  this saw
in several instances, and found it an excellent instrument.   Charriere's pattern.
  Fig.  3.  The Mushroom Saw, and  Fig. 4, the Circular Saw, belonging  to
pj„ l                                                  Charriere's pattern.
  Fig.  5. Hey's Saw.                                       KolbVs pattern.
  Fig.  6. Barton's Metacarpal Saw.
  Fig.  7. A fine flexible " Keyhole " Saw, for incising the bones  of the face.
                                                          Kolbe's pattern.
  Fig.  8.  The " Chain  Saw," with the needle  attached for  carrying one end
round a bone.                                           Charriere's pattern.
   Fig. 9. The Handles, to be attached to the saw after the needle is removed.
                                                       Charriere's pattern.
   Fig. 10. A Trephine  of  large  size.  1. The crown.  2.  The slide to raise the
centre-pin.                                                Kolbe's pattern.
   Fig. 11. A smaller Trephine.                                 "
   Fig. 12. A short, stiff Brush to clean the teeth of the trephine. "
   Fig. 13. An Elevator for raising a  depressed bone.            "       "
   Fig.  14. A Lenticular Knife, for the removal of spiculae  from the opening
in the  skull made by a  trephine.                             Kolbe's pattern.
   Fig.  15. A Scraper or Raspatory, useful in caries, etc.         "       "
   Fig.  16. A Steel Hammer, or Mallet.                   Charriere's pattern.
   Fig.  17. A Steel Gouge, with the shaft passing through a wooden handle.
                                                       Charriere's pattern.
   Fig. 18. A chisel of  the same kind.                          "       «
   Fig. 19. Liston's strong Bone Nippers.                    Kolbe's pattern.
   Fig. 20. Strong Bone Forceps, for  removing  sequestra in Necrosis.
                                                            Kolbe's pattern.
        (52) 
Plate  5

\(
*%
17
 
 
SURGICAL  ANATOMY OF  THE  HEAD.                53
portion, where, in rare cases, it is necessary to perforate  the mastoid  cells,
in order to relieve deafness.
  The Vault of the cranium is mainly important to the surgeon in conse-
quence of the relations existing between the bones which compose it and the
internal parts.   These  bones are so  arranged as to  form a cavity which is
accurately filled by  the  brain.  They are of the class known as flat bones,
and  consist of two layers of compact matter  with an intermediate diploe
or cancellated structure, which contains a large number of veins or sinuses.
The layers or tables of the  skull are covered and nourished by an endos-
teum, which is the outer lamina of the dura mater, as well as by an externa]
membrane called the Pericranium.  In  all operations upon the vault of the
cranium,  the  pericranium should  be disturbed as  little as  possible, and
always reapplied to  the skull, Kodier and others having  shown that it is
capable of reproducing bone  when  thus  replaced in  connection with the
scalp.
   The  Dura  Mater, or  fibrous  covering  of  the brain, is attached to the
internal table of the skull by fibrous and vascular adhesions, and is regarded
as useful  in the nourishment of  this table.   In its  duplicatures are  found
several large  veins or sinuses,  the principal of which,  on its upper part, is
the  Superior Longitudinal Sinus, Plate YII. Fig. 1.    This sinus  runs from
before backward, in the  median  line of the cranium, and is liable to  be in-
jured if a trephine is applied  in  its  course.  Several arterial  branches  are
also found within the vault of the cranium, outside the dura mater, and often
more or less deeply imbedded in  the inner table of the skull.  Of these arte-
ries, the most  important to  the  surgeon  is the  meningea  media, or middle
artery of  the dura  mater, which  is first noticed within the cranium, near the
level of the external angular process of the os frontis and the anterior angle
 of the parietal bone, whence it ramifies in  numerous  anastomosing branches,
 Plate YII. Fig. 1.   This vessel,  like the  longitudinal  sinus, is also liable to
be  wounded in the operation of  trephining, and, when opened, is sometimes
 ligated with  difficulty,  in consequence of its deep channel  in  the  bone.
 Cases, however, are recorded in  which  hemorrhage from it and from the su-
 perior longitudinal sinus has been arrested by  pressure with lint.  The Peri-
cranium,  or periosteum of the cranial bones, adheres closely to  their external
surface, especially at the sutures, and by its vascular connections assists in
 preserving the vitality of the outer table of the skull.
   Outside of the pericranium, upon the  summit of the vault, is found the
tendon, and at the  front and back of the same region the bellies of the oc-
cipito-frontalis muscle, the fibres of which  run nearly vertically.  The  course
 of these fibres should direct the line of all incisions in  this  region, a transverse
 wound of the scalp being occasionally difficult to heal,  from the retraction of
 its edges  caused by the action of the  muscle.  The connective tissue between
 the occipito-frontalis tendon  and the  pericranium is freely developed, and
 attaches  these  two parts so loosely together  that  the  tendon  and muscle
 move with great facility upon the pericranium.   The  connective tissue be-
 tween the tendon and the integuments is, on the contrary, sparsely developed,
 uniting the two tissues very closely together.  In this  layer is found a small
 amount of fat, as  well  as the tegumentary blood-vessels and nerves; it is
 also the seat  of most of the tumors  found upon the  scalp, the flattened and
 spheroidal shape of which is mainly due to the closeness of the structure
 and its want of extensibility.  This sparse connective tissue is one cause of
 the great liability  of the scalp to take on erysipelatous inflammation ; and
 the rapidity with which the disease  runs on to mortification is owing to  the
 nutritive  vessels of the  integuments being compressed against the  cranium,
 whenever effusions occur in its  dense  and unyielding structure.   Its char- 
54
PRINCIPLES AND  PRACTICE OF  SURGERY.
acter will also be noticed in any attempt to place a ligature upon a divided
vessel in the scalp, the difficulty of drawing out the vessel being due to the
peculiarity just referred to.  The skin immediately above this layer contains
the hair and sebaceous follicles, both of which may become  the seat of dis-
ordered nutrition.
  In  studying the structure of the scalp from its  surface to the bones, we
have, therefore, 1st, the skin with its hairs and follicles; 2d, a dense  con-
nective  tissue, closely adherent to surrounding  parts, that contains fat, as
well as most of the blood-vessels  and nerves;  3d,  the occipito-frontalis
muscle and its tendon; 4th, a  loose areolar substance that permits free
motion  of the muscle  and tendon  upon the parts beneath ;  and,  5th, the
pericranium closely adherent to all parts of the bones, but especially to the
sutures.   Wounds of the scalp are very apt to separate the integuments
from the pericranium, in consequence of its loose  connections; but as the
tegumentary vessels usually remain in the flap, it is  generally only neces-
sary to replace the latter in its proper position, in order to enable the parts
to heal.   The density of  the  tissue, and the tendency of suppurations  to
travel in the connective  tissue between the tendon of the occipito-frontalis
and the pericranium, should always be borne in mind  in injuries or opera-
tions on this region.  Sutures employed to unite  these  parts should  only
pass to  the tendon, and not beneath it, and the  metallic sutures are  gen-
erally to be preferred to any other, as being less irritating.
  The anatomical relations of the Face will be referred to hereafter.
                            SECTION II.

              DISORDERS AND OPERATIONS UPON THE  HEAD.

  Wounds of the Head and Fractures of the Skull having been previously
alluded to, the operations required in  the treatment of the disorders of
this region may now be studied.   These consist of such as are necessary for
the relief of affections of the soft parts, and those demanded by injuries  and
diseases of the bones  or dura mater.   In all these cases the surgeon  will
find it a useful preliminary measure to  shave the scalp freely before com-
mencing his  operation,  except  in extirpating small encysted sebaceous
tumors, where the  presence of  the adjacent  hair, the tumors  themselves
being bare, will be useful  as a means of promoting the approximation of
the incisions, union being generally in these cases so prompt  as to  enable
the patient to  avoid the notice generally excited by a shorn scalp.

                   § 1.—Operations  upon the Scalp.

  Among the  affections of  the scalp most frequently requiring surgical in-
terference are Encysted Tumors, and Naevi or Vascular Tumors.
  I.  Cystoma or Encysted Tumors of the Scalp, like those seen elsewhere
are of various  kinds, and, when found in this region, are usually situated in
some  portion of the scalp exterior  to the occipito-frontalis tendon.   They
are seldom covered with hair, the distention of the skin by the growth of
the tumor usually destroying the action  of the hair follicles.
  The variety of encysted tumors anciently called Atheromatous or Melice-
rous,  contains  cheesy or more liquid matter, and are generally regarded as
due to obstructed and enlarged sebaceous follicles, as before stated.*   Thev
* Vol. i. p. 360. 
OPERATIONS  UPON THE SCALP.
55
are most frequently located immediately beneath the skin.  Unless of long
standing and of some size, these tumors do not adhere to the pericranium;
but, when  more fully developed, they sometimes induce such inflammatory
action in  this membrane as results in adhesion, and, in  some instances, in
cartilaginous degeneration of that portion of the  pericranium next to the
sac.  Occasionally I have seen these tumors induce direct absorption of the
outer table of the skull, so as to create a cup-like cavity, the edge of which
was rough and slightly elevated.  No blood-vessels  enter these tumors,
their organization being low.
   Ordinary Operation.—If the tumor is small, pass a sharp-pointed, narrow
bistoury, with the back to the cranium, directly through its middle, and cut
the sac open  from within outward.  Then, after squeezing out the contents,
reflect the  edge of the skin so as to retain it in one  pair of  forceps, while
the divided edge of  the sac is seized in another pair, and drawn out from
its attachments.   If the adhesions, however, are  strong, careful dissection
may be necessary to free the tumor from the pericranium, lest the latter
membrane  be injured and necrosis supervene.
   In large encysted tumors, it is  sometimes necessary to make an elliptical
incision through the  scalp, so as to remove such  portions of the latter as
would prove  superabundant; then, puncturing the sac, proceed as before;
but encysted  tumors  of a size requiring this mode of operating are rare, and
any apparent excess of scalp will usually disappear soon after the removal of
the sac, or cause no inconvenience to the patient.   To attempt a dissection
of the entire cyst is both tedious and useless.
   Dressing.—Cleanse the part thoroughly; see  that no portion of the
shining sac remains  at the bottom of the wound, and tie or twist a few ad-
jacent hairs together over the wound, in order to close it, or, if the incision
has  been  free,  apply a compress and bandage.   The hemorrhage  seldom
requires attention, or may be easily arrested by pressure, being  usually so
slight as seldom to demand even a bandage.
   II. Aneurism by Anastomosis, or Erectile Tumors.—A class of tumors
formed chiefly by enlarged capillaries united together by free connective
tissue, and before described* as Angionoma  or Telangiectasis, is sometimes
found on the  scalp as well as in  other portions of the body.   In most in-
stances, these tumors only involve the integuments, and are supplied by one
or two vessels which, entering near the centre of the structure, have  no di-
rect vascular connection with the skin of the adjacent  parts.  Most fre-
quently they  will be found of small size, though they occasionally attain the
dimensions of an  orange.  Being composed almost entirely of enlarged
capillaries, as before  stated.f  the hemorrhage from them will  be free when
the diseased structure is incised, though it is slight, and generally  amenable
to pressure, when the incisions are kept out of the  new growth.
   Operations.—When seated in the  scalp, these tumors  may be eradicated
by various  means of treatment, the object of all being to  interrupt the sup-
ply of blood  to  the  tumor, or to remove the tumor entire from the  sur-
rounding tissues.
   In small tumors the development of moderate inflammation in the diseased
part will often suffice to produce an obliteration of its circulation, after which
the hypertrophied structure will either slough out or waste away; but, in other
instances,  constriction of the tumor by ligatures or  pressure may be required
to accomplish the  same object, though the  most certain  mode of cure will
be found in extirpation.  In  all cases  of anastomosing aneurism it is im-
portant to operate at an  early period, as its growth  is often rapid, and the
* Vol. i. p. 365.
t Ibid. 
PLATE  VI.
              OPERATIONS UPON  THE SCALP AND SKULL.

  Fig. 1. A front view of an Angionoma on the forehead of a child, showing
the combination of incision and  strangulation as recommended by Liston.
Four  flaps, formed by a crucial incision simply through the skin, have been
turned off, and two needles, armed with double ligatures, have been passed at
right  angles to each other through the base of the tumor.  The  loop of each
ligature being then cut, so as to form eight ends, two of them, 1 2, 3 4, 5 6, and
7 8, are to be tied firmly, so as to strangulate the tumor in four sections.
                                                            After Liston.

  Fig. 2. A Comminuted Fracture of the Cranium, showing a small  fragment
removed by the forceps, and the elevator as passed into the opening thus made,
so as  to elevate the depressed portion  of the skull.  When a fracture.is thus
comminuted, the employment of Hey's saw across  an  angle of the fracture, or
the application of the  forceps, will often enable the surgeon to make room for
the entrance of the elevator without employing the trephine.  Whenever the
latter instrument can be dispensed with, the  danger of injuring the dura mater
is much diminished.                             After Bourgery and Jacob.

  Fig. 3. A view of the removal  of a necrosed portion of the  Parietal Bone,
the integuments having been sufficiently dissected off from the head to permit
the necrosed bone to be seized by the forceps and elevator.
                                               After Bourgery and Jacob.

  Fig. 4. Removal of  a large tuberculated Exostosis from the posterior portion
of the left parietal bone.  The integuments  have been everted by a crucial in-
cision, and the tumor sawed through vertically.  Hey's saw is seen in the act
of removing it from the skull by cutting off its base.
                                               After Bourgery and Jacob.

   Fig. 5. A view of the Head of the patient operated  on  by  M'Clellan  of
Philadelphia, for a large spina ventosa of the cranium, showing the relative size
of the incisions, and the depression left by its removal, as described in the text.
                                                         After M'Clellan.
   Fig. 6.  The cancellated appearance of the tumor when removed.
                                                         After M'Clellan.
        (56) 
■:.;■:
w^k:m
 
 
OPERATIONS UPON THE SCALP.
57
hemorrhage in proportion to its size, especially when the tumor is at all
injured in the  operation of extraction.
  Treatment  by Exciting Inflammation.—Vaccination, as suggested by
the Germans, may be performed by introducing  the  vaccine virus into  the
tumor, as in the usual operation for protection from small-pox.  The result-
ing inflammation has, in some instances, been quite severe, without termin-
ating in a cure,  and  the practice is now seldom resorted" to.
  Heated Needles.—Bushe, of New  York, induced obliteration of the ves-
sels and sloughing of the diseased  structure by  introducing numerous nee-
dles—twenty or thirty—heated to a white heat,  through different parts of
the base of the  tumor.   Mott and others have  also employed this method
with success, as follows: The needles being  heated to a white heat in the
flame of a spirit-lamp, and then passed immediately through the base of the
tumor, in various directions, should be quickly withdrawn, so as to cauterize
the part and  prevent any hemorrhage from the  numerous punctures.   The
operation is said to be productive of but little  pain, and to avoid the forma-
tion of a scar.
  Caustic  Threads.—N. R. Smith, of Baltimore, has  frequently cured  the
disease by the following operation : Soak a thread in a saturated solution of
caustic potash, and, after drying it at a fire, pass it through a needle ; transfix
the base of the tumor, and, leaving the thread in position, remove the needle.
Pass  several in the same manner, and the tumor  will soon waste away with-
out causing any troublesome symptoms.*
  Seton.—Stevens, of New York, following the  suggestion of Fawdington,
of Manchester, of introducing a seton, has operated  successfully by the fol-
lowing modification  of his proceedings: A  blunt-pointed needle,  armed
with several silk threads, being passed from one  edge of  the swelling, com-
pletely beneath it, to the other, the needle is withdrawn, and the silk thread
left as a seton in the wound.   No hemorrhage usually results, if the threads
are sufficiently numerous to fill up the track of the needle; but suppura-
tion ensues,  and, in  one case reported by John  Watson,  of  New York,
a cure followed, in which the  cicatrix was only observable on minute exam-
ination.
  Ligatures.—These means  have  been employed by  Liston, Bell, White,
Lawrence, and others, both in Europe and the United States,  in various
ways, so  as to cut off the circulation  from the base of the tumor by direct
action upon its nutritious arteries ; but if applied so as to include the skin,
the ligatures are liable to cause intense pain and violent inflammation of the
surrounding parts, and, in children, may even excite convulsions, or severe
constitutional disturbance.   To obviate these risks, it will be found advisable
either to pass the threads around the  base of the tumor by means of needles
introduced immediately beneath the skin, as in the subcutaneous  suture of
Dieffenbach, or, when the  skin is but slightly or not at all affected, to turn
it back by a careful  dissection, so  as  not to open the tumor;  then passing
two curved needles,  armed with double ligatures, through  the  base of the
tumor, cut off the loops of each thread and tie  the  eight ends together so
as to strangulate it,  and cause its removal by sloughing, Plate VI. Fig.  1.
  Barton, of  Philadelphia, operated  successfully with the ligature, by pass-
ing two hare-lip pins at right angles to each other, through  the base of the
tumor, and then carrying a strong thread around them, and also across the
top of the tumor, so as to strangulate all the portions included between the
pins and the ligature; the object of the pins  being to confine the ligature
* American Journal of Medical Sciences, vol. vi. N. S. p. 260, 1843. 
58
PRINCIPLES AND  PRACTICE OF SURGERY.
about the attachment of the tumor, as well as to compress its structure upon
them.
  Brainard, of Chicago, has employed  Collodion, in small tumors, and re-
ported cases of cure.   As a simple  remedy acting by constricting the ves-
sels, it may be resorted to in cases of a limited  character.  It should be
applied to the surface of the skin over the tumor by means of a brush.  In
three cases I have recently obtained a cure by painting the surface  of the
tumor witli a solution of corrosive sublimate four parts, in collodion thirty
parts, as suggested by Mackay, of Edinburgh.   In about six days the  eschar
drops  off, when,  if the structure has not sloughed  out,  it may be again
touched.  But. in small growths, one free application suffices.   The ulcer
heals readily under the water-dressing, or mucilage.
  Excision.—A careful examination of many of these tumors having  shown
that they are not, in most instances, intimately connected with the surround-
ing  parts, the practice of excision, as originally recommended by Bell, in
England, and Physick, of Philadelphia, may be safely pursued when they
are of moderate size, provided the  incisions are kept in the healthy  tissue.
In their removal by excision, pass a needle and thick  ligature through the
tumor; tie its ends so  as to form a  loop and facilitate the elevation  of the
tumor from subjacent parts; then, making an  elliptical incision around its
base, dissect out the growth without cutting  into its structure.   In the
scalp, the loss of integument and the  hemorrhage will  occasionally  be an
objection to this plan of treatment, especially if the tumor is large, and in
these instances the following operation may be  useful.
  Partial Incisions Renewed  at Intervals.—In a case of congenital an-
gionoma, which covered nearly  the  whole of  the right  side of the  head,
Gibson,  of Philadelphia, commenced its removal  by making an incision
around one-third of the base, taking up all the bleeding vessels as they
were divided,  and interposing lint between the edges of the wound  so as
to prevent the union of the integuments and the tumor  at the point of
incision ;  then, after an interval of a few days,  he incised another  third,
secured the vessels,  interposed  lint in  a similar manner,  and, in a week
afterward, removed the tumor.*
  Physick, of  Philadelphia, in a similar case, cut round  the tumor, tied up
the vessels as they sprung, suffered the parts to remain with lint interposed
to prevent immediate union,  and the  tumor soon afterward wasted away.f
In a few instances, ligature of the carotid arteries has been resorted to, and
the tumors subsequently excised.
  III. Aneurisms of the Scalp. — Dilatation  of the  blood-vessels of the
scalp, and varicose enlargements, or large aneurisms by  anastomosis with
other tumors,  sometimes produce a condition of the vessels which  from its
pulsation, resembles  an aneurism, and which it is  difficult to remedy  by an
operation, in consequence of the hemorrhage  that ensues.   In  such  cases
B. Dudley, of  Kentucky, recommended compression by means of  the com-
mon roller and properly adjusted compresses, and has succeeded in speedily
curing cases of this kind in which the disease occupied one-half of one  side
of the head and forehead, and involved  all the upper eyelid with the  inner
and outer canthus of the eye.
  Estimate of these Methods of Operating—In cases of angionoma where
the skin is not much  involved in the disease, or where the  tumor is not  larger
than a walnut, or where the cicatrix would not create much deformity ex-
cision will, I  think,  be found  most prompt, and preferable to any  other
operation, the  hemorrhage being, in most instances, according to my expe-
* Dorsey's Surgery, vol. ii. p. 272, 1823.          f Op. citat., loc. cit. 
OPERATIONS UPON THE SCALP.
59
rience, readily controlled by ligature or by pressure, particularly when care
is  taken to incise only the healthy structure, and not to open the tumor;
and there  are few surgeons who have tried excision that have not preferred
it to other means, particularly when they had proper assistants.
  John C. Warren, of Boston, long favored this operation, especially when
the tumor was seated near the  eyes, nose, mouth, or other natural apertures.*
In his practice, three cases were treated by caustics applied externally so as
to cause a slough, eight  by ligature, and eighty-five  by excision, all suc-
cessfully, f
  Where the tumor is very vascular and  large, or so  situated as to cause
deformity by the cicatrix,  the  seton, as  employed  by Stevens  and Watson,
will be found to answer a  good purpose; or cauterization by the heated nee-
dles may effect  a cure, especially if the needles be made large.   Vaccination
is hardly worth the trial, unless in  the hands of a timid practitioner.   If the
large size of the tumor should create just apprehensions  of the hemorrhage
likely to result from its  prompt  extirpation,  the repeated operations of
Physick and Gibson will,  it is thought,  answer better  than  the ligature of
the carotids.   In  the  cases reported by  Mussey  and  Warren, the cure of
large vascular tumors on the scalp did  not ensue  upon the ligature of the
main  arteries of the neck  In the treatment of  the  smaller tumors, seen
soon after  birth, the application of corrosive sublimate will often suffice for
the cure.
  IV. Venous Tumors of the Scalp.—The veins of the scalp sometimes be-
come enlarged, and present a  varicose condition, which Fergusson, of Lon-
don, has recommended should be treated by means of  needles and pressure
from ligatures,  in the  manner referred to in the treatment of varices of the
leg.   This condition  of the voins of the  scalp, independent of other com-
plaints, must, however, be very rare, as I have never seen an  instance of  it
during my attendance either in the  United States or in the Parisian hospitals.
   V.  Cephalsematoma.—Cephalaematoma—/e^a/by, head ;  aip.a, blood—or
the bloody tumors occasionally found on the heads of very young infants, may
perhaps require the attention of the surgeon.   These  tumors have been
divided by ValleixJ into  those in which the sanguineous collection is sub-
aponeurotic, sub-pericranial,  or  sub-meningeal.    These tumors  differ, in
position, from the bloody infiltration of the scalp, which is the result of  a
tedious labor, as this  is most  frequently seen near the  vertex ;  whereas the
common position  of cephalsematoma is the line near, but not at, the junction
of the angle of the right parietal bone with its fellow.  The sub-pericranial
cephalaematoma is the most common  form, and demands prompt attention,
in order to prevent such a separation of the pericranium from  the bone as
may result in caries or necrosis.   These  tumors are said, by Nelaton,§ to
be most frequently seen immediately after birth in first  children.  Generally,
nothing more is necessary for  their cure than time and  cold  applications ;
but when the effusion is large, and likely to elevate the periosteum to any ex-
tent, it may become necessary to evacuate  the clot  in order to save  the bone.
Under these circumstances, a puncture which is merely  sufficient to give exit
to the blood, without  admitting the entrance of air beneath the scalp, is all
that is requisite.   The reader who is desirous of more  detailed information
on the pathology  of these tumors  will be  repaid by perusing  the  paper of
Geddings,  of Charleston. ||
* Warren on Tumors, p. 461.
f Cooper's Surg. Diet.—Appendix by Reese, of New York, article Naevus.
% Maladies des Enfans.                       \ Pathol. Chirurgical.
|| In the North American Archives, vol. ii. p. 217. 
60
PRINCIPLES AND  PRACTICE OF  SURGERY.
  VI.  Division of the Supra-orbitar Nerve.—In some cases of injury of the
forehead,  and especially in  contused wounds, the supra-orbitar  nerve has
become involved in the cicatrix, or given rise to such a neuromatous  tumor
as rendered the division of its trunk necessary,  in order to relieve the neu-
ralgic pain resulting from the condition referred to.  In such cases the object
may be easily accomplished by a subcutaneous section.
  Operation.—In order to  secure  the  division  of the  main  trunk of the
nerve,  which is often superficial at its exit from  the  supra-orbitar foramen,
the surgeon should introduce a sharp-pointed and narrow bistoury flatwise
beneath the integuments, and close to the bone, on the external or temporal
side of the foramen,  passing  it a few lines  toward  its  inner side.   Then,
turning its edge toward the integuments  and its back to the  bone, let him
divide  all the tissues from behind forward until sensation  is destroyed, taking
care not to cut through the  skin;  then, turning  the bistoury again flatwise,
withdraw  it at the point of entrance, closing the orifice immediately with
adhesive plaster.  Should a return of  the disease lead  to the suspicion of
reunion in the nerve, a dissection and excision of a portion of its trunk may
become necessary.  Among the  most decided cases of relief afforded by this
operation  are those reported by John  C. Warren, of Boston,* who divided
the three branches of the  fifth pair many times with success.  He has also
operated on other nerves,  in cases of severe neuralgia, especially in connec-
tion with those of the jaws  and extremities, such as the infra-orbitar, sub-
maxillary, and  portio  dura, all  of which have  been divided by him with
marked relief to the neuralgic disorders of their branches.


            § 2.—Operations upon the Bones of the  Cranium.

  The  operations practiced on the bones of  the cranium  are those required
by diseases or injuries of one or both tables  of the skull, such, for instance,
as caries,  necrosis, exostosis, fracture,  or  for the  evacuation  of  bloody or
serous  effusions from within  the cavity of the cranium.  In the diagnosis or
treatment  of  any of these affections, the operator will find it advantageous
to shave the scalp at the point to be examined or operated on, so as to ren-
der the sensation given by the  scalp less deceptive to the touch,  as well as
prevent the adhesion of the discharge and dressings to the hair.  He should
also have at hand one or more of the  instruments  referred to and shown in
Plate V.   In many cases, and especially when  there is  no wound  at the
part, he will find it necessary to incise the scalp; the incisions required  under
such circumstances  being either in the form of an  L, V, or ^__' the  last
being the best,  and so arranged that their dependent position may favor the
escape  of  subsequent collections of pus.
  I. Operations for Garies and Necrosis of the Cranium.—In  operating
upon the skull  for either caries or necrosis, the  bone  should  be  sufficiently
but not too freely exposed, by dissecting back the scalp to the necessary ex-
tent, and the  same precepts be observed that  are  applicable to these diseases
in the bones of the extremities,  to wit, care  taken not to remove the  peri
cranium, or membrane  covering the bone.   After this,  all the softened or
dead structure should be thoroughly taken out, by means of the raspatory saw
trephine, elevator, or  forceps, Plate  V. Figs. 14, 15, until the surrounding
bone shows,  by its color  and  vascularity, that  it is capable  of  taking on
healthy action,  when the pericranium should be  replaced, in order to favor
the  growth of new bone.
Boston Med. and Surg. Journal for 1S2">. 
          OPERATIONS UPON THE BONES OF THE  CRANIUM.        61

  In operating for the removal of an enchondroraa, exostosis, or other bony
tumor of the cranium, the first incision should be so made  through the in-
teguments as freely to expose its base, and enable the operator to separate
it from  the  skull with the  saw, gouge, chisel, or cutting  forceps, either by
cutting  through its centre down  to its base,  Plate  VI.  Fig. 4, or by ex-
posing the base and  then  sawing  through the tumor on a line with the
general  convexity of the head.
  A remarkable case of " spina ventosa" of the cranium  having been  pre-
sented to  M'Clellan, of Philadelphia, the following operation was practiced
for its removal.   The tumor was  4 inches in length, 3% inches in its short
diameter, and about If inch above the surrounding portion of  the skull.
  Operation of M'Clellan. — The  patient was  a man  twenty-two  years
of age, and  had suffered from various  symptoms connected with his head
for  three  years; it was therefore decided to operate upon the tumor  as
follows:  Two long  incisions being made at right angles, and near  the cen-
tre of the swelling, the scalp was dissected up from the whole  surface, and
to some extent around the  sound bone.   Then with a long,  narrow saw,
held at a tangent to the circumference of the cranium, the entire tumor was
cut  off at its base.  The appearance of the  cells of  the tumor, and of the
scalp subsequent to its removal,  is shown  in Plate VI.  Figs. 6 and  5.
Owing to the  character of  the tumor as thus  shown, it was deemed neces-
sary to remove the whole mass from the  surface of the dura mater  beneath
it, which rendered the operation much more tedious and difficult, but which
was  accomplished by circumscribing the whole  mass of the tumor by the
circular edge of Hey's saw, and then prying it out  in  successive fragments,
by means of an  elevator, which was occasionally aided by the  bone-nipper
and forceps.*   The dura mater, when exposed, had been so much depressed
by the  external development  of the tumor as to present a  deep cavity,
capable of holding four ounces and a half.   In removing some spicula of
bone, this membrane  was wounded,  but  the  hemorrhage was  arrested by
pressure.  Very little irritation ensued on the operation.  In nine days, the
compresses were loosened by suppuration, and, on removing  them, the whole
surface was found to be granulating, and  an orifice  which  had been  made in
the  longitudinal sinus was closed.   The patient subsequently recovered, and
his case, owing to the change  in his mental disposition, attracted consider-
able attention from  Combe and other phrenologists.
  II. Trephining the Cranium.—As the brain fills accurately the cavity
formed by the bones of the head, any cause which  diminishes the space natu-
rally occupied by this organ generally impairs its functions, and leads to a
train of symptoms which may terminate life.   To obviate these, and relieve
the  cerebrum  from  pressure, the  operation of perforating the  skull, so  as
either to restore its natural convexity or give  exit to  effusions within it, was
suggested, and has been practiced since the times of  Hippocrates, B.C.  4G0,
the  skull being perforated  either by the trepan or by the trephine, and the
operation named after the instrument which was employed to accomplish it,
as trepanning or trephining.
  The trephine  is a circular saw, which  is made to perforate the skull by
frequently turning the hand from  pronation  to  supination, the division of
the  bone  by its application  constituting the operation of trephining.   The
French surgeons of the present day, like those of the  time of Hippocrates.f
employ a somewhat similar saw, though it is one which, like the antique in-
strument, is fitted to a brace, and worked  like a brace and bit.    This instru-
* M'Clellan's Principles and Practice of Surgery, p. 340.
f Hippocrates on Wounds of the Head, translated by Riollay. London, 1783. 
62
PRINCIPLES AND PRACTICE  OF SURGERY.
ment retains the old name of trepan—zpt-aio, I perforate—and the operation
is  hence called trepanning.  The trephine differs  from the trepan  not so
much  in the shape of the  saw,  as in its being made to act by moving in a
continuous circular course rather than in alternate semicircles, as is the case
with the trepan.  The sawing portion of  the trephine is named the crown,
in  the middle of which  is the centre-pin,  or point to steady the saw in  its
first movements. This instrument is the one employed in the United States,
whenever it is necessary to perforate the cranium ;  but the necessity for its
use is less frequent at the present period than  it was formerly, many of the
older  surgeons having deemed it right to trephine the skull in every possible
affection of the head, whether due to  a depressed fracture or not.  As the
trephine merely cuts an  opening in the skull, the other instruments hereafter
named will be required to  elevate the bone or remove the detached portion.
   When, from a depressed fracture or effusion of blood outside the dura
mater, the brain is compressed, and the surgeon is satisfied that the removal
of  the compression will probably enable the brain to recover its functions,
he may prepare for  the  operation as hereafter directed.  In some cases of
compression of  the  brain from a depressed fracture of the skull, the line of
the fracture is  such that cutting off an  angle of the adjacent fragment by
Hey's saw, or by a chisel or gouging forceps, will make a sufficient opening
for the introduction of the elevator without resorting to the trephine.
   As  the propriety  of trephining for the relief of disorders of the head is a
point  which it  is difficult to settle,  I would offer the following  synopsis of
the symptoms which have usually been  deemed sufficient to justify the opera-
tion :—
   It is generally proper to trephine, or otherwise open the  cranium, when
marked  evidence of a depressed fracture  and of compression of the brain
is  present.   If the depressed  bone can be  distinctly felt or seen through a
wound in the scalp, and  there is yet  no evidence of compression of the brain,
the patient should  be carefully  watched, and the operation only resorted to
when the evidence of disorder from the depressed bone is  positive.
   The propriety of trephining, under  any circumstances, is, however,  a
question-on which  surgeons have long  differed,  some  trephining in  every
case of unconsciousness, and others limiting the operation to cases of marked
compression.  Without presuming to suppose that  any individual opinion
can settle  this vexed question, I only offer  the  expression of my  own expe-
rienee as favorable to the performance of the operation in all cases of com-
pression due to a depressed fracture, as well as to cases of epilepsy conse-
quent on such injuries, when the depression can  be recognized, though the
recent experience of military surgeons  is evidence  against the propriety of
the operation, as will be stated  after the description of the operation.
   Preparation  for  the  Operation.—1st.  Shave the  patient's head  around
the seat of the injury, and arrange the  instruments upon  a board or tray in
the order  in which  they are designated, or in  that in  which the operator
thinks they may be required.  2d. Place the patient so that his head  may
be readily acted on without the operator stooping too much; take care, also,
that the bed or table is not too high, as this may likewise create  difficulty'
and fatigue the surgeon in the manipulation of his instruments.
   Ordinary Operation.—If the scalp is uninjured, and an incision is required
in  order to expose the bone, it should be made by  dividing the scalp either
in  a crescentic form, as  advised by Pott and  Velpeau, or in that which is
V-shaped  or crucial -J-, as recommended by Physick, in order that the part
upon  which it  is proposed to operate may be left bare, the flaps being dis-
sected withthe pericranium, that the latter may be replaced again.  Should
a wound already exist, it may be enlarged to  the necessary extent without 
           OPERATIONS UPON THE BONES OF  THE  CRANIUM.        63

making an incision of the shape above described.   Having thus exposed the
bone, the trephine should  be taken  in the right hand, with  the centre-pin
projecting, and  held, as seen in Plate VII. Fig. 3, that the crown can be
applied either upon the edge of  the depressed bone, or sufficiently near to
permit of its being raised by the elevator, when inserted through the opening
cut by the trephine.   Then turning the hand steadily and slowly from pro-
nation to  supination, and pressing firmly upon the handle so as to cause the
saw to cut itself a track in the outer table, make a few turns ; remove the
instrument,  draw up or take  out the centre-pin,  test the  depth of the track
of the saw with a tooth-pick, and, reapplying the instrument, renew the saw-
ing until the diploe is reached. This structure, if well developed, may often be
recognized by the bloody character of the sawdust, or by the more free action
of the saw, though the absence of either is no sign that the trephine has not
entered the diploic structure of the skull, as it is sometimes but sparsely devel-
oped. After testing again  the depth of the track, saw cautiously, examining
the  state  of the furrow from time to time, until the  skull is perforated, or
nearly so, the latter being told by gently acting in the furrow with the forceps
or lever, and endeavoring to raise the piece.  When the disk is found to be
sufficiently free,  it may be either  pried  out with  the  elevator or removed
with the forceps, or it may come away  in the crown of the trephine without
any special  effort being made for its removal.  On removing the disk of bone,
the dura mater will be seen perfectly exposed, and if the case is a depressed
fracture, the operator may introduce the elevator very cautiously between
this membrane and the  cranium, and, keeping the point of  the  instrument
close to the latter, use the thumb  or the sound part of the adjoining bone as
a fulcrum, so as to elevate  the fractured portion to its proper level, taking
care to  mould it to its former convexity by pressing with the fingers  upon
the outside  of the skull.  If, on perforating the  bones, blood is found to be
effused outside of the dura mater, careful manipulation will enable the  oper-
ator to turn it out without injuring the  membrane, as this is generally de-
pressed and separated from the inner table of the skull by the effusion.  If,
however, the blood is evidently beneath the membrane, it may be question-
able whether the danger from its puncture is not greater than that which
would ensue if the effusion were left to nature.   The judgment of the sur-
geon, based upon the  urgent character of the symptoms, can alone decide
this point.  Patients have recovered when the membrane has been punctured
and  even considerably lacerated; yet no judicious operator would deem such
a result a precedent, except in cases of great emergency.
  If, in the  application of the trephine,  any of the blood-vessels of the  dura
mater are accidentally cut, the bleeding may be checked by pressure,  or by
ligature, as  was done by Dorsey, of Philadelphia, in a case in which hemor-
rhage from a wound in the  superior longitudinal sinus was so free as to de-
mand the application of a dossil  of lint^or by applying  a ligature to the
wounded  vessel, as was done in a wound of the  middle  artery of the  dura
mater, by F. Dorsey, of Maryland.*
  Hemorrhage from the same artery, which was deeply imbedded in its
channel in the bone, was also arrested  by Mutter, by plugging the vessel in
its bony canal with a small  piece of soft wood, as recommended by  Physick.
Bleeding from the integuments may be readily checked by a needle and liga-
ture, or by the latter applied  in the usual manner with the tenaculum.
  Dressing.—After the perforation has been completed, the parts should be
cleansed, the flap, including the pericranium, neatly applied over the open-
ing,  and retained in position by  a compress of lint  thoroughly saturated
* Dorsey's Surgery, by Randolph, vol. i. p. 323, 1823. 
PLATE  VII.
       A VIEW OF THE STRUCTURE OF THE HEAD AND OF THE
                     OPERATION OF TREPHINING.

  Fier. 1. A side view of a lateral section of the head, showing the relations of
tfce scalp, skull, and brain, with its blood-vessels.  1. The scalp, after the hair
has been shorn. 2. The  tendon of the occipito-frontalis muscle.  3. The divided
edge of the bone, showing the outer and inner tables, and the diploic structure.
4.  The shining  surface of the dura mater.  5, o. o.  The  superior longitudinal
sinus, extending from the cristi galli to the Torcular  Herophili.  6. The middle
artery of the dura mater, where it first  passes on to the vault of the cranium.
7.  Its anterior branch.   -  Its posterior branch.  9,  9. The lateral sin.;? of the
dura mater in its course  alone the occipital and temporal bones to empty into
the internal jugular vein.                        After Bernard and Haette.
  Fig. 2. A view of a stellated and depressed Fracture of the Cranium, showing
the point at which the perforation of a trephine should be  made,  so as to ele-
vate the  depressed portion.  1. Point of perforation of the trephine.   2.  The
depressed portion of the skull.                                   After Be'.L
  Fig. 3. A lateral view of the  operation of Trephining, as practiced on the
right parietal bone.  The patient is represented as comatose from a depressed
fracture, and lies with his head firmly supported and steadied on a hard  pillow
placed well under the neck.  The integuments over the depressed portion have
been incised and dissected back sufficiently far to expose the fracture, while the
surgeon, holding the handle of the trephine firmly  against  his palm, and with
the forefinger extended upon its shaft, is just commencing to pronate and supi-
nate his hand so as to work the crown of the instrument and cause it to  excise
a portion of the skull sufficient for the introduction of the elevator, or the evac-
uation of the clot.                                     Brawn from Xature.
  Fig. 4. View of the position of the Lenticular Knife, as employed in remov-
ing any spi.ula left on the internal tuble of the skull after  the  use of the tre-
phine.  1.  Position of the hand in using the lenth.l.ir.
                                               After  Bernard and Hu^tr
        (64) 

:l

M
v
' -i*..*?*-
nin^w  A *>V/M" 
 
OPERATIONS UPON THE  BONES  OF THE CRANIUM.        65
with tepid water, the water-dressing being applied so as to favor union, care,
however, being taken to secure the free exit of pus, should any form beneath
the integuments, and attention given to  any signs of meningeal inflammation.
In all cases the strictest diet should be  rigidly observed until the risk of in-
flammation has passed  away.   After recovery, the head  may be protected,
if the individual  is exposed to injury,  by  using a thick-crowned  hat for
several months, or until  fibrous  or osseous  matter closes the perforation in
the bone.   The popular idea of closing the opening in the  skull by a silver
plate doubtless had its origin in the application, outside the scalp, of a pro-
tecting bandage ; but a thick hat answers every purpose.
   Remarks.—The propriety or impropriety of trephining, in cases of injury
or other disorders of the head, is,  as has been previously stated, a question
which at all times has had able advocates on both sides.  That the applica-
tion of the trephine was at one period unnecessarily resorted to, cannot be
doubted, as we find that it was employed in cases of concussion of the brain,
under the idea that blood was effused at particular points of the head, merely
because the bone was discolored or seemed too vascular.  Though the result
of such practice has been to throw doubt upon the utility of  the operation,
there can be no question that evil has also ensued from the opposite extreme,
patients having been permitted to die  when the application of the trephine
might have saved them.  Judgment is therefore necessary in order to pre-
vent the  misapplication of this, as of many other useful remedies.  In some
instances, the  relief afforded by the application of the trephine has  been
very prompt, and in a case reported by Quintard, of Georgia, the elevation
of the depressed bone  gave instantaneous  relief from insensibility, loss of
power, etc.   Dudley,*  of Kentucky, has also reported  numerous cases of
prompt relief  from epileptic symptoms which  followed the removal  of a
spicula, or of a depressed bone ; and Holston, of Ohio, has likewise reported
numerous similar cases.f   Harden, of Louisville, is so well satisfied of the
advantages of trephining in most  cases that he proposes, at the close of an
account of numerous cases,J  the  following rule:  "That  in  every  clearly
ascertained fracture of the cranium  with  depression, the bones should be
elevated or removed, whether there be a scalp wound or not."  There  are,
however,  some surgeons who doubt the propriety of perforating the skull by
a trephine, preferring  other instruments.   Thus Goldsmith,  of Louisville,
objects§  to  the use of the trephine, advising,  as safer and less destructive of
the  skull, the  removal of a fragment by means of a chisel    Others, again,
prefer cutting  out a  portion  by gouge-like forceps.   Goldsmith has espe-
cially advocated  the value of preserving and replacing the pericranium.
   Statistics.—The following  table of cases, collected from various sources,
shows the number of cases  trephined  and of  those  not trephined, with the
comparative results of  each plan  of treatment, although nothing is  said of
the  peculiarities  of either set of cases, a fact which must always aid in the
decision  of the operation :—
Laurie and King.
H. H. Smith.
Lente, N. Y.
Cases.	Trephined.	Cured.	Died
77	51	11	40
Not stated	42	28	14
Not stated	45	11	34
138          50
* Transact, of Med. Society of Georgia.  Report of Committee on Surgery.
f Bibliography, p. 62.
j Western Journ. of Med. and Surg., vol. ix. p. 203, 1852.
| Louisville Med. Journ., vol. i. No. II. 1860.
 VOL.  II.—5. 
66
PRINCIPLES AND PRACTICE  OP SURGERY.
   Laurie and King also present the following:—

              Cues.      >": t :r phined.     F.er w-r-yl.        Died.
               77           -'»           1-

   Whether the latter injuries were more serion- than those reported by them
in the former statement i«  not mentioned.
   Lente,* of Xew York, who has furnished a m^t ela'ora'e account of 12S
cases of severe fractures, as presented in the Xew York Hospital, and a por-
tion of which is included in the above numbers, has arrived at the following

   Out of 12S ca^e? of fracture of  the  skull, 106 died.   This extraordinary
mortality he regards as due to the  violent character of the  accidents which
caused the fracture;  yet we notice  that in 45 of these bad cases,  about one-
fourth of those trephined recovered, and that out of the 22 recoveries, one-
half were trephined successfully.   The operation  was performed ; ;-  ? ^ 7a -
tically in ten, of which three were cured; and therapeutically in 32. of which
eight were cured.
   Id 2»  or 2»V31  percent  of all his ca^e-. both the brain and it? membranes
were lacerated.  In ten there was hernia cerebri, of which only two recovered.
In twelve cases, where the symptoms of compress:on were well marked, the
patients not being in immediate danger of death, the  pnpils were dilated in
ten, contracted in  ttco.
   In five cases of those trephined, an incision was made in the dura mater
—none of these recovered.
   Although these statistics are far from perfect, yet they tend to show that
in fractures of the skull met with in civil hospitals, and attended with svmp-
toms of  compression, the operation of trephining affords a better chance  of
recovery than leaving the case without an operation.  The different opinions
of military surgeons  has been  already given in connection with wonnds  of
the head.+
   In epilepsy, trephining has been followed  by some success, and  the  r>er-
formance of the operation in well-marked cases has sometimes been attended
with the happiest  results.   Of fourteen cases that I have collected of the oper-
ation in this complaint, all were reported cored but one.
   It may therefore be assumed, as a general rule, that  :r?pLir.inf, or the
removal of depressed portions  of bone by any instrument that will'readily
accomplish it, may be advantageous in civil "hospitals  under the following
circumstance-:—
   1st. In bad  compound  fractures, where the depression can be seen and
the :>ynjptoEis of  compression are well marked.
   2d. In simple fractures,  where the depression is p-.sitivelv felt and simi-
lar symptoms exist.                                          '
   3d. In bad compound fissures of the cranium, accompanied bv free hemor-
rhage frrni within the skull, and attended with svmptoms of cbmpre^ion
   But the necessity of  puncturing  the dura mater in anv case should alwav;
induce an unfavorable prognosis, or a verv guarded one.
   In view of the  variety of opinions, it wilHe well, in every case that  it  is
proposed to operate on, to explain to the patient's friends the series char
acter of the accident, and the fatal  tenderer  of the injury, whether operated
on or left to nature.
   III.  Trephining the Frontal Sinus.—Operation.—In  the  rare  ca<e*  in
which it m .;  be  ,-emed  necessary to  apply a trephine upon  the frontal

       * New York Med. Journ., voL viii. j. 29.          f Vol.  L p. 4S3. 
           OPERATIONS UPON  THE  BONES OF THE CRANIUM.        67

sinus, the operator should proceed precisely as in the application of the in-
strument upon the vault of the cranium, recollecting, however, that an open-
ing in the outer table of the skull, which at this point is often quite thin, is
all that is necessary.
   IV.  Puncturing  the Head for  Hydrocephalus.—An effusion  of  serum
within the ventricles of the brain, or in its membranes, being usually the
result of serious organic disease, but  little benefit can be anticipated from
an operation  that simply  looks to the removal  of the effect, instead  of the
cause, of the difficulty.   When, however, medical treatment has failed, tap-
ping the head for the removal of the fluid may be deemed worthy of trial,
as a last resort, and with a view of prolonging life,  although the post-mortem
examinations  in most instances  have  shown that the cerebral  structure was
so much  diseased as to leave but little reason to anticipate the general adop-
tion of this operation.   In the  United States, it has  been performed  by
Physick,* of Philadelphia, by Glover, of Charleston,!  by L. A. Dugas,  of
Georgia, and by  J. B.  Whitridge, of South Carolina, and  many  others.%
Dugas tapped his patient  seven  times, and drew off sixty-three ounces  of
liquid, the patient living from June 25th to October 18th. When the effect
of the heat of the summer  upon children is recollected, it will doubtless be
admitted that life  was prolonged in this case beyond what might have been
anticipated.   In the case of Whitridge, the child lived from August 31st to
October  31st ensuing.   Accounts of  cures effected by tapping are  also re-
ported as performed by James Yose, of Liverpool,§ by  Conquest,  of Eng-
land, || by \Vest,^[  though I have not been able to examine the latter paper.
In one case reported by Conquest, the number of  operations performed  on
it was five, at intervals of from two to six weeks, and the total amount with-
drawn was about  fifty-eight ounces.  Conquest also  appears to have had
marked success  in his operations, having ten patients to live out of nineteen
operated on.**   Of sixty-three cases, carefully collected  from  different
authors,  and reported by West, of England,-f"j- not more than  two  out  of
seven recovered;  six dying within four days, and only one  surviving six
months.
   Ordinary Operation.—Introduce a needle and canula, or a fine trocar, as
advised by Conquest, at the frontal suture, midway between the crista galli
and the anterior fontanel, or at any point of the  fontanel or other opening in
the head not  likely to interfere with the corpus  striatum or the sinuses, and
carry it deep enough to reach the cavity containing the fluid, as may be told
by the  want of resistance at the point of the instrument.  This will most fre-
quently be found to  be before the trocar has penetrated two inches.   Then,
after allowing the  fluid to escape through the canula slowly and cautiously,
make moderate compression upon the cranium either by the turns of a roller
or by strips of adhesive plaster  tightly applied, as advised by Blane and
others.   It may, I think, be doubted whether, as a general rule, there  is any
advantage in  compressing the skull from the commencement of the opera-
tion, as has  sometimes been done, as the distended condition of the brain
will generally  suffice to force out the liquid with  sufficient rapidity, while the
gradual evacuation, by  enabling  the skull to adapt itself to the diminished
size of its contents, will obviate the evils sometimes seen if compression  is
  * Philadelphia Medical Journal, vol. iv. p. 316.               f Ibid. p. 403.
  % Am. Journ. Med. Sciences, vol. xx. p. 536, 1837.
  j Medico-Chirurgical Transactions, vol. ix.     || Lond. Med. Gazette, March, 1838.
  *[ In  the same journal, April,  1842; as well as in the Bulletin G6n. dc Therapeu-
tique, vol. xxiii.
  ** London Medical Gazette, March, 1838.        ff Ibid. vol. ii. April, 1842. 
 0>            PRINCIPLES AND PRACTICE  OF SURGERY.

 not accurately pre-erved.  Various ob-*acles may present themselves during
 this   peration, such as the  ?udden  arrest • f the flow of the -eruru from  a
 -m.ll particle clogging the canula. '>r the hemorrhage of a vein, or faintnes-.
 or convulsions, for all which the surgeon should be prepared: thus the in-
 troduction of a probe will s  >n clear the  canula. a little time check the hem-
 orrhage, faintne--  be  obviated by lowering the head and applying ammonia
 to the nostrils, and the convulsions often cease when the e.-eape >.<i the  fluid
 is cheeked by placing  the finger over the  canula   If, however,  the operation
 is conducted as advi-ed by  Physick. of  Philadelphia, without conipre-sincr
 the head—that is. by all/.ving'the fluid  to escape sl-wly through  a small
 canula, and simply by the contraction of the natural tissues, until it ce£-es to
 flow freely—the pressure from the fluid within the brain will be - > gradually
 removed that the application of  mo ierae external pressure will more  than
compensate for i:s  disappearance. In all case- when a bandage is applied to
 a cavity containing liquid at the moment of its  being  punctured, the press-
 ure, according to the views of Physick, evacuate; the fluid so  rapidly as to
create a marked change in the relation of the parts, which is nut the  case
 when its  escape is due solely to vital coi.tractility, and. in the  case  of  a
brain which has been much  d -tended, may be quite sufficient to destroy its
function.   Compression  of  the  head during the  operation ha-, however,
been -trongly urged by Conquest, and hi- -uece-- has certainly been  very
marked.   After a sufficient amount of the liquid has been evaeuaTed—as in-
dicate i  by the  pulse—the puncture -hould be closed, the bandage applied
and kept accurately adjusted, and a proper medical treatment persevered in.
  As the subject of Paracentesis Capitis ha- recently excited s ime atten-
tion. I cite the following case as an additional illustration of the character
of these  operations:—
  Operation of Peace, of  Philadelphia. — Marked  disease  of the brain
having apparently  commenced -oon (three day-, after birth in the child of
a healthy  woman, and  the sen-e-  beii.g nearly destroyed, it wa- determined.
as the child was now seventeen mo. t:.s old. and must certainly sink under
the continued progre-s of the di-order, to attempt its relief by ps :a cntesis
capitis, which was  done as follows :—
  Operation.—A small silver canula. armed with a grooved trocar, being in-
 truauce i about one inch to the right of the longitudinal sinus, and  hah an
 inch  from the superior margin of the os fr>ntis. the trocar wa-  removed and
followed by a jet  of  limpid - r .m  which continued to  flow until about
 twenty ounces w.ere evacuated, moderate pressure being maintained upon the
 head during the operation by the hands of assistants.  After the evacuation
 of this amunt and the removal of the canula, a pledget of tirv lint was ap-
plied  to  the puncture, and  lightly secured  by a strip of adhesive \> a-t^r ;
 after which  the whole head wl.- permanently c mp-e--e 1 by  broad strips of
 plaster,  so applied  a; to envelop it completely.   So on after the operation
 the pul-e  was god. and the  child took the brea-t with aviditr, no untoward
 symptom  supervening until  the fourth day after the operation, when it be-
 came more restless, with increased heat of head, etc.. and died on the sixth
 day.   A considerable amount of serum continued to flow from the puncture
 throughout this period of six days.   A  po«t.mortem examination  -howed
 that the hemispheres of the brain had been di-t-nded into mere sacs, and  that
 the ventricle^ still  contained about four pints uf turbid -rum.  The whole
 amount  effused was calculated to have been eight pints and four ounces.
   Among other mea-ures which have  been  tried in these almost hopel  ;s
 cases, and especially in those which are  chronic, is the injection of iodine
 as -  gge-t-d by Velpeau in dh-eases of the serous cavitie- generally. Brain-
 ard,  of Chicago, when trying this method, employed a solution of iodine gr 
           OPERATIONS  UPON THE BONES OF  THE  CRANIUM.        69

 ybjth; iodide of potash gr. |th ; water  f^ss; gradually increased to iodine
 grs. xii; iodid. potas. grs. xxxvi,  and water oj ; all of which was injected,
 and with apparent benefit at the time of the report.*   But further experi-
 ence in its use  is necessary, though analogy seems to present some proba-
 bility of success.  As the operation of paracentesis has as yet presented but
 little to encourage surgeons in its  repetition, it may be well to try the effect
 of long-continued and gentle pressure  by means of bandages or  adhesive
 strips, as advised by Barnard, of England.
   V. Removal of Fungoid Tumors of the Dura Mater.—The development
 of fungoid tumors  upon the dura  mater sometimes leads to the absorption
 of both tables  of the skull,  and  the appearance of  the fungous growth
 directly beneath the integuments   From the nature of the  parts involved,
 and from the observation of the cases, many surgeons have regarded this dis-
 ease as hopeless; but as successful operations have been performed, and as
 the result of post-mortem examinations has often shown that the disease is
 frequently  limited to the dura mater,  or rather does not encroach upon the
 brain, the propriety of operating under even these dangerous circumstances
 is a question  which  the operator  must decide for himself at the  moment.
 Among the cases reported, one out of three of this apparently hopeless op-
 eration has succeeded, and the surgeon may therefore deem a repetition of it
 advisable, although his prognosis should be guarded.  In a case reported by
 J. C. Warren,  of Boston,f a lady, twenty-two years of age, in 1846 had a
 tumor on the right side of the forehead and right temple, which had shown
 itself the preceding year.   The tumor  was smooth, uniform in its appearance,
 diffused in  the surrounding parts, had no distinct boundary, was not discol-
 ored, somewhat elastic, not painful nor tender,  and never had been.   No-
 thing like a depression could be discovered in the central part.   In  1847 the
 skin became ulcerated, and a fungus about the size of an egg showed itself.
 This was of a red color, without sensation to the touch, without pain or in-
 tellectual disturbance when pressed on, bled readily, and a probe penetrated
 the  substance  of the tumor to the depth of three  inches,  yet the patient
 recovered.  The operation was performed as follows :—
   Operation of John C. Warren,  of  Boston—An incision  being  made on
 four sides of the tumor, so  as to make four flaps  of the skin,  the latter were
 separated from  the fungous mass as exactly as possible ; the soft and cere-
 brifonn matter cut  away in detached  portions, the disease traced  through
 an irregular opening in the bone to the dura mater,  and the actual cautery
 applied freely to the surface.  The hemorrhage,  which was great, was sup-
 pressed by two  or three ligatures and  the cautery, and the subsequent symp-
 toms were  of a favorable character.  The wound healed slowly, but after
 some months closed entirely; has remained well  ever since, and the patient
 has had no unpleasant feelings in her head, or any other symptoms of dis-
 ease.  As the case was witnessed by a great number of medical gentlemen,
 there can be no doubt as to the character of the  disease.
   In a previous case, in which the disease developed itself in a young man, it
 returned after removal, and caused death.
  In the case of a lady operated on in the  Massachusetts General Hospital
in 182*, the disease also returned, but  the patient did not die until two years
after the operation. J
  S. D. Gross,  of Philadelphia, has published§ the history of a case which,
in the hands of Jas.  C. Johnson, formerly of Louisville, fully illustrates the
fact that these cases frequently present examples of great tolerance of injury,
* Transact. Am. -Med. Assoc, for 1850, p. 371.           f Ibid. p. 403.
% Warren on Tumors, p. 510.        \ History of Kentucky Surgery, p. 60, 1853. 
 70            PRINCIPLES AND  PRACTICE  OF SURGERY.

 and that operations up n them are not necessarily and promptly fatal.   In
 tliis case, an old gentleman, after sufferiug excruciating pain for some time,
 was f jund to have on the top of his head a hard, firm, immovable, and indo-
 lent tumor about the size of a pigeon's ess. which increased and became
 sft and  pul-ating inducing the belief that it was aneurismal.  An operation
 being decided  on. a crucial incision three inches long denuded the tumor,
 which, on being disengaged from its attachment to the periosteum and dura
 mater, and elevated  from its bed on the skull, was found to leave the latter
 perforated to the extent of  about a quarter of  a dollar in diameter.  The
 hemorrhage, which was slight, vras arrested, and the wound dressed in the
 usual manner with adhesive strips, a compress, and bandage.   On r■.-::.  vlng
 the dressings on the eighth  day. the tumor was foand to be again springing
 up, rapidly acquired  the size of a hen's >^^^. and was pedunculated.  It was
 now excised a  second time,  but the hemorrhage  was  so profuse as to create
 apprehension.   This being checked, the tumor reappeared in another  fort-
 night, and was treatel by the advice of Dudley, by a sponge, compress, and
 adhesive  strips long enough to reach from one side of the head to the other.
 The tumor, after  being thus checked, again  sprouted, and  was treated  by
 nitrate of silver, butter of antimony, the knife, and actual cautery, with hut
 little benefit.   Eighteen months subsequent to the first operation, an empi-
 ric, by caustics, removed the entire mass, until a cavity was left in the brain
 "capable of receiving a common-sized teacup."  Many pieces of bone hav-
ing come away, the destruction of  the cranium had reached three inches in
 diamet-r.  This patient now traveled a long distance, and did not die until
nearly two years after the first notice  of the tumor, no disorder of the brain
 havi.g been indicated at any moment.  Xo post mortem was  permitted, but
 a manual examination indicated the presence of s:alactiforme exostosis, etc.
  In a case which I saw some  time since, the /■"-'-mortem examination
clearly showed that though  the tumor sprang from  the dura mater, and  bv
 pressure  on the compact matter of the skull had expanded Its fibres so as to
form a spina-ventosa like tumor, yet the under surface of the dura mater
was not depressed by the tumor, and  that the !arter might,  therefore, have
been removed  without causing any greater  injury  to the brain than that
 resulting from  the application of a trephine.
  Eemarks.—Although the character of these fungous tumors of the dura
mater has long been well known,  having been thoroughlv   described  bv
 Louis* Abernethy, and other-, all of whom entertained the opinion that thev
 originated from the dura mater, or in the bones of the cranium, vet few sur-
 geons have deemed it advi-able to  recommend an operation for their relief.
 Yelpeau. however, in an able article upon the complaint.t states tha*. in his
 opinion,  'extirpation is indicated in these cases of fungous tumors of the h  ad
 as well as in tho-e  situated elsewhere, but that they, like other form- of an-
 cer, also present contraindicati  :.s.r  From reviewing the opinion expressed
 by him. in the  article referred to. as well as from the re-ults of my own ex-
 perience, it may, I think, be as-umed  as a rule that, if the operation can  be
 thoroughly performed without excessive loss 0f blood, the chances of the re-
 turn o: the  disease and the ultimate cure of the  patient may be placed on a
 par with  the operations for cancerous developments  in other portion- of the
 body.  In four cases which  it has fallen to my lr.t to witne--. the p -^-mor-
 tem  examination of two not operated on satishled me  that the dise;.-e had
 progressed  from the  outer lamina of the dura mater toward  the seal;, lJUt
 had  not encroached on the brain.  In the other two ca-es. though the tumors

     * Memoir*- de I'Acad. de Chirurgie, tome vi. p. 301. edit. F^-i.ne, 1^37.
     j Dicuoaaaire de Meleciue, tome x. p. 532. Paris, lr.5. 
SURGICAL  ANATOMY OF THE FACE.
71
were moderately developed, no operation was deemed advisable, and the sub-
sequent result is unknown; but when last seen, one was rapidly progressing
to ulceration.  I would therefore feel disposed to attempt the removal  of
these tumors by the knife, or rather by it and the use  of caustic potash, in
such cases as would justify any one in operating for a malignant disease gen-
erally.
                          CHAPTER  II.

      DISORDERS AND OPERATIONS CONNECTED WITH  THE  FACE.

  The Face, as a region,  being composed of various sub-regions, as the
eyes, nose, and  mouth, their disorders, as well as the  operations required
for their relief, will be treated of under special heads after  a brief anatomical
description of each of the  portions concerned.
                            SECTION I.

                   SURGICAL ANATOMY OF THE FACE.

  The Face, as a surgical region, is bounded by  the  superciliary ridges
above, by the base of the inferior maxilla below, and is formed by the supe-
rior maxillary, inferior maxillary,  malar, nasal, palate, and ethmoid bones,
together with those of the vomer and  inferior turbinated.   Its  external
portion is composed of the skin, muscles, vessels, and nerves.
  The skin of the face presents nothing of direct interest to the surgeon.   Its
sebaceous follicles, especially upon the nose, are the occasional seat of tumors,
which  require  the ordinary elliptical or crucial incisions for their removal.
When  any tumor upon the face  is  so situated that its removal will leave a
wound in a very movable portion of the integuments, the use of  a stitch or
two of the interrupted metallic suture will, as a general rule, prove to be a
better means of uniting its edges than the employment of adhesive plaster.
  In all operations upon the integuments of the face, attention should be
always  given to the line of the  incision, in order that the  cicatrix may be
brought as much as possible within the folds created by the action of the
subjacent  muscles, the levatores anguli  oris,  zygomatici, and  buccinators
being those  which are chiefly interested.
  The action of the levator anguli  oris aud of the buccinator muscles should
also  be recollected in the  operations for hare-lip,  their contraction being
the main cause of the difficulty  experienced in uniting the  wound after the
operation.                                        » ,   - . ,      •      n
  The vessels  of the face are principally branches of the facial arteries and
veins, hemorrhage from which may be easily checked by compression at the
point where the  artery passes over the jaw, or by leaving the wound open to
the air for a few minutes.   Should this not suffice, then the ligature may be
employed; but it is better to avoid this if possible, as the union is more per-
fect,  and the scar less apparent  subsequently.   The nerves that  supply the
face are branches of the second branch of the fifth pair coming out at the in-
fra-orbitar foramen, or branches  of the seventh pair, or portio dura, which, 
72             PRINCIPLES AND  PRACTICE OF  SURGERY.

emerging at the stvl -mastoid foramen, are distributed to most of the mus-
cle-   The division of the main trunks of either of the-e nerves, in removing
tumor- or other operation- upon the face, is apt to cause distortion  of tne
features or loss of-en-ibility, though, in some few, ase- the sui sequent heal-
ing of the parts has restored the motion and sensation of  the portion  who-e
supplv bad been involved in the operation.   But. in nearly every instance, as
auv deep incision mu-t cece-sarily divide some portions of the nerves  of the
part, the surgeon can  do  little more than bear in mind the  importance of
avoiding them, if possible, or at least of not ex i-ing  their trunks if they
should be divided, as union may possibly rest re their function.
  The Face is subdivided into the regions of the eyes, n se, and mouth, the
anat mical detail- of which may be briefly referred to before mentioning the
disjrdtrs and the operations practiced for their relief.
              I 1.—Anatomy of the Appendages of the Eye.

  The Appendages of the eye consist of the lids and the lahrymal apparatus
  The lids are composed of a thin, delicate skin, in which are numerous hori-
zontal folds:  of a loo-e and very movable connective  ti-s.e. which latter is
often the seat of ency-*e I tumors ;  of a layer of circular muscular fibres, the
orbicularis palpebrarum, and on the upper lid of a vertical muscle, the Hevator
palpebral, which together create  the folds of the skin ju-t referred to: and of
two tarsal cartilages, which are thick up  n the margin of the lid-, thinner at
the di-tance of a few lines  intermediate  to the mu-cle and the conjunctiva,
and beveled on their margin so as to secure a gutter for the tears.  The car-
tilages tend to prevent the puckering of the lids, wl.ich would  otherwise en-
sue upon the  contractions of the orbicularis muscle.   The levator palpebrae
muscle is situated in the upper lid between the orbicularis and  the cartilage;
arising near the optic foramen, it is attached to the edge of the  cartilage near
its middle.  The tensor tarsi muscle of Horner ari-e- from  the posterior
superior part of the  s ungui-. j ust  in advance of the vertical suture between
the "- plannm and the os unguis.  Haviug advanced three lines, it bifurcates,
one bifurcation being inserted upon the upper lachrymal duct  and termina-
ting at is junction or near it, while the lower bifurcation ha- the same rela-
tion  to the lower lachrymal duct   The  base of the caruncula . ..   .viaaiis
is placed in the angle of the bifurcation.  Its use i- to draw the orbital
portion of  the lachrymal sac away  fr :>m  the  nasal  portion  and thus dilate
the sac *   The external tensor  mu-cle of Mostlvt is a small mu-cle that
run-  parallel to the  abducen- arising from the orbital surface of the malar
bone; anterior to it- union with the orbital face of the spheneil. it runs for-
ward, its tendon blending with the fibrous ti-ue at the outer angle of the eve-
lid.  When tense, thi- muscle dra vs the external canthus outward aud back-
ward, antag oizi.g the tensor tarsi Hor.ueri.   These  two ma«,;l^ play an
important part in seeping the cartilages applied against the  balL  Tue con-
junctiva or mucous coat of the  eyeball is the  last iaver of the lid-.  It is
reflected from the ball over  the posterior face of the lids as far as the edge of
the cartilages. ^,\ by its character as a mucous membrane favors the motion
of tne lid upon the eyeball.   Between this membrane  and the  cartilage- lie
the Meibomian glands, or the tortuous canals which open upon the  edge of
the cartilage, and lubricate  its  surface,  thus  preventing the  escape of the
tears over the lids, and  also facilitating their  ptsage along  the grooved
* Homers -mecial Anatomy, rol ii. p. 3'i-v  Phila. 1S51.
f Bost. M~d. and Sur-. Journ., vol. xlix. No. 1, p. i6, August. 1^33. 
ANATOMY OF  THE  LACHRYMAL  APPARATUS.
73
edge of the cartilages to the puncta lachrymalia or openings of the lachrymal
ducts found  in  the  cartilages  near  the internal canthus  of the eye.  The
cartilages are attached at the internal canthus by the internal palpebral liga-
ment, which is also the point of origin of the fibres of the  orbicularis palpe-
brarum muscle.  Rendering this ligament tense  by extending the lids toward
the external canthus, furnishes a guide for the point of incision in puncturing
the lachrymal sac in epiphora or fistula lachrymalis,  if the swelling is not too
great.

               § 2.—Anatomy of the Lachrymal Apparatus.

   The Lachrymal Apparatus consists of the lachrymal gland which secretes
the tears, of the puncta lachrymalia which receive  them,  and of the canals
which conduct them  into the nose.
   The lachrymal gland—Plate XI. Fig. 1—is placed immediately below and
within the external  angular process  of the frontal bone.   Its secretion is
emptied upon the eyeball by six or seven ducts which lie  between the con-
junctiva and  the cartilage of the upper lid.  It lubricates the part, facilitates
the motion of the lids, and  washes out small foreign particles, as dust, etc.,
accidentally introduced between the lid and the  ball, or upon the ball.  The
course of the tears  toward the puncta lachrymalia generally  carries such
matter to the internal canthus.
   The puncta lachrymalia,  or  openings of the canalicula lachrymalia,  are
found bordering on the internal end of the  upper and lower tarsal cartilage,
but are distinct from it.  The upper punctual looks downward, and the lower
points upward, and  each  in the ordinary condition  of the part will admit a
bristle.   The lachrymal canals or ducts are  situated  immediately beneath the
skin at the internal canthus of the eyelids, in their posterior margins and be-
hind the orbicularis  muscle.   One is found  in each eyelid,  and is about half
an inch long, the lower being rather the longer.  In each  lid the canals run
perpendicularly  at first upward and downward  from the free edge of the lid
for about two lines, after which they converge  and enter  the lachrymal  sac
behind the internal  palpebral ligament.  Stretching or elongating the lids
outwardly toward the temple  will generally remove the angular commence-
ment of the canals, and favor the passage of a fine probe into the saccus lach-
rymalis.
   The lachrymal sac—Plate XI. Fig. 1—is an oblong cylindrical cavity, or
enlargement of the ductus ad nasum,  situated in the depression of the os un-
guis aud of the upper part of the same depression found in the nasal process
of the superior maxillary bone.  It  is covered  in front by the ligamentum
palpebrale, as well as by a few  fibres of the orbicularis muscle.  The course
of the sac is  first slightly forward  and from above downward, but from the
level of  the orbit it passes  obliquely backward at an obtuse angle with its
course at first.   It decreases as it descends, and below the edge of the tendon
constitutes the lining of the bony ductus ad nasum, and is sometimes desig-
nated simply as the nasal  duct.  It is composed of two layers, an external
fibrous one, continuous with the periosteum, and an internal mucous mem-
brane which is continued from the puncta or even the conjunctiva, into the
Schueiderian membrane.  On a line with the floor of the orbit there is a doub-
ling or valve formed in the  membrane, and occasionally there  is another at
the nasal orifice formed by the Schneiderian membrane.
   The position of these folds is certainly an objection to the introduction of
sounds,  from  the  nostril, into  the ductus  ad  nasum,  as  recommended by
Laforest.   The length of the duct varies in different subjects,  being on an
average fifteen lines,  and its  inferior orifice is pretty regularly found beueath 
PLATE  VIII.
                        EYE   INSTRUMENTS.

   Fig. 1. Desmarres's Bifurcated Forceps, for holding the skin during the pas-
 sage of a suture.                                 After Bernard and Huette.
   Fig. 2. Charriere's modification of Adams's Forceps.
                                                Aft-.r Bernard and Huetie.
   Fig. 3. Desmarres's Forceps, for holding the upper eyelid during the removal
 of little en.ysted tumors.                         After B-:-nard and Huette.
  Fig. 4.  Charriere's Rat-tooth Forceps.              "      '•
  Fig. 5.  Charriere's Curved-pointed Forceps.
  Fig. 6. Physick's Forceps, for perforating the iris in the formation of an arti-
 ficial pupil—one end is a flattened  plate and the other a punch, the iris being
 cut by closing the blades.                              From tne instrument.
  Fig. 7.  Fine-teethed Forceps, for pterygium.     After Bernard and Baette.
  Fig. S.  .-Self-acting Speculum  of Buschenberger and Goddard; the lower bar
 moves  on the shaft, and is capable of resisting the contraction of  the lids.
 With this instrument no assistant is necessary.                Ko'.bi's patten,.
  Fig. 9.  A Silver Spring Spe.uluni.                            '•
  Fig.  10. Anel's Syringe.                                      *■       '■
  Figs. 11, 12. Anel's  Points,  adapted to  the  syringe,  when injecting the
 puncta lachrymalia.                                         Kolbe's pattern.
  Figs. 13. 14. Front  and side view  of Ware's style fur fistula lachryma lis
                                                           K:lWs:-i^rn.
  Figs. 15. lo, IT. 1-. 19, 20.  Fine  Eye Scissors,  of  different shapes,  both
 st: ,.::bt and prob3 pointed, and adapted to the operations of ptervoinm. strabis-
 mus, siittihg up the puncta lachrymalia. etc.                  Kolbe's pattern.
  Fig. 21. A modification of Anels  Probe, for dilatiug the puncta in eases  of
 e? iphora.                                                  jr-n-     **
 -  l                                                        r^uioc > pattern.
  Fig.  22. One form of the knife sometimes used  to ineise  the conjunctiva in
 ptervgium and strabismus.                                   jr.n--     ,.
 r   •c                                                     KAbcspa Her n.
  Fig.  23. Hook of Hays, of Philadelphia. i„r seizing the muscle in the opera-
tion for strabismus.  The curve is adapted to  the convexity of the baU.
                                                           -fi7i/.''.t's pattern.
  Fig.  24. The Elevator of Comperat, for sustuiair.g the npr-r lid in .T,-ra-
tions for cataract.                                Aft„ Bernard awJ g]'^ 
YW
4
I
1
Fio. 11.
&
^i
Pig,. tu
<s
Fip

Fig. 23.
Fit,.
_)
z*L
libnari ii Ssns
8245 
 
FOREIGN  BODIES  IN THE EYE.
75
the inferior turbinated  bone about five lines from  its anterior extremity—
Plate XI. Figs. 1,  2—about seven lines from the bony orifice of the ante-
rior nares, and about eight lines from the posterior inferior corner of the ori-
fice of the nostril in the recent subject.
                             SECTIOX II.

              DISORDERS OF THE APPENDAGES OF  THE EYE.

                        § 1.—Blows upon the Eye.

   Blows  upon the orbit of  the  eye  produce generally more or less ecchy-
mosis and discoloration of the tissues all  round it, in  consequence of the
rupture of small vessels beneath  the skin, the violence of the blow  being
pretty well  indicated by the extent of the discoloration.  The ecchymosis
thus created is the "black eye" of popular language.
   Treatment.—Contusions of this part are to be treated:  1. By such
means as  are calculated to check the effusion of blood into the subcutaneous
areolar tissue.   2.  By such as will lead  to the absorption of  that already
effused.   In order to attain the first object, nothing is better than cold and
moderate pressure, articles of a stimulating character, such  as  the tincture
of arnica, or other stimulating tincture being resorted to after a few  days,
in order to promote the absorption of the effused  blood.   But when  these
articles are  employed, the evaporation of the alcohol, and  the  friction con-
nected with their application, is doubtless an aid to absorption.   The  prac-
tice of painting the injured part flesh color, with water-colors, which is some-
times resorted to, to  conceal the  lividity, retards absorption, and, while  it
improves the appearance of the patient for a time, postpones the period of
his cure.

                     \ 2.—Foreign Bodies in the Eye.

   Foreign bodies of various kinds may lodge between the lids and the ball,
or be driven into the eye itself, and in either case should be removed as soon
as possible,  in order to  keep down inflammatory action.
   Treatment.—The  treatment depends upon the character of the foreign
body, and the position  which it has assumed.  Thus, if caustic substances,
such as lime, have been introduced between the eyeball and the  lids, bland
injections, as those of olive oil, mucilage, etc., should be immediately em-
ployed, with an eye-syringe, to counteract their corrosive effect, while others,
as a locomotive cinder,  or a piece of metal,  should be directly acted on.
   When the foreign body has passed back into the folds of the conjunctiva,
and cannot be readily seen by opening the lids, the latter should be everted,
as may be readily accomplished by pressing a probe or the end of a pencil
upon the lid, while, with the other hand, traction is made upon  the tarsal
cartilage.  The eversion being accomplished, the eye can be fully examined
for the foreign body,  the latter being generally readily discoverable, when  it
may be wiped out with  the  end  of a handkerchief, or with a camel's-hair
pencil.   If numerous particles, as sand,  etc.,  are attached to the surface of
the lid, washing of the  part with a syringe, and the subsequent application
of mucilage, may be demanded.   It sometimes happens that, owing to the
force of its  propulsion, a foreign  body is driven into  the  structure of the
eye, as into the conjunctiva, or through the conjunctiva into the sclerotic
coat; or it may be imbedded in the structure of the  cornea itself.  Turners 
7 '.             PRINCIPLES AND PRACTICE  OF  5' P.  ERY.

who work in m-tals are exeeedinglv liable  t ■  these accident- ^..1 pieces
of vteel or other   -al being  hrown off bvth- revolnnms of the lathe, ai'l.
striking upon the eve, pr-n-,trat:n? it  more or le- deeply.   In sucha case,
if the fragmetr has'been driven quit-  through the coats into t:   ball of the
eve  it i-  -nerallv useless t, attempt  ;■■:• remove it. a-  an at-  -- wnl form,
and it will be thrown off when that  opens, a process which involve? the de-
struction of the eve. and the c n-equent 1  -- of s ght.
  If the fragment, however, is simply imbedded  in  he -  ler et? coat. or in
the  lamina? of the  rnea, it may generally be removed by being drawn out
with the point of a curved cataract  needle—any  little particle which is  not
removed in this manner being left to be thrown off by the ordinary processes
of -u'puration and uleeration.
  If the foreign  :>dv is driven into  the substance of the cornea,  and cannot
be extracted except by incising the corneal layers, it is best to wait ur.'il the
fragment is loosened by the ulcerative process,  particular attention beinj paid
to the treatment of the ulcer, lest it result in the production of corneal  pa-
citv.  The inrlanimation arisihg from  these in tirie- should be combat- i  by
cold mneihighajus applications to the ball, as directed for conjunctivitis.
                      \ 3.—Wonnd- of the Eyelids.

  Injuries of various kinds, as well as surgical operations s metimrS lead to
the production of Wounds of the Eyelids, the Treatment of whi ?h requites the
use -f sutures and the observance of the general principle- de bribed in con-
nection with wounds.   The sntures in  these woun us should get:era! y be of
fine lead thread, and removed about forty-eight hours after their introdu-rton.
0:. account of the  l.«ose nature of the connective t:—  e  of the pa-', these
wounds are liable to cause ecchym -:- from  the infiltration <"f  the blood be-
neath the -kin. a result which should be explained to the patient at the com-
merce mut of  the treatment
                      | 4.—Tnmors of the Eyelil-.

  Several of the tumors sren in other portions of the body are - tmetfutes
fonnd developed in the eyelids.   Most frequently they are a yariety of the
encysted tumor, which is seated in  the areolar tissue, and readily rem  ved
eith-r by irci-ion of the cyst and the introduction of a sharp-poirred pencil
of nitrate of silver, so as X > create a si >ugh of the sac:  or by incising the
integuments and sac. and drawing the latt-r out with fine forcer---: or r:.ev
may be ii-sected out,  if care is  taken  to avoid cutting an opening/ entirelv
through  the lids, a- this is  apt  to prove difficult to  heal, from the con-tan:
escape <>f  e ;rs through the wound.   An important rule  in removing these
tumors by the knife is  to make the incision parallel to the course of the fibres
of the orbicularis muscle, either through the skin from without inward, or
from the in-ide of the  conjunctiva to the skin, according to the depth of the
tumor.   Usually, the  tumor is removed from that side on which it seems to
be most superficial, though  the  incision through the conjunctiva is least apt
to p-oduee a scar.
  I>e-marres. of Pars, employs a pair of forceps with  broad  ends, with a
fenrs-ruu in one of the Wales. Plate VIII. Fig.  3. well  calculated t.. sun-
port the lid. and at the same time circumscribe  the tumor; and when the
surgeon cannot obtain proper assistants, these forceps will prove most  •. .;u.
able.   Generally, however,  this operation  is too simple to require anvti.ihjj 
HORDEOLUM.—OPHTHALMIA  TARSI.                I t
more than to close the lid  if the external incision is practiced, or its ever-
sion if the tumor is to be excised through the conjunctiva.  Then the tumor,
being seized with fine and small forceps, or a tenaculum, may be readily  dis-
sected out.  The operation of Desmarres, as well as that by eversion of the
lid and incision of the conjunctiva, is shown in Plate IX. Figs. 1, 2.
  Vascular tumors of the lids are occasionally noticed, but unless of unusual
size  may be treated like the encysted class, by the means just detailed.   In
large aneurisms by anastomosis, or those of such size as to promise  free
hemorrhage, the production of inflammation in the tumor by the introduc-
tion of  a seton through it, as practiced by Lawrence, will generally answer
a better  purpose.

                            \ o.—Hordeolum.

  The Hordeolum, or Stye is  a little inflammatory swelling of the size of
a grain of barley—whence the name—which is often quite painful, and gene-
rally due to inflammation either in  the areolar tissue of the lids, or in one or
more of  the Meibomian glands, the inflammation causing the obstruction of
the duct and the accumulation  of its secretion, from the distention of which
an abscess follows; or there may be simply the creation of a phlegmon of the
lid.  This affection may be confounded with a condition which  is, in fact, a
true abscess, and the result of inflammation of the areolar tissue between the
fibres of the orbicularis palpebrarum and the skin, which runs the course of
abscess  elsewhere, and is far from being as painful as the true hordeolum.
  Treatment.—In either case the treatment is precisely that which is adapted
to any ordinary abscess, warmth and moisture being applied either by means
of  poultices or the warm water-dressing, or something more  stimulating, as
the  alum curd.  As soon as the formation  of pus  is observed,  it should be
 evacuated by means of a cataract needle, or some similar instrument.
   The popular plan of treating styes, by extracting one or two of the cilia,
is only  successful when the bulbs of  these hairs are so  situated that their
withdrawal ruptures the abscess and evacuates its contents.
   The chronic induration  and  thickening  of the edges of the  lids which is
left after a stye, or after a succession of styes, should be treated by means
calculated to produce  absorption  of the fibrin, to which  the  induration is
due; such means are to be found  in  frictions with mild mercurial ointment,
or with  red precipitate, or iodine  ointment, etc., or in painting the edge of
the  lid  with a camel's-hair pencil moistened  with  a solution  of nitrate of
silver, grs. v to the ounce of distilled water.
                        \ 6.—Ophthalmia Tarsi.

  Ophthalmia Tarsi or Psorophthalmia is a complaint of an  inflamma-
tory character that involves the Meibomian glands, the secretions of which
are in consequence disordered so that the  eyelids  are glued together during
sleep.   This affection is common  among  the strumous children of asylums
and hospitals,  with whom it assumes a chronic character, and is exceedingly
obstinate, resulting in destruction  of the bulbs of the eyelashes, loss of the
cilia, aud a thickening of the conjunctiva of the lid, the latter being often
more or  less everted, so as to present the peculiar raw appearance of the
edges of the lid which has been denominated " blear eye."
  Treatment.—In its acute form this affection  is to be treated by the anti-
phlogistic measures adapted to inflammation elsewhere;  but when it becomes
chronic, greater advantage will be obtained from improving the patient's gene- 
 i "^             PRINCIPLES  AND PRACTICE  OF SURGERY.

 ral health by the use of tonics, chalybeates. etc., as well as by stimulating local
 applications, than from the use of depletory measures.  In the case of serotinous
 children, much benefit will also be derived from the continued administration
 of cod-liver oil. and from such  general  means as are adapted to the  treat-
 ment of the tuberculous cachexia.
   The  local treatment is to  be  conducted upon those general principles
 which regalite the treatment of  vitiated  s-cretin and ulceration  in  other
 structures.   The use of astringent ointments will often prove highly advan-
 tageous, such as that of the precipitated carbonate of zinc, which may be
 smeared upon the edges of the !i us.   Ointments  of an  alterative character,
 calculated to act  upon the diseased Meibomian glands, are also  exceedingly
 useful, and of these the  best :s probably the citrine ointment—Unguentum
 Hvdrargyri Xitratis of the  Pharmacopoeia—which may be applied to  the
 edges of the  closed lids  either pure or  diluted with varied proportions 0f
 simple cerate, according to the acuteness of the disorder.   It should be  ap-
 plied, by means of a camel's-hair pencil, the last  thing before retirng at
 night: the  patient immediately closing his eyes and not  opening  them again,
 if po-sible, till he falls asleep.  Upon rising in the morning the  eyes should
 be washed  in warm water, not in cold, as the latter, by the reaction which
follows  its  use, gives rise to increased vascular action.
  Sometimes ophthalmia tarsi results in  the production of  such changes of
structure as require local applications to  modify more completely the action
 of the part, lest  destruction of the  mucous membrane, eversion of the  lid,
and other unpleasant consequences result.  In this case, nothing better can
be recommended than light cauterization of the edges  of the lids with  the
nitrate  of silver, in substance, or in a solution ten grains  to the ounce of
 water.

                            \ 7.—Trichia«i*.

  Trichiasis—~p'/'<.  a hair—is the name given to a complaint  which  con-
sists in the in-growing or misdirection of the eyelashes.   As normally placed,
the eyelashes of the upper lid are convex downward, and those of the lower
lid convex  upward, so that when they meet, dust is effectually excluded from
the eyes, and yet there is no danger of the hair- coming in contact  with  the
delicate conjunctival surface.   Sometimes, however, as  a result of disease.
whether such as elongates the lid, or only affects  the bulbs of the cilise,  the
eyelashes are brought against  the bab, producing much  irritation,' and
resulting finally, if unrelieved, in inflammation  of a troublesome character.
  Treatment.—The treatment may be palliative or radical   The palliative
treatment consists in the extraction  of the ciliae bv means of cilise f -ee-.s
and, if the  extraction is performed carefully, the relief will be complete  :or
the time.   Generally, however, a new growth of ciliae reproduces the disease
and it may then become necessary to resort to  some radical mode  of  core
If the disease is produced by inversion of the  lids  or  entropion it will  be
relieved by the operation appropriate to that condition ; but if due  to a dis-
order of the bulbs of the ciliae,  the only method upon which the -'io-hte<t
reliance can be placed is cauterization of a sufficientlv active character to
destroy the bulbs completely.
  Disticbiasis—-■:?, double, and c-.-zo-, a row—designates the existence of a
double row of eyelashes, one of which grows inward.  The treatment of the
 second, or  inner row, is similar to that just mentioned as demanded bv Tri
chiasis,  the employment of a magnifying glass being often useful in detect
the positions of some of the lashes.                                   "   c 
ENCANTHUS.—SYMBLEPHARON.                  79
                            g 8.—Encanthns.

  This complaint—named from its position, ev, in, xavftoq, the angle of the
eye—consists  in an enlargement or degeneration of the caruncula lachry-
malis.   When requisite, the tumor may be removed by seizing it with a tena-
culum  or forceps, and excising it with fine-curved
scissors,  or with a small  scalpel, taking care not to
remove the conjunctiva, so that the cicatrix shall
hold the ball to the inner canthus.
               § 9 —Epicanthus.

  Epicanthus—;-r, upon, xavftoc, the angle of the
eye—consists in the formation of a fold in the skin
at the root of the nose, in consequence of which the
internal canthus is,  in a measure, concealed. It is a
rare complaint, and occasionally requires an operation in  order to  enable
the patient fully to expand the lids.  The operation of Von Ammon, of
Dresden, consists in pinching up a longitudinal fold of the skin, excising it
at the root of  the nose  of a sufficient width to efface the epicanthus, either
with the knife  or scissors, and then uniting the elliptical wound thus made
by a hare-lip suture, Plate IX. Fig. 11.
                        \ 10.—Ankyloblepharon.

  Ankyloblepharon—ayxuXrh contraction, fiXzyapw, the eyelid—is a disorder
so named from the preternatural adhesion to each other of the free margins
of the lids.  It is generally the result of the inflammation produced by burns,
caustics, etc.  The  union of the edges of the lids may be either partial or
total, and is usually found at the external canthus, where, if partial, as is
often the case, a director may be passed  between the  lids and the eyeball,
and  the  adhesions divided either  by a probe-pointed  bistoury or by  probe-
pointed scissors.  If they are more extensive, and the  eye is entirely  closed,
the lid may be raised in  a vertical fold, and a small opening made through it
at the external canthus, in order to permit the introduction of the director;
when the operator, after satisfying himself that the lids do not adhere to the
ball__symblepharou—may pass a bistoury along the director, and divide the
adhesions at the edges of the cartilages.
   After the operation, care must be taken to prevent the reproduction of the
complaint, by anointing the wounds thus made with some mild cerate, or by
lightly cauterizing their edges with the nitrate of silver; or by separation of
the lids  by  adhesive  plaster, by collyria, or by liniments;  or by uniting the
conjunctiva  to the skin  at the external canthus, by a fine silver suture.  But
great difficulty may  be  expected, and a partial failure  is not uncommon.
                          § 11—Symblepharon.

  Symblepharon—<ruv, with, and ftXscpapw, an eyelid—is an adhesion of the
conjunctival surface of the lids to  the ball of the eye, in which the cornea par-
ticipates, and is generally the consequence of violent inflammation resulting
from the'introduction into the eye of caustic or other irritating substances, as
Fig. 382.
A front view of an Encauthus of
      some size. 
PLATE   IX.
                   OrERATK'N-S  UPON THE EYELIDS.
  Fig. 1. Extirpation of an encysted tumor from the upper lid by an inc.s on
on its external face.  1. The incision over the tumor.   2. Desmarre's ring for-
ceps.                                           After Bernard and H-r,e.
  Fi°\ 2. Extirpation  of an encysted tumor  in the lower  lid. by an incusion
throujh its mucous membrane.  1.  Desmarre's bifurcated forceps holding the
lid. as everted over 2. the handle of a cataract needle.   3. Fine forceps raising
the tumor.  4. Its dissection by the straight bistoury in the line of the fibres of
the •>:!ocularis muscle.                           After Bernard and II   h.
  Fig. 3. The ordinary operation for ptosis.  1. A pair of forceps pinching up
the necessary amount of the skin of the upper lid.   2.  The horizontal fold thus
raised.   3.  The scissors excising the raised portion, close to the  grasp of the
forceps.                                        After Bernard and Huette.
  Fig. 4. The shape of the wound,  1. 2. 3, left after the removal of the  skin on
the eyebrow—in Hunt's operation for ptosis.       After Bernard and Hnerte.
  Fig. 5. The wound united by fine hare-hp sutures, and its effects in elevating
the lid.                                         After Bernard and Huette.
  Fig. 6. "Weber's operation for ectropion of the  lower lid by excision of the
middle of the tarsus cartilage.                   After Bourgery and Jacob.
  Fig.  7. Yon Amnion's operation for  syinblepharon.  The portion of the Ud
which is adherent to the ball has been included in the base of a V incision. 1 3.
2 3, which, starting at the tarsus cartilage, has been carried through the  lid.
                                               After Bernard and Huette.
  Fig.  8. The same operation completed; the edges of the incision through the
skin and muscle of the eyelid have been united by three hare-lip sutures, so as
Xv leave a triangular fold of the conjunctiva attached on the edge of the tarsus
cartilage, but otherwise free from the lid,  thus favoring its motions on the ball.
                                               After Bernard and HueUe.
   Fig. 9. Dieffenbach's operation for the cure of a triangular wound of the lower
lid. left in  removing a tumor.   1, 2. 3.  The wound.  4, 5. The flap  which  is to
be  inclined so as to close it.                      After Bernard and Huette.
   Fig. 10.  Jones s operation for blepharoplasty. or the formation of a new lid
by sliding up a flap from the cheek. The operation is represented as completed.
1, 2, 3.  The triangular  flap  raised from  the  cheek, and fitted into the Ud by
various points of the suture.  3, 4.  Closure of the wound left by the removal of
the flap from the cheek.                          After Bernard and Huett*.
   Fig.ll.  Yon Amnions operation for epicanthus.  1,2.3. The elliptic! wound
 resulting from  the removal of  a fold of the skin at the root  of  the nose.
                                                After Bernard and  Huette.
        (SO) 
:r**.

''"imtW''**

-XX
hs;Sv., 
 
PTOSIS.
81
a drop of oil of vitriol, or a particle of lime, or red-hot iron.  Division of the
adherent points by probe-pointed pterygium scissors—Plate YIII. Figs. 16,
1T> 18—or, if slight, their laceration by a pin  or cutting instrument  passed
between the lids and the ball, as  practiced by Amussat,  will generally over-
come the complaint.  Or a double thread may be passed through the adhe-
sion, and one end  tied close  to the  sclerotica with great firmness, and  the
other toward the lid less tightly, as  proposed  by Petrequin ; but care must
be exercised to guard against the reproduction of the band.
   As it has been found very difficult to prevent the renewal of the adhesions,
the ingenious operation  of  Yon Amnion may be resorted to,  Plate IX.
Fig. 7.   Circumscribe, by two incisions—1, 2, and 2, 3—through the whole
thickness of the lid, that  portion which  is adherent to the eyeball, and  the
triangular  flap thus separated from the remainder of the lids will follow the
eye in all its motions.   Then, by two  or three small  pins and the  twisted
suture, unite the edges of the wound, so as to leave  the triangular flap—
Plate IX.  Fig. 8—inside, and adherent  to the eyeball, until the wound  has
fully cicatrized, when the  flap may  be dissected from the ball without  any
risk of the production of new adhesions.*
                              § 12.—ptosis.

  Ptosis — —<MrT!c, a falling — signifies either a total or partial  inability to
raise the upper lid, and may result either from a congenital excess of integu-
ment, or from want of power in the  levator palpebrae muscle, or from spasm
of the orbicularis palpebrarum, in consequence of  which the lid droops upon
the eyeball.  When dependent on paralysis of  the levator palpebrae muscle,
or the nerve of the third pair supplying it, Garratt, of Boston,f recommends
the application of Faradian electrical currents, a remedy well worthy of trial;
one of the electrodes being applied to the external canthus, and the other
to the middle of the orbital ridge, the current being at first lightly  applied.
When this, or such other remedial  measures as are adapted  to the disorder
causing the falling of the lid, as blisters, strychnia, etc.,  have failed in afford-
ing relief,  an operation  may become necessary, in order  to  accomplish the
mechanical elevation of the lid and open the eye sufficiently for the purposes
of vision.
  Operation.—To accomplish  this in the ordinary method, raise a transverse
fold of the upper  lid in a pair of forceps, and either with  the scalpel or scis-
sors—Plate  IX.  Fig.  3—cut  off the portion thus raised, so as to leave  an
elliptical wound, which should  not, however, include the conjunctiva, uniting
the edges  of the  incision by two or  three fine stitches of the interrupted
suture.   A very important  point in  the result of the operation  is the correct
calculation of the  amount of integument to be included  in the fold seized by
the forceps;  if too much is raised, the patient may subsequently suffer from
ectropion,  or be  unable  to close the  lid; and  if too little, it may become
necessary to repeat the operation.
  In  the operation of Hunt,  of Manchester—Plate IX. Fig. 4—the eye-
brow is first shaved clean above the point at which a semi-elliptical piece is
to be excised, the extent of the flap being calculated according to the amount
of the  relaxed  portion of the lid.    This  flap may be  circumscribed  by an
elliptical incision of the lid  and eyebrow,  I, 2, 3, the lower half being made
first, and the upper dissected until it exposes the lower fibres of the musculus
frontalis.   Then,  on  uniting  the  wound  by three stitches  of the twisted
 * Bernard and Huette, p. 115.            f Electro-Physiology, p. 643.
VOL. II.—6 
82
PRINCIPLES AND  PRACTICE  OF SURGERY.
suture, the cicatrix will form in  the eyebrow, and be subsequently concealed
by the hair, Plate IX. Fig. 5.   The adhesion thus formed between the lid
and the frontal muscle will enable the patient to elevate the lid by the con-
traction of the muscular fibres just referred to.

                         \ 13.—Lagophthalmu*.

  Lagophthalmus—Aayoc, a hare, and o<pOaXp.oc, an eye—or hare eye is the
name given to a complaint due to a loss of power in the orbicularis palpe-
brarum muscle, in consequence of paralysis of the portio dura, which then
leaves the eyeball  uncovered and exposed to  particles of dust,  etc., thus
inducing inflammation, as the eye remains uncovered both day and night.
  Treatment.—As  this condition  is due to a local paralysis, created often
by injury or local disorder, as paralysis from cold, etc.,  the application of a
small blister over the eye or temple, and below the ear, and dressing the raw
surface with  strychnia  applied as a powder, diluted with powdered gum-
arabic, or in the  form  of ointment, may prove useful.  The galvanic current
passed through the muscle is also highly useful.

                         g  14.—Blepharoplasty.

  The formation of a new eyelid at the expense of some portion of the
adjacent integuments  is termed  Blepharoplasty—{iktifapw, the eyelid, and
T.Xaarixoq, forming or formative—and may be required for the relief of cica-
trices from burns, or for the loss of the substance of the lid resulting from
the removal of large tumors, or in order to remedy an  error consequent on
an  extreme  miscalculation of the  portion of  integument removed in the
operation for Ptosis just described, or for the cure of Ectropion.   Under
any of these circumstances, the ordinary rules for plastic operations* must
be borne in mind, especially the necessity  of making an apparently exces-
sive flap at first, in order to counteract the contraction which is so apt to
follow all plastic operations, and in a very marked degree those  performed
to remedy the defects  of cicatrices.  As the different methods of operating
in plastic surgery will be  described subsequently, the  account at present
may be limited to the operations usually resorted to in  the formation of the
eyelids.
   Operation of Wharton Jones, of'England, or the formation of a flap by
stretching  the integuments, Plate IX. Fig. 10.  After having  pared the
edges of that portion of the lid which is  to be renewed, so as to obtain a
fresh surface, two incisions in a V—1,  4, and 2, 4—are  to be made near the
wound, as upon the forehead, if in  case of the upper lid, or upon the malar
or superior maxillary bone, if for the lower; the top  of the V-flap, thus
formed, being intended for adhesion to the lower portion of the lid.   After
thus circumscribing the flap, it should then be dissected from the base of
the triangle 1, 2, to near the summit 4, and, when freed from the subjacent
structure, excepting at  its summit, it should be gently drawn upon until it
fills in the desired space, when it may be  retained  in  its new position  by
several stitches of the interrupted suture.  The gap left in the portion from
which it  has been drawn  may then be closed by  approximating the edges
and uniting them with the hare-lip suture.  The figure represents the flap
1, 2, 3 in its new position, and the union of the sides of the gap 3, 4 by the
hare-lip suture, which thus converts a wound of some size into a mere line.
* See Operations on the Nose. 
ECTROPIUM.
83
   The reader will readily see, by reference to the figure, that  the wound at
3 was of the width of 1, 2, previous to its elevation.
   In the operation performed by Dieffenbach, or the formation of a flap
by sliding  the adjoining skin,  a sufficiently triangular flap, 3, 4, 5, Plate
IX.  Fig. 9, was raised so as to  fill the gap or wound  1, 2, 3, allowing, as
before stated, for subsequent  contraction, which may usually  be calculated
at about one-third of the whole flap.   This being dissected free from its
attachments, with the exception of its pedicle  3, 5, was afterward slipped
into the wound 1, 2, 3.  The other gap,  3, 4,  5, from which  the  flap had
been formed, was then left to cicatrize  as a simple ulcer.
   In the German operations of  Graefe  and Fricke, which are  modifications
of the ancient twisting of the  flap as  practiced in India, the cicatrix, or
diseased portion, was removed so as to leave a fresh surface, 1, 2, 3, 4, Plate
X. Fig. 1.   Then  a properly shaped flap, 3, 5, 6, of  good dimensions, and
at least one-third larger than the wound, was dissected  from  the  adjoining
sound skin, and twisted at 3, so  as to  adapt itself to its  position.  Being
subsequently attached by the interrupted suture to the surrounding portion
of the lid, the space caused by its removal was closed by the hare-lip suture,
as in 2, 3,  Plate X. Fig. 2.


                            \ 15.—Ectropium.

   Eversion of the  Eyelids,  or Ectropium — exrpe-w, to turn out—may
result either from adhesion  of the external  surface of the lids to the sur-
rounding integuments;  from a diseased condition  of the conjunctiva, or of
the tarsus cartilage; or from irregular action or want of power in  the orbi-
cularis muscle.

                 Fig. 383.
Fig. 383.—Ectropium of the Upper Lid, showing the amount   Fig. 384.—Ectropium of the Lower Lid, the
   of palpebral conjunctiva exposed to the atmosphere.           result of a cicatrix in the cheek.

   In the milder cases of the disease, or those resulting from a hypertro-
phied  condition  of the conjunctiva, much  may  be accomplished  by  free
leeching, astringent collyria, or cauterization  of the conjunctiva  in lines
parallef to the fibres of the orbicularis, which, though forming a linear cica-
trix, is yet buried in the  surrounding folds, and causes little irritation; or
by the excision of a fold in the same direction, by raising it with the simple
forceps, and  removing it with fine  scissors.  But in more  obstinate cases,
blepharoplasty, or the formation of a new lid, must be resorted to, in order
to enable the tarsus cartilage to apply itself properly to the ball.   In these,
as in all plastic operations, I repeat that it  is important to avoid  making
the flap too small, as its contraction will continue for weeks subsequently;
double the amount apparently required being  often  barely sufficient, after
its adhesion in its new position.
Fig. 384
^Tr/fltffffl 
84
PRINCIPLES AND  PRACTICE OF  SURGERY.
  Blepharoplastic  Operation for Ectropium.—The following operations
are a few of those of an original character that have been  employed in the
United  States :—
  Operation of Horner, of Philadelphia.—Make  an  incision two inches
long down  to the boue parallel with, and at the inferior margin of the orbi-
cularis muscle—Plate X. Fig. 8, 1, 2—dissecting up the whole thickness of
the lid from the adjoining bones; then make another incision, 3, 4, an  inch
long, from  about  the middle of the first, downward, toward the angle of the
jaw.  From the termination of this, direct another, 4,  5, toward  the  point
of the nose, so that the last two incisions shall define  an  angle of integu-
ments, 6, which, being dissected up as far as its base,  is to be turned into
the beginning of the first incision.
  The angle 6. or that  taken from the cheek, being now inserted into the
lower eyelid, Plate X. Fig. 9, and the  angle 3 drawn to  fill up  the  gap,
pins should be  fixed  so  as to keep  the  parts in place.  An almost imme-
diate correction of the deformity ensues, and ordinary dressings will be found
sufficient to accomplish the cure.
  Brainard, of Chicago, in a very bad case of ectropium of the left eye,
resulting from a burn, modified  Fricke's operation as follows:—
  Operation.—The eyelid being first dissected  up  so  as to place it in its
natural position,  a wound an inch  and a half long by  three-quarters of an
inch  broad was  left beneath the lid.  To  fill this, a  flap was taken  from
behind  the external angle of the eye, of a corresponding  form, but some-
what larger, in  order to allow of contraction, Plate  IX. Fig.  10.   This
flap, being  turned upon its  base, was then brought into the  wound left by
dissecting up the lid,  and retained there  by numerous  points of  the inter-
rupted suture;  the wound created by the removal  of the flap being subse-
quently closed by adhesive  plaster and simple dressings.  In two weeks the
patient  returned home relieved of the deformity.
  In the operation proposed by Sir Wm. Adams in 1812,  Plate X Fig. 3,
which is especially adapted to cases in which  the  tarsus cartilage is much
elongated, the edge of the lid was seized with forceps, and a V-shaped piece
of sufficient width at its base to  restore the position of the  lid—in some in-
stances equal to four lines—removed with the scissors.  The wound, being
then  united by one or two fine pins and  the twisted suture, soou cicatrized.
  Dieffenbach proposed  to diminish  the  conjunctiva in order to restore the
lid  to its proper position.   To accomplish  this, he cut  transversely  through
the skin on the  outside of  the lid, as at  1, 2, Plate X.  Fig. 4, and  through
all  the thickness of the other tissues  until he reached the conjunctiva, when,
seizing this membrane with the forceps as at 3, he drew a fold of it out through
the  incision in the integuments, and excised  it with fine  scissors.  Then,
uniting the conjunctiva and the  edges of  the wound by a few stitches of the
interrupted suture, the free edge of the lid was drawn up by the process of
cicatrization.
   Desmarres, in order to avoid the cicatrix  which  arose from the operation
of Sir W. Adams, proceeded as follows:  He first made  a horizontal incision,
1, 2, through the tarsus cartilage—Plate X  Fig. 5—at the external canthus  ;
then  a second one from 3, at such  a distance from the  first  as corresponded
with the size of the piece of the cartilage to be removed, carrying this inci-
sion to  the termination of the first at 2.   Then, uniting these by two others
1, 4, and 3, 4, he  excised this portion of the lid, and, uniting the whole wound
by  the  twisted suture, Plate X.  Fig. 6, caused the cicatrix  to be concealed
in the wrinkles found at the angle  of the  eye.
   Remarks.—When Ectropium is very marked, and especially when it is the
result of cicatrization from  the  effects of burns, the plastic operations just 
ENTROPIUM.
85
referred to offer the best chances of success; but if the tissue from which the
flap is formed is  not perfectly healthy, and indeed even when  it has all its
natural characters, the operator, according to my experience, may look for
disappointment from its  subsequent contraction, unless  he is  liberal in his
calculations of the amount required to meet the subsequent contractions of
the flap.

                            \ 16.—Entropium.

  Entropium—evrpz-oj, to turn in—is the reverse of ectropium, and character-
ized by inversion of the  lids, in consequence  either of some change in the
part, as relaxation  of the integuments or contraction in the conjunctiva or
cartilages, or, as has been urged by Walton, to
over-action of a part of  the orbicularis palpebra-
rum muscle, by which the eyelashes are brought in
contact with the ball, and keep up a continual irri-
tation.  In this, as in the preceding affection, the
treatment must be regulated by the cause.  In the
early stages the  use of  astringent collyria, or of
adhesive strips to draw the lid outward, or similar
simple measures, may accomplish the  cure if  the
deformity is not very great.   The production of   a vu-w of Entropium as nffecting
a slough in the skin by the linear application of  a  ^*£?*$*'*jZ tl Z\
piece of soft wood wet with sulphuric acid, as pro-  of the eye.
posed by Quadri, and the subsequent cicatriza-
tion of the ulcer may also answer, though it leaves a  scar.   But if these
means fail,  or if the disease is obstinate, an operation consisting in excision
of the integuments will be required.
   In many instances, the excision of the lid, as  recommended in ptosis, will
be found  to answer a good purpose.
   Operations by the Excision of a part of the Lid.—Janson, of Paris,
drew the  tarsus into its proper position by raising a vertical fold of the in-
tegument with broad forceps, Plate VIII. Fig. 2,  and, after excising it with
the scissors, Plate X.  Fig. 1, united the wound by the twisted  suture, as at
4, 5, of the  same  figure.   If the excision of this one fold  is not sufficient, two
or more  may easily be added to it, until the lid is brought by the cicatrices
to its proper relations with the eyeball.
   Operation  of Dorsey, of Philadelphia.—Dorsey having, in July,  1810,
been  led to the study of this complaint, concluded  that half the eyelid might,
if requisite, be cut off without much inconvenience, as  the natural contrac-
tions of the orbicularis palpebrarum, by throwing the skin into folds, showed
that much of the lid was naturally in excess.   He therefore suggested the
following operation :—
   Operation.—Pass a hook through the edge of the eyelid, in order to gain
a secure hold of it,  and,  with a pair of sharp scissors, cut out completely all
that portiou of the lid from  which the cilia proceed.   This wound healing
readily, the patient  was  cured in a few  days by the contraction  of the lid.
   Saunders, about the  same period,  suggested  his method of operating,
which was as follows :—
   Operation.—Introduce a  thin plate  of horn  or silver, with a curvature
corresponding to that of the eyelid, and with its concavity turned toward
the globe ;  stretch the lid upon it, and  make an  incision through the integu-
ments and the orbicularis muscle immediately behind the roots of the cilia,
to the tarsus, from  the punctum to the external canthus.  Then dissecting
off the exterior surface of the tarsus until the  orbital margin is  exposed, cut 
PLATE   ;X.
   OPERATIONS FOR THE RELIEF  OF AFFECTIONS OF THE  EYELIDS.

   Fig. 1.  Blepharoplastic  operation of Graefe  on the Upper  Lid, effected by
 twisting the flap.  1, 2, 3, 4.  The elliptical wound left  in the upper lid  by the
 removal of a tumor, etc.  3,  5, 6. The incision  circumscribing a flap upon the
 skin at the external angle of  the orbit, and destined to fill up the  wound.
                                                After Bernard and Huette.

   Fig. 2.  A view of the operation as completed; the flap is retained in the lid
 by the sutures 1, 1, 1, while the space 2, 3, left  by the removal of the flap, is
 closed by a fine hare-lip suture.                   After Bernard and Huette.

   Fig. 3.  Operation  of Sir William Adams for  Ectropium.  1. The first inci-
 sion made through the lid by cutting from within to the tarsus; the edge of the
 tarsus beyond this incision is  then held by 2, the forceps, and a triangular piece
 of the lid  removed by 3, the scissors.              After Bernard and Huette.

   Fig. 4.  Dieffenbach's operation for  Ectropium.  1, 2. Longitudinal incision
 through the skin  and muscle of the lower lid;  the mucous membrane is then
 seized with 3, the forceps, and  a fold  excised with 4, the scissors ; a  suture unites
 all together  and the cicatrization of the conjunctiva in the wound inverts the
 edge of the lid.                                 After Bernard and Huette.

   Fig. 5.  Desmarres' operation for Ectropium.  1, 2. The first incision at the
 external canthus.  2, 3. The  second incision, which, commencing  at 3, termin-
 ates at 2. 1, 4, 3, 4. Two incisions, which, starting  from the terminations  of
 the first, unite at 4 on a line with the reflection of the conjunctiva from the lid
 to the ball.                                     After Bernard and Huette.

   Fig. 6.  The same operation, as completed.         "       "      "     "

   Fig. 7.  Operation  of Janson for  Entropium.   1. Adams's  forceps raising a
 fold of the skin of the lid near the internal canthus.   2. Scissors curved  on the
 flat, excising the portion thus raised.   3, 4. The same kind of incision com-
 pleted near the external canthus.                 After Bernard and Huette.

   Fig. 8.  A view of Horner's operation for Ectropium in the Right Eye, result-
 ing from a burn.  1, 2. An incision  along the edge of the lower lid to  free it
 from the cheek.   3, 4. A second incision, an inch long, from the middle of the
 first toward the angle of the jaw.  4, 5. A third incision from the termination
 of this toward the point of the nose.  3, 6. Two angular flaps formed by these
-incisions.                                                    Ayter Homer.

   Fig. 9.  The termination of  this operation.   1, 2. Lower edge of lid.   6. The
 lower angular flap raised to the edge of the lid, and fastened  at its angle by a
 pin.  3. The upper angular flap depressed to fill in the gap.     After Horner.

   Fig. 10. Brain^rd's modification of Fricke's operation for  Ectropium  in the
 Left Eye  resulting from a burn, the flap being taken from behind  the  external
 angle of the eye, and rotated upon  its base so  as to fill up the space left by
 detaching the lid from the cheek.    '                        After Brainard.
(86) 
H£.

Nfe
Fi&

v
Fig,
. ;

Fifc.4
    h:.h«;:.-i
J5JJ5!.
H£. b
>  " — '  '"'
fyfi'S/x,
' r xtX0****>*&,
'f ■$

Y\i


R|€::
ia;u«i.VSJ 
 
ENTROPIUM.
87
through the conjunctiva by the side of the tarsus, and disengage the flap at
each extremity, the only caution being to leave the punctum lachrymalis unin-
jured.   The  fungus subsequently formed in the cicatrix is either to be cau-
terized  or excised.
   When the inversion  of  the lid is due to a contraction or cicatrix in the
conjunctiva or in the cartilage, and is the result of deep ulceration, the opera-
tions of Sir P. Crampton,  Guthrie, or Tyrrell  may be employed.
   Crampton's Operation.—In this  operation, the  tarsus cartilage is to be
divided perpendicularly at each  canthus by two incisions, each about three
lines long, care being taken to avoid the punctum, after which a transverse
incision of the conjunctiva should be  made so as to unite the two vertical
cuts.   Two or three ligatures being then passed through  the skin at its tarsal
margin, the divided portion of the eyelid is to be carried up to the eyebrow,
and the ligatures fastened  to the  forehead by strips of adhesive plaster.
   Guthrie's Operation.—This is a modification of Crampton's, and is per-
formed as follows : Two perpendicular incisions, a quarter of an inch long,
having freed the tarsus cartilage from its attachments at each end, and any
vicious curvature of the cartilage being overcome by dividing it at the place
where it is bent, cut a fold of skin of the length of the  lid between the ver-
tical  cuts, and remove it  as close  as possible to its margin.  The  edges of
the wound being then  united by fine sutures, secure the lid to the forehead
as in the  preceding operation, and apply caustic frequently to the perpen-
dicular incisions, so as to cause them to heal by  granulation.
   In cases due to  contraction of  the orbicularis palpebrarum muscle, as sug-
gested by Key, in  1825, and since urged by Walton, the  following method
of operating may suffice :—
   Walton's  Operation. — An assistant  standing  behind the patient, and
making the  lid tense  by drawing it outward and forward while raising the
brow, make two incisions through the skin and muscle, one parallel  with, and
as close as possible to the roots of the ciliae, and  the  other so that it will
form  an elliptical flap of about three lines at its greatest width and termin-
ate at  each  end of the tarsal cut, thus making an oval wound.   The flap,
thus  isolated, being then  forcibly drawn  forward  and  slowly dissected by
vertical strokes of the knife, close the wound by three or four fine sutures,
and apply the  cold water-dressing.   The hemorrhage yields to the pressure
of the finger or cold water applied before closing the wound.  In fifty cases
operated on in this manner, Walton has never seen a bad symptom.
   Estimate of the Value  of these  Operations.—In estimating the value of
the operations just detailed as practiced on the eyelids, so much must depend
upon the  peculiarities of each case, that it is,  perhaps, best to leave a deci-
sion of their value  to the judgment  of each operator.  In deformities result-
ing in Ectropium,  and  consequent on  burns or ulcers, the tendency to con-
traction is so great that, in all the plastic operations, too much integument
can scarcely be obtained.   In all such instances, blepharoplasty presents the
best chances of success ; but even then the operator should be very guarded
in his prognosis.   In  the case of a young lady in whom the upper lid had
contracted adhesions to the edge of the  orbit, in consequence of a burn,
leaving the eyeball exposed to dust and  other irritation,  I formed a flap from
the forehead, making it more than three times as  large as the space to be
filled  in the lid, and, fastening it in position, obtained union by the first in-
tention.   Yet six months subsequently, the cicatrization of the wound from
which the flap was taken, and the contraction of the latter, had again elevated
the lid nearly to the edge of the  orbit.
  In entropium, I should,  as a general rule, prefer the operation of Key, as
modified by Walton, to most of the others.   The operation of Dorsey is,  I 
 88            PRINCIPLES  AND  PRACTICE OF  SURGERY.

 think, preferable to that of Saunders, not only from its simplicity, but from
 its completeness.   In  cases due to  the  contraction of the cartilages,  the
 operation of Guthrie is generally preferable to the operation of Crampton.


                            SECTION  III.

     DISORDERS OF  AND OPERATIONS ON  THE LACHRYMAL APPARATUS.

   The principal disorders to which the lachrymal apparatus is exposed  are
 scirrhus, or such other degeneration  of the lachrymal gland as may necessi-
 tate its removal; obstruction of the puncta lachrymalia; thickening and stric-
 ture of the ductus ad nasum, or suppuration and ulceration of the lachrymal
 sac.  Sometimes there is a marked diminution in the secretion of the gland,
 and a corresponding dryness of the eye that is termed Xeropthalmia, which
 demands mucilaginous washes, and such  local and  general treatment as is
 required for the relief of diminished  secretions in other glands.   When  the
 puncta are  contracted or obliterated, the tears  flow over  the  cheek, or the
 eye is watery, constituting the condition designated  as  Epiphora.   In con-
 traction  of  the puncta lachrymalia,  or of the canalicula lachrymalia, that
 creates  epiphora, it occasionally becomes necessary, after  employing anti-
 phlogistic measures and  mild collyria, to dilate the puncta and canals by a
 probe, or to slit them up, or to wash  out  the sac and ductus ad nasum, and
 diminish inflammation.
   1. Dilatation of  the Puncta.—To one familiar with the anatomical rela-
 tions of the part, catheterism of these  ducts is a simple affair, and may be
 accomplished by introducing  Anel's  probe, or, what is better, the  blunted
 point of  a fine cambric needle fastened in a handle, or the instrument repre-
sented in Plate VIII. Fig. 21, into the punctum, and repeating the opera-
tion from time to time, as it may be required.
   2. Incision. — Bowman, of London,  advises  enlarging the  lachrymal
canals by dilatation,  with probes of different  sizes,  after enlarging  the
 punctum by inserting the point of  a  pair of fine scissors  to the distance of
 one line, and dividing the ring at the orifice, by one cut.
   3. To  Dilate the Canals and Ductus ad Nasum.—When the punctum is
pervious, draw the eyelid toward the temple, in order to straighten the cana-
 licula and prevent a fold of the mucous lining from being  pushed in front of
the point of the instrument.  Then introducing a fine probe—or one fastened
into a light handle to  facilitate its manipulation—Plate VIII.  Fig.  21, into
either punctum, by  passing it perpendicularly into  the  orifice,  and carrying
the handle toward the temple, or nearly parallel with the lids, pass it gently
toward the  inner canthus of the eye.  On reaching the sac, elevate the in-
strument from  the  horizontal nearly to a  perpendicular direction,  and carry
the handle obliquely forward,  when the point will pass readily into the nose,
Plate XI. Fig. 2.   The figure shows the probe when it has reached the  sac
and is about to pass into the duct, and the dotted line indicates its course down-
 ward.  The introduction of a probe  from the nostril  into the  duct, as sug-
gested by Laforest, is also shown in the drawing;  but the operation has  lit-
tle to recommend it, being opposed to the anatomical relations  of  the parts
 and the  same end is better accomplished by operating from above
   4. To  Wash out  the Canals and  Sac.—Introduce one of the fine points
 of Anel's syringe into the lower punctum, holding the instrument with  the
 forefinger upon the  piston, as shown in Plate XI. Fig. 3.   Then elongating
 the lid, throw in the fluid by the motion of the forefinger,  taking care not to
 press the point of the syringe into the membrane  lining  the canals, nor to 
OPERATIONS ON  THE  LACHRYMAL  APPARATUS.          89
  push a fold of it in advance of the instrument.  If the liquid does not pass
  out of the syringe as freely as the orifice  should permit, withdraw the point
  a little, and again passing it forward it will be easy to avoid any duplicature
  of the membrane.  While injecting either punctum, the other should be closed
  to prevent regurgitation.  If the  liquid passes  freely through the duct, the
  fact will soon be rendered apparent by its escape either  from the  nose or
  throat of the patient, according as the head  is held  forward  or backward.
  The  liquid injected may consist either of simple water or of mild  alterative
  collyria.   If the operator can only use his right hand, he must stand either
  in front of or behind his patient, according to the eye to be operated on—
  that is, in  front for the  left eye, and behind the  patient when  operating on
  the right ; but if he is ambidexter, his position will be immaterial.
     5.  Dacryocistitis—Saxpuov, a tear, and xoar^, a bladder—or inflammation
  of the lachrymal sac, is a complaint that usually runs the  course of mucous
  inflammation elsewhere ; that is, either disappears by resolution, or ends in
  suppuration and  stricture of the canal.   When it results in suppuration, or
  when an abscess of this structure ulcerates, and opens upon the integuments,
  it constitutes the coudition known  as Fistula Lachrymalis, and requires the
  dilatation  of the ductus ad nasum  to restore the  patulous condition of both
  the duct and saccus lachrymalis if adherent to adjacent parts.
     The introduction of a bougie, style, or canula requires the formation of an
  opening through the  integuments into  the  sac, unless the discharge from the
  abscess has created a fistulous orifice by ulceration.
     In many cases the ductus ad nasum, if strictured, can be dilated by a probe
  passed through the punctum lachrymalis and  the sac into the  nose.  But in
  very chronic cases it may become necessary to  induce absorption of the fibrin,
  or to establish suppuration, as is done in very bad strictures of the urethra,
  and in these cases a bougie may be worn in the  duct for many  weeks, though
  this is not now as frequently done as it was formerly.
     The ordinary operation of introducing a  style or bougie  into the duct
  is performed as  follows:  Endeavor  to render the ligamentum  palpebrale
  prominent  by  drawing the lids outward,  as it  is the great point of refer-
  ence, the  sac  lying somewhat in front and  below it.  When, on account
  of the swelling or inflammatory  thickening  of the integuments, the oper-
  ator  cannot  feel  this  ligament, he  must be guided in  his  puncture by
  the  prominence formed by the distended sac, or  by  his  knowledge of its
  proper position,  and  especially its relation to the edge of the orbit, or by
  a  fine probe  passed  into the sac through the lower  punctum, if possible.
  Then taking a narrow, straight, and  sharp-pointed bistoury,  and, standing
  in front of the patient for the left eye, and behind him if the disease is in the
  right one,  puncture the  integuments and anterior surface of the sac by press-
  ing the point of the knife (with its back turned toward  the nose) obliquely
  downward and backward.  On entering the sac, bring  the handle to a nearly
  upright position, and carry it forward slightly toward the nose, and down-
  ward, so  as to make  the point  pass  backward  and obliquely  outward  and
  downward, Plate XI. Fig. 4.   Retaining the bistoury  in the duct, pass a
  probe along the  knife as a director  until  it reaches the nostril, and, with-
  drawing the bistoury, pass the style, or bougie, or canula along the course of
  the probe, and, withdrawing the latter, fasten the instrument down by a piece
  of adhesive plaster, or simply trust to its retaining its position in consequence
  of the depth to which it has been introduced.  Some surgeons,  and especially
\ the French, prefer passing the canula of Dupuytren along a groove made in
 Hhe knife,  in order to  conduct it into the duct  with greater certainty; but in
  the United States, the style of Ware, with the head blackened by a little varnish
  or sealing-wax, and employed in the manner just directed, is used whenever 
PLATE  XI.
OPERATIONS PERFORMED FOR THE OBSTRUCTION OF THE LACHRYMAL
                               PASSAGES.

  Fig. 1. A side view of the relative positions of the  different portions of the
liachrymal Apparatus of the Left Eye. The upper and lower eyelids, with a small
portion of the bones and integuments on the side of the  nose, have been removed
so as to expose the structure freely.  1. The lachrymal gland in its natural posi-
tion at the edge of the orbit, near the external  angular  process of the os frontis.
The conglomerate structure of the gland is well shown.  2. The superior punc-
tum lachrymalis, with the course of its canalicula, to  the saccus  lachrymalis.
3. The inferior punctum lachrymalis in  its course to the sac.   The head, or en-
largement of the ductus ad nasum, sometimes designated as the Saccus Lachry-
malis, is seen between the lines of 2 and 3.  4.  The ductus and nasum, exposed
by removing its anterior parietes.   Its course  from the puncta down to the in-
ferior turbinated bone, and the direction to be given to instruments introduced
into it, can thus be readily understood.            After Bernard and Huette.
  Fig. 2. A three-quarter view of the Face. Anel's probe has been introduced
into the upper punctum and carried into the lachrymal sac, whence it may be
made to enter the nose.  The dotted line shows the course that the instrument
would take, and the probe in the  nostril indicates the position of the instru-
ments when passed into the duct from the nose, as  in the plan of Laforest.
                                               After Bernard and Huette.
  Fig. 3. The position of the operator's fingers, when washing out the lower
punctum  with Anel's Syringe.  The mode of holding the  syringe so as to prevent
undue pressure on the canal is also shown.         After Bourgery and Jacob.
  Fig. 4. Operation of puncturing the Lachrymal Sac  of the Left Eye in cases
of obstruction.  The forefinger of an assistant is represented making traction on
the lid so as to render  the position of the palpebral ligament apparent, if the
swelling and inflammation permit it. A straight, narrow bistoury has punctured
the integuments and anterior face of the sac, and, while retained in its position,
a probe has been passed along the  blade of the  knife  into the duct and thence
into the nose.                                   After Bernard and Huette.
  Fig. 5. Operation upon the Right Eye ; the bistoury,  after puncturing the sac,
has been retained in its position until Ware's  style could be introduced.   This
is now seldom resorted to.               Modified from Bernard and Huette.
  Fig. 6. Fistula Lachrymalis, and  the introduction of a  bougie into the duct
through the fistulous orifice, as formerly practiced.
                                               After Bernard and Huette
       (90) 
Rg.l

^T%. .**

^mu'- .....  -i|fc
,*»*"V
 
 
OPERATIONS ON  THE  LACHRYMAL  APPARATUS.          91
it is deemed necessary.   To guard  against a change in the relations of the
soft parts, consequent on the escape of the pus when the sac is opened, the
employment of a probe passed into the duct before the bistoury is withdrawn,
if the style cannot be passed in the first  instance, will be found most service-
able ; and I have more than once seen surgeons entirely baffled in the intro-
duction of the style, in consequence of  withdrawing the  bistoury before the
probe or style was fairly in the orifice made in the sac.   From the  collapse
of the sac after its puncture,  there  is  also, occasionally, risk of  the  style
passing outside of the lining membrane, or between it and the bony duct, so
as to separate the  former entirely from  the bone, thus leading to entire ob-
literation of the cavity, as well as to  disease  in the os unguis.   Whenever,
therefore, great difficulty is experienced in introducing the style, caution in
reference to this accident becomes  necessary.  If the duct is obliterated, a
perforation  may be  made through the  os unguis  from the  sac ;  but if it is
only closely strictured, the practice of employing caustic, as recommended by
Haxhall, of Richmond, will be  found serviceable.  The plan proposed  by
Haxhall is the same as that recommended  by Ducamp in stricture of the
urethra,  viz., first to take a mould of the stricture by a soft bougie, and then
apply lunar caustic to the constricted  part.   The  same idea was previously
suggested by  Xath.  Smith, of Dartmouth College, in 1817, though he em-
ployed caustic potash instead of the lunar caustic.  His mode of using it was
as follows :—
  Nathan Smith's Operation.—Render the tendon of the orbicularis (lig.
palpebrale) conspicuous, cut into the sac, introduce  a probe, and find the
obstruction.  Then substitute a bougie armed  with a morsel of caustic potash,
press the alkali upon the opposing membrane, and the obstruction will soon
be overcome or the  passage dilated.  Catgut is  not  a  good material for a
bougie in these cases, as it is irritating and  becomes  decomposed, favoring
the formation  of fungous granulations around the  orifice, owing to  the sepa-
ration of its fibres as twisted  and the  irritation they develop.
  6.  Perforation of the Os Unguis.—When the duct is so perfectly obliterated
that its patulous character cannot be restored, then it may be necessary to
make a perforation into the nostril by means of a punch—Plate  XIII. Fig.
23—or a fine  trocar, or the bone may be punctured and the fragments care-
fully picked out, in  order to guard against  the  subsequent closure of the
wound.  To prevent extensive fracture or laceration of the neighboring parts,
the puncture  must be  made with care.   This  operation is, however, rarely
resorted to.
  After-Treatment.—After the  introduction of  the  style or bougie, they
may be fastened in  their position by  a  morsel of adhesive  plaster, though,
most frequently, the swelling of the integuments  will  be sufficient to retain
them.   After  the lapse of six or eight days, the style should be removed by
seizing its head with a pair of dissecting forceps, and withdrawn  by a move-
ment which is the reverse of that employed for its introduction.  The point
of a syringe being then placed in the canal,  the part should be  thoroughly
washed, and the pervious character of the passage tested  by the escape of
the  water either from the nostrils or into the throat of  the patient.  Then
replacing the style, the same means should be resorted to from time to time,
until  all  inflammation has subsided, after which  common  cleanliness is  all
that is requisite.   The patient should, however, wear the style for at least six
months, or until the permeable character of the ductus ad nasum seems well
established.   On finally removing it, the orifice will heal readily under the
occasional application of the nitrate of silver.
  Remarks.—In the early stages of inflammation in the sac or its duct, and
in the lighter forms of stricture, the antiphlogistic treatment, and the dilata- 
92
PRINCIPLES AND  PRACTICE OF SURGERY.
tion of the ductus ad nasum by a probe passed through the punctum lachry-
malis into the nose, will often suffice for the cure ; but when the stricture is
denser, and  the disease is more advanced, puncture of the sac and the sub-
sequent introduction of a bougie or style in the manner just detailed may be
required.  Puncturing the os unguis can only be demanded when the sur-
geon finds it impossible to introduce an instrument  into the nose, and  can
only therefore be attempted as a last resort.
CHAPTER  III.
                   DISORDERS OF THE EYEBALL.


  An account of the disorders of the eyeball  and of the anatomical relations
of its component parts may be limited either to a  brief enumeration of the
general characters of each portion,  or extended into a minute description of
the structures concerned.   From  the importance of the diseases of this
organ, the latter course has generally been pursued by surgeons who have
devoted themselves  especially to this branch of the profession.  The general
character of the present work, and the necessity of affording to other subjects
an equal  amount of space, must, however, preclude any attempt at a  more
detailed account of these than is essential to the comprehension of their
treatment by  the student.
                            SECTION  I.

                     ANATOMY OF THE EYEBALL.

  The eyeball is composed of six coats and three humors.
  The coats  are the conjunctiva, sclerotica, and cornea, which may be de-
scribed as external; and the choroid, iris,  and  retina, which  are within the
former.   The humors are the aqueous, crystalline, and vitreous.
  The Conjunctiva,  or mucous coat, after lining the lids, is reflected upon
the ball, and  covers both  the sclerotica and cornea.   To the sclerotica it is
loosely attached by areolar tissue, in consequence of which it is liable to fluid
infiltration, as well as to  great vascular engorgement, either of which may
raise it from the sclerotica.   The course of its blood-vessels is tortuous.   To
the cornea it  adheres very closely, furnishing it a thin layer, which is occa-
sionally the starting-point of ulcerative inflammation.   The  Sclerotica is a
dense fibrous  coat which  has, by some, been considered as an expansion of
the dura mater of the brain.   In connection with the operations performed
upon the  eyeball, it may be described  as extending from the  optic nerve as
far forward as the circumference of the  cornea, the two being closely adapted
to each other by a beveled surface.   The resisting character of the sclerotica 
ANATOMY  OF THE EYEBALL.
93
renders it necessary to press an instrument against it perpendicularly and
with some little force, in order to perforate it readily.   The vessels of the
sclerotica are generally arranged in straight lines ;  hence their engorgement
is readily distinguishable from that of the conjunctiva.   The muscles of the
eyeball are inserted into the sclerotica, and are consequently surrounded by
the  loose connective tissue between it and the conjunctiva.  The Cornea is a
firm and resisting  coat, seated  at the front of the ball; it is composed of
numerous lamina?, separated from each other by a  thin  pellucid fluid in the
healthy condition, but liable to become opaque from inflammation.  The sec-
tion of the cornea,  owing to its density, and the arrangement of its layer,
requires that the instruments employed should be of the best quality, and
also that some caution be exercised  by the operator, lest he simply separate
its layers instead of passing the  knife entirely through  or behind them.  The
cornea possesses no vessels capable of carrying red blood in the healthy con-
dition, though in inflammation  its capillaries  will  admit it.  In  health, it
possesses little sensibility; but, in disease, it is occasionally exceedingly sen-
sitive,  its incision having  caused fainting, as occurred in the practice of
Physick, of Philadelphia.   Horner has also reported the same fact.
  The Choroid is a vascular coat placed immediately within  the sclerotica,
and of equal extent with it, being closely fastened  at  its anterior margin to
the corresponding portion of the latter, by a ring called the ciliary ligament.
The Iris is set in the front margin of this  ligament, so that the cornea and
sclerotica may be peeled off without impairing its continuity with the cho-
roid coat.*   The arteries of the choroid coat are the two long and the short
ciliary arteries.  The long ciliary arteries pass one on either side, externally
and internally, between  the choroid and  the  sclerotica in the middle line of
the  eye.  They are consequently liable to be wounded in the operations of
absorption or depression of  cataract, unless the needle is made to transfix
the sclerotica a line or two above or below the plane of its transverse diam-
eter, or very near to the circumference of the cornea.
   The Iris is placed as  a diaphragm behind the cornea, on a line with the
ciliary ligament, and has the power of contracting and expanding, as will be
referred to under the operations for cataract.   The Retina has so little con-
nection with  operations on the eye as to require no special notice.  Between
the  posterior surface of the cornea  and the anterior face of the iris is the
Anterior Chamber of the eye;  and between the posterior surface of the iris
and the front of the lens is the  Posterior Chamber, the two communicating
through the  pupil,  and being occupied by the aqueous humor.
   The Crystalline Humor is a double convex lens, of which the posterior con-
vexity is the  greater. It is invested by a capsule, which is separated from it by
the liquor Morgagni.  In consequence of the adhesion of the capsule to the
hyaloid membrane, and the contact of the ciliary processes, the lens is readily
maintained in its position ;  all  the operations upon it consequently destroy
these attachments.   The Vitreous Humor fills up the great bulk of the eye,
and is directly behind the  lens, the latter being received into a depression
upon its anterior face.   It is surrounded by the hyaloid membrane, which is
strong enough to sustain it, and  also prevents the depression of cataract,
unless its cells are  previously lacerated with the needle.
* Horner's Anatomy, vol. ii. p. 414. 
94
PRINCIPLES  AND PRACTICE  OF SURGERY.
SECTION  II.
DISORDERS  OF THE  COATS OF THE EYEBALL.
                           \ 1.—Conjunctivitis.

   Conjunctivitis, or inflammation of the conjunctiva, resembles the inflam-
 mations of other mucous membranes generally.
   Etiology.—It may arise from various causes, as simple exposure to cold,
 resulting in  catarrh; from  the presence of foreign bodies  between the lid
 and the ball; from wounds—in fact, from  any  cause likely to result in the
 production of inflammation elsewhere.
   Symptoms___The symptoms are as follows: The patient experiences pain
 in the eyes of a  sharp pricking character, the sensation being similar to that
 experienced from the presence of a  foreign body in the  eye, and due simply
 to engorgement and consequent enlargement of the superficial vessels of the
 conjunctiva.  There is also a sense of heat and stiffness, and some intolerance
 of the motion of the upper lid, the  lids  being  kept partially closed.  The
 irritation extending to the lachrymal gland, the action of that organ be-
 comes excessive, and there  is  consequently  increased lachrymation, the
                                     tears overflowing and running down
              Fig. 380.                upon the face, while,  as  the  secre-
                                     tions become changed by the inflam-
                                     matory action, the tears mixed with
                                     the vitiated secretion of the conjunc-
                                     tiva often become acrid and irritating.
                                     The eye is red  and  bloodshot, and
                                     the  character of this  vascularity
                                     should  be  noticed particularly,  on
                                     account  of  its value as a diagnostic
                                     mark, as it  serves to distinguish be-
                                     tween conjunctivitis and  sclerotitis;
                                   2 the enlarged vessels in conjunctivitis
                                     being tortuous,  reticulated  in  their
                                     character,  and  giving the  appear-
                                     ance of a network, while in sclerotitis
                                     they are quite  straight, and radiate
                                     from the cornea  toward the circum-
                                     ference of the eye, Fig. 386.
                                        If the disease is violent, it also de-
                                     velops a certain  amount of constitu-
c,  .,      .      .  ,  ,.    .           tional disturbance, this consisting in
febrile reaction,  with digestive and circulatory derangements
  Occasionally,  instead of the simple affection just  described, more  marked
symptoms occur, and the condition is presented which is designated as Puru-
lent Conjunctivitis.  In  this variety an increase of the secretion of the part
is first noticed;  then there is  a tendency in this secretion to  become white
thick, and opaque  at first, afterward yellow and purulent, and finally  thin'
acrid, and irritating ;  greenish in color, and presenting characters of ichor •
or it may resemble sanies, the pink color being produced by  the rupture of
some of the superficial vessels, and the escape of the coloring matter of the
blood. This thin, acrid, irritating  pus, running down over the face, is apt to
produce  more or less excoriation or  eczema of the  cheek.   In a short  time
a fullness and swelling of the lid are noticed, which increase  frequently to
such an extent as to result in  closure of the eye, in addition to which  there
 Diagram to snow the Characteristic Vasclmrity
of Conjunctivitis and Sclerotitis.—1. T.irtuous vas-
cularity of conjunctivitis.  2. Straight vessels of scle-
rotitis.  Alti r \\ hartun Jones.. 
CONJUNCTIVITIS.
95
may be a protrusion of the folds of the mucous membrane ; or this protrusion
may take place before the swelling of the lids has gone on to such an extent
as to close the eye, thus  producing a true ectropion.   The disease  continu-
ing, the inflammation may be extended  from the conjunctiva to the submu-
cous areolar tissue, which is found  between that membrane and the  sclerotic
coat, and the effusions of serum or of lymph thence resulting may elevate the
conjunctiva to such an extent that  the cornea appears deeply sunken  in the
eye, thus producing the condition designated as Chemosis. If this condition
continues, the  cornea itself is  apt to  become involved, and the disease be
complicated with the symptoms of corneitis, which may even go to such an
extent as to result in  sloughing of the cornea.
   Etiology.—The causes of  purulent conjunctivitis are varied, as exposure
to a bright light for a great length of time ; derangements  in the constitution
of the patient, and certain conditions of the atmosphere which are not under-
stood.   When produced, conjunctivitis is  not unfrequently capable  of being
propagated by contagion, and will consequently often sweep  through the
entire wards of a hospital.
   Diagnosis.—The tortuous character  of the blood-vessels and their super-
ficial position  generally render the  diagnosis of  conjunctivitis easy.
   Treatment.—The  treatment of simple  acute  conjunctivitis is based upon
general principles.  Antiphlogistics are  imperatively demanded if the pa-
tient has a good constitution,  and, if  he is plethoric, they may be carried
with advantage to a marked extent.   Where the attack is violent  under
these circumstances the treatment must  also be prompt, local bleeding, by
means of leeches,  being  resorted to, and purgatives and  diuretics  freely
administered,  especially the saline cathartics,  while cold water  is constantly
applied over the closed lids by means of wet cloths.
   Much advantage will also be derived, after the first few days, from the use
of astringent collyria.   As a general rule, a solution of any of the astringent
salts, such as sulphate of zinc,  acetate  of lead, etc.,  of the  strength of half
a grain to the ounce of distilled water, will  make a collyrium suitable to
begin with ; but the  acetate of lead must not  be  used in  cases which are
complicated with ulceration of the cornea, as there will result from  its use a
white deposit  of carbonate of lead in the ulcer, which may lead to the pro-
duction of a corneal speck.  Much comfort will be derived  at first from
the cold water-dressing applied over the  closed  lids, as well as  from the ap-
plication to the ball of mucilaginous washes, as the  mucilage of the pith of
sassafras.  When the  disease becomes chronic, more stimulating applications
are demanded, and the nitrate of silver may be applied of  the strength of
one-quarter or one-half grain to the ounce of distilled water.
   Purulent Conjunctivitis will  require a more active  treatment, and here
advantage will be found from using, from the  first, a stronger solution of
nitrate of silver—say a grain or  a  grain and  a half to the ounce—with the
view of modifying the action of the diseased mucous membrane.   Advant-
age will also  be frequently derived from  painting the inner surface  of the
lids with a pencil  dipped in a still stronger solution  of the nitrate of  silver,
say six or eight grains to the ounce.   When there is marked chemosis, the
patient will often be benefited by making punctures in the conjunctiva, with
a view of allowing the effused serum to escape, or by applying  a few leeches
directly to the conjunctiva, at the internal canthus.
   Gonorrheal Ophthalmia.—Gonorrhceal Ophthalmia,  a  very high grade
of puruleut conjunctivitis, is produced by the contact of gonorrhoeal mat-
ter with the conjunctiva.  That  such  a disease may be produced in this
manner should always be borne in mind by the surgeon, when treating gon-
orrhoea,  the  patient  being warned of  the  possibility of this,  that so for-
midable  a disease  may thus be prevented.  Gonorrhceal  ophthalmia is very 
96
PRINCIPLES AND  PRACTICE OF SURGERY.
violent in its grade, sometimes running its course and  resulting in total  de-
struction of the eye, if uot promptly met, in from twenty-four to forty-eight
hours; but, except in its degree  and cause, it is  very  similar to ordinary
purulent ophthalmia.
   Gonorrhceal ophthalmia being a peculiarly violent grade of conjunctivitis,
requires to be treated very promptly, in such a  manner that  the specific in-
flammatory action shall be changed and another substituted.  The lids, there-
fore, should be thoroughly everted, and, their inner  surface having been well
cleansed  by wiping them with a piece of moist soft sponge,  they should be
painted with  the solid stick of nitrate of silver, so as to form a delicate white
film over their surfaces; then water  should be freely squeezed on them from
the sponge, so as to wash off any of the free caustic, after which  they may
be allowed to come in contact with  the eyeball.  This application,  instead
of adding to the pain,  often gives prompt relief, with  an amelioration of
the symptoms, and may he followed next day by a strong collyriura of thirty
grains of the nitrate to the ounce  of  water, a  portion of  which  may be
dropped  into the eye, or the lids painted with it by means of a camel's-hair
pencil.   By these means there is some hope of arresting  the progress of the
complaint, which otherwise, in a few hours, is liable  to result in sloughing of
the cornea and destruction  of the eye, as has been shown in many melan-
choly instances.
   Scrofulous Conjunctivitis. — This modification  of conjunctivitis, which
is  met with in children of the tuberculous diathesis, among the poor and in
the inmates of asylums and hospitals, is much the same  in its symptoms as
the ordinary  inflammation of the conjunctiva, above described;  but  there is
a  greater disposition to febrile reaction.   The  lids, in this instance,  are
nearly always much tumefied, with a congested state of  the vessels ;  hence,
as the upper lid  moves over the inflamed ocular conjunctiva,  it causes great
irritation, and the  patient, particularly if a child, turns  upon his belly and
buries his face in the  pillow, or covers it with  his  hands, to aid in keeping
the eyes closed.   The muscles of the face, and  particularly  the orbicularis
palpebrarum, are also violently contracted, so  as to  cover the ball.   The
pus secreted  by the conjunctiva, when the inflammation  is of a high grade,
is  generally  very irritating, and, running  over  the face, produces  eczema
and excoriation.   The corneal conjunctiva is also apt to be involved in this
form of conjunctivitis, in consequence of which  ulceration of  the cornea  fre-
quently supervenes, the cicatrix  left by the ulcer,  should  it  heal,  being
slightly depressed, and presenting more or less  opacity  of the cornea, thus
creating  what the vulgar call a "feather on the sight."  As the eyes are
generally kept closed during the day, though sometimes  more open at night,
photophobia, or intolerance of light, has  long been regarded as the cause,
and presented as a  symptom, of this form of conjunctivitis and ulcer of the
cornea.   There is, however, no anatomical  connection between these coats
and the retina, and it is probably incorrect to explain the closure of the  lids
as due to au  effort to exclude the  light.   When a particle of sand is intro-
duced into the eye there is a marked disposition to close the lids, and  here
it  is certainly due to an effort to prevent the friction caused by the  motion
of the upper lid.   In ulceration of  the cornea the  friction of the lid is also
the main source  of  the suffering,  and it is, doubtless, the  same result that
induces the child to keep the lids persistently closed in  this  variety  of con-
junctivitis.
   Scrofulous ophthalmia  is to be treated by means of  those constitutional
measures appropriate in ordinary cases of the tuberculous diathesis, tonics
stimulants, and  chalybeates  being resorted  to instead  of antiphlogistics'
while the local  treatment is to be carried  out upon the same  principles as
the other forms of conjunctivitis, being proportioned in activity to the  grade 
                      PTERYGIUM.—SCLEROTITIS.                   97

of the complaint.   Great relief is to be obtained  from everting the upper
lid, cleansing it, and then applying, with a camel's-hair pencil, a solution of
the nitrate of silver, grs. v to the ounce of water.
                           \ 2.—Pterygium.

   The  Pterygium—xrzpu*, a wing—is a varicose  excrescence, or enlarge-
 ment of the vessels  of a portion of the  conjunctiva, accompanied with hy-
 pertrophy and thickening of the membrane
 itself, which is generally triangular in shape,            Fig. 387.
 and found in  the inner corner of the ball, as
 well as occasionally on its  outer margin, or
 sometimes in  both points, Fig. 387, the apex
 of the  triangle in either case presenting to-
 ward the cornea.  This condition may result
 from any of the chronic forms of conjunctivi-
 tis, and may be removed by extirpation, with
 a pair of curved scissors, Plate VIII. Fig. 17,
 or by  cutting it across transversely,  and
 thoroughly cauterizing the wound with the
 Solid Stick  Of the nitrate Of Silver, SO as tO    A front view ofa Double Pterygium.
 close the vessels,  and cause  the portion of
 the pterygium, which is on the cornea and impairs the sight, to disappear by
 atrophy.

                             \ 3.—Sclerotitis.

   Sclerotitis, or inflammation of the sclerotic coat of the eyeball, is some-
 times called rheumatism of the eye, or rheumatic ophthalmia.   It is found
 to follow upon changes in the condition of the atmosphere, and is some-
 times due to  extension of inflammation from  some  neighboring  tissue, as
 from the iris or the conjunctiva.  It may also be produced  by wounds, or by
 any of  the ordinary causes which lead  to the development  of inflammation.
   Symptoms—The symptoms of sclerotitis are as follows: There is a dull,
 heavy pain in the ball, which is severe and pulsatile in its character.   There
 is pain  in the temple, and tenderness  of the ball upon pressure, the pain
 being more severe at night, and the cornea becoming hazy. There is, how-
 ever, little or no increased lachryraation, unless the disease  is combined with
 conjunctivitis, while the pupil remains unchanged, unless  it is complicated
 with iritis.
   Diagnosis.—Sclerotitis may be readily diagnosed from  conjunctivitis  by
 the character of the vascularity, as pointed out under the  head of conjunc-
 tivitis.   If the two diseases exist at the same time,  the two varieties of vas-
 cularity will be present simultaneously  and readily recognized.
   Treatment.—The treatment is similar to that of  rheumatism, free purga-
 tives being administered, and combined  with the use of antimonials or of
 Dover's  powder.   Wine of colchicum  seeds, in the dose of ten to twenty
drops three times a  day, will also  prove  of service, though sometimes  it
 will require to be given in large doses, say a  teaspoonful three times a day,
when it will be useful not only as a purge but as a sedative.  The local ap-
plications should all  be warm, and  may consist in the warm water-dressing,
applied  according to the exigencies of the case.   Counter-irritants are often
serviceable, such as the application of small blisters to the temples  or behind
the ears; and advantage will frequently be derived  from rubbing upon the
     vol. n.—7
 
98
PRINCIPLES AND  PRACTICE OF  SURGERY.
lids the extract of belladonna, rendered thin with water, or aconitia, in the
proportion of a grain to the drachm of lard ;  or a plaster of opium may be
applied to the temple, and worn  for  several days; or cloths wet  with a
solution of the sulphate of atropia, a half grain to the ounce of water, may
be hud upon the lids.  These anodynes prove of service, both by allaying the
pain and diminishing the flow of blood to the part.
                             | 4.—Corneitis.

  Symptoms.—The symptoms of Corneitis are haziness of the cornea; a dis-
position to increased lachrymation, from its connection with the conjunctiva,
which is spread as a thin layer over its front lamina; intolerance of light,
and of the friction of the upper lid; while it is not unfrequently complicated
with conjunctivitis and  sclerotitis, all their symptoms being also  present.
If the disease progresses to any extent, it may result in a true ulcer of the
cornea, or  there may be  deposits of lymph in  the structure of the  cornea
itself, producing opacities which have  been designated by  various appella-
tions, according to their degree.   When  very slight, it is  designated as a
nebula, this being a mere cloudiness or circumscribed  haziness in the vision
of the affected eye, and  often requiring some care on the  part of the  sur-
geon to perceive it.   A  thick opaque spot in the cornea, such as results from
the healing of a corneal ulcer, is designated as leucoma;  and  when there
are vessels running  over the surface of the cornea, to communicate with a
spot of opacity somewhere on the cornea  itself, the condition is designated
as pannus.
  An amount of lymph greater than that in a leucoma, and which produces
a distinct  white spot, is designated as  albugo.
  These deposits of lymph in the substance of the cornea are very difficult
to relieve, though much may be done in the way of prevention by care in the
treatment of the early stages of  the corneitis and by cauterizing, with the
nitrate of  silver, any ulcers that may form upon the cornea.
  Treatment.—Corneitis, being accompanied most frequently with conjunc-
tivitis, requires very much the same  t»eatment as was directed for simple
inflammation of the conjunctiva, great  attention being given to the formation
of the little blisters or abscesses which appear beneath the conjunctiva cover-
ing the cornea, and are the commencement of the  corneal ulcers.  As soon
as an abrasion of the corneal conjunctiva is seen, or  an ulcer which is only
superficial shows itself, it should be lightly cauterized, in order that  it may
heal under the eschar or film  thus created, which will protect  the  surface
from  the  irritation of the tears;  while, at the same time, the lids should be
kept closed by tying up the eye, or by applying a strip of adhesive  plaster
to the upper lid and fastening the other end to the cheek.  When it  is
promptly  met, an nicer of the cornea  will often heal without creating opa-
city.   Should, however, an opacity unfortunately form, it  is to be treated
by such applications as  will stimulate the vessels of the part, and favor the
absorption of the  lymph that causes the whiteness of the spot.   The  pop-
nlar remedy of dropping sugar-house molasses into  the eye is not a  bad
one, and  acts simply as a stimulant.   Benefit  has also been derived  from
the direct application to the spot of red precipitate ointment, by means
of a camel's-hair pencil; from the use of a collyrium consisting of a  half
grain of  corrosive sublimate dissolved in an ounce  of water,  applied bv
means of  a camel's-hair pencil, or from one of nitrate of silver' in solution
of six or eight grains to the ounce.  Fumigation with the vapor of hydro-
cyanic acid, by means of a glass bottle with a neck so shaped as to fit the 
STAPHYLOMA.--IRITIS.
99
eye, has also been recommended, and may prove useful as  a stimulant.   At
one time the sulphate of cadmium was supposed to possess peculiar efficacy
in removing opacities of the cornea; but personal experience has not shown
that it has any more power than the sulphate of zinc.
  The cure of albugo and of leucoma has been attempted by excising the
outer layer of the cornea in order to allow the applications to be brought
directly in contact with the lymph, the spot being afterward cauterized with   »
the nitrate of silver; but this treatment has been very generally unsuccessful.
                            \ 5.—Staphyloma.

  As a consequence of various affections of the cornea or of the interior of
the eyeball, the cornea becomes  prominent, pro-
jects beyond the lids and creates an unsightly  de-          Fig. 388.
formity, besides giving rise to considerable irrita-
tion from  the  fact that it collects  on its surface
the little  particles of dust which are constantly
floating  in  the atmosphere.   This condition is
designated as staphyloma—sraipuXr], agrape—from
its conical or globular form, Fig.  388.
  Etiology.—The causes are various.   It may be
a consequence of inflammatory action in the globe
resulting in effusion, or in softening of the vitreous     a side view of staphyloma.
humor; or it may ensue on dropsy of the aqueous
humor, the pressure  of which causes the cornea to protrude; but frequently
this condition is the result of the morbid  alterations in the cornea already
stated.   It  is generally accompanied with opacities of the  cornea  more or
less dense, and the patient suffers from loss of sight as well as from the irri-
tation consequent upon the complaint.
  Treatment.—The treatment in such a case is  simple; nothing  curative
can be effected, but much relief may be obtained from evacuating the humors
of the eye, as the patient loses nothing by the  operation,  his sight being
already destroyed, while he  gets rid  of the deformity, and  of the suffering
entailed by the constant irritation of the  eyeball from the foreign matter
which adheres to its prominent surface.
  The operation  may be effected by slicing off the more prominent parts of
the staphyloma, and  allowing the humors to be thus gradually evacuated; or
the same end may be attained by a simple puncture with a lancet.
  An artificial eye may be subsequently employed, and if well fitted, will fol-
low the motion of the  stump, and greatly diminish the deformity left by the
evacuation of the humors of the ball.
                               | 6.—Iritis.

  Inflammation of the iris,  according to  the  law of nomenclature above
alluded to, is termed Iritis.
  Etiology.—The causes are numerous, and are to be found in some peculiar
condition connected with secondary syphilis,  which is perhaps the most fre-
quent origin of the complaint;  or it may be created by exposure to cold;  by
blows; by  wounds made during operations  upon the eye, as in the operation
for cataract; or it may result from  a simple extension of an inflammation set
up in some other coat, and thus be a consequence of conjunctivitis, of cor-
neitis, sclerotitis, or choroiditis.
 
100            PRINCIPLES AND  PRACTICE OF  SURGERY.
Fifj. 380.
 Iritis, showing the characteristic Vas-
cularity, the Lymph on the Iris, and the
contracted irregular Pupil.
  Symptoms.—When iritis is developed by any of these causes the symptoms
are as follows :  There is violent pain in the eye, this pain being deeply seated,
                             and referred to the course of the optic nerve
                             or to  its origin  in the  brain, in  addition to
                             which, changes in the color of the iris are soon
                             apparent, the  tint appearing  darker than  is
                             natural, owing to the afflux of blood to the tis-
                             sue.  There is also often  a change in the shape
                             of the pupil, in consequence of the irregular
                             contraction of its muscular fibres, and there is
                             usually noticeable a  zonular redness around
                             the cornea, this zonular  redness being of that
                             variety of vascularity  which is characteristic
                             of sclerotitis, Fig. 389.
                               The effects  of the  inflammation  may  also
                             show themselves in a way that produces se-
                             rious consequences; thus the iris may become
                             adherent  at its pupil  by the organization of
                             the effused lymph, either  posteriorly to the
                             capsule  of the  lens,  creating  a  condition
                             which  is described as  synechia posterior, or
                            it may adhere  anteriorly to the cornea,  and
develop the condition designated as synechia anterior.
  Inflammation of the iris may run on to such a grade  as will result in sup-
puration, the effused pus  escaping into the  anterior chamber, and causing
various degrees of yellowness  in  the color of the aqueous hnmor, to which
the name of Hypopion has been  given.   If the effusion of pus is  very free,
it may produce a bulging of the cornea forward, and result in the  establish-
ment of staphyloma.
  Diagnosis.—The diagnosis of iritis is generally easy, the change of color
being the  most marked  symptom.  It is, therefore, very  important to bear
in  mind the  fact that  there  may be peculiarities in the color of perfectly
healthy eyes, which, to a certain extent, would simulate the disease.   Thus,
an individual may naturally have  one eye gray, and one slightly  greenish;
and, under these circumstances, the surgeon would sometimes fall into error
if he depended for his  diagnosis upon the color of the iris alone.   Still, aa
a general rule, where there is a difference between the color of the two  irides,
particularly if the  pupil is irregularly contracted, and  the other  local  and
constitutional symptoms of the disease are present, the case  may be safely
set down under the head of iritis.
  Prognosis.—The prognosis  of  iritis depends  very  much upon the period
at  which  it comes under the  surgeon's observation.  If lymph  has  been
effused, if the pupil is  irregularly contracted, and particularly if the condi-
tion of things is such  as  to lead the snrgeon to suspect  either synechia an-
terior or synechia posterior, the prognosis will be unfavorable.   If the case
is seen at  an  earlier stage, and  before there is reason to suspect the effusion
of lymph, the prognosis will be much more favorable.
  Treatment.—The treatment of iritis is precisely that  which -would be
proper in the treatment of inflammations of any other highly vascular and
important structure, as  it  must be of the most active antiphlogistic charac-
ter.   The inflammatory process  here, as elsewhere,  always  presents an in-
creased vascularity, which, if left unchecked in the iris, will  result in an
effusion of lymph,  the dangers  of which have  been  pointed out,  if it does
not result in an effusion of pus.   The treatment should therefore be com-
menced by the  administration of  a brisk purge;  and this, to be serviceable 
CHOROIDITIS  AND RETINITIS.                 101
should contain a mercurial, so as to modify the general secretions.  The old
practice of salivating, under the idea of breaking down the effused fibrin, is
now generally regarded as incorrect and useless.
  To alleviate the pain  from which the  patient suffers, opium may be re-
sorted to, this being also indicated on account of the sedative, and conse-
quently antiphlogistic properties of the  drug.   But the most  important
measure is the local use of the  sulphate of atropia in solution, which, (see
Cataract,) while it serves to relieve the pain, also acts by directly diminish-
ing the inflammatory action, upon the old principle, "Ubi irritatio ibi affluxus
est." The solution of atropia answers another important point, as, by relax-
ing  the circular fibres of the iris, it allows the radiating fibres to contract,
and thus, producing  dilatation  of the  pupil, removes, in  a  great measure,
the risks of the adhesion  of its edges^and, by narrowing the iris, leaves less
tissue to be acted  on  by the disease.
  Should it happen, either from neglect or unskillful  treatment, or notwith-
standing good treatment, that the disorder terminates iu an obliteration of
the pupil by the adhesion of its edges,  and the patient is thus left blind, an
operation will become necessary, in  order  that, by the formation of an arti-
ficial pupil, the rays of light may be transmitted to the retina.   In selecting
the portion of the  iris in which the artificial pupil  is to be made, care should
be taken to choose that which is directly posterior to some  portion of the
cornea that is clear, if any opacities exist,  as hereafter described.
                    | 7.—Choroiditis and Retinitis.

   That the choroid and retina, as tunics of the eye, are liable to inflamma-
tion, and to the changes  of function and  structure induced by disordered
circulation and nutrition, cannot be doubted, especially in view of the great
vascularity of the choroid coat, and the proximity of the retina to it.  Hence
choroiditis  and retinitis, or choroido-retinitis, are very generally spoken of
by ophthalmologists.  How to recognize the disorder of deep-seated tissues
like the choroid or retina,  has always been  the difficulty;  and the results of
congestion  and inflammation in these coats have therefore, doubtless, given
rise to the varied conditions of defective vision hitherto spoken of as Amau-
rosis, (armupos, obscure,) this terra signifying loss of sight, without any change
of structure to an ordinary observer.  Amaurosis  has, therefore, long  been
a general term  applied  to all cloudiness or imperfection of vision not evi-
dently due to opacities of  the lens or of the cornea.  The discovery of our
ability to inspect the interior of the  eyeball, and the invention of the oph-
thalmoscope having euabled  the  surgeon to investigate the diseased  and
natural condition of the interior  structure of the eye, these disorders are
now more certainly recognized, and  their  treatment reduced to something
like scientific accuracy.  Without entering into the details of either, it must
suffice, in a  work of a  general character, merely to allude  to such points as
will show the present conditon of  surgical knowledge, and  refer the reader
desirous  of  more specific instruction to the varied treatises and monographs
on ophthalmic disorders.
   The Ophthalmoscope, as now formed, enables the observer to recognize
not only the condition of the choroid and  retina,  but  also of the  lens  and
vitreous humors of the eye;  and the disordered conditions thus  shown may
be best alluded to in connection with the use of this instrument.
   After Cummings, of England, had demonstrated  that it was  possible to
see the retina of the healthy eye during life, his  investigations led Helmholz,
of Konigsberg, in 1851, to  suggest an apparatus by which we could examine 
102
PRINCIPLES  AND  PRACTICE OF  SURGERY.
Fig. 390.
the retina by artificial light, after which Ruete, of Vienna, in the following
                          year, invented the plan of illuminating the re-
                          tina by means of a concave  mirror with a hole
                          in its centre, through which the observer looked,
                          this being the essential principle of most of the
                          ophthalmoscopes at present in use, a very great
                          variety  of which  have  since  been  produced,
                          some of them being exceedingly complicated.
                          Of these  instruments, it is generally conceded
                          that the simpler forms are not only more eco-
                          nomical, but of the  greatest practical utility.
                          That which  is  regarded  with  most  favor in
                          Great Britain and  this country  is the pattern
                          generally  known as that of  M.  Anagnostakis.
                          It consists of a  small, circular, concave mirror,
                          of about ten inches focus, having a hole  bored
                          in its centre, and mounted  with a shell or metal
                          rim and handle, Fig. 390,  and of a simple, bi-
                          convex lens, Fig. 391, of about two inches focal
                          length without mounting.  Both mirror and  lens
                          should be of good  quality, in  order to obtain
                          the best results.
                             As the  rays of light from  an illuminated re-
                          tina are convergent,  they are made to diverge
                          and come to a focus on the observer's retina, by
                          his holding a concave lens between the patient's
                          eye and his own, and regulating the focus by
                          moving it from or toward the eye of the  pa-
                          tient, Fig. 392.
  Mode of Examination by the Ophthalmoscope.—If the patient's  eye is
tolerant of light—and if it is not, the ophthalmoscope cannot be safely used—
The opening in the mirror is repre-
     sented as too large.
Fig. 392.
          Diagram giving a view of the examination of an eye by the Ophthalmoscope.

dilate the pupil by the use of a few drops of the  solution of the sulphate of
atropia, as directed in cataract.   Then seating him, in a dark room, near a 
CHOROIDITIS  AND RETINITIS.
103
table, so that the light may be placed by the side of his head, (affected side,)
the surgeon holds the mirror in his  right hand, before and near to his own
eyes, inclining it so that he may  cast the rays of light which it reflects
directly into the  patient's eye.   Then,  with his left hand adjusting the con-
cave lens so  as  to  bring  the rays to  a focus, he will have a good view of
the interior of the  patient's eyeball.   Sometimes it is useful to shield the
patient's eye  from the light by  directing him to hold a fan or screen  at the
side of his head, between  it and the light.  A steady light is important—
gas being better  than a candle or lamp.
   Appearances of the Healthy Eye.—The interior of the  healthy  eye of
man is of a red  or orange  color, being  more pink in the fair, and more
orange in the dark  complexions, presenting throughout, in both, the color
of  the choroidal  vessels, with the branching vessels of the retina  here and
there on the field.   The vessels  of the retina are to be seen emerging from
the entrance  of the optic nerve, which is the yellow spot  usually seen, this
being free from vessels.   If the  choroid is congested, the  bright, blood-red
color of the interior will be of  a marked character.  If the retina is dis-
eased, its vessels will be enlarged and tortuous,  or  there  may be spots of
extravasation of blood seen upon it in clots, or opaque spots of varied de-
grees of extent and density.  To appreciate these changes, the student must
carefully examine, and become familiar with, the appearance  of the healthy
eye, and make allowance for the congestion caused by the  examination.

                    Fig. 393.                  Fig. 394.
  Fig. 393.—A representation of the normal condition of the retina, as shown by the Ophthalmoscope. On the
centre there is seen the papilla of the optic nerve, with the arteria and vena centralis retinas—which may ba
distinguished by their color. (After Schauenberg and Von Trizt.)
  Fig. 394.—Black spots upon the retina, probably the remains of effused blood, and resulting from injury
produced by the iron point of a top, which perforated the iris and cornea. (After Von Trizt.)

   Abnormal  conditions of the crystalline  lens, as in commencing cataract,
may also be thus readily recognized.  According  to Desmarres,  "there is no
opacity of the crystalline body, however small and slight it may be, that can-
not be detected by  the aid of the ophthalmoscope."  The importance of dis-
criminating between the very earliest stage of incipient cataract and amau-
rosis  cannot be over-estimated, yet it is precisely at this very earliest stage
that the diagnosis is sometimes most difficult, or even impossible, except with
the help of this instrument.
   Disease of the Vitreous Humor, as opacities due to the presence of lymph,
or intra-ocular hemorrhages, as well as various opaque or dark floating bodies,
the precise nature  of which can as  yet only be  conjectured, but which are
supposed  to be altered blood by Dixon, may also, it is said, be satisfactorily
investigated by the ophthalmoscope.   The only well-known  Cysticercus has
been detected, in several cases of partial or complete blindness in the vitreous
humor, by Von Grraefe, and one case is reported by him in which this parasite, 
104           PRINCIPLES  AND PRACTICE  OF SURGERY.
after its recognition by the ophthalmoscope, was removed through an incision
in the sclerotic coat.   The patient's sight was greatly benefited for the time,
but it was feared that chronic choroiditis, which was apprehended at the time
of the report, might prevent the ultimate success of the operation.
   Morbid Conditions of the retina, as retinitis, congestion, or anemia, ac-
cumulations of liquid  behind the retina causing it to separate from the cho-
roid as in posterior hydrophthalmia, opacities and structural alterations of
the retina, can also be only satisfactorily diagnosed by means of the oph-
thalmoscope.
                 Fig.  395.                        Fiff. 39fi.
  Fig. 396.—The ophthalmoscopic iippearance of pai tial choroiditis—the gray poitn.ii dl,F«. ing bloodless, with
probable exudations.  On the margin are seen evidence of severe congestion, with sputs of effused lymph
(After Von Trizt.)                                                           v
  Fig. 396.—Large masses of effused lymph, seen in the eye of a female blind for six years.  There was also
diseased pigmentum nigrum and atrophy of the retinal blood-vessels. (After Von Trizt.)

   On account of the normal  transparency of the retina, congestion, exuda-
tions of lymph, and some other anomalous conditions of the Choroid can be
recognized in  the same manner.
   Figs. 395 and 396  illustrate some of these changes, and show the organic
disorders, often connected with loss of vision, resulting from diseases of these
deep-seated coats,  most of these changes  being unappreciated  before  the
discovery of the ophthalmoscope.


                             SECTION III.

            OPERATIONS ON THE EXTERIOR OF  THE EYEBALL.

  Anatomy of the Muscles of the Eyeball.—The  eyeball is moved by six
muscles—Plate XII.  Fig. 2—two of which are oblique and four are straight.
The straight muscles all arise from around the optic foramen, and are inserted
by broad aud  thin tendons into the sclerotic coat of the eye about three or
four lines from the cornea, Plate  XII. Fig. 4.
  The superior oblique muscle also arises from near the optic foramen but
the inferior oblique takes its  origin from the nasal  process of the  superior
maxilla at the side of the os unguis.   Both are inserted into the sclerotica
about half way between the cornea and the optic nerve.   Between all the
muscles and the conjunctiva is found a white fibrous membrane  which lines
the ocular conjunctiva throughout.   This membrane extends from the pal-
pebral ligament in  front as far as the  cornea, and  then turning backward
forms a complete envelope for the sclerotica until it reaches the optic  nerve
with the  neurilemma of which it  appears to be continuous.   On the sclero-
tica it is  very  movable, and a layer of cero-cellular substance is interposed
between them.  At the points of  insertion of the tendons, it is folded around 
STRARISMUS.                          105
them so as to form a fibrous sheath—Plate XII. Fig. 3—which degenerates
into cellular tissue  on the  muscle.   This membrane is designated by Mal-
gaigne as the Subconjunctival fascia.
                            \ 1.—Strabismus.

   Strabismus—qrpa^nq, twisted—or squinting is a disorder due to a want of
parallelism in the axis of the two eyes, which is kept up by the defective action
of some of the muscles of the ball.   The muscles involved are most fre-
quently the recti, although the oblique muscles are also at times affected.
The squint generally depends upon excessive contraction of one of the mus-
cles,  and this  is usually accompanied by preternatural  relaxation of its
antagonistic muscle.
   Varieties.—If the contraction affects the internal rectus  muscle, the com-l
plaint is called a converging squint, (strabismus convergens,) the  affected
eye being turned inward toward the  inner canthus.  The opposite condition
is designated divergent squint, (strabismus divergens,) and  in this the inter-
nal rectus is relaxed,  while the external is preternaturally contracted, thus
causing the ball of  the eye to roll toward the external canthus.
   If the oblique muscles are affected, the eye  may be rolled inward and
upward, or  outward and downward ; but these varieties are more rare.
   Etiology.—The causes which create the squinting are various.  Thus, it
may arise from congenital weakness of sight; from congenital malformation ;
from imitating others who squint; or be caused by looking too steadily and
too frequently at small objects ; by irritation of the stomach and bowels ; by
worms, etc.
   Treatment.—The treatment of strabismus is both constitutional and local,
and on account of  the  neglect of the  constitutional treatment, many local
remedies—as operations for its  relief—have failed, which which would other-
wise have been perfectly successful;  a general treatment should, therefore,
precede any operation.   If the cause is found to be irritation of the stomach
and bowels, this condition must be attended to ; if due to worms, they should
be  removed by means  of anthelmintics;  and if the patient is debilitated
and anemic, the  use of chalybeates  and tonics is indicated.  By thus im-
proving the patient's  general health, we may anticipate an improvement in
the condition of that  muscle of the ball upon which the complaint depends,
particularly when the excess of action on one side is the result of paralysis
of the opposite muscle.
   Advantage will also be derived from exercising the motions of the eye, as
the muscles of the eyeball may be strengthened and improved by judicious
exercise, precisely as those of other parts of the body.  The patient should,
therefore, stand before a mirror, and, covering the sound eye with his hand,
endeavor to look straight at it, as he  can readily do.  Or, in children, the
same result may be  obtained by placing two gilt balls—fastened behind the
head upon a semi-circular wire—near the external canthus of the eyes, and
inducing the little patient to look at them.  When it is evident that the stra-
bismus is produced by paralysis of one  of the muscles of the eye, such means
must be employed as  are likely to correct this condition ; thus, a blister of
small size may be put upon the temples, and the raw surface dressed with a
cerate consisting of a quarter of a grain of strychnia to an ounce of simple
cerate.
  Electricity has also been said to prove serviceable, particularly that form
of electro-magnetism  which is  produced by Faradian currents created by
the revolution of coils of wire before  the ends of a horseshoe magnet.  Such 
PLATE XII.
                OPERATIONS PRACTICED ON THE  EYEBALL.

    Fig. 1. Excision of a Pterygium  by the Bistoury.  1, 2. The fingers of the
  assistant who controls the lids.  3. The forceps seizing the pterygium, and
  raising it from the  eyeball, while it is excised toward the internal  canthus by
  the bistoury introduced beneath it.                After Bourgery and Jacob.

j    Fig. 2. A Vertical Section through  the External  Face of the Right Orbit,
  showing the Muscles of the Right Eye.  1. The eyeball.  2. Levator palpebral
  superioris muscle.  3.  Rectus superior.  4.  Rectus externus.  5. Rectus infe-
  rior.  6.  Inferior oblique muscle near its insertion.   7. The point of the origin
  of the recti muscles near the optic foramen.  The eyelids are seen iu position.
                                                  After Bernard and Huette.
    Fig. 3. A side view of the Sheaths of the Muscles of the Right Eye.   1. The
  eyeball.  2. The sheath of the levator palpebrae.   3.  Sheath of rectus superior.
  4. Sheath of rectus  externus.  5.  Sheath of  rectus inferior.  6.  Sheath of infe-
  rior oblique.                                     After Bernard and Huette.

    Fig. 4. A front view of the Eyeball, showing the insertions  of the  Ocular
  Muscles into the Sclerotica, and their tendinous expansion upon the ball.
                                                  After Bernard and Huette.
    Fig. 5. A front view of Hays' Operation for Strabismus, as practiced on the
  left eye.  The sound eye has been covered by a handkerchief, and the eyelids of
  the squinting eye distended by the spring speculum placed outside of the tarsus
  cartilage, while the  surgeon, raising a fold of the conjunctiva near the  internal
  canthus, divides it vertically with the scissors.  The muscle, being thus exposed,
  is seized  and divided as shown in Figs. 7 and 8.                 After Nature.

    Fig. 6. The Operation of Sedillot.  1. The speculum applied inside the lids.
  2. A double hook inserted into the ball to steady it.   3.  Forceps raising a fold
  of the conjunctiva.   4.  Division of the conjunctiva by slightly curved scissors.
                                                  After Bernard and  Huette.
    Fig. 7. An enlarged view of the Operation of Hays, showing the division of
  the muscle.                                                  After Nature.

    Fig. 8. The Muscle, as raised on a Hook.        After Bernard and  Huette.

    Fig. 9. Division of the  Muscle in Sedillot's Operation; the  chief difference
  being in  the scissors and hook employed for  this purpose.
                                                  After Bernard and  Huette.
          (106) 
 
 
STRAEISMUS.
107
a current may be passed daily through the temples;  but it is necessary to
nse it with caution,  particularly in the case  of children, where the fright
produced by the incautious application of it, by inducing violent struggles,
screaming, etc., might  result  in  an afflux of blood to  the part,  the  per-
nicious  influence of  which would more than  counterbalance any good that
would follow the application.
  But  when the careful employment of these means has failed, and the sur-
geon is satisfied that the squint is caused by a direct and continuous contrac-
tion of one of the muscles, he  may derive benefit from an operation.
  Operation for Strabismus.—The credit of suggesting the operation for
the relief of squinting has been generally assigned by European writers to
Stromeyer, but in the United States it is well known that he had been an-
ticipated,  and the operation performed many years before his account was
published, by Gibson,* of Philadelphia, who in 1818 operated in four cases,
though he was subsequently induced to lay it  aside from  the  opinion of
Physick being adverse  to it, the latter gentleman fearing that it would en-
danger vision.  To Stromeyer, however, is certainly due the credit of having
brought the  operation  into general notice in 1838, and to Dieffenbach be-
longs the honor of having established its success beyond a doubt.  In the
United States, the operation was subsequently performed by Willard Parker,
of New York, in 1840, and by Pancoast, A. C. Post, Gross, Detmold, and
Dixon, shortly afterward, who in several papers called attention to its utility.
Since then, it has been repeated by nearly every surgeon.  As the advantages
of this operation  appear, however, to have been  doubted by many, in conse-
quence  probably of  the failures which have  resulted from imperfect opera-
tions, or those injudiciously performed, I would state that most of the evi-
dence continues to be favorable to its performance, in proper cases.
   Various modes of operating have been employed by  different  surgeons,
though all have the  same object, to wit, the division of the contracted mus-
cle, and only differ in the means employed.
  Stromeyer controlled the movements of the eyeball by a fine hook inserted
into the conjunctiva, elevated a fold of the same membrane by forceps, incised
it with a cataract knife, and, raising the muscle upon a hook, divided it with
scissors or a curved  knife.
  Dieffenbach elevated  the upper lid with Pellier's speculum, depressed the
lower lid  by the finger of an  assistant, drew the eyeball outward  by a fine
hook  in the  conjunctiva, elevated a fold by another  fine hook,  incised the
conjunctiva between the hooks with curved  scissors, elevated the muscle on
a curved hook, and divided it  with the same scissors.
  Sedillot separated the lids by a spring speculum, inserted a hook into the
sclerotica to steady the eye, elevated a fold of the conjunctiva with forceps,
and divided it with curved scissors, Plate XII. Figs. 6, 8, 9, pursuing in the
remainder of  his operation the course just detailed.
  There is, however, according to my observation, no necessity for a hook
to fix the  eyeball, and the following plan, which I have frequently  practiced
with success, and which is the process long pursued  at  the Wills Hospital
for the Eye, in Philadelphia, is much more simple.
  Ordinary Operation.—Close  the  eye, generally the soundest  one, with a
handkerchief or bandage, in consequence of which the affected eye becomes
straight, if the case  is a proper one for the operation.   Then, having sepa-
rated the  lids by a speculum, seize a fold of the conjunctiva over the muscle
half way between the cornea  and the inner cauthus and a little below the
equator of the eyeball, with a pair of good forceps, Plate XII. Fig. 5;  elevate
* Principles and Practice of Surgery, vol. ii. p. 375.  Philadelphia, 1841. 
108            PRINCIPLES AND PRACTICE  OF SURGERY.
 it, incise it obliquely, not vertically, with a snip of the curved scissors; divide
 the fascia, if necessary, in  the  same way, pass a large curved  hook, Plate
 VIII. Fig. 23, having a convexity at least equal to that of the ball, beneath
 the muscle from below upward, and divide it with the same scissors.
   Seizing the conjunctiva in this manner is quite sufficient to steady the eye,
 and the subsequent steps of the operation are  equally simple.
   After-Treatment.—A little cold water and a fine sponge usually suffice to
 check the slight hemorrhage resulting from the incision, when, if the muscle
 has been thoroughly divided, the  patient will  generally be able to keep the
 eye straight.  The eye should then be left open, bathed frequently  with cold
 water, and the patient directed  to use it, while  the other is kept closed.  The
 use of a simple collyrium will generally relieve the conjunctival injection in
 a few days, when both eyes may be used, so as to acquire a proper parallelism
 of vision ; but, occasionally, a little fungous growth results from  the incision,
 and may require excision or to  be  removed by caustic, though it is not com-
 mon, except where the conjunctiva has been very freely divided.
   Guerin has proposed a subconjunctival  division of the muscle as being
 least  likely to permit that protrusion of the ball which is occasionally noticed
 when the primary incisions have  been very free;  but as the ordinary oper- ,
 ation does uot  induce this  when properly performed, and insures  the more
 perfect division of the fibres of the muscle and its tendon, the plan has nothing
 specially to recommend it.
   Operation of  Tavignot.—The  object of all the operations performed for
 the relief of strabismus being to  bring the pupil to  the  centre of the orbit
 by elongating the contracted muscle, little or no regard is paid to the con-
 dition of that of the opposite side, which, from being kept constantly upon
 the stretch, is unable to resist the action of  the  muscle which causes  the
 squint.  To obviate this, Tavignot has proposed  a new operation, the object
 of which is to shorten the muscle  which is elongated, instead of elongating
 that which is contracted, as in the ordinary operation ; he therefore operates
 as follows :—
   First Operation.—The longest muscle—say  the external rectus in conver-
 gent strabismus—being exposed in the usual manner, a blunt hook, with an
 eye at its extremity, is passed underneath the muscle so as to detach it from
 the globe of the  eye by lifting it up.   The hook  being then carried forward,
 so that its concavity may embrace the  muscle at  a  little distance from its
 aponeurotic expansion, a silk thread is passed through the eye  of the hook,
 and the latter removed, so as to leave the ligature  under the muscle.  By a
 double twist of the ends of the thread, a simple and resisting knot is formed,
 which is then tightened, and one end of the  ligature cut off, the other being
 brought out at  the corresponding angle of the eye and fastened by a little
 piece of plaster on the edge of the orbit.
   The first effect of this ligature is to render the lateral fibres of the muscle
 more central, and thus induce its shortening; while the second is to develop
 such an adhesive inflammation  as not only  permanently fixes the  abnormal
juxtaposition of the muscular  fibres, but also creates an adhesion of the
 muscle to the sclerotic coat.  As the ligature is only a temporary applica-
 tion, and not intended to divide the muscle, it  should be removed at the  end
 of the second or commencement of the third day, by drawing gently on the
 end which remains.
   Should this operation not prove sufficient, as would, perhaps, be found to
 be the case in very severe strabismus, another is to be performed thus:__
  Second Operation.—The hook being passed under the  muscle, as in  the
 first operation, the  ligature  is to be passed  not directly under the muscle
 but under the hook, so as to embrace the muscular expansion.   Then  in 
EXTIRPATION OF  THE  EYEBALL.
109
order to see if the globe is perfectly restored to its natural position, a differ-
ent colored thread should  be passed through the loop of the ligature, and a
single knot formed  in the first  ligature so as to constrict  the muscle, when
the hook may be  withdrawn, and the eye left to itself.  If the globe is now
not brought sufficiently back, a larger amount of muscular tissue must be
embraced by the ligature; but if the globe is brought too far round, then a
less amount must be inclosed—the ligature that constricts the muscle being
in either case relaxed as soon  as possible.  Owing to the  position of the
colored thread, this relaxation can be readily accomplished by pulling one
end of the ligature with one hand, and drawing the thread which was passed
through its  loop  with the other, by which manoeuvre the  knot will be made
to yield readily.  Then, passing the hook again under the muscle, recommence
the operation, keeping in mind the experience just obtained as to the amount
of the muscle to be constricted.
   Remarks.—The  principle of this operation is so evident as to require no
further explanation.

                    \ 2.—Extirpation  of the Eyeball.

   When, from malignant disease or other causes, it becomes necessary to
remove the entire eyeball, it is of great importance that as much of the upper
lid should be preserved as is possible, in order to protect the cavity of the
orbit from foreign matter as well as to favor the subsequent use of an  arti-
ficial eye.
   Ordinary  Operation.—The patient  being either  seated or lying down,
pass a large curved needle, armed  with a strong ligature, through the ball,
as far back as possible; remove the needle, and tie the  ligature in a loop,
so as to give the  assistant the control of the tumor.  Then, incising the lids
at the external  commissure,  if the globe is much enlarged, but not other-
wise, rapidly dissect the lids from the ball by cutting through the reflexions
of the conjunctiva.   Now passing the scalpel or straight  bistoury along the
os planum, carry  it  around the  orbit so as to divide the attachments of the
two oblique  muscles, and, on approaching the external canthus, remove, if
requisite,  the lachrymal gland.  Then, without drawing too strongly upon
the ligature, lest injury be done to the origin of the optic  nerve, put the four
recti muscles upon  the stretch, and, passing the knife to the bottom of the
orbit on its external side,  free their attachments to the ball, and remove the
eye, arresting the hemorrhage by cold cloths, or by lint wet with the solution
of the persulphate of iron.  The advantage  of the ligature over the forceps
or volselum,  as a means of controlling the tumor, will be found in the  firm-
ness of its attachment to the  ball, owing to  the fibrous character of the
sclerotic coat.  When scissors are  preferred to the scalpel, they may be em-
ployed as follows :—
   Operation of Mettauer, of Virginia.—Mettauer, of Virginia, repeated
Bonnet's operation  in the following manner :—
   The patient being in the recumbent posture, and under the influence of an
anaesthetic, the eyelids were divided as usual at the external canthus, and a
curved needle and ligature passed through the ball so as to retain it in  posi-
tion.   The eye being then drawn forward, an incision was made by passing
one blade of a pair of curved scissors through the conjunctiva and  beneath
the muscle on the inner side of the eye, as  in the operation of strabismus.
The four recti and the two oblique muscles being thus divided close to  their
insertions, the optic nerve was  cut by passing the scissors around it, and
the eye removed.
   The dressing was simply lint wet with water. 
110
PRINCIPLES AND  PRACTICE OF SURGERY.
  This case, two months after the operation, and another similarly operated
on by him two years previous, were well at the time of the report.
  Remarks.—When cancer or other disease is limited to the eyeball, and
the areolar and adipose  tissue in the  orbit is  healthy, preference may be
given to the mode of operating followed by Mettauer, as it is thorough, neat,
and simple ; but, in other cases, the older operation first detailed will be re-
quisite in order to enable the surgeon to remove all the  diseased structure
from the orbit.  The success of early  extirpation  of the eye in malignant
disease is more marked than when it has been developed elsewhere, Robert-
son, of Edinburgh,  having cured  twenty out of twenty-three cases.   This
operation  is not, however, so universally favorable in its results,  similar
growths being apt  to appear subsequently in the brain, or other organs, as
is generally the case in operations for malignant diseases.
                       \ 3.—Tumors in the Orbit.

  When fibrous or other tumors in the orbit are of such a size as to forbid
their extirpation  through the lids, it may become  necessary to  divide the
external canthus,  dissect them out, and then unite the wound by a stitch of
the interrupted suture;  a piece of linen wet with cold water being the only
dressing that is generally required.   When tumors,  and especially  those
which resemble  scirrhus, are found upon the tarsal cartilages, their removal
may be accomplished by a V incision, or in a manner similar to that spoken
of under the operation for Ectropium.  The bony tumors of the orbit will
require  careful  consideration, lest the attempt to remove them involve the
brain and its membranes.

                            SECTION IV.

   DISORDERS OP  AND OPERATIONS ON  THE  INTERIOR  OF THE EYEBALL.

                            § 1.—Cataract.

  Cataract is that diminution or total loss of vision which is the result of
certain  changes produced by disease in the lens, or on its capsule,  or on
both.   The function of the  lens being to  aid vision by concentrating and
modifying the rays of light in such a manner that the reflected image of ex-
ternal objects may be fairly thrown upon the retina, it is  placed immediately
behind the pupil, close to the iris, and directly in the axis of vision,  being
surrounded by its own proper capsule, between which and itself there is said
to exist a small quantity of fluid, described by anatomists as the Morgagnian
fluid.
  From these facts  it will be perceived that should  the lens and its capsule,
or either of them, become  opaque,  and the rays of light pass imperfectly
through them, or  not pass at all, no impression, or a very imperfect one, will
be made upon the retina.   When such a condition occurs, it is easy to un-
derstand that if we could get rid entirely of the opaque lens and its capsule,
and correct the imperfections of vision which its  removal produces, by  wear-
ing spectacles of  a  similar convexity to that of the lens, sight would be re-
stored ;  and this  is  what is actually done  in the  different operations for
cataract.
  Etiology.—The causes of cataract are various, and  not clearly known •
sometimes  it is  thought to be the result of inflammatory action, either com-
mencing primitively in the lens, or communicated to it from the other  struc- 
CATARACT.                         HI
tures of the eye.   The excessive stimulus of exposure to a glaring light by
stimulating the nerves of the eye, and producing inflammatory action, often
induces the complaint;  hence cataract is common among  glassblowers  and
the operatives in iron founderies.  Late hours employed in looking at minute
objects by a dim or a glaring  light have also an effect in the production of
the disease;  and it is sometimes found, therefore, in professional men  and
students, in seamstresses, in embroiderers, and  the  whole class  of persons
similarly occupied.  Cataract is also not unfrequently the result of wounds,
or of old  age, while it is sometimes congenital;  it is also found in the eyea
of other animals as well as of man, being said to be not unfrequent in the
eye of the calf.
  Varieties.—Cataract may be of various kinds, and it is hence divided into
several  varieties; this division being made according to its consistence, thus
creating the so-called hard and soft cataracts, the diseased lens being harder
or softer than the normal one.   It is also spoken of as mature and imma-
ture, while other varieties are made  according  to the seat of the disorder,
as lenticular, capsular,  or capsulo-lenticular.  A variety also exists in
which the part particularly affected is the liquor Morgagni, which, becoming
thick and opaque, is hence sometimes designated as  Morgagnian cataract.
  There are also varieties which are  dependent on color, the diseased lens
appearing, when  examined, to be white, gray, amber-colored, brown, radi-
ated, etc., while other varieties are named in accordance with the contents of
the capsule.  If these are thin, watery, and whitish, it is called a milky cata-
ract ; if thicker, and jelly-like, gelatinous; while, if hard or like bone in their
consistence, it is termed osseous. Now, it is a matter of some importance to
be able  to diagnose between these various kinds  of cataract, as the operation
which would exactly suit one variety would be  useless and unjustifiable in
another.  It will therefore be  useful to detail some of  the symptoms by
means of which these varieties can be distinguished.
  Symptoms.—As a general remark,  it may be stated  that  most of the
varieties of cataract may be detected  by simple inspection,  as some of them
are not only readily recognized by the  color and transparency of the  lens,
but also by its position aud size.
  1. Soft Cataract creates in the lens a prominence which does not natur-
ally belong to it, in consequence of which it tends to project through the pupil,
a condition which can be readily observed by looking at the eye sideways.
The lens is here larger than natural, while in hard cataract its size is dimin-
ished, or is of the natural bulk.   Soft cataracts can also be distinguished by
their color, which is of a grayish hue,  light, almost white, or of a slightly
bluish tint, resembling the color of skimmed milk, there being in this color
little or no admixture of yellow.   The opacity  also is not uniform, but re-
sembles rather a cloud, being darker in  some parts than in others.  The
soft cataract should not be confounded with the fluid cataract, which is much
more watery in its consistence, there being in the latter a breaking down of
everything like solidity in the structure of the lens.  In color this variety is
a dull gray, presenting  an appearance which has been compared  to thick
oatmeal gruel, or to good thick rich cream, and in this gray there is gener-
ally more or less  yellowness of color.
  2. Hard Cataract is, on the contrary, often positively yellow, or gray and
yellow combined  in various proportions so as to present the various shades
of brown ;  or it is amber-colored, or resembles wax slightly softened by heat.
As a general rule, the appearances  presented by cataract will be sufficient to
inform the surgeon whether the lens or its capsule is involved in the disease,
the capsular cataract being much whiter around its circumference than at any
other part, and presenting, generally,  opaque stria?, by which it may readily 
112           PRINCIPLES AND PRACTICE OF SURGERY.
be recognized.   Even when the capsule alone is involved and  the  lens is
sound, it is possible for the experienced ophthalmist to detect it, the opacity
not having the  same density as is seen when the latter is also involved.
  Complications.—The complications of cataract consist chiefly in the opa-
city of the lens being combined with some affection of the iris, as adhesion ;  or
with some loss  of power in the nervous portions of the eye.  Thus the same
individual may  have both  cataract and dimness or loss of  sight from an im-
paired condition of the retina or of the  choroid coat; while the iris may  be
adherent to the capsule of the lens, etc.   In the first of these cases it would
be useless to operate, for when the obstruction was removed, and  the rays of
light were allowed to pass freely through and impinge upon  the retina, they
would  find that structure totally unconscious of the impression ; while, if ad-
hesions existed between the lens  and the iris,  the removal of the cataract
would  probably induce iritis.   Cataract may also be complicated with oblit-
eration of the pupil, and with opacities  of the cornea.
  Diagnosis.—The diagnosis of cataract is very important, as the disease
is comparatively common, and physicians  in country districts, who would
be unwilling to operate, are frequently called upon to express an opinion  in
such cases, in order that if the eye requires it, the patient may travel to some
distant point to have an  operation performed.  Errors of diagnosis may,
however, be generally avoided, and a positive opinion in regard to the exist-
ence of cataract be accurately formed by means of the ophthalmoscope,  as
before  described, or perhaps more readily, by an inexperienced observer, by
means  of Sanson's catoptric  test, which depends upon the fact that if in a
darkened room a small candle is held before the healthy  eye,  three images
or reflections of it  will be  seen in the ball, one  being formed on the surface
of the cornea, which is large and upright;  one, faint and inverted farther in;
and a third, upright, clearer, more  distinct, and deeper in  the  eyeball than
the  inverted, but not so distinct as the  first erect image.   In cataract one
or more of these images is always wanting, for reasons that will be presently
shown.
  Catoptric Test—The formation of these three images in the healthy eye will
be readily understood by a brief reference to the character of the surfaces
which reflect  them; thus  the cornea presents  a convex surface which not
only transmits light, bnt,  like all transparent bodies, reflects  more or less  of
it, in consequence of which it  acts precisely like a convex mirror;  this, as is
well known, giving upon its  surface an erect image  smaller than the object
itself, and of a size diminishing as the convexity of the lens  increases. When,
then, a candle is held before the  healthy eye, the reflection from the cornea
causes  the formation of a  distinct image which is erect, and  corresponds in
its movements with the movements of the candle, thus forming the first  of
the  three images  of the catoptric test.   The anterior surface of the lens
forms also  a  convex mirror, but it is a mirror much  smaller and more con-
vex than that formed by the  anterior surface of the cornea.  This image,
therefore, is erect and distinct, though not so distinct nor so large as the an-
terior image ; and,  like that, it follows the motions of the candle, and is the
third or deepest image of the catoptric test, Fig. 397.   The posterior
surface, or,  more  correctly,  the anterior face of  the  posterior  surface
of the lens,  presents,  however,  a concave surface,  performing the part
and obeying the laws of a concave mirror, which, as is well known, forms
a small inverted image, that  is generally seen in the focus of the mirror
or at some distance anterior to its  surface.   This inverted image is there-
fore noticed between the two upright images just described ; it is fainter
than either of them, moves down whenever the  candle is moved up, and up 
                               CATARACT.                            113

whenever the latter is moved down, its motions  being precisely the reverse
of the motions made  by the candle.

                                  Fig.  397.
  A Diagram of thf. Catoptric Test of the State of the Lexs.—A.  The cornea. B. The front of the
 lens. C The anterior surface of the posterior side of the lens.  D. The candle.—1. The anterior erect image
 formed on the cornea.  -. The deep-seated erect image formed on the front of the lens. 3. The middle and
 invertc.l image formed by the posterior face of the lens. (Original.)

   In order to derive full advantage from the  application of this test, the pupil
 should be dilated by placing around the eye some of the extract of belladonna,
 or by dropping into it the  solution of the  sulphate of atropia.  The room
 should also  be  darkened, while the  operator,  seating himself upon a chair
 rather higher than that upon  which the patient is placed, holds a bright
 candle before the eye; and looks first for the most  anterior image, which is
 invariably to be seen if the cornea is clear. That found, he should proceed—
 disregarding the first image entirely—to look for the second, or the  small
 inverted  image, which will  be  present in the healthy eye, but not in  one
 where there is cataract, the opacity  of the lens preventing the rays of light
 from falling upon the concave  mirror, where this inverted image is formed.
 In the same manner, if the capsule of the lens is affected so that the anterior
 surface of the lens loses its mirror-like qualities, the deep upright as well as
 the inverted image will have disappeared.
   The diagnosis of cataract, therefore, is positive, although of course the catop-
 tric test alone will not enable the surgeon to decide whether or not the com-
 plaint is complicated with any other disorder, as retinitis, choroiditis,  etc.,
 either of  which  would render the performance of the operation doubtful.
   Treatment.—The treatment  of cataract is mainly operative, and may now
 be studied.
   Preliminary Treatment.—As the result of the operations for cataract
 depends,  in a great measure, on the  absence of inflammatory action, a well-
 directed  preliminary treatment is essential  to  the favorable termination of
 an operation.   In every instance strict attention should, therefore, be given
 to the healthy condition of the patient's system.   Let the surgeon see that
 there is no  sign of fever, and yet that there is sufficient strength of pulse
 to insure adhesion of the  flap in the cornea, if extraction is to be prac-
 ticed ; let him  also  see  to  a thorough  evacuation of the bowels, as  well
 as to the  fact that there is  no  diarrhoea.   As a general rule, an antiphlo-
 gistic diet should be observed several days before and after the operation;
 but if  the patient is advanced in life, and  the pulse becomes irritable, good
 diet and  tonics may possibly prove  beneficial.  A  very general rule, given
 in most  of the  works on ophthalmic surgery, is, " Never to  operate  on a
 patient with  a foul tongue."   Yet  it has occasionally occurred to me to
see patients  who, from always having the tongue more or less furred, even
in ordinary  health, did very well when operated on  under these circum-
    VOL.  II.—8 
PLATE  XIII.
                        EYE  INSTRUMENTS.

  Fig. 1. Beer's Triangular Cataract Knife.       After Bernard and Huette.
  Fig. 2. Richter's Knife, slightly differing in the width of the blade from that
of Beer.*                                       After Bernard and Huette.
  Fig. 3. Wenzell's Cataract Knife.
  Fig. 4. Beer's Lancet-shaped  Knife.
  Fig. 5. Cheselden's Curved Corneal Knife, for incising the capsule, or enlarg-
ing the cornea in extracting cataract.  Daviel's  scoop or spoon is attached at
the other end of the handle.                      After Bernard and Huette.
  Fig. 6. Beer's Straight Knife, for enlarging the incision in the  cornea in the
operation of extraction of cataract.              After Bernard and Huette.
  Fig. 7. Beer's Hook, for extracting the capsule.    "
  Fig. 8. A front view of Dupuytren's Couching Needle.
                                                After Bernard and Huette.
  Fig. 9. A side view of Dupuytren's Couching Needle.
                                               After Bernard and Huette.
  Figs.  10, 11.  A side and front view of Adams's Couching Needle.
                                               After Bernard and Huette.
  Figs.  12, 13.  A three-quarter and side view of Scarpa's Needle.
                                               After Bernard and Huette.
  Fig. 14. A side view of Walker's Needle.          "      "
  Fig. 15. Benjamin Bell's Speculum.               "      "
  Fig. 16. Pellier's Elevator.
  Fig. 17. A modification of Wardrop's Forceps, for stretching the free edge of
the eyelids in excising the tarsus cartilage.       After Bernard and Huette.
  Fig. 18.  A Tenotome, sometimes employed in strabismus, but better adapted
to larger muscles.                                           Kolbe's pattern.
  Figs.  19, 20.  Straight and Curved Spring  Scissors, for minute sections, and
applicable to operations on the  conjunctiva, etc.           Charriere's pattern.
  Fig. 21.  Curved Forceps,  for the removal of the canula, sometimes employed
in fistula lachrymalis.                                    Charriere's pattern.
  Fig. 22.  Fine blunt-pointed Forceps, for extracting the cilia in trichiasis, etc.
                                                        Charriere' s pattern.
  Fig. 23.  Laugier's Trocar, for perforating the os unguis, or the bony ductus ad
nasum in fistula lachrymalis, when the ordinary channel cannot be dilated.
                                                After Bernard and Huette.
   Fig. 24.  Bistoury for  fistula lachrymalis.                   Kolbe's pattern.
   Figs. 25, 26.  Bellocque's Canula, for tamponing the nostril, showing the spring
as open and also as closed.                                   Kolbe's pattern.
   Fig. 27.  Charriere's Exploring Needle.  The needle, being grooved and per-
forated, is passed into the  cavity to be examined,  and then the spring being
touched, the piston of the syringe is moved, and draws into  the syringe, through
the grooved needle, some of  the liquid contents of the part into which it is thrust
in the exploration.                                     After the  instrument.

               * Walton has recently shortened this knife, as stated in the text.
(114) 
Hate   13
ft,; a. Ke.l2.
Fi£13
Fi£ 10
Fig. 14
Kbman ■% 
 
CATARACT.
115
stances.  Indeed, no rule of general treatment can here be given that will not
be found to have some  exception  to its universal observance.  Caution and
judgment in this, as in other operations, can alone properly prepare the
patient's constitution.
   The local treatment,  previous to operating for cataract, consists in the pro-
duction of such a dilatation of the  pupil as will enable the operator to obtain
a good view of  the lens, diminish the  risk of  wounding the  iris, and admit
the free access  of the  aqueous humor, if the operation  of absorption  is
selected.
   Dilatation of the pupil was formerly accomplished by smearing the lids,
eyebrow, and temple  with the extract  of belladonna or stramonium, diluted
with water to the consistence of thick  cream,  and applied every ten minutes
for an hour previous  to operating ; or  by dropping into  the eye a  solution  of
the extract; but both  are  objectionable  as uncertain  in  their  effects and
filthy in their use.  A better and more certain  method is to drop a few drops
of a solution of the  sulphate of atropia, two grains to the ounce of water,
once or twice daily into the eye, or apply cloths moistened  with the solution
to the closed lids a few minutes before operating.   The dilatation, in most
cases, is prompt, and  in one instance continued for three days after the  oper-
ation,  leaving the iris like a fine ring near  the circumference  of the cornea.
   The credit of suggesting the  employment of narcotic agents for dilating
the pupil has been long assigned, by European writers, to Himley, of Got-
tingen, who recommended  the  use  of the extract of belladonna in  1801.
Four years  prior to this period, however, a  similar suggestion  had  been
made,  aud  published in  Philadelphia, by Samuel  Cooper, a graduate  of
the University of Pennsylvania, who, in  an  inaugural essay, published  in
1797, reported numerous experiments  on the  effects of the  datura stramo-
nium on the system generally, as well  as on the  pupil of the eye.*  I have
also been informed by Benjamin H. Coates, of Philadelphia, that Rush and
Physick both taught this in their lectures,  and that Physick always resorted
to  the formula  of Cooper for its preparation.f  To Cooper is, therefore,
due any credit that may be connected  with the suggestion.
   Another step  in the  treatment  of cataract, previous to operating, is the
application of a bandage on the eye opposite  to that which is to be operated
on, as advised by Celsus, as it tends very materially to steady the eye if there
is any vision, especially in children.
   The position of the patient, of the operator, and of the assistant, together
with the  period  at which the operation should be performed, and the kind
of operation to be selected,  may also be placed under the same head, and  be
briefly referred to at  present.
   The position of the patient and the surgeon depends very much upon the
kind of operation to  be performed.   For  extraction, the recumbent posture
of the  patient is the best, as it adds to his safety by diminishing the tendency
in the  humors of the eye to escape through the opening in the cornea; but,
in the  operations of depression or absorption, it will generally be found more
convenient to place the patient on a moderately low chair, with a side light,
and let the  operator sit directly before him on a  higher stool, or  chair with-
out arms, so as to be at perfect liberty in his  movements.   Some operators
prefer  following the  advice of Scarpa, and  employ a  stool on which they
place the foot of the  same side of  the  operating  hand,  resting the  elbow  on

  * A Dissertation on the Properties  and  effects of the Datura  Stramonium,  or  the
Common Thorn-Apple,  and on its  Uses in Medicine, by Samuel Cooper, M.D. 8vo.
Philadelphia, 1797, p. 16,  experiment 15.
  f Several copies of the Dissertation may  be found in the Library of the Pennsylva-
nia Hospital, Philadelphia. 
11G            PRINCIPLES AND  PRACTICE OF SURGERY.
the knee thus raised.   Such a position is, however, purely a matter of con-
venience, and one which, to many, would  prove exceedingly embarrassing.
If the surgeon's hand requires such a support to steady it, prudence  should
suggest that he had better lay aside his instruments.   When an anaesthetic
is administered, of course the position of the patient must be the horizontal
one, with the head moderately elevated.
   The position of the assistant should be behind the patient, with  one hand
placed under the patient's chin, so as to  steady the head  against his own
breast; while the pulps of the index  and second or ring  finger of  his other
hand should be brought to the same length and to the same level, so as to
raise the lid  by drawing the tarsus cartilage toward the  superciliary ridge,
where  it should be retained until the surgeon directs its release.  If the eye-
lid is moist and difficult to  hold, the  assistant should dry it thoroughly, or
touch the points of his fingers in a little flour or other dry powder, previous
to seizing the  lid.  A speculum, or the  elevator of Pellier, Plate XIII.
Fig. 16, may be resorted to, if the orbit is deep; but,  as  a general rule, the
eyelid  may be best kept in position by the fingers placed  as just described.
   The period at which cataract should  be operated on was once  deemed a
matter of importance, both  as respects the season of the  year, and the age,
ripeness, or perfection of the opacity in the lens;  but any season, with fine
clear weather, will answer, while the best period, in reference to the matura-
tion of the cataract, is  that when  its  presence  in both eyes is well  ascer-
tained.  The existence of opacity being once well settled,  it is best not to
wait for the  entire loss of vision or perfect  maturation of the cataract, as
every week after  a well-marked  opacity  is evident, is liable  to increase the
density and toughness of the diseased structure, and, consequently, add to
the difficulty and  risks of the operation.
   Three kinds  of operations are performed for the removal of cataract, to
wit: extraction,  absorption, and depression,  the  selection of  either being
usually decided by the following facts:—
   1st.  Absorption, depression, or reclination are attended with but  little risk
of the loss of the eye,  and may be repeated as often as is  necessary; they
are well adapted  to soft or hard cataracts, in which  the anterior chamber of
the eye and the eye itself are small.  Depression of a  hard  cataract, it should,
however, be recollected, is liable to produce choroiditis or retinitis, and con-
sequent blindness, while not unfrequently a  lens, when depressed, will rise
again into the axis of vision.
   2d.  Extraction is an  operation  peculiarly calculated  for hard  and firm
cataract, but requires considerable dexterity on the part of  the surgeon and
his assistant, as well as a large prominent eye, with a full anterior chamber, on
the part of the  patient.  Linear extraction is a modification of extraction spe-
cially adapted to  soft cataracts.  Of these operations, extraction is  the more
prompt and brilliant; absorption, depression, or reclination the safer.  Phy-
sick and M'Clellan, in Philadelphia, and Roux, in Paris, favored extraction-
but the majority of surgeons in the United States seem to prefer absorption
or linear extraction.   Sichel, of Paris,* " has no exclusive preference for any
operation, as he depresses hard cataracts in all ages, although he prefers their
extraction in aged patients.   He breaks up all soft or half  soft cataracts in
patients below  forty, and especially below thirty; but extracts them in indi-
viduals over forty, and in all those over fifty, as he finds that breaking up
such cataracts  in these patients is followed  by swelling  of the lens,  which
compresses the internal coats of the eye, and causes violent inflammation.  In
patients below forty, and especially in children from  six months  to fifteen
* Gazette des Hopitaux, No. 54. 
CATARACT.                          117
years, he has  found the tolerance, after the  use of the needle by a skillful
hand, very great."
  In order to operate upon  both eyes equally well, whether the patient be
placed in the sitting or recumbent posture, it becomes necessary for the sur-
geon to change  his position, unless he is ambidexter, as he must otherwise
operate upon the left eye with his right hand while in front of the patient,
and on the right eye  with his left hand, if in  front, on account of the promi-
nence of the nose; while, if he wishes to employ the right hand in both eyes,
he will be compelled to place himself behind the patient.   Having consider-
able facility in using  the left hand,  a change  of position  has never been ne-
cessary in my case; and as this facility can be readily acquired by daily exer-
cise, an operator will ultimately find  it more satisfactory to attempt it, and
practice with  the  left as well  as with his right hand, in order to be  able
always to retain his position in front  of the patient, as this offers many facili-
ties in manipulation as well as in sight.
  Operations.—The  operations  for  cataract are, as has just been stated,
divided into three kinds :  absorption, or that in which the  lens is dissolved
by the action of the aqueous humor ;  depression, in which it is pushed below
the axis of vision,  and lies buried in the vitreous humor;  and extraction,  in
which it is promptly removed from the eye.   Reclination is a modification
of depression.
  I. Operation by Absorption.— The  success of this operation being due
to the  power possessed by the  aqueous  humor of dissolving the lens, the
object of the operator  should be to  lacerate it and its capsule, and throw
them forward into the anterior chamber of the eye.  The preliminary steps in
all the operations are  very much the same, as respects diet and the dilatation of
the pupil; it is, however, of more consequence in absorption than in extrac-
tions to obtain a full  dilatation of the pupil, not only in  order to admit the
free action of the aqueous humor upon the lens, but also to protect the iris
from injury and enable the operator to see exactly what he is doing.   The
needles required for cutting up the lens and its capsule  are very varied, it
being said that there  are upwards of  seventy different kinds, a few of which
are shown in Plate XIII. Figs. 8, 9,  10, 11,  12, 13 ; they seem to have been
selected very much  at the  fancy of each operator, though that of Saunders
or of Scarpa  is most  frequently resorted to.   All that is really essential is,
that they should have a sharp double edge, and not be too long.
  Isaac Hays, of Philadelphia, recommends  the following knife needle :—*
" This instrument, from the point to the bead near the handle, is six-tenths
of an inch.   Its cutting edge is nearly four-tenths of an inch.   The back is
straight to near the  point, where  it is  truncated, so as to make the  point
stronger, but at the same  time leaving it very acute ; and the edge of this
truncated portion of the back is made to cut.   The remainder of the back is
simply rounded off.   The cutting edge is perfectly straight, and is made  to
cut up to the part where the instrument becomes round.  This portion requires
to be carefully constructed, so that as the instrument enters the eye it shall
fill  up the incision, and thus prevent the escape of the aqueous  humor."
" The handle  should  be octagonal, with equal sides and of the  same thick-
ness its whole length."
  Ordinary Operation.—The capsule and lens being acted on by means of a
needle introduced through the sclerotica, the operation has hence been called
scleroticonyxis.  The pupil being dilated, one eye bandaged, and the head
supported against the breast of the assistant, or else the patient lying down,
  * Knife needle for the operation of cntarnct by solution or absorption, by Isaac Hays,
M.D.  Am. Journ. of Med. Sci., vol. xxx. N. S. p. 81, 1855. 
118
PRINCIPLES AND  PRACTICE OF  SURGERY.
the surgeon should depress the lower lid with the index and second finger of
the hand corresponding with the eye to be operated on, and the assistant at
the same  time  elevate the upper lid, as directed  in extraction ; or, if the
operator is dextrous, he may sustain both lids  himself, by separating them
with his thumb  and forefinger.   Then, seizing the  handle of the needle be-
tween the thumb, fore,  and second finger of the  hand opposite to that of the
eye to be operated on, and holding the instrument like a pen, with the fingers
strongly flexed,  and the little and ring finger resting against the cheek-bone,
present  the point of the needle perpendicularly to the sclerotica,  with  its
convexity upward and  its edges transverse, one or two lines behind the cir-
cumference of the cornea, and about half a line above or below the median
line of the ball, so as to avoid the long ciliary artery.  Being satisfied with
its position, and while  the patient is looking toward his  nose, puncture the
sclerotica, and rotate the handle of the  instrument a quarter of a circle be-
tween the fingers;  then  turning the concavity of  its point, if  Scarpa's, or
the breadth of the blade, if  that of Saunders, backward, pass it toward the
centre of the eye, and  depress the  handle  toward the temple.   When the
point, dextrously managed, has reached the centre of the pupil, turn  the cut-
ting edge of the  needle to the  cataract, and cut the capsule—Plate XIY.
Figs. 3, 6—and  lens into several fragments, throwing them forward  into the
anterior chamber, where they will subsequently disappear by dissolution ; or
they may  be removed by linear extraction,  as hereafter stated.
   If the cataract is soft and milky, one operation will generally suffice, but
if the lens or its capsule is more resisting, it may become necessary to repeat
the operation several times, at intervals  of a few weeks.
   After-Treatment.—The eye being closed  and  protected from the  light,
cold cloths may be  applied,  and the same  treatment pursued as is  directed
in  extraction.  The pupil should, however, be kept dilated for several  days
after the operation, in order to  permit the free access of the aqueous humor;
and it is not requisite to enjoin  such absolute rest as is directed in the opera-
tion of extraction.  Should inflammation of the eye supervene, it should be
treated on the general  antiphlogistic plan.
   When the capsule remains thickened, or when fragments do not disappear,
a repetition of the operation will generally be required.
   Keratonyxis, or the operation  of absorption  by a  needle  introduced
through the cornea, was suggested by Conradi, but introduced iuto  practice
to a considerable extent by Saunders, and is hence sometimes designated as
his operation.   It  consists  in  introducing the needle through  the cornea,
and lacerating the capsule in front; but, as it  is liable to give exit to the
aqueous humor, induce prolapse of  the iris, and leave a scar in  the cornea,
the operation through the sclerotica is preferable in the majority of instances.
   II. Operation by Depression or Couching.— The preliminary  steps of
this operation being precisely the same as those required in  absorption, a
repetition of them is unnecessary.
   Ordinary Operation.—The position of  the patient being either sitting or
recumbent,  and that of  the  surgeon being  the same  as in  the preceding
operation, the  needle  should be introduced  into the sclerotica  about two
lines  behind the cornea, and  passed directly to  the centre  of the  pupil
between  the iris and the capsule,  Plate  XIV. Fig. 8.   Then,  depressing
the handle,  cause the point of the  instrument  to apply itself on the top of
the lens, and depress it  backward  and  downward, by elevating the handle
and carrying it slightly forward, Plate XIV.  Fig. 7.   After placing  the
lens in  the vitreous humor  below the axis of  vision, retain it there a few
seconds, and withdraw the needle by reverse  movements through  the sclero-
tica, with its convexity forward.  The different positions of the needle during
the operation are shown  in Plate XIV. Fig. 4. 
CATARACT.
119
  If the lens rises before the needle is removed, it must be again depressed,
and if it escape into the anterior chamber, and cannot be drawn back, it may
be removed by the section  of the cornea, as in the operation for extraction.
  In Reclination, the lens  is turned on its  axis  so as to be placed horizon-
tally instead of being depressed perpendicularly, Plate XIV. Fig. 2.
  Operation of Malgaigne.—Malgaigne being of the opinion that the rising
of the lens, when depressed with  its capsule, was due to the attachments of
the latter  being  rarely totally destroyed,  and to the fact  that  its capsule
resisted  absorption, and was liable  to rise a long time  after the operation,
proceeds as follows :—
   The patient lying down or being seated, and the surgeon placed either
before or behind  him, so that he can always use his right hand, the needle is
introduced—as before directed—so as to pierce the posterior and inferior part
of the lens ; the capsule divided, and then, the needle being passed above the
lens with its concavity looking downward, a simple movement of depression
suffices to cause  the descent of the lens,  whence it will not rise again, as the
walls of its capsule collapse immediately.   This proceeding Malgaigne pre-
fers, especially when the lens  is  hard.  Bretonneau and Velpeau  lacerate
freely the cells of the hyaloid membrane before depressing the lens,  in order
to prepare a way for its descent  into  the vitreous humor, and have fouud it
often successful.   About two  months after either the operation of absorp-
tion or depression, the patient may very gradually commence the use of the
cataract glasses,  which are intended to aid vision by supplying the place of
the lost lens.
   III.  Extraction___The operation of extraction is particularly suited to the
cases of hard cataract in adults with  prominent eyes, and to operators who
possess a perfect control of  their fingers.   The assistant  must  also be one
perfectly familiar with his duty.   He should place himself behind the patient,
and elevate the upper lid,  either  with  his  fingers placed as before directed
 or by introducing Peltier's  speculum beneath the lid, drawing  it directly
upward, making himself sure that the lid  cannot escape from his grasp, and
yet holding it so as to avoid pressure upon the eyeball, after the section of
the cornea.   On one occasion I saw  an assistant evacuate  the  entire con-
tents of the eye, in consequence of pressing upon  the  ball.   Occasionally,
and especially in timid patients, the surgeon may find it  necessary to restrain
the rolling of the eye by pressure on  the ball with  his  fore and second or
third finger, while depressing the lower  lid; but it can rarely become neces-
 sary for the assistant to make any pressure upon the eye, and, as a general
 rule, it should be strictly avoided.   Various-shaped knives have been recom-
 mended for this operation, and are known as those of Beer, Wenzel,  Richter,
 and Ware, Plate  XIII. Figs. 1, 2, 3; but most surgeons resort to the triangular
 knife of Beer, in  preference to the others, except under peculiar circumstances.
 The other instrument consists in Daviel's  scoop and Cheselden's knife, together
 with small scissors and forceps, Plate XIII. Figs. 5, 6, 7.  The  operation is
 arranged in three parts : incision  of the cornea, laceration of the capsule, and
 extraction of the lens;  although occasionally the first two are performed at
the same time.   The incision of the cornea may be performed either at the
 superior, exterior, or inferior portion of its circumference, Plate XV.  Figs.
 4, 3, 1.   Lawrence deems the superior section the best, the  exterior next,
 aud the inferior  the most  objectionable, although the easiest to perform, as
 it exposes the patient to a  rapid escape of the aqueous humor, to prolapse and
 wound of the iris,  as well as to trouble in  the adjustment of the corneal flap,
 from the  action of the edge of the lower lid.*  Sichel always extracts by
* Lawrence, by Hays, Phila. edit. 1817, p. 640. 
PLATE  XIV.
                 OPERATION OF  COUCHING CATARACT.

  Fig. 1. A vertical section of the Eyeball, to show its component parts.  1. The
cornea.  2. The sclerotica.  3. The choroid  coat.  4. The retina.  5.  The iris.
6.  The anterior chamber.  7. The lens.  8. The vitreous humor.  9. The optic
nerve.                                           After Bernard and Huette.
  Fig. 2. Reclination  of the  Lens,  as shown in  a vertical  section of the eye.
1.  The natural position of the lens.  2.  Its reclination in the vitreous humor.
                                                After Bernard and Huette.
  Fig. 3. The operation of absorption, or  breaking up of a cataract, as prac-
ticed on the left eye.  1.  The right hand of the surgeon puncturing the sclerotic
coat.   This puncture is usually made within  two  lines of the circumference  of
the cornea, and not as  far  back as is represented in  the figure.   2, 2. The
fingers of an  assistant  elevating the upper lid.   3, 3. The fingers of the left
hand of the operator depressing the  lower lid and steadying the  ball.
                                                After Bourgery and Jacob.
  Fig. 4. The different positions of the needle in  the operation of Couching, as
performed upon the left eye.   1. The needle is now held in the right hand like a
pen, the  hand supported  by  the little  finger resting on the cheek-bone; the
needle is also represented puncturing the sclerotica at the  usual point, that is,
about  two  lines behind the cornea, but below the transverse diameter  of the
eyeball.  2. The second position of the needle.  3. The elevation of the handle
necessary for the entire couching of the lens, or the third position of the needle
in this operation.
  Fig. 5. Couching of Cataract in  the right eye.  1, 1. The first and second
fingers of an  assistant raising the upper lid.  2, 2.  The first and secona fingers
of  the operator depressing the lower lid.  3.  The cataract needle held like a
pen in the left hand, the little and ring finger supported on the cheek-bone, and
puncturing the sclerotica about two lines behind the cornea, and a little above
the transverse diameter of the ball, so as to avoid the long ciliary artery.
                                                After Bernard and Huette.
  Fig. 6. Position of the needle in the act of lacerating the  front of the capsule
in the operation of absorption, as shown in Fig. 3.  After Bernard and Huette.
  Fig. 7. Position of the  needle in couching, as the lens leaves  the axis  of the
pupil; the handle of the instrument being moved gradually  upward, and  the re-
verse, the point of the needle will carry the lens downward and backward, until
imbedded in the vitreous humor.                  After Bernard and Huette.
  Fig. 8. The same operation as shown in Fig. 5,  after the needle has entered
the posterior  chamber, and partially depressed  the  lens.   1. The relative posi-
tion of the handle of the instrument to the axis of the eye at this period.  The
needle, having passed between the iris and the lens, is seen, with its concavity
resting on the top of the lens, previous to couching it.
                                                After Bernard and Huette.
       (120) 
\\
Rtv
 
 
CATARACT.
121
 the upper section, the advantages of which, he thinks, are very great, as the
 upper eyelid forms  a  kind of supporting bandage, which is  still further
 increased by his method of applying five strips of adhesive plaster over the
 eyelids of each eye, and  covering them by graduated compresses and  a
 bandage  in such a manner as to exert a gentle compression  on the edges of
 the wound, and  prevent its becoming separated during the movements of
 the patient.*
   Ordinary Operation of Extraction.—The  propriety of dilating the pupil
 previous  to extracting cataract is a question not positively settled, its ad-
 vocates claiming extra safety from wounds of the iris by the knife, and its
 opponents charging it with exposing  the  patient to the sudden loss of the
 vitreous  humor.  Although its dilatation certainly renders the iris more
 secure, yet I think a dextrous  operator  would probably prefer operating
 without dilatation, as the iris would be but little exposed to injury from a
 knife  properly  managed.   The  general  preliminary measures  being, how-
 ever, completed in accordance with the views of the surgeon, the operation
 may be performed as follows, varying the line of the incision according as
 it is wished  to perform the superior, exterior,  or inferior section.   The
 former, being the best, may be taken as the type.
   The surgeon, either sitting or standing, and being either in front of or be-
 hind his patient, according as he is ambidexter or operates only with the right
 hand,  should elevate  the lid by the index  and second finger of his left hand,
 separating them, and pressing their pulps against the sides of the eyeball, if it
 is necessary to steady it.   Then holding the knife by its handle, with  the
 thumb and fingers flexed, as in the downward motion of the pen, and rest-
 ing the ring and little finger upon the cheek-bone, if desirable,  to support
 the hand, let  him insert  the  point of the knife perpendicularly into  the
 cornea on its temporal side, about half a  line from its circumference, or line
 of junction with the sclerotica, and, making sure  that the point of the in-
 strument  penetrates the entire thickness of the cornea, aud enters the ante-
 rior chamber of the eye, and that it has not passed between  its lamina, pass
 it parallel to and in front of the iris, in the line of the transverse diameter of
 the eye, over to the internal side of the  cornea, at a point corresponding
 with  that at which it  entered, Plate XV. Fig. I.  If  this is steadily and
 quickly done, the entire section of the cornea  will be readily accomplished
 simply by  the width of the knife.
   The assistant should now be directed to  allow the lids to close.  After a
 few seconds'rest, they may be gently wiped and  opened as before, great care
 being  taken to  avoid pressure on the ball.   Then the surgeon, while eleva-
 ting the lid, should press very gently against the ball from  below upward,
 so as to render the lens prominent, or introduce the back of the little  knife
 attached to Daviel's curette beneath the edge  of the cornea!  flap, and press
 its point against the capsule of the lens and  lacerate it, as is shown  in the
 inferior section in Plate XV. Fig. 5.   Generally, the lens escapes promptly,
 in consequence  of the compression of the ball  by  the muscles  of the  eye.
 If it does not, moderate pressure against the ball  with the handle of the
 curette, Plate XV. Fig. 6, or seizing the lens with the  forceps, Plate XV.
 Fig. 8, or with the curette, will facilitate it;  but in all these movements great
 caution must be exercised lest  the  vitreous humor also protrude.    The
 operator should then  see that the iris has  not  prolapsed  or been caught be-
tween  the  flap and the edge of  the cornea;  and, being satisfied  that all is
right, let him at once close the  eye, and cover it with  a light  bandage so
constructed as to exclude the light, without pressing upon the ball.
* Gazette des Hopitaux, No. 54. 
PLATE  XV.
 OPERATIONS  FOR EXTRACTING CATARACT  AND THE FORMATION OF
                          ARTIFICIAL PUPIL.

  Fig. 1. Extraction of the Cataract from the left eye by the inferior section.
1,1. The first and second fingers of an assistant raising the upper lid.  2, 3. The
middle and forefinger of the surgeon depressing the lower lid. -4.  The knife held
in the right hand of the  surgeon; its point, having passed through the cornea
and across the anterior chamber, is seen at its exit near the internal canthus.
                                               After Bernard and Huette.
  Fig. 2. The completion of the section of the Cornea.      "           "
  Fig. 3. Extraction by  the oblique section of the Cornea.   "           "
  Fig. 4. Extraction by  the superior section of the Cornea.  "           "
  Fig. 5. Incision of the Capsule  of the Lens, in  the inferior section, by the
knife of Cheselden,  as modified  by Boyer; but the knife that incises the cornea
in extraction may also be made to cut the capsule as it passes across the lens.
                                               After Bernard and Huette.
  Fig. 6. Expulsion of the Lens in the inferior section.  1. The forefinger of the
operator steadying the lower lid. 2. Gentle pressure upon the ball by the handle
of the knife applied to the upper lid.             After Bernard and Huette.
  Fig. 7. Section of the Cornea by the knife of Furnari.     "           "
  Fig. 8. The same  operation, showing the removal of the cataract by forceps
introduced through the opening  in the cornea.     After Bernard and Huette.
  Fig. 9. Mulder's operation  for  Artificial Pupil.   An opening  in the cornea
admits scissors, by which  the four  angles resulting  from  the  crucial incision
made  in the i»s are  excised.                       After Bernard and HuMe.
  Fig. 10. Velpeau's operation for Artificial Pupil.  The knife incising both the
cornea and iris, so as to cut a flap in the lower portion of  each.
                                                After Bernard and Huette.
  Fig. 11. Pancoast's operation for Artificial Pupil in the first stage.  1. Finger
of assistant  holding up the lid.  2.  The  cataract knife puncturing the cornea
and iris.                                                   After Pancoast.
  Fig. 12. Pancoast's operation for the formation of an Artificial Pupil  in the
second stage.   1. Finger  of an assistant elevating the upper lid.   2. Probe-
pointed scissors incising the iris transversely, so as  to form  a quadrangular
PUP*1-                                                    After Pancoast.
  Fig. 13. Langenbeck's  operation  for Artificial Pupil.   A small incision  is
made  in the cornea only  large enough to admit a fine hook, by which a portion
of the iris is drawn  down, and left to adhere to the  wound of the cornea.
                                                After Bernard and Huette.
  Fig. 14. Scarpa's operation by displacement of the  Iris.  1. A cataract  needle
is seen detaching the iris from the ciliary ligament, so as to leave an opening on
its circumference.                                After Bernard and Huette.
(122) 
^- 3-
Plate 15
Fl£5
f





 fa
'VET-


-
, ;. ;

■-
"afc^X^

 
 
              DISLOCATION OF LENS.—ARTIFICIAL PUPIL.          123

   After-Treatment—The after-treatment must be regulated by circum-
stances, though generally  it should be  strictly antiphlogistic, the patient
being directed to  keep cold cloths applied over the lids of the affected eye,
to remain quiet in a dark room, to take nothing but liquids for food, and to
avoid conversation for the first three or  five days.  In most cases it will  be
found advantageous to keep the lids fastened by five little strips of adhesive
plaster for a day or two, in order to prevent derangement of the wound  by
the motion of the  lid, especially in intractable  patients.   The dressing em-
ployed  by Sichel  in the superior section also requires, as has  just been
stated, the addition  of graduated compresses and a bandage.   On the fifth
day, if the lids are not red or swollen, and the patient is free from fever and
pain, the eye may be gradually opened,  and  the condition of the  parts  in-
spected.  If there  is no prolapse of the iris, if the pupil is clear and regular,
and if there is no very high degree of inflammation, the rigid  rules before
observed may then be relaxed, and the  patient simply use a shade instead
of the wet cloths,  chew a little bread or  vegetable food, and  be allowed  by
degrees to see the  light.  Subsequently, but not before two months after the
operation, cataract  spectacles may be occasionally employed, as the patient
will be compelled  ultimately to use them, in order to compensate for the loss
of the lens.
   The performance  of the inferior and  exterior sections of the cornea are
so similar to that  just detailed  as not to  require a special description.
They are well represented in Plate XV.  Figs. 1, 2, 3.
   Linear Extraction.—A valuable modification of the operation of extrac-
tion, embracing some of the steps of the operation of absorption, and spe-
cially adapted to such cataracts as can be cut into fragments, is now gaining
professional  favor  as being less tedious  than the operation of absorption,
and less hazardous than that of extraction to most surgeons.
   Operation.—Introduce a fine needle through the  cornea, divide the cap-
sule and  lens, and throw the largest fragments into  the  anterior chamber.
Then,  with a fine  cornea knife, enlarge the opening made in the cornea  by
the needle, and, introducing a curette or  small scoop into the anterior cham-
ber  through the corneal opening, which should not surpass two lines in
length, remove the fragment without disturbing the capsule.


                      \ 2 —Dislocation  of the Lens.

   It sometimes happens, as a result of  blows,  or other violence, that  the
lens is displaced, either backward into the vitreous humor, or forward into
the  anterior  chamber,  though most frequently forward.   If it  is thrown
backward into the vitreous humor, nothing can be  done  but  to treat any
inflammation that  may arise upon  general principles, and, when the patient
has recovered completely, supply him with a cataract glass.  But  if the lens
is dislocated  forward into  the anterior chamber, it sometimes  acts as a
foreign body, and creates such an amount of irritation and inflammation as
justifies the surgeon in making a section of the cornea  and removing it, as
in the ordinary operation for the extraction of cataract.


                  \ 3.—Formation of an Artificial Pupil.

   This operation,  originally suggested by Cheselden, of England, in 1728,*
and performed by him on a boy fourteen  years of age, was published in  the
* See Observations, etc. Cheselden's Anatomy, 13th edit.  Lond. 1722. 
124            PRINCIPLES AND  PRACTICE OF  SURGERY.
Philosophical Transactions for that year, and  also in the appendix to the
fourth edition of his Anatomy, as well as in Ledran's  Surgery.  Cheselden
furnished, however, so brief a  description of his plan  as to create doubts in
the minds of his contemporaries as to the various steps of the operation,
though it was well understood that his object was the  formation of an  open-
ing in some portion of the iris, which should  serve  as a substitute for the
natural pupil.
  These  doubts, and the various changes produced by disease both in  the
cornea and iris, together with the diversified character  of the causes creating
them, have led other surgeons at different periods to  various  modifications
of his operation, although they have followed the principle laid down by him ;
the creation of  a new point by which the light  might  be transmitted to the
retina being the object of all of them.
  These  different modes of operating have  been classified under five heads.
  1st. Division of the iris through the sclerotica, or through an opening in
the cornea, called by ophthalmologists Coretomia—x»prh the pupil, and -"P-rj,
a section.
  2d. Excision of the iris, Corectomia—/"prh  the pupil, and sxroar,, ex-
cision.
  3d. Separation or tearing of the iris from its  ciliary attachments, called
Coredialysis—z<>pr„ the pupil, and diaXvau;, dissolution or loosening.
  4th. Separation aud excision combined, or a modification of the corectomia
of Wenzel.
  fith. Distortion of the natural pupil.  (Hays.)
  I. Coretomia.—Operation of Cheselden.—With a very narrow and pointed
knife  or  needle, cutting on but one edge, Cheselden  punctured the sclero-
tica about two lines from the cornea, as in the operation of couching.  Pass-
ing the needle  flatwise  through the posterior chamber until its point had
traversed two-thirds of its transverse diameter,  he cut through the iris from
behind forward, by a sawing  motion, and withdrew  the instrument  as it
entered.
  II. Corectomia, or Excision of the Iris.—This operation was  originally
performed by Wenzel in  1780
  Operation.—Introducing a cataract knife through  the  cornea,  as in  ex-
traction,  Wenzel carried  its point  through the  iris, and made a slit in it of
sufficient length to permit free vi-ion, taking special care  not to press upon
the eye lest its  contents should be evacuated.   On withdrawing  the  knife,
the escape of the aqueous humor caused a flap  in the  iris  to bulge forward,
and this being increased by gentle pressure with the finger on the ball, a por-
tion of the iris was then cut off with  fine scissors.
  Operation of Physick, of Philadelphia.—Physick made a section of the
cornea and  iris by a  cataract  knife, in a manner similar to that performed
by Wenzel, and, introducing through the  opening a  pair of forceps,  Plate
VIII. Fig. 6, terminating in  small plates,  one  of which contained  a  sharp
circular punch,  similar to that  used by saddlers, he seized the iris between
the blades, and  cut out a piece by closing the plates of the instrument.*
  Operation of Beer.—After  incising the cornea, Beer introduced a fine
hook, or  teethed forceps, seized the iris, drew it  out, and cut off the project-
ing portion with the scissors.
  Operation of Velpeau.—Velpeau punctured the cornea with a thin, long,
double-edged knife, resembling the serpent-tongued lancet; then, passing the
point through the iris, from before backward, penetrated the posterior cham-
ber, and, passing a line or two  across  it, brought the knife out again into
* Dorsey's Surgery, p. 347. Philadelphia, 1823. 
ARTIFICIAL PUPIL.
125
the  anterior chamber, by  cutting through the iris from  behind forward.
Passing the point again through the  cornea, he cut a flap both in the iris
and cornea at the same moment, Plate XV. Fig. 7, the flap in the iris re-
tracting upon itself, and leaving a triangular artificial pupil.*  This oper-
ation is also but a modification of that of Wenzel.
   Mulder, after incising  the cornea,  introduced fine scissors, and cut out
the  four angles of a crucial opening made through the iris, Plate  XV.
Fig. 9.
   Operation of Pancoast, of Philadelphia, f—Pancoast, having slightly mod-
ified the  operation of Maunoir, forms the artificial pupil  as  follows: The
patient being seated in a good light, an assistant raises the upper lid while
the  surgeon depresses  the lower and  enters the point of Wenzel's cata-
ract knife into  the cornea at the usual  place for extraction.   As  soon  as
the  point is seen  in the  anterior chamber, the handle is  brought forward
and the point directed obliquely backward upon the iris, so as to pierce it
at about  half a line from  its ciliary margin, where the lens is most distant
from it, and least  liable to injury.   As soon as this puncture is made, the
handle is carried backward, so as to bring the iris forward on the point of
the  knife, which is  then carried on so  as to divide both the iris and cornea,
until the point of the instrument has advanced half way between the place
of puncture of the iris and the closed pupil, Plate XV. Fig. 11, when the
instrument  is to be carefully withdrawn, the escape of the  aqueous humor
being very slight when  this is well done.  The incision of the cornea should
be about one-fifth of its circumference, and  that of the iris should have a
shape concentric with its outer margin.
   The delicate probe-pointed scissors of Maunoir being then inserted, closed
and flatwise, through the  corneal opening, should  be slightly opened, and
the  handles  turned so as  to look obliquely downward and forward, so that
the  blade next the cornea may not injure it.  Then, one blade  being carried
through the puncture of the iris, behind that  membrane, and  the  other in
front, as far as the centre of the old pupil, Plate XV. Fig. 14, the handles
are  to be brought  directly horizontal, and  the second incision  made by
closing them.  Not a drop of blood will escape, and an artificial pupil will
be at  once formed, which will be widest at its centre.   The subsequent use
of belladonna for  a few days assists  in keeping the new pupil dilated  as
widely as possible.
   III.  Coredialysis, or Laceration of the Iris.—This operation, as sug-
gested by Scarpa, was performed by him, in 1801, as follows :—
  Operation of Scarpa.—"The patient being seated and held as in the oper-
ation for cataract, the sclerotic coat is to be punctured with a needle (Scarpa's)
about two lines from the union of  the sclerotica with the cornea, and the
point of the needle made to advance as far as the upper and internal part of
the margin of the  iris, that is, on the side next the nose   The instrument
should then be made  to pierce the upper part of the internal margin of the
iris  close to the ciliary ligament, until  its  point is just perceptible in the
anterior chamber of the aqueous humor;  I say just perceptible, because that
part of the anterior chamber being very narrow, if the point of the needle is
made to advance ever so little before the iris, it must pass into the substance
of the cornea.  As soon as the point of the needle  can be seen in the ante-
rior  chamber, it should be pressed upon the iris from above downward, and
from the internal toward the external angle, as if with the  view of carrying
the instrument in a line parallel to the  anterior face of the iris, in order that
* Bernard and Huette, p. 153
j- Operative Surgery, 3d edit., p. 218. 
12Q           PRINCIPLES AND  PRACTICE OF SURGERY.

a portion of its  margin may be separated from the ciliary ligament,   This
separation being obtained, the point of the needle should then be depressed
in order to place it upon the inferior angle of the commenced fissure, which
may be prolonged  at pleasure by drawing  the iris  toward the temple, and
carrying  the instrument from before backward, in a line parallel to the ante-
rior surface of the iris, and the greater axis of the eye,"*  Plate XV. Fig. 14.
   Operation of Langenbeck.—This surgeon opened the cornea by a small
knife or needle, and then, passing a fine hook through  the wound, with its
convexity presenting upward, carried  it through the anterior chamber with
the hook presenting flatwise between  the cornea and  the iris to the very
margin of the latter.  Then, turning its point against the iris, he transfixed
it by gentle pressure, drew the hook and the iris very carefully through the
wound, drawing upon the iris until the new pupil was sufficiently large, and,
finding that the iris when  not drawn  upon would  remain  in the wound, he
withdrew the hook and left the iris to  contract adhesions in the opening of
the cornea, Plate XV.  Fig.  13.   It is essential to  the success of this oper-
ation that the opening in the  cornea should not be larger than is requisite
for  the introduction of the hook, otherwise it will  be difficult to  retain the
prolapsed portion  of the iris in the wound.
  IV.  Distortion  of the Natural Pupil.—Hays, of Philadelphia, in 1840
formed an artificial pupil by the following operation:—
   Operation.—The patient lying down, the lower lid  of the right eye was
depressed by an  assistant, and the upper lid held by the operator with the
two forefingers so as to  steady the ball with the  third finger   Then a sec-
tion of the cornea, commencing near its junction with the sclerotica, a little
below its middle, aud  extending so as  to divide one-fourth of the circum-
ference, was made by a  cataract knife  being carried steadily  and  quickly
forward so as to prevent the escape of the aqueous humor, and prevent pro-
lapse of the iris before the  incision was completed.  As soon as the knife
was withdrawn, the humor  escaped with  a gush, and the lids were allowed
to close, and, on separating them after the lapse  of a minute or two, the iris
was found prolapsed so  as to draw the lower edge of the pupil  quite to the
incision.   The patient subsequently enjoyed excellent vision."J*
  Afcer-Treatment.—After any operation for artificial pupil, it is of great
consequence that the antiphlogistic treatment, with the use of belladonna or
atropine, should be rigidly observed, the  strictest attention  being given to
the prevention of vascular  excitement, by  diet, venesection, purging, and
cold applications outside of the lids.
  Remarks on the Value of these Operations.—From the variety  of cir-
cumstauces requiring the formation of an artificial pupil, it is impossible
for a surgeon to select  any one  method of operating  as  preferable to the
others, and his choice must,  therefore,  be decided by the peculiarity of the
case.   The position of the pupil  must also be governed  by the opacity of
the cornea; but, as a general rule, the most eligible place for it is as near
as possible to the centre of the  old one.  When  it becomes necessary to
form  a pupil near the circumference  of the iris, the nasal  is by some
deemed preferable  to the temporal side, in consequence of its affording more
probability of a correspondence  with  the optic axis of the other eye.  Gib-
son, of England, with others  of extensive experience,  object to this, and
deem the opening on the temporal side preferable to any other,  as perniit-
  * Observations on the Principal Diseases of the Eye, by Antonio Scarpa.  Translated
from the Italian by James Briggs, Surgeon.  Lond. 180<">, p. 412
  f Lawrence on the Eye, edited by H;iys.  Philadelphia, p. 456. 
ARTIFICIAL EYES.
127
ting a wider field of vision ;*  but here, as in the other questions connected
with the operation, the decision must be regulated by the circumstances of
the case.  The inferior and external portions are less eligible, and the supe-
rior is objectionable from being more covered  by  the eyelids.   As illustra-
tive of the peculiar advantages of one  mode of operating over the other,
the following conditions of the eye may be referred to :—
   1st,  When the opacity is in the centre of the cornea of one eye, the lens
being round, and the iris not prominent anteriorly, and when the other eye
is sound, coretomia, or incision of the iris, will be  best suited to the case.
   2d.  Coredialysis, or displacement, is  specially adapted to cases of opacity
of the cornea  involving  a greater portion of its  convexity, but where the
circumference is clear.
   3d.  When the capsule of the lens is  affected, or the iris is adherent ante-
riorly or posteriorly, the other operations mentioned may be resorted to.
   The extent and importance of the subject will,  however,  forbid any spe-
cial recommendation of any operation ; and in this, as indeed in  most of
the affections of the eye, the reader will find it advantageous to consult the
works of those who have  devoted  themselves specially  to ophthalmic sur-
gery.

                    § 4.—Insertion of Artificial Eyes.

   When from any cause the ball of the eye has been partially or even en-
tirely evacuated of its humors, and nothing is left but a bulb or stump to
which the muscles are attached, or when the cornea  has been  rendered so
opaque that vision is impossible and the eye a deformity, it is often desira-
ble to conceal  it by artificial means.   In  the perfectly  opaque cornea, the
humors of the  eye should be partly evacuated by  puncture,  and then, when
the wound has healed, an artificial  eye  may be employed with great advant-
age to personal  appearance, the artificial eye being moved by the motion
that remains  in  the  eyeball.   So perfectly is this the case, that an unpro-
fessional observer will often be unable to tell a glass eye from a natural one.
Artificial or glass eyes  are polished enamel disks, colored like the natural
eye, and made both  in  Europe and the United  States, those of domestic
manufacture being now so perfect as to compare favorably with the best that
are imported.   They may be obtained through any druggist or optician at
moderate prices, costing about six  dollars each, if bought in quantities.
   Introduction.—After selecting an eye  of the color, convexity, clearness
of sclerotica, and size of pupil most like the remaining eye of the patient,
seize it between the thumb and forefinger of the right hand and dip it into
a glass of tepid water.   Then  with the left  forefinger  and thumb elevate
the upper lid, and, sliding the artificial eye under the edge  of the lid, push
it gently back into the orbit and let the lid  close on it.  On depressing the
lower  lid by the left middle finger,  slip  the false eye within it, the subsequent
action of the lids holding it  in  its  place against the ball, and giving it the
proper central position in the orbit.
   In order to remove it, take a probe or bodkin,  and, depressing the lower
lid, slip the probe between the lid and the  ball and  slightly under the edge
of the  glass eye; then using it geutly as a lever, catch the artificial eye as it
escapes from the lids on the palm of the hand, or in a handkerchief held to
receive it.
   After its removal, let it be thoroughly washed in tepid water, dried, and
put away in soft cotton—especially in  cold weather—to preserve an equal
* Littell on the Eye, p. 267. 
128
PRINCIPLES AND PRACTICE OF SURGERY.
temperature, and  prevent  its cracking.  In selecting  an eye, see that the
edges are perfectly smooth, lest they irritate the stump of the ball.   At
first, the artificial  eye should only be worn a few hours for fear it prove too
irritating.  When the enamel becomes roughened by wear, a new eye must
be obtained.  If inflammation is developed in the stump of the eyeball, colly-
ria should be employed, and the use of the artificial eye temporarily omitted.
                         CHAPTER  IV.

               PLASTIC  OPERATIONS ON  THE  FACE.

  The production of deformities, in consequence of the loss of integument
in various parts of the body, but especially about the face, led surgeons,  at
an early period, to devise some means by  which they could remedy the
inconvenience  and conceal the defect.   This result  has  generally been
obtained either by drawing upon the  surrounding parts, or  by taking flaps
from some more distant portion, and  modeling them to  a proper form,  so
as to furnish the amount necessary to  supply that which was wanting.  In
all these efforts the success of the operation  depended entirely on the pro-
duction of such an amount of inflammation as should result simply in adhe-
sion, while, at  the same time, sufficient vitality was  maintained in the  new
portion to insure the preservation of  its  structure.   On recalling the posi-
tion of the surgeons of that period, and  the  limited amount of knowledge
of the  effects of inflammation  that they possessed  as  compared with  that
acquired since  the observations of Hunter, we cannot but regard their op-
erations as indicating a high degree of skill, as well as illustrative of their
close observation  of the efforts of nature in  healing wounds;  and notwith-
standing the claims often advanced for the superior character of the surgery
of the  present day, it may be doubted whether modern operators have ever
shown  a higher degree of ingenuity  and surgical skill than that possessed
by those of the period of Taliacotius.
  Plastic surgery having originated in the attempt to remedy the deformity
arising from the loss of the nose, the  detailed account of the  different op-
erations may be best given in connection with the  section devoted to dis-
orders  of that  organ;  and the following example of the restoration  of a
portion of integument upon the forehead is therefore presented,  at present,
merely to preserve the uniformity of arrangement which has heretofore been
observed.

                             SECTION  I.

 METOPLASTY,  OR  RESTORATION OF  THE INTEGUMENTS  ON THE FOREHEAD.

  An ingenious application of the principles of plastic surgery to a case  in
which a large deficiency of the integument on the forehead required to be
supplied from  the surrounding parts  has been suggested and performed by
Watson, of New York, and is, it is believed,  the first operation of the  kind
ever practiced.  The following account  is  condensed from his paper,* and
illustrated by drawings copied from his portfolio.
* American Journal of Medical Sciences, vol. viii. p. 637, 1844. 
METOPLASTY.                         129
   Anaplastic Operation for a Hole in the Forehead.—A carpenter, aged
 42, was admitted into the New York Hospital in April, 1844, with necrosis
 of the os frontis of six years' standing, probably the result of syphilis, con-
 tracted some twenty years previous, and of which he believed himself cured;
 the disease on the forehead, according to  his own account, having resulted
 from an injury.  At his  admission, a large ulcer existed on the forehead,
 Plate XVI. Fig. 1, exposing a considerable portion  of the os frontis, the
 greater part of the external table of which had already exfoliated, and was
 held in place merely by the overlapping of the soft parts.   A fistulous open-
 ing existed at the upper  border of each orbit, and  another was  on the left
 temple, through which the pus escaped.   The upper eyelids were somewhat
 elevated and deformed by adventitious adhesions around these fistula?.  The
 exfoliated portion of bone was removed by J. K. Rodgers, who was obliged
 to enlarge  the opening by a short incision in the scalp  at the  upper and
 left angle of the ulcer; the undermined integuments rolled  in upon them-
 selves, from want of support, turning a portion of  the hairy scalp inward
 upon the face of the sore, and adhering in a fold along the left border of
 the ulcer, Plate XVI. Fig. 1.
   Operation of Watson.—After shaving the scalp,  and removing  the cuti-
 cle from the centre of the ulcer, by washing  it with  concentrated aqua am-
 monia?, the integuments along the left border of the ulcer were unfolded  by
 the free use of the scalpel.
   The point  of the knife was then carried  completely around the circum-
 ference of the opening, through the whole  thickness of the soft parts,  so as
 to remove a strip of integument varying from an eighth to a quarter of an
 inch in width, thus  making a smooth and fresh border for the subsequent
 adjustment  of the flaps.
   Two quadrilateral flaps, the one  on the left and the other on the  right
 side of the opening in the forehead, were then raised by making four  incisions
 horizontally backward, and nearly parallel with  each  other, two  on  each
 side, one from each upper, the other from  each lower angle of the  opening,
 Plate XVI. Fig. 3, the flaps being detached from the pericranium.
   The diseased portions of bone were then removed, as far as they could be
 detected, by means of the cutting pliers.   The largest of these portions was
 the  projecting rim of bone at the  left frontal sinus, the removal of which
 caused  a slight depression over the left orbit.   The  hemorrhage,  which had
 been profuse, was then checked by ligatures.
   An attempt was next made to approximate the lateral flaps so as to cover
 the opening, but this could only be  partially accomplished,  as they could be
 made to meet only to the extent of an inch from their lower  edges, even after
 considerable stretching.   The portions thus approximated  were secured  by
 sutures, but left a large V-shaped gap in  the upper part  of the forehead.
 To close this, a free incision was carried from near  the upper and right angle
 of the ulcer, in a curved direction  toward the crown of  the  head,  Plate
 XVI. Fig. 3; the flap thus made being dissected up and  rotated  so as to
 bring its lower  and right angle downward on the  centre  of the forehead,
 thus supplying effectually  the deformity; the edges being then  accurately ad-
justed  by numerous  points of sutures, Plate  XVI. Fig. 3,  strengthened by
 adhesive plaster, and covered by a compress  and  bandage.   The dressings
 were subsequently kept wet with cold water.  The first dressing was removed
 on the  sixth day, and about three-fourths  of the  line  of incision  found  to
 have united  by the first intention.   At the second dressing, on the ninth or
tenth day, cicatrization had progressed somewhat further, and in five weeks
the patient left  the hospital, at which period the wound had entirely cica-
     VOL. II.—9. 
PLATE  XVI.
 METOPLASTY AND  RHINOPLASTY,  OR PLASTIC OPERATIONS ON THE
                         FOREHHAD  AND NOSE.

  Fig. 1. A front view of the Face of a  patient, forty-two years of age, who had
a large ulcer in the forehead, accompanied with syphilitic caries of the frontal
bone, previously to being operated on by Watson, of the New York City Hos-
pital.  The ulcer is represented with thickened and  inverted edges, and as re-
taining a portion of the  necrosed  bone; a fistulous orifice is also seen at the
upper border of each orbit, with another  in the left temple, through which pus
escaped freely.  The eyebrows and upper eyelids are shown as slightly elevated
and deformed by the adventitious adhesions existing around these fistula?.   The
bone in the centre  of  the ulcer presents the ordinary characters of caries and
necrosis.                           Copied from a likeness taken by Watson.
  Fig. 2. Represents  the condition of the patient near the termination of the
treatment.   A linear cicatrix  is seen on the forehead, with  one or two larger
points or depressions in  the skin caused  by its adhesion to the surface of the
bone.                                                      After Watson.
  Fig. 3. Represents the line of incision, together with the sutures and  lines  of
union in the wound immediately after the operation.           After Watson.

  Fig. 4. Rhinoplasty, as practiced according to the Indian method, by Delpech.
A triangular, or somewhat  V-shaped flap, 1, 2, 3, has been cut upon the fore-
head, so that the point of the V will correspond with  the root of the nose.  At
2 an additional portion  has  been excised with  the  flap in order to form the
column of the nose, and at 4 the flap is seen rotated upon its base, so as to be
brought down in front of the nasal cavity.  To favor this rotation, and prevent
the constriction of the vessels in the flap which would otherwise result, the inci-
sion at the base of the flap has been  made slightly longer on the right than on
the left side of the nose.   The numerous sutures requisite for the approximation
of the flap to the nose, together with the bougies introduced into the nostril for
the support of the ala?, and to preserve  the orifices of the nostril, are also repre-
sented.                                          After Bernard and Huette.
  Fig. 5. A side view of  the original Taliacotian operation, or that  revived by
Graefe, with the bandage or jacket  worn  to support the arm until adhesion occurs
in the base of the flap.   1, 2, 3. The flap, cut from  the skin  of the arm, and
attached over the nasal cavity by  numerous sutures.
                                                After Bernard and  Huette.
        (130) 
i."■■::,a; .$• .5V'7;.s 
 
OPERATIONS  UPON THE EXTERNAL NOSE.           131
trized, with the exception of a  papillary opening communicating with a
small point of carious bone that had been overlooked in the operation, and
had  not then exfoliated.   Plate  XVI.  Fig. 2 represents the patient when
cured.

                            SECTION  II.

                   ANATOMY OF THE EXTERNAL NOSE.

  The general relations of the nose to the surrounding parts are so well
known that reference to them in detail is deemed unnecessary.  The structure
of the nose, proceeding from the outside to the cavity of the nostril, is com-
posed of the skin, cartilages, bones, and mucous membrane.
  The skin  on the  upper portion, or root of the nose, is similar to that on
the  forehead, is loosely attached to the subjacent parts by a free areolar
tissue, and is, therefore, very  movable.   At the point and lower half of the
nose, or sides of the nostril, it is abundantly furnished with sebaceous folli-
cles, and is attached to the cartilages by short fibrous filaments which render
it very immovable and difficult to dissect from the subjacent parts, without
injuring  them.   These follicles  are generally  the seat of the lipomatous
tumors found in this region.  When they attain such a size as to demand
extirpation, it may be accomplished in the manner and with the precautions
hereafter stated.   The wound may be  subsequently closed by sutures and
adhesive strips, or, if very extensive, as is sometimes the case, be left to heal
by granulation and cicatrization.  The skin of the alae of  the nose is some-
times the seat of a rapidly spreading ulceration, designated by dermatologists
as Lupus.  Its consideration belongs properly to a treatise on the diseases
of the skin.
  The cartilaginous portion of the nose is formed by a  vertical cartilage or
septum, placed in the middle line of the nose, continuously with the bony
septum formed by the vomer  and nasal lamella of the  ethmoid bone, and of
the oval cartilages or oblong oval plates, which, forming the structure at the
point, are directed upward and  backward from  the cartilaginous septum.
The contact of the oval cartilages with each other forms the columna nasi.
  The ala? nasi, or convexities on the sides of the nostrils, owe their shape
to several small cartilages, united by ligamentous matter.   They keep the
nostril patulous, and also permit  its free motion.
  The mucous  membrane covers these cartilages as well as the bones of the
internal nose.

                            SECTION III.

                OPERATIONS UPON THE EXTERNAL NOSE.

  The operations practiced upon the external portion  of the nose may be
demanded either for the  removal of lipomatous tumors ; for occlusion of the
nostril as the  result of  ulceration or burns, or for the cure of deformities
arising from loss of substance.
  The class of tumors usually known as Lipomatous, and described as such,
or as carcinomatous, are occasionally seen  on  the  lower extremity of the
nose.  These  tumors have been very  indefinitely described by  European
writers, who have sometimes merely referred to them as "an increase in the
thickness of the skin, which sometimes becomes a prominent swelling,"* or
as "a hypertrophied condition of the integuments and subcutaneous adipose
* Ferguson, p. 426, 2d edit.  Philada. 1853. 
132           PRINCIPLES AND  PRACTICE OF SURGERY.

tissue."*  The soundest view of their pathology will, therefore, it is thought,
be found in a paper on Polypi and other Tumors of the Nose, by Watson, of
New York, who regards them as neither carcinomatous nor lipomatous, but
as dependent on a hypertrophy of the integuments and connective tissue, at-
tended with sero-fibrinous infiltration and with excessive development of the
sebaceous crypta?  proper  to the  integuments.  He also regards them as
mainly dependent on enlargement of the sebaceous crypts of the nose, being
in fact analogous to the polypous growth.   They are slowly developed, un-
attended by pain, and occur either singly or in groups, being disposed to
assume a pyriform shape, to become pendulous and to grow to an enormous
size, reaching, in some instances, to the lower lip,  and in others below the
base of the  chin.f  Their appearance is often a strictly local complaint, as
they are limited  to the skin,  do not involve the nasal cartilages, and, though
vascular, and disposed to bleed  freely, may be  removed  by shaving or
dissecting them off from the  cartilages, care being previously taken to intro-
duce a finger into the nostril so as to prevent the injury of the ala? by the
incisions, the ulcer, when large, being allowed to heal by the second intention.
  The relief of the contraction of  the  nostrils resulting from lupus,  scrofu-
lous ulcers, or burns requires the formation  of an  opening by paring away
the tissue around the  nasal orifice,  and an endeavor to heal the ulcer by the
use of nitrate of silver.   The production of the opening is sufficiently easy,
but its preservation, even with  a free excision of the surface of the alae, is
frequently very difficult, cicatrization and subsequent contraction often closing
it as soon as the tubes or sponge-tents are removed.
  In a young lady, in whom both nostrils were completely closed, as the
result of scrofulous ulceration, the  mucous  membrane was perfectly sound,
and its secretion free enough to escape by the posterior nares; yet, notwith-
standing free excision, the use of tents, caustic, etc., I failed to effect a per-
manent restoration of  the  passage.
                           \ 1.—Rhinoplasty.

  The ancient punishments of cutting off the nose, as well as the marked
deformity caused by its loss as the result of sloughing, induced surgeons at
a very early period to devise some mode of correcting the deformity.   Plastic
surgery, indeed, appears  to have  originated mainly in the desire to conceal
the loss of  so prominent  a portion of the face, and much ingenuity has been
shown in devising flaps, obtaining grafts from other parts, etc., in connec-
tion with this special class of operations.
  The restoration of the  whole or of a part of the nose constitutes a variety
of the class of plastic operations designated as Rhinoplasty.  These opera-
tions are among the most tedious and painful in surgery, and, before under-
taking them,  the surgeon will find it advantageous to resort to the following
preliminary measures :  1st, make the patient fully aware of what it is neces-
sary to suffer ; 2d, inform him of the chances of failure from want of vitality
in the new portion ; 3d, of the great tendency to contraction in the new or-
gan ; 4th, of the probable difference in  color and texture between it and the
nose in its  natural condition.   When  the result is fully understood  by the
patient, the surgeon  should proceed  to study most thoroughly the probable
shape and natural characters of the lost part; make ample calculation for the
shrinking of the flap, allowing, generally, for the ultimate loss of at least two-
* Miller's Practice, p. 162, 3d edit.  Philada. 1853.
f Am. Journ. of Med. Sciences, April, 1842, p. 345 
RHINOPLASTY.                         133
thirds of the portion at first taken ;  and, cutting pieces of thick, or moder-
ately stiff paper, or, what is better, kid or soft leather, fit them to the part,
or mould a wax nose upon the deficient  portion, and, by flattening it, en-
deavor to obtain an accurate pattern of the shape of  the integuments that
will be required, marking it upon the skin that is to furnish the new struc-
ture by means of lunar caustic.   In addition to this, let him also prepare his
patient most carefully by an appropriate general treatment, and select such a
period and locality as will be most likely to ward off an attack of erysipelas.
In operating for the restoration of a nose where the bones and cartilages are
all destroyed, he should also make his patient comprehend that,  as the bridge
has been destroyed, the new nose will never present the convexity of the old
one, but  that,  though thus defective, it may yet look better, and render him
more comfortable than he was before the operation.
  The various modes of performing plastic operations have been arranged
under three classes : 1st, the Indian method, or original plan of the Brah-
mins, in which the flap is taken from the integuments of the forehead ; 2d,
the Italian or Taliacotian operation, where the flap is taken from an extremity,
usually the arm, near the insertion of the deltoid muscle, several days before
it is applied to the deficient portion;  3d, where it is taken from the forearm,
with some modifications, as practiced by Graefe and others among the Ger-
mans ;  and 4th, the French  plan, in  which a piece taken from the neighbor-
ing parts is slid over or rotated so as to cover the deficient  portion.
  To these may be added the insertion of a piece directly removed from some
other portion  of the body, aud attached to the deficient part.
  Plastic surgery, as illustrated by the plastic operations performed  on the
Face, dates from a very early period, having been long practiced in India in
order to remedy the losses occasioned by the punishment of criminals, whence
the origin of  the Brahmin method of operating.   In  1597, Taliacotius, of
Venice, whose attention had been largely devoted to the relief of these de-
formities, operated  by taking a  flap  from a distant part, and applying it to
the part which was to be restored, subsequently freeing it from its stem, when
it had  united.   Having published a volume on the subject,  in which he de-
tailed his methods of operating, the term Taliacotian has  since been often
employed to designate all plastic operations,  though it should be strictly
limited to his or Branca's peculiar plans.   Graefe, of Germany, modified this
method in 1815, resorting to  immediate union of the flap;  while Labat, Serre,
and others, in France, in 1834, published long accounts of their success by
means of flaps taken from adjoining parts.   In the United States, the Talia-
cotian operation had nearly fallen into oblivion,  when it was successfully re-
vived, in  1837, by Mason Warren, of Boston, who modified  the operation of
Graefe by  taking the flap directly from the forearm instead of the arm.  Since
then, rhinoplasty in different'forms has been frequently  resorted to with vary-
ing success, by Pancoast and  Mutter, of Philadelphia; and  the  original
Taliacotian operation  for restoration of the end of the nose has been fre-
quently performed by Horner and other surgeons.  In nine cases operated
on by  Pancoast, and combined with the " plastic suture," the parts uniformly
united by the first intention.
  As  the Brahmin method is  preferable to that of Taliacotius, when the
forehead is capable of furnishing the  flap, I mention it  first.
             § 2.—Indian or Brahmin Method of Rhinoplasty.

  Operation of Mason Warren, of Boston.—The patient, a young man,
aged 28 years, had lost, from ulceration, the  whole nose, cartilages, septum, 
134            PRINCIPLES AND PRACTICE  OF SURGERY.

and bones.   In the place of the nose there existed an opening, about one inch
in diameter, bordered by a firm cicatrix; and, the  septum being destroyed,
the cavities of the two nostrils were thrown into one.  The four front teeth,
with the alveolar processes, had also been lost, and  there was an opening be-
tween the lip and the upper jaw through which a probe might be passed from
the mouth into the nasal cavity.   The favorable circumstances connected with
the case  were the  healthy state of the integuments surrounding the opening
of the nasal fossa,  the great height of the forehead, the whiteness and deli-
cacy of the skin, and the good state of the patient's health.
  Operation, Sept. 7th, 1837.—A piece of  pasteboard, cut in  the shape of
the letter V, that is, triangular, and with a projection  from its  base corre-
sponding with the columna of the nose, was placed upon the forehead,  and a
trace made around it with the nitrate of silver, as recommended by Lisfranc,
in order that it might not be effaced by  the blood.   A  trace was also  made
around the  opening of the nasal fossa, at the points where it would be neces-
sary to remove the integuments for planting  the  new skin taken from the
forehead.   This was done the night previous  to the operation.   The cloth-
ing being arranged, the patient was laid on  a  table with his face toward the
window and the operator behind him, so as  to have the full command of the
head.  The traces  made by the nitrate of silver were about two-thirds of an
inch apart between the eyebrows; each side of the  triangular portion of the
skin was  three inches and a quarter in length, with a base of three and a half
inches, and the projection from the columna  of the nose, which  was  to be
taken entirely from the scalp, previously shaved, was an inch and a half long,
and  two-thirds of an inch wide.
   "The head being firmly supported by two assistants, the incision was com-
menced between the eyebrows and the flap of the skin dissected up so as to
isolate it entirely from the skin of  the forehead, except where, for the pur-
pose of nutrition, it was left adherent at the root of the nose.  The incision
on the left side, between the eyebrows, was  extended a little  further  down
than on the right, the better to facilitate the twisting of the flap.   This inci-
sion included the skin, subcutaneous cellular tissue, and a portion of the occi-
pito-frontalis muscle, care being taken not to  raise the periosteum from fear
of necrosis.   The flap, thus dissected and twisted round to the left side, was
carefully wrapped in a compress of linen cloth, and before the operation was
proceeded  in further, attention was given to diminishing the large wound
made  in the  scalp (forehead)—Plate XVI.  Fig. 4—little hemorrhage had
taken place, and the temporal arteries which had been cut very soon retracted
and  ceased bleeding.  The angles of the wound were now brought together
by the twisted suture, two pins being employed on either side.  Its  edges
between  the eyebrows were also approximated in a similar manner, and by
this means the wound in the forehead was at once diminished to less than half
its original size ; it was still further reduced by the use of a few strips  of ad-
hesive plaster; and a little scraped  lint filled  up the remainder  of the wouud.
Some spread  cerate was placed over the whole surface with a pledget, and
the dressing was secured by a bandage round the head.
   " The  next object was to fasten the borrowed skin in its place.   In order
to do this, it was necessary to freshen the borders of the opening in the nasal
fossa, the traces of which, as stated, had been previously  made with the ni-
trate of  silver.  For this purpose,  a short, narrow knife, somewhat similar
to a cataract knife, was used, (resembling the original knife of Taliacotius,)
and a strip of integument a third of an inch broad, including all that had
been indurated in  the old cicatrix, removed.   The knife was also passed be-
tween the lip  and  upper jaw, in  which  existed, as  before  stated, an  open-
ing large enough to pass a probe, and the adhesions between the two for 
RHINOPLASTY.                        135
the space of an inch entirely cut away, for the double purpose of giving the
columna of the nose a more deep and firm  adhesion, as well as to close up
by inflammation the unnatural communication between the mouth and nasal
cavity.
   " The flap was now brought down into its place, its angles a little rounded
with the scissors, the  better to simulate the alae of the nose, and the whole
secured in its place by pins and points of the interrupted suture."  In a
subsequent  operation, the interrupted suture was used, and is generally
preferable.
   " From that portion of the skin which was to  form the columna, the epi-
dermic side  was pared a little, so that it might form an  adhesion, not only
underneath to the jaw, but on its sides to the quadrangular wound made for
it in the upper lip.
   " A little  scraped lint was now placed under the ends of the pins, and a
strip of oiled lint introduced into each nostril to prevent  adhesion ; another
strip was placed upon the nose to preserve its temperature, and the dressings
were confined by a  band of adhesive plaster fixed to the forehead above and
partially divided in the middle, so that it might descend on each side of the
nose to the  lip."*
   A double T-bandage, made of narrow tape, the horizontal  portion of
which is applied to the upper lip, and the two vertical portions carried over
the root of the  nose, will also  serve  a good purpose and be  free from the
objections to the use of adhesive  plaster, f
   Operation of Pancoast, of Philadelphia. J—After marking out the flap, as
described in the preceding operation, cut out a second  model in adhesive
plaster and  fit into  the space just marked out on the forehead by placing its
apex perpendicularly between the eyebrows ;  or, if the forehead is low, to
place it in an oblique  instead  of  a vertical direction, so as to avoid cutting
into the hairy portion of the scalp.   After thus delineating the  flap on the
forehead, the points for the sutures  and their corresponding places on the
sides of the nasal  opening should be denoted with ink  or colored  varnish,
Plate XVII. Fig. 4, in order to insure the accurate adjustment of the flap to
the nose.  The peduncle of the flap  at the root of the nose should  also be
calculated so as to  leave it from a half to five-eighths of  an inch wide, in
order to permit the rotation, and also  preserve the nourishment of the flap
by one or both  of the  angular arteries of the nose.
   The first step, now, consists in  so freshening the edges of the stump of the
nose that it may leave a groove  for the reception of  the  flap, the  nostrils
having been previously filled by lint so as to prevent the blood flowing back
into the throat.
   The second is the dissection of the flap from the forehead and the closing
of the wound—made  by its removal—with twisted sutures, compress, etc.
   In a third step, the flap is brought down to its  place  and retained there
by the following suture, to which the operator attributes  much of the happy
results that  have attended his nine  operations,  all of which united by the
first intention.   This  suture he forms in the following  manner :—
   The Plastic  Suture.—Three waxed silken ligatures, armed with a needle
at each end, are to be placed in the  groove at each side of the  nostril, by
passing one  needle from without inward through the inner wall of the groove,
and then from within  outward, at a point about one-eighth of an inch above
its first puncture, in such a way as to leave this needle and that attached to
* Boston Med. and Surg. Journ., vol. xvi. p. 69, 1837.
| See vol. i. p. 131.
\ Operative Surgery, 3d edit. p. 350, et supra, 1852. 
PLATE   XVII.
           RHINOPLASTIC AND CHEILOPLASTIC OPERATIONS.

   Fig. 1.  Appearance of John Glover prior to the operations of Cheiloplasty
aud Rhinoplasty.                                          After  Pancoast.

   Fig. 2.  View of his face with the chin depressed. The mouth, being contracted
into a rigid orifice, was  enlarged laterally by the stomato-plastic operation of
Dieffenbach for atresia oris, after which two flaps were made,  as marked in the
lines upon the cheeks, so as to form the upper lip.            After  Pancoast.

   Fig. 3.  Appearance of his face  after this operation, showing the position of
the sutures and the improvement in the mouth.               After Pancoast.

   Fig. 4. Shows the  steps of the  Rhinoplastic operation  performed  upon him
subsequently.  The edges of the nasal cavity being freshened by  a gooved inci-
sion, the outline of the new nose was marked on the forehead before cutting the
flap.  The dots indicate the position of the sutures.           After Pancoast.

   Fig. 5. The wound in  the forehead  being closed by the hare-lip sutures, the
flap was reverted, and attached in  the groove on the edge of the nasal cavity by
three stitches of the interrupted suture, which were tied over little rolls of adhe-
sive plaster, after Graefe's method.  The edge of the septum is also attached to
the upper  lip.  The twist in the pedicle is seen in  the root of the nose.
                                                         After Pancoast.

   Fig. 6. An accurate likeness of John Glover, sixteen months after  the opera-
tion-                                                     After Pancoast.
(136) 
 
 
RHINOPLASTY.
137
 the opposite end of the same ligature resting on the cheek, the loop on the
 inner side of the groove being thus made to embrace about one-eighth of an
 inch of its inner surface, Plate XVII. Fig. 4.   Then, when the edge of the
 flap is adjusted to the groove, the two needles are to be passed through the
 margin of the flap  from within  outward,  so that, when drawn tight, the
 ligature will necessarily sink the edge of the flap to the bottom of the groove,
 and bring the upper and under surface of the edge of the flap in contact with
 the outer and inner edge of the groove, and thus facilitate the union ; after
 which the ligatures  are  all to be tied over  small rolls of adhesive plaster,
 after the manner of Graefe and Labat, so as not to  strangulate the parts in-
 cluded in the loop, Plate XVII.  Fig. 5.  After applying greased  lint in-
 ternally and externally, the warm water-dressing was continued on the nose,
 and the pedicle near the forehead not divided for five or eight weeks.
   Remarks.—In the performance of these operations, great attention should
 be given to the following points :—
   1st. To mould a good nose—in soft wax—to the nasal cavity, and then
 flatten it out, in order that it may serve as a model for the flap.
   2d.  To obtain a sufficiently large  and full flap from the forehead, of the
 shape, but not the size of the model,  as it is almost imposible to anticipate
 the amount of the subsequent contraction of the new covering of the nose.
   3d. To dissect up all the integuments of the forehead above the periosteum,
 the latter being left untouched.
   4th. To make a good groove on  the  sides of the nostril,  and bevel the
 edges of the flap, so as to fit it accurately.
   5th. To unite the edge of the flap to the sides of the groove by the plastic
 suture.
   6th. To unite the column  of the new nose to the gum, and to bevel its
 edges so as to prevent their union with the margins of  the flap which form
 the alae of the nostril.
   7th. To guard against contraction of the orifices of the nostrils, or their
 union with the septum, either by the use of rolls of greased linen, by the in-
 troduction of a piece of catheter, or by beveling off the edge of the alae,
 and turning it into the nostril so as to form a sort of hem to the edge of the
 orifices, as suggested by Labat.
   8th. If the nasal orifices contract, then to pare them off and treat the sur-
 face  with nitrate of silver until healed, taking care to distend  the  opening
 during the process.
   The greatest care in nursing is  also essential, especially for the first few
 days, lest  the patient should, by  any inconsiderate movement,  disturb the
 flap before union has occurred.
   Cheiloplasty and Rhinoplasty.—A man, aged fifty-three, had lost all the
 soft parts  of the nose and whole of the upper lip, from the commissures of
 the mouth to the canine fossa of each side, as well as the septum narium and
 the turbinated bones, the cavities of  the antrum Highmorianum and of the
 sphenoidal sinuses being exposed.  His  appearance, with his mouth closed,
 is shown in Plate XVII. Fig.  1. The mouth, when opened, presented a rigid
 circular orifice three-fourths of an inch in diameter.
   Operation of  Pancoast.—The  mouth  being widened after  Dieffenbach's
method, Plate XX. Fig.  7, the free surface of the  gum was freshened, and
 an incision was then made  obliquely  upward and outward for a quarter of
 an inch from the point where the gum was covered by integuments, and from
the end  of this another cut was made for about the  same distance, nearly
parallel with the  incisions for widening the mouth, but inclined  a  little
downward.  The cheeks being now loosened from the gum and malar bone
by incisions on the side of the mouth, the flap of skin and subcutaneous fatty 
138
PRINCIPLES AND PRACTICE  OF SURGERY.
matter was raised from the surface of the muscle by beginning the dissec-
tion at the angle  next the nose, Plate XVII. Fig. 2.
  The arterial branches,  which  were divided, having been twisted, the flaps
were drawn downward and forward over the raw surface  of  the gum  and
fastened together with the hare-lip  suture,  Plate XVII. Fig. 3, the inner
edge of the rotated flaps being thus united in the  middle line of the  lip.
The face being then dressed with lint wet with lead-water and laudanum,
the patient recovered in about two  months.   The nose was subsequently
formed as follows :—
  The hair being shaved from  the  temple and forehead, the nasal orifices
closed with lint to prevent the entrance of blood,  and the  patient lying
down with the head supported by a pillow, a flap was raised from  the fore-
head, as shown in Plate  XVII. Fig. 4,  the  skin being divided at a single
sweep of the knife, the blade of which was inclined  outward so as to cut a
beveled edge.  The apex of the  flap, which was about five-eighths of an
inch wide, rested  between the eyebrows, and the tonguedike portion which
was to form the columna nasi extended up into the scalp.   The base of the
flap was nearly three  inches wide, in order to allow  for its subsequent con-
traction.   The flap, after being dissected up, was then turned down on the
left side and wrapped  in linen, while the wound in the forehead was closed
by four interrupted sutures, after which the flap was  applied to the fresh-
ened edges of the new lip and  gums, the whole being held in position by
the plastic suture before described, and tied  over rolls of adhesive  plaster,
as in Graefe's method, Plate XVII. Fig. 5.   Union having  occurred, the
pedicle of the flap was divided, five weeks  subsequently,  by passing a di-
rector under it, after which it was smoothly  fitted down to the roots of the
ossa nasi, in a cavity which was made for its  reception by excising a portion
of the subjacent integuments.  By  the  twelfth day union was perfect,  and
the patient left the hospital so much improved that, sixteen months subse-
quently, his likeness was taken,  as represented on Plate XVII. Fig. 6.
  Remarks. — This very fortunate  case,  though forcibly illustrating the
skill of the operator, can only be regarded as an example of the successful
cases, and, though it  may  stimulate others to repeat it, should not induce
any surgeon to be sanguine in his general prognosis of this class of oper-
ations.
  Taliacotian Operation.— In the Italian, or Taliacotian  operation, as
it is more frequently termed, the  nose,  upper  and lower lips, or  ear, have
all been restored by means  of flaps taken from other portions of the body,
and especially from the integuments of  the arm.
  In operating for the restoration of a nose, Taliacotius made two parallel
incisions in the integuments of  the arm  over the belly of the biceps muscle,
at such distances  from each other, and of such lengths, as seemed likely to
furnish a sufficient flap, allowance being made for the subsequent  shrinking
of about two-thirds of the  portion  taken, cutting it so as to free  the  skin
from the fascia.   The incisions corresponded with the vertical portions of
the letter H ; or he elevated the skin by broad forceps, and then transfixed
it, as in the ordinary introduction of a  seton in the neck.  In either case,
after passing the  knife beneath the  skin from one incision to the other, he
introduced a piece of linen spread with cerate in order to prevent  adhesions
between the flap and the subjacent'parts, and allowed the wound  to suppu-
rate for ten or fifteen days, in consequence of which a contraction of the
width  of the flap was effected, while it was also thickened and  rendered
more organizable.  A bandage, consisting of a jacket, with a hood for the
head, and a sleeve to contain and support the arm, Plate XVI. Fig. 5, with
bands to hold it fast to the head, so that the flap could be steadily kept at- 
RHINOPLASTY.
139
tached to the nose, being next prepared, the edges of the surface to be
restored were freshened by paring off the cicatrix, by means of a thin  and
broad-bladed  knife, the flap freed from  the  arm by its upper extremity, the
arm brought up to the head, and the fresh end of the  flap attached to the
raw surface of the nose by means of numerous  points of the interrupted
suture; after which the bandage was tightened,  and the  arm left attached
to the head, as seen in Plate XVI. Fig. 5.
   After fifteen or  more days, when union had taken place, the  attachment
of the flap to the  arm was divided and  trimmed so as to fill up the remain-
der of the deficient portion, this  end being retained in its position by a few
turns of  a bandage, passed from  the head around the nose,  lip, or ear, ac-
cording to the part operated on.*
   Remarks.—This operation, though  applicable to all parts of the face, is
especially adapted to the  restoration of the tip of the nose, the loss of por-
tions of the lips and  ears being  more  readily supplied by flaps taken from
the adjacent parts by either sliding or rotating them upon their base.
   With some slight modifications, the  Taliacotian operation was success-
fully performed by Mason Warren, of Boston, in April, 1840.f   In  this
case  the flap was  separated from the arm  on the fifth day, union having
then occurred.
   By a modification of the  French method, Pancoast, of Philadelphia, has
also succeeded in restoring the middle of the nose,  together with the ala of
the left side.  In this case a great portion  of the  hard palate, the sockets
of the upper incisor teeth, the cartilaginous septum, superior lateral carti-
lages, inferior turbinated bones, together with a considerable portion of the
inferior oval cartilages, and the integuments of the nose, had been destroyed
by scrofulous ulceration,  the tip  and margin being drawn upward and  also
depressed inward by the cicatrization, Plate XVIII. Fig. 3.
   Pancoast's Operation.—The patient  being laid on a  table, with his head
supported by pillows, the integuments of the depressed cicatrix, just below
the  ossa nasi, were dissected off so as to obtain a beveled raw surface to
receive the margins of the flaps, and the end of the nose separated from the
ossa nasi by pushing a sharp-pointed,  straight bistoury, with  the back to
the  cheeks, across the cicatrix,  and cutting outward.   It  was also found
necessary to divide some  adventitious adhesions within the nostril, and to
extend the incision of the cheek  outward  and downward through the  root
of the oval  cartilages, before the tendency to retraction of the tip could be
overcome.
   A triangular flap of integuments being then marked out on each cheek,
just below the malar protuberance, of a size  calculated to fill  the breach,
the outer limb of each triangle was rounded so as to give a  prominence to
the ridge of the nose, when the  base  of the  flaps were  brought together,
and the edges of  the flaps beveled inward  toward  their  centre, in order to
furnish an oblique surface, by which they might rest in the raw edges of the
nose, Plate XVIII. Fig. 4.   Being dissected up with as much subcutaneous
areolar substance  as could be taken without involving muscular fibres, the
hemorrhage was arrested  by torsion, and the flaps so twisted upon the pedi-
cle, from below upward, as to make  the lower margin of the  flap on  the
cheek become the  upper on the nose.
   The flaps were then united by their bases upon  the dorsum of the nose,
  * Gasparis Taliacotii Borroniensis.  De Curtorum Chirurgise per insitionera, additi
cutis traducis, instrumentorum omnium atque deligationum iconibus et laterilis.  Ven-
etiis, 1597.  This book,  together with many other  rare and ancient medical works,
may be found in the Loganian portion of the Philadelphia Library.
  f Boston Med. and Surg. Journ., vol. xxii. p. 261. 
PLATE  XVIII.
                 RHINOPLASTIC  OPERATIONS.

  Fig. 1. Restoration of one-half of the Nose and part of the Cheek by a flap
taken from the Forehead.                                  After Pancoast.

  Fig. 2. Side view of the same with the Flap in situ, showing the arrangement
of the sutures upon the cheek.                              After Pancoast.

  Fig. 3. Likeness of a Patient operated on  for the removal of a Deformity
caused by the destruction of the hard Palate, Septum Narium, and all the soft
parts of the  Nose, with the exception of the  lip and columna, these being dis-
torted and fastened to the lower end of the ossa nasi.         After Pancoast.

  Fig. 4. A  view of the Gap left in the Nose of Fig. 3, after  the dissection of
the cicatrix  and depression of the tip of the nose.   The outlines of the flaps
cut from the  cheeks to fill up  the gap are also shown.         After Pancoast.

  Fig. 5. A  side view of the same, showing the application of the Sutures and
the closure of the  wounds left in the formation of the flaps.    After Pancoast.

  Fig. 6. A  front  view of the  same, showing  the arrangement of the Twisted
Sutures to both the nose and the wounds left in the cheeks.    After Pancoast.
(140; 
F^ 2
 
 
RHINOPLASTY.
141
and  by their sides to  the adjoining  parts, Plate XVIII. Fig. 6, by small
palladium  pins  and the twisted  suture.  The nostrils were  lightly stuffed
with oiled  lint, and the wounds on the cheek united by hare-lip sutures, ap-
plied so that the  stress should be toward  the canthus of the eye,  and not
upon the  middle  of the eyelid, which  might have caused ectropion, when
lint, wet with warm water, and covered with oiled silk, completed the dress-
ing.  At  the first change of dressing, complete union was found  to  have
taken  place  everywhere except at the  median line, where there was some
suppuration.
   After some further additions to remedy defects arising from ulceration and
contraction, the nose,  ten months after the  operation, looked quite natural.
   Restoration of the  Alae Nasi  may be accomplished either by a half  flap
of the  Indian method, by the  Taliacotian  operation, or, if the loss is very
limited, by a piece taken from some other part, and immediately attached in
the opening, an operation which  has fully succeeded in the hands of Mason
Warren, of Boston.*
   Restoration  of the Columna  Nasi.—Liston's Operation.—In defici-
ency of the columna nasi, Liston  took the flap from the upper lip in the fol-
lowing manner :  The point of the nose being raised, and its apex freshened
at its attachment, by two vertical  incisions on each side of the centre of the
lip, he cut a  flap of the entire thickness of the part, wide enough to allow of
shrinking,  when the fraenum  being freely dissected off, the flap was everted
upward, so that its mucous membrane presented outwardly.   Then remov-
ing the membrane from the top of the flap, the latter was attached by a pin,
through its end, to the apex  of the nose, and fastened by the twisted suture,
uniting the lip as in the hare-lip operation. Exposure to the air soon changed
the mucous membrane, and after a time it resembled the original structure
of the columna. f
   For many other plastic operations, and for much valuable experience, the
reader may advantageously consult the papers quoted in  the  Bibliography
of this part,  all  of which contain  drawings explanatory of the various steps
in the operations, and are creditable specimens of the ingenuity of  the sur-
geons in relieving shocking deformities.
   Value of  these Operations.—In  estimating the value of Rhinoplastic
operations generally, and especially those for the restoration of the entire nose,
much must depend upon the  nature of the deformity.   Most frequently, or
when the operation is  at all  proper, the deficiency will be very great,  and
under such circumstances even  an  imperfect-looking nose will be deemed by
most patients better than none. But when it is remembered that the integu-
ment of the new organ will retain most of the ordinary appearances of skin,
while that of the  natural nose possesses a large  number of follicles;  that
the hair upon the flap  is apt to  grow and  require the frequent use of the
tweezers for  its extraction;  that  the  new nose will generally be paler than
the surrounding skin, and that, except in the Taliacotian operation, a cica-
trix of some size will be visible at the part from which the flap has been taken,
the surgeon may well hesitate and think whether, with the risk of failure or
an imperfect success, it may not be better to  import from Paris, or elsewhere,
an artificial nose, the manufacture of which  has now attained considerable
perfection.   If,  on its  reception,  the  patient's vanity is not gratified, the
operation  may then be undertaken with less chance of censure, should the
result not  entirely correspond  with his or  her anticipations.   In the suc-
cessful cases, which are those mainly reported, there is certainly great cause
* Boston Med. and Surg. Journ., vol. xxii. p. 268, 1840.
f Liston's and Mutter's Surgery, p. lt!8.  Philad. 1846. 
142
PRINCIPLES AND PRACTICE  OF SURGERY.
for satisfaction; but, as this class of operations has been at different periods
lauded highly, and  then fallen into disrepute, is it  not probable that the
number of failures, or  abortive attempts, will  again  throw it into compara-
tive oblivion ?  Plastic operations  for the restoration of small deficiencies
have been and are positive triumphs of science; but those for the restoration
of an entire nose are  by no means so well established, notwithstanding the
renown(?) attached to the successful cases.  In most of those coming under
my notice, the so-called "new nose" was an ugly appendage to the face.
                       CHAPTER  V.

DISORDERS  OF, AND OPERATIONS ON, THE  NASAL CAVITIES.
                           SECTION  I.

                              ANATOMY.

  The internal nose consists of two large fossa? in the middle of the superior
maxillary bones, which  present a very irregular surface.   These fossa? or
cavities are separated by the vertical septum, which, in the natural condition
of the  part, is a plane  surface, and  corresponds with the inner side of the
nostril.   The upper part of  each fossa is formed by the cribriform plate of
the ethmoid bone, the cells of which diminish very much the width of this
portion of the cavity, so  that the space between the upper and middle turbi-
nated bones and the septum  narium  is frequently not more than three lines.
  The  bottom or floor of the nostril is formed by the palate process of the
superior  maxillary and palate bones, and is concave and about half an inch
wide.
  The  external face is very irregular, presenting a number of convexities or
prominences, Plate  XIX. Fig.  1, which are intended to  afford a greater
surface for the lining or olfactory membrane.  Among these prominences,
that caused by the convexity of the inferior turbinated bones  is very ap-
parent, and tends much to diminish the breadth of the nostril throughout its
whole depth.  The middle meatus of the nose, or the space between the mid-
dle and inferior  turbinated bones, contains  the orifice of the antrum  High-
morianum.  This orifice is  usually placed  about the middle of the bone,
but its  precise situation  and  direction are so uncertain  that it is found with
some difficulty in the subject, though quite apparent in the skull.
  The  inferior meatus of the nose is between the lower turbinated bone and
the floor of the nostril.   At  the anterior part of this meatus, about five lines
from the anterior extremity of the turbinated bone, is the orifice of the ductus
ad nasum.
  This orifice is found at the upper  part of the inferior meatus, about eight
lines from the floor of the nostril.
  The  mucous membrane lines the whole nose,  penetrates into the several
sinuses and cavities communicating with it,  and is continuous at the nostrils 
OZ^NA.
143
with the skin, and  at the posterior nares with the lining membrane of the
pharynx.
   The posterior orifice of the nostrils, or the posterior nares, is divided, like
the anterior, by a vertical septum, (vomer.)   Its perpendicular diameter is
about an inch, but its transverse diameter is only six lines, (Velpeau;) points
which should be remembered in the introduction of the tampon for the arrest
of epistaxis.

                             SECTION II.

                   DISEASES OP THE NASAL CAVITIES.

                             \ 1.—Ozaena.

   Ozaena—<>Z<i>, I smell of something—may be defined as an unhealthy inflam-
mation of the Schneiderian mucous membrane, which is generally connected
with disease of the periosteum,  or with caries or necrosis of the bones of the
nose, and is very frequently a result of syphilis.
 # Symptoms.—The symptoms  of ozaena are, first, those of coryza; but the
discharge  presently becomes  profuse, then  muco-purulent, and then rapidly
assumes the  stinking odor which is characteristic of the  disease, and  from
which it is named.   Sometimes the  ulceration of the  mucous  membrane is
deep, and  involves the bones, spreading  rapidly and casting off  scales of
bone, when, if the disease is syphilitic in its character, the  nasal bones fall
in, and produce all those deformities which have been alluded  to in connection
with secondary syphilis.*
  Diagnosis.—The diagnosis of ozaena  may  be  made  by noticing  that it is
characterized by a fetid discharge from the nostril, though such a discharge
will also sometimes take place in children, particularly those  who are scrofu-
lous, but in whom it is unaccompanied by any disease of the bone ; a point
which renders the diagnosis comparatively easy.
  Prognosis.—The  prognosis  of ozaena will depend very  much  upon its
causes and complications;  if due to syphilis, the prognosis  will be unfavor-
able, and in all cases should be guarded, lest the caries of the bones create
deformity  and the entire destruction of such as are involved.
  Treatment.—The treatment  of ozaena should be both constitutional and
local.  If  the disease  arises from a tuberculous taint, or is due to syphilis,
the general treatment  adapted to these conditions will, of course, be neces-
sary ; while, if  the patient is weak  and exhausted, tonics and  chalybeates
will be imperatively demanded.  The local treatment should be conducted
npon general principles ; thus, as there is ulceration of a mucous membrane,
which is more  or less connected with disease of the bones, alterative and
astringent washes may be expected to prove serviceable, especially weak  solu-
tions of the salts of lead, which, being thrown into the nostril, diminish the
fetor by combining with any free sulphuretted hydrogen which may be  pres-
ent.  The  strength of a solution of acetate of lead for this purpose should be
from five to ten grains to the ounce of water.  The  mild chlorides are also
serviceable in the same manner,  such as the chloride  of soda in  the form of
Labarraque's solution.  I have  obtained much benefit in several cases from
the use of chloride of lime, in  the proportion of two drachms to the ounce
of water, as suggested  by Horner.  In those cases accompanied by the dis-
charge of  a scab each morning,  I have derived benefit from injecting into or
painting  the nostril with  glycerin, or with  melted chicken fat or goose
* Vol. i. 
144
PRINCIPLES AND  PRACTICE OF SURGERY.
 grease, as advised by  Physick.   xYdvantage will  also be  found from  the
 alterative effects of solutions of nitrate of silver.  But when  the caries or
 necrosis of the turbinated and other bones has gone  to any extent, the disease
 will often prove exceedingly intractable.


                            \ 2.—Rhinolithes.

   Rhinolithes is the name given to nasal calculi, or little concretions, which
 consist generally of inspissated mucus and some of the phosphates.   They
 may be of various sizes, from  that of a  pea to that of a  bullet, or a little
 larger, and  should  be removed from the nose in the  same manner as any
 other foreign bodies; they are, however, very rarely met with.


                  § 3.—Foreign Bodies  in the Nostril.

   Foreign Bodies in the nostril may be of various sorts and sizes, as beads,
 pieces of ribbon, peas, grains of coffee, or  any other articles  likely to be
 thrust up  the nostril by mischievous children.   Grains of coffee, which are
 sometimes introduced, are particularly troublesome ;  because, imbibing moist-
 ure  from  the  part, they swell, and  may thus  not  only become firmly im-
 bedded, but also produce displacement  or fracture  of  the turbinated bones,
 or even fracture of the vomer.
   Treatment.—To get  rid of these foreign bodies, a pair of forceps may be
 used, if properly curved to suit the nostril, the instrument being introduced
 into it close to the  septum, in order to avoid the inferior turbinated bone,
 when a little manipulation will enable the surgeon to seize the foreign  body
 and withdraw it.  Foreign bodies may also sometimes be extracted by means
 of a probe bent into the shape of a hook;  or their  removal may frequently
 be accomplished by the use of the syriDge, which is a better plan.   Some-
 times it will be necessary to push the foreign  body backward into the poste-
 rior nares and extract it from behind the soft palate.


                  I 4.—Abscess of the  Septum Narium.

   The presence of foreign bodies and other causes, most of which  are not
understood, sometimes produces abscesses in the septum narium, the  seat of
 which is in the  areolar substance found between the two layers of cartilage
of which the septum  is formed.   The result of such an abscess is, of course,
a separation of the two  layers of the cartilage,  in consequence of which the
patient soon notices such a bulging of the septum toward one or the other
nostril as creates a deformity.
  Treatment.—The  treatment  is  simple, the abscess being punctured and
treated as abscesses  elsewhere, the chief  danger being from the continued
distention of the cartilages inducing a condition of the  septum  narium which
will cause permanent deformity.   The ulcer left after the evacuation of the
abscess should be stimulated by nitrate of silver or other alterative applica-
tions, and when, as a consequence of the complaint, dryness of the  nostril
occurs, glycerin  may be used. 
POLYPI IN THE NOSTRILS.                   145
                            SECTION III.

                   OPERATION  ON THE  NASAL CAVITIES.

               \ 1.—Arrest of Hemorrhage from the Nostril.

   Bleeding from the nostril, when excessive, and when the use of powdered
 galls or tannic acid, or raatico, or  gum-arabic, or alum, or diluted persul-
 phate of iron has failed, may usually be  arrested by plugging up  both the
 anterior and posterior extremities of the nostrils so as to prevent the escape
 of the blood, and  cause the formation of a clot.
   Plugging the  Nostril with  Bellocque's  Canula.—This  instrument—
 see  Plate  XIII. Figs. 25, 26—consists of a curved silver tube, in  which is
 placed a piece of  watch-spring of sufficient length to reach from the uvula
 to near the front teeth.  To one end of this spring is attached a silver but-
 ton, with an eye capable of readily receiving a ligature ;  to the  other is
 screwed a  probe, which is intended to push out the spring.
   Operation.—After preparing  a little pellet of charpie, of a size  corre-
 sponding with the opening  in  the posterior nares,  and after passing a long
 ligature through the eye of the  button at the end of the spring, and  drawing
 the latter fully within the canula, pass  the tube along the floor of  the nos-
 tril,  keeping it close to the side of the  septum, until  it reaches the uvula.
 Then, pushing forward  the  spring,  the button will  readily  pass into the
 mouth, its  passage in front of the uvula being facilitated  by the forefinger
 introduced  into the mouth.   When  the button is near the teeth, one end of
 the  ligature should be drawn  out of the mouth, and the pellet of charpie
 attached to it  by  tying the ligature round its middle, Plate  XIX. Fig. 1.
 Then, on drawing back the spring into  the  canula, and removing the latter
 from the nose,  the pellet will be drawn  up into the posterior nares,  so as to
 leave one end  of  the ligature  in the mouth and  the other in the nostril.
 It only remains to plug up the  front of  the nostril, and tie the two ends of
 the ligature rather loosely in a  loop near the teeth, or to carry them toward
the cheek and fasten them with adhesive plaster.
   Should the  surgeon not be  able to obtain Bellocque's  canula, he may
 readily carry a ligature through  the nostril and mouth by means of a common
 elastic catheter; the ligature being passed through the eye of the instrument,
 and  the latter withdrawn after the pellet is in  position.  In either case, after
 the lapse of several hours, the lint in front of  the nostril should be removed
 by the fingers or forceps, and that from the posterior nares displaced  either
 by pressing it  into the throat by a probe, whence  it may be  drawn by the
 thread left  attached to it for this purpose, or it may be drawn out by traction
 on the end of the  ligature left in  the mouth.


                      § 2.—Polypi  in the Nostrils.

   Pathology.—Various divisions of Polypi have been described by writers,
 and  especially by Dupuytren, in all of which more attention has been given
 to their consistence than to their general pathological characters.  In  an
excellent paper by Watson, of New York,* much has been added to  our
knowledge  of the origin and structure of these tumors, and I cannot present
        * Amer. Med. Journ.. vol. iii.p. 325, New Series, 1842.
VOL. II.—10 
PLATE XIX.
   ANATOMY OF THE INTERNAL  NOSE, WITH THE OPERATIONS FOR
                            NASAL POLYPI.

   Fig. 1. A vertical section of the Head, in its median line, so as to show the
 interior of the Nose, Mouth, and Throat.  1. The middle turbinated bone.  2.
 Inferior turbinated bone.  3. Anterior and cartilaginous portion  of the nostril.
 4. Middle palatine suture.  5.  Roof of the mouth.  6. An ear catheter passed
 along the floor of the nostril and entering the orifice of the Eustachian tube.  7.
 Middle meatus of the nose.  8. Inferior meatus,  near the  nasal orifice of the
 ductus ad nasum.  9. The sound of Laforest introduced into the duct.  10. Sec-
 tion of the uvula.  11. Bellocque's canula passed aloug  the floor of the nostril
 and  soft palate, behind the uvula into the pharynx.  The spring has been pro-
 truded, and the ligature with the pellet of charpie attached is about to be drawn
 back into the posterior nares in order to close one side, as in tamponing the nos-
 tril.   12. The epiglottis cartilage.  13. Section of the oesophagus.  14. Genio-
 hyoglossus muscle.  15. Origin of the genio-glossus muscle.  16. Section of the
 lower jaw  at  the chin.  17. Structure  of the chin.   18. A probe introduced
 into  the buccal orifice of the duct of Steno.        After Bernard  and Huette.

  Fig. 2. A front view of the manner in which the loop is seized and drawn for-
 ward in the operation of tamponing the  nostril.   After Bourgery and Jacob.

  Fig. 3. A vertical section of  the Nose, showing the application of  a ligature
 around a guttural polypus by means  of the " porte ligature" of Charriere.   1.
 The  ligature passed in a loop through the nostril.  2. The "porte," which has
 seized it in the pharynx, and directed  it around the  base of the tumor.  This
 instrument opens at the end by  means of a spring, so that it can  seize or be de-
 tached from the  ligature without difficulty.   The forefinger of the surgeon will
 often do quite as well.                           After Bernard and Huette.

  Fig. 4. Section of the Face, so as to show the  removal of a pyriform nasal
 polypus, by means of the wire ligature and double canula as practiced by Phy-
8ick-                                                           After Bell.

  Fig. 5. A side view of  Mott's  operation for the removal  of a  large nasal
polypus which filled the entire nostril.   The integuments have been  incised and
dissected back, while the dotted lines  show the course of the saw through the
bones'                                                          After Mott.
       (146) 
1!!
■&/    1:'
^    '#
A,£s
i /,://// X: S,!/i.s 
 
POLYPI IN THE NOSTRILS.                  147
the reader with any details more valuable than those furnished by his article.
From this the following account is condensed.
   Kinds of Polypi.—Six kinds of polypi may be noticed in connection with
the surgical affections of the nostril.
   1st. The  mucous or soft polypus, caused by the  accumulation of mucus
within the muciparous follicles, and arising either from a change in the con-
sistence  of  the  mucus itself,  or  from obliteration and  obstruction  of the
ducts; resembling, in this respect, the sebaceous and encysted tumors of the
scalp and other portions of the body, all of which, like polypi,  may become
pedunculated if acted on by the weight of the contents of the sac.
   2d.  The polypus from hypertrophy, induration, and infiltration of the mu-
cous  and submucous tissues of the  nostril, and similar  to the tumors  fre-
quently seen near the lower part of the rectum.   These  tumors are, in fact,
a  prolapse  of  the thickened  and infiltrated  Schneiderian  membrane, and
attended with an effusion of fluid into the subjacent connective tissue, as the
result of inflammation.
   3d.  Fleshy polypi, or caruncular excrescences,  of  a florid red color, and
though not painful, except when  irritated, are possessed of a certain degree
of sensibility.  These are less disposed to assume a pedunculated attachment
than any other benign form of polypi.  Similar growths have been found at
the inner edge of the meatus urinarius of the female, and in  the external
meatus of the  ear, by  Sir A. Cooper, and others have seen  them in  the
rectum.
   4th. Fibrous polypi, supposed by Velpeau to have their special origin in
the fibrous tissue covering the bones in the nasal cavity, and to lie between
the bone and the proper mucous tissue.   When very  large, these are usually
found  projecting into the posterior fauces, though the other forms may also
project either forward or backward.   These tumors are invariably attached
by a firm  and fibrous pedicle.
   5th. Gelatinous polypi, which are of rare occurrence.  In one  case, the
disease appeared to have originated in the antrum  between the mucous mem-
brane and the bone, and then  to have encroached on the surrounding parts.
It was surrounded by a sort of imperfect capsule, with subdivisions of areo-
lar tissue, some of which were exceedingly delicate, and all of them filled
with a gelatinous, semi-fluid substance of a transparent, pale-white or amber
color.  At some points, this matter was more like soft calfs-foot jelly, with-
out any visible envelope, but here and there the tumor contained  opaque, gru-
mous, bloody deposits.  The bones retained their  proper character, and had
not degenerated, and all the surrounding tissues were simply affected by the
pressure of the tumor.
   6th. External polypi, generally called lipoma, and referred to in a previous
page.
   7th. Carcinomatous polypi, most frequently originating in the periosteum
or bony structure of the upper jaw, and, sooner or later, invading  and de-
ranging the  surrounding tissues.
   Seat of Polypi in the Nose.—This is to be ascertained  mainly through
dilatation of the nostril, by introducing the blades of  the dressing forceps, or
by a speculum,  or by directing the patient to blow through the  nostril so as
to force the  polypus forward.
   Most frequently polypi arise from the mucous membrane spread over the tur-
binated bones, or near the orifice  of the maxillary sinus, being seldom found
ou the septum, and also as rarely arising from the floor of the nostril.   The
first two forms are generally confined to the tissues lining the  external and
upper wall of the nostril.   The third form, though not so strictly limited, is
often found near the external orifice of the nostril, at  or below the turbinated 
148           PRINCIPLES AND PRACTICE  OF SURGERY.
 bones.   The fourth is most frequently found to arise in the posterior fauces
 immediately behind the  top of the  septum, or probably from the  septum
 itself.*  In a  case which I attended some  years since, the tumor extended
 from this  point  along the body of  the sphenoid  bone, and left it perfectly
 denuded of its periosteum, as was shown after its removal.
   The  fifth, or  gelatinous polypus, as already seen, arises in the  antrum
 Highmorianum;  and the sixth, though frequently arising on the nasal surface
 of the upper maxillary bone, is restricted to no definite point of attachment.
   Symptoms.—The symptoms of soft polypus  in the nose are well marked.
 The patient complains of feeling something  in his nostril, and has, therefore,
 a constant desire to blow his nose, from which  he  finds a thin mucous  dis-
 charge.  He also notices that he breathes through the nostril more freely
 in dry weather than in moist.   As the polypus grows, the symptoms become
 marked, its bulk encroaching upon  surrounding parts, until it may at last
 block up the entire nostril, and so press on the orifice of the ductus ad nasum
 as to prevent the passage of the tears into the nose.  In consequence of this
 the tears will often overflow the eye, and the patient, being ignorant of the
 true cause, refers all his  symptoms to a troublesome  coryza, which he is not
 able to get rid of.   As the tumor grows still larger, it may protrude from
 the nostril anteriorly, and show itself externally, or it may project backward
 through the posterior nares into the top of the pharynx;  or it may work
 its way, if its growth still continues,  through the fissures in the bones of the
 face, and  appear in parts  apparently wholly unconnected  with the  nostril;
 thus tumors have  been  produced in the temple as a  result  of an exces-
 sive growth of one of these  soft polypi in the nose.   Another symptom
 which, so soon  as the polypi have attained any size, develops itself in a very
 marked manner, is an alteration in the voice, which assumes a peculiar nasal
 twang,  on  account of the obstruction of the nostrils interrupting the rever-
 beration of sound, the patient speaking as he would do if he held his nostrils
 between his thumb and finger.
   Upon looking into the nose this polypus can generally be seen as a smooth,
 pinkish swelling, owing to its being covered  by the Schneiderian membrane;
 but caution must  be used  lest  the anterior extremity of the inferior turbin-
 ated bone be mistaken for the polypus, when it projects toward the anterior
 nares.
   The fleshy, fibrous, or hard polypi present  characters which,  in  many
 respects, correspond with the variety that has just  been described; thus,
 they have a tendency to -grow rapidly and invade the surrounding parts,
 producing, by  their pressure, caries  and necrosis  of the  bones with which
 they come in contact.  Those of the  bones thin enough—as the walls of the
 antrum  under  certain conditions—are also apt to become distended, and
 the patient is horribly deformed, creating a distortion of the features, which
 has been designated as "frog-face," Fig.  398.
   Prognosis—The prognosis  of soft polypi in the  nostril is favorable, as
 the tumors  can generally be removed, and  although  they will frequently
 return, yet  they can be removed again and again, until the tendency to their
 reproduction is finally overcome, unless they be malignant or have induced
 serious organic changes in the adjacent parts.
   Treatment.—The treatment of soft polypi may be either palliative or rad-
 ical ; the palliative consisting in puncturing  the tumor with a sharp-pointed
 bistoury, evacuating its contents, and  allowing it to collapse.  Although this
treatment is in  the majority of cases only palliative, yet it is not unfrequently
 followed by destruction  of the sac  and a  disappearance of  the disease
* Watson, loc. cital. 
POLYPI IN  THE  NOSTRILS.
149
Should, however, this  not happen, as is more frequently the case, the sac
will begin shortly to refill, and resort must be had to the operation of extir-
pation as a means of effecting a radical cure, as hereafter stated.
  Sometimes  a polypus can be  removed  simply by causing the patient to
sneeze violently, when, in the efforts consequent upon this action, the tumor
will be expelled by being torn off from  its base by the air as it is forcibly
driven through the nostril.

                                 Fig. 398.
     Frog-face, or the deformity caused by Polypi of the Nose encroaching on the bones of the face.
                                (After Liston.)

   To produce this effect, ordinary snuff may be employed, or one of a more
stimulating character, as powdered sanguinaria, cloves, rhubarb, or  pow-
dered sage, though any active sternutatory will answer the purpose.  Having
by any of these means gotten  rid of the tumor, any wash which is astringent
and alterative in its character may  be  used as an injection into the nostril,
with a view of preventing the reproduction of the complaint—the best of
these being the nitrate of silver.   When the latter salt is used, the precau-
tion should be taken of anointing the upper lip and the orifice of the nostril
with sweet oil, in order to prevent the wash from discoloring the skin.
   The extraction of the soft polypi may be attempted either by the polypus
forceps, by the wire ligature and  double canula of Physick—Plate  IV. Fig.
12—or by the knife; caustics, sternutatories, etc. being comparatively limited
in their application, or resorted to either as palliative means, or as adjuvants
to other plans of treatment.
   Removal by the Forceps.—The  patient being directed  to blow his nose,
and being  seated  before a good  light,  with his head well supported, intro- 
150            PRINCIPLES AND  PRACTICE OF  SURGERY.
duce the forceps closed, and with the width of the blades corresponding to
the vertical diameter of the nostril, grasp the tumor as near as possible to
its base, then, rotating the instrument in the hand so  as to twist the tumor,
pull it away with a jerk as soon  as  it is felt  to yield to the torsion move-
ment.
  Strangulation and Extraction  by the Wire  Ligature  and Double
Canula.__This plan, which is that most frequently resorted to in the United
States,  and which  is the least liable to  injure the bony structure, is prac-
ticed as follows: Pass a piece of well annealed iron wire through the barrels
of the canula, and fasten  one end firmly around one wing of the instrument.
Then, seiziug the free end of the wire, push or  pull it through one of the
barrels of the canula until a loop of the  proper size  is formed at the  end
which is to be passed into the nostril.  On carrying this into the nose with
the loop parallel with and close  to the septum, turn it transversely beneath
the fundus of the tumor, and endeavor to slide it over and up to the pedic-
ulated  portion, Plate XIX. Fig.  4; after which the free end  of  the wire
should  be  seized with forceps  similar to those used  by bell-hangers,  and
drawn as tightly as possible.   If  the polypus  is not too  dense in  its struc-
ture, this will constrict its pedicle to a mere  shred, and it only remains to
tear it  away at the end of the canula, in the loop thus tightened.   After a
few minutes, the patient  should be again directed  to  blow his  nose, espe-
cially on the side  affected, when, again forming  a loop,  fish about in  the
nostril for another tumor, which is to be extracted as before.
  In large polypi, and especially where they protrude by the posterior nares,
it may become necessary to strangulate them and leave them to slough off.
When the wire ligature can be made  to surround the tumor, the more per-
fect strangulation accomplished by it should cause the surgeon to give it the
preference.  But its large size will occasionally preclude its use  in this man-
ner.  In the case of a large polypus which projected behind the soft palate
as low as the extremity of the uvula, and filled completely the posterior nares
and cavity of the nose, Physick, after vainly attempting to  extract it with
the  ligature and forceps, passed a portion of tape, made stiff by means of a
piece  of silver wire, into  the nose and throat, and, getting it  around the
base, tied the tumor  in this manner.   In a similar case, in which I assisted
Gibson, a violin string was passed around the base by means of Bellocque's
canula,  and  both ends brought  out of the nostril, when they  were passed
through the barrels of a  canula and  the tumor strangulated, as in the usual
application of the  wire ligature.   The canula was kept in the nostril until
the third or fifth day, when the tumor sloughed off.
  Operation of Mott.—In a large fibrous polypus,  which filled  the nostril,
Mott removed the tumor,  after  the ligature had failed, by making a section
of the soft parts from the inner canthus of the eye to near the angle of the
mouth, and  sawing out the greater part  of the os nasi, ascending ramus of
the superior maxillary and inferior turbinated bone,* Plate XIX. Fig. 5.
  Excision.—Except in  the  very rare cases of exceedingly firm polypi, or
those  near the nasal orifice, this operation can seldom  be required.  When
resorted to at the anterior orifice, the tumor should be  hooked forward, and
excised  either with a probe-pointed bistoury, or with scissors, though the  first
is preferable.
  In all these operations, if the subsequent hemorrhage is excessive,  tampon-
ing the  nostril may be required.
  Value of these Operations.—In most cases of soft polypi, the wire liga-
ture and double canula will prove most  serviceable, next the forceps,  and
lastly excision, especially of the fibrous variety.
*Am. Journ. Med. Sciences, vol. v. p. 87, 1842. 
CHAPTER  VI.
DISORDERS OF, AND OPERATIONS ON, THE LIPS AND MOUTH.
                             SECTION I.

           ANATOMY OF THE EXTERNAL PORTION OP THE MOUTH.
                                          *
   In studying the parietes of the mouth, two parts are to be separately no-
ticed : first, its orifice as formed by the lips, and, second, its sides as consti-
tuted by the cheeks.  The tissues composing both these portions are the skin,
areolar tissue,  fat, blood-vessels,  muscles, and nerves, together with the
mucous membrane.
   The skin and areolar substance present nothing requiring a special descrip-
tion.   The muscles of this region are the orbicularis oris, closing the orifice
of the mouth;  the zygomatici and levatores anguli oris, which draw back
its angles ; the buccinator, which dilates its cavity, and forms the greatest
portion of the sides of the cheek;  aud the masseter, which assists in closing
the jaws, being inserted into the lower jaw in advance of its angle.  The de-
pressors and levators of the lips complete the enumeration.
   The  principal blood-vessels are the facial artery and vein,  with  their
branches, both  of which pass on to the face,  side by side, over the surface of
the inferior maxilla,  directly in advance of the anterior edge of the masseter
muscle; being at this point quite superficial, they may be readily compressed
by the pressure of the finger against the jaw just in advance of the muscle.
The nerves are the  branches  of the seventh pair, (portio dura,) which are
widely distributed over the face after the trunk emerges from the parotid gland
—Plate XXIV. Figs. 1,  2—and the infra-orbitar, (second branch of the fifth
pair,) which, coming out through  the  infra-orbitar foramen of the superior
maxillary just below the  middle of the orbit, is also freely distributed to all
the tissues.   Expression and motion are due to the portio dura,  and sensa-
tion to the branches of the. fifth pair.
   The salivary glands,  Plate  XXIV. Fig. 1, although opening into the
mouth, are yet  so situated as to be rather intermediate to the head and neck;
and the description may, therefore,  at present be limited simply to their ducts
as mainly belonging to the region under consideration, the position and opera-
tions practiced  upon the  glands themselves being reserved for the account of
the neck, owing to the importance of their vascular connections with this
part.
   The duct of Steno, or  the parotid duct, departs from the anterior edge of
the gland, a few lines below the zygoma, traverses the outer face  of the mas-
seter, and perforates the  buccinator muscle and  the lining membrane of the
mouth, so as to have its orifice opposite the second large molar tooth of the
upper jaw, Plate XIX. Fig. 1.  Its position may be  accurately  marked by
drawing a line from the tip of the nose to the lobe of the ear.  The duct of
the submaxillary gland may be found opening by a small projecting orifice
                                                          (151) 
152            PRINCIPLES AND  PRACTICE OF  SURGERY.

on the anterior margin of the fraenum lingua?.  The ducts of the sublingual
open  either into that  of  the  submaxillary, or directly into the mouth, on
either side of the fraenum.*
  The further  details of this portion of the face, being of but little practical
value  to the surgeon, may be omitted, with a simple reference  to the expla-
nations of the figures, Plate XIX. Fig. 1, and Plate XXIV. Figs. 1, 2.
                            SECTION  II.

                       OPERATIONS ON THE LIPS.

  The operations upon the lips are chiefly those required  for the enre of
hare-lip, of cancer, of atresia or closure of the mouth, and  for cheiloplasty
or the formation of a new lip.
                            •
                         § 1.—Simple Hare-lip.

  The congenital defect of union in the two halves of the lip, termed Hare-
lip, may usually be remedied by paring off or freshening the  vertical portion
of each half, and then uniting them by suture.
  Various modes of accomplishing this have been proposed  by surgeons, bnt
differ  mainly in the character of the incision.   Without, however, referring
to these in detail, this account may be limited  to that which I have gener-
ally found successful.
  Operation.—The child, being either  firmly held, or with its arms bandaged
to its  side or tied up in  a bag, the end of which is drawn  around its neck,
should be placed  in a semi-recumbent posture, or, if  lying down, raised  up
from time to time during the operation, so as to prevent the escape of blood
into its throat and stomach, as this is apt to induce fever.  Then, seizing the
left half of the lip with the left forefinger and thumb, dissect  it freely from its
attachment to  the  gum, and, seizing the right half in the same  manner, dis-
sect it also freely from the gum, this free dissection of the  lip from its  at-
tachments being essential to success, by diminishing  the subsequent strain on
the line of union.   After freeing the lip very fully at  this point, next intro-
duce a spatula of shingle, or other soft wood, beneath the lip,  and have its
free extremity held by an assistant.   Then, seizing the left half at its free
angle with a tenaculum or forceps, extend the  flap upon the spatula, and,
commencing at the nostril, cut through the lip so as to make the incision to
its lower  edge in a slightly semicircular or bent direction, like an A jointed
or bent outward at the cross-piece, the joint or angle being near but not
quite  in the centre, as proposed  by  Barton, of Philadelphia, and  also by Gue-
rin,f of Paris, Plate XX. Fig. 1.   This edge of the lip being then seized by
the assistant, the coronary artery may be compressed between the thumb and
forefinger, so as to check the bleeding.
  The opposite half being now treated in the same manner, the wound will
exhibit two almost semi-elliptical  cut surfaces, so  arranged as to present
their concavity toward the median line of the fissure, Plate  XX.  Fig.  1.
  Then, passing a ligature through the lower edge of each  flap,  and  draw-
ing upon it, adjust accurately the angles of the incision to  the same level,
and, giving the ligature into the hand of an assistant,  so as to preserve their
position, pass  a sharp-pointed steel or  insect  pin through the flaps from left
* Horner's Anatomy.                 f Gazette M6dicale, June, 1844. 
SIMPLE HARE-LIP.                      153
 to right, taking care not to carry it through the mucous membrane.  After
 surrounding this pin with a twisted suture, next introduce a second or even
 a third pin, and  approximate  the  surfaces of the  incision  well up into  the
 nostril by other ligatures, Plate XX. Fig. 5, when the ligature first intro-
 duced at Ihe lower edge of the lip, and which should have been held by  the
 assistant during this time, may be withdrawn.
   Dressing.—After cleansing  the lip, and cutting off the points of the pins,
 the sutures should be firmly supported by strips of adhesive plaster, slit so
 as to allow the ends of the pins to pass through them, and extended from
 the middle of one cheek across the lip to the other cheek, in order to take  the
 traction off from the pins.  Three days subsequently, the latter must be with-
 drawn by a rotatory movement, without, if possible, disturbing the ligatures
 or plaster, as may be readily accomplished  either by nicking the latter over
 the head of the  pins, or by drawing them through the slits made in the strips
 previous to their application.   On the fifth day, the cheeks being well sup-
 ported by an assistant, these strips may be removed, and new  ones  applied
 every two days  during the first week  or  until the  union is accomplished.
 Throughout, or at least until  the sixth day, the child, if unweaned, should
 be fed with a spoon;  but after this it  may be allowed  to suck with  the
 plasters on.   During  the  first twenty-four hours after the  operation, it is
 also especially necessary that the patient should  be watched, lest hemorrhage
 occur, and the blood, escaping into the mouth, be carried into the stomach,
 without the bleeding being suspected.   If, however, the pins are inserted
 in the lip deeply enough to pass  behind the coronary arteries,  the compres-
 sion  of these vessels  by the  ligature will allow but  little probability  of
 hemorrhage.
   Remarks.—The advantages of  the  semi-elliptical incisions over those
 which are straight will  be  found in the absence of the  notch in the lip,
 usually consequent on  the  contraction of the wound, the angular character
 of the incisions  preventing the linear shortening of the cicatrix.  The value
 of the temporary ligature in the free edge of the lip will  also be found  in
 the greater accuracy with which the angles can be adjusted  before inserting
 the first pin.
   Mirault, of Angers, France, operates as follows:   By a straight incision,
 he pares off one-half of the fissure, Plate XX. Fig. 2.   Then, incising  the
 other  portion, (generally the left,)  he cuts it so as to leave a pedicle of the
 membrane on the free  edge  of this flap, which, being carried  across the
 fissure and united to the opposite half, prevents the  formation  of any notch
 or depression, Plate XX. Fig. 3.
   Malgaigne, in order to avoid the notch  on the free surface of  the lip,
 makes a curved  incision from above downward, so as to pare off the  mucous
 covering of the  fissure, but without cutting  it free  from the inferior angle,
 or that continous with the margin of the lip.   Leaving the  portion thus
 pared  off  adherent, and depending  by this  pedicle,  he unites the wound  by
 pins and  the twisted suture.   Then, trimming and shortening the  pedicu-
 lated  portion with the scissors until there is only a piece in each half long
 enough to fill up the notch, he  unites them on a level with the lip by a small
 and fine pin.
  Judging from personal observation, hare-lip is a very common complaint,
it having  occasionally happened to me to have three patients under treat-
ment  at one time;  and in one winter at the  Clinic of the University of
Pennsylvania, I  treated ten in the course of  six  months.   Out of the large
number that I have seen—I should think more than eighty—but two fail-
ures  have occurred,  after pursuing the plan above  stated;  and in one  of
these, (double,) the result was  undoubtedly due to  an attack of cholera in- 
PLATE  XX.
         OPERATIONS PRACTICED ON THE LIPS AND MOUTH.

  Fig. 1. A front view of a single Hare-lip, with the  lines of the incision for
freshening the edges as advised by Barton.   1, 1. The semi-elliptical incisions.
                                      Modified from Bernard and Huette.

  Fig. 2. Operation of Mirault, of Angers, for single Hare-lip. 1. The flap cut
from one side.                                   After Bernard and Huette.

  Fig. 3. The  same operation, showing the line of union and position of the
principal pin.                                   After Bernard and Huette.
  Fig. 4. Front view of a double Hare-lip, showing the  septum or anterior edge
of the intermaxillary bone, containing the two central incisor teeth.
                                               After Bernard and Huette.

  Fig. 5. Application  of the single Hare-lip Suture to the case shown in Fig. 1.
                                               After Bernard and Huette.
  Fig. 6. The  union of the parts, after the operation of double  Hare-lip, when
both sides are to be united at the same time.   The risk of sloughing of the  cen-
tral part, from excessive inflammation or want of vitality, is an objection to this
mode of operating.                              After Bernard and Huette.

  Fig. 7. Atresia of the Mouth consequent on ulceration, showing Dieffenbach's
operation.  1,  2. The  integuments as left by the two incisions which start  from
3, the mucous  membrane remaining untouched. 3. Point for the introduction of
the scissors. 4, 5.  The lines of incision. The ulceration has exposed the gums
and teeth at the opposite corner of the mouth.     After Bernard and Huette.

  Fig. 8. View of a Mouth, as contracted in consequence of an ulcer. 1, 2.  The
two points at which the sharp-pointed scissors were introduced so as  to divide
the integuments  on both the upper and lower lip toward the median line.  The
mucous membrane, being subsequently divided, was reflected  over the edges of
the incision and  fastened to the skin by several points of the interrupted suture.
                                               After Bernard and Huette.
  Fig. 9. The appearance of  Fig. 8 after the integuments had been removed.
1. The mucous membrane untouched.  This is to be divided in the median line
of the mouth, and reflected so as to form a rounded edge to the new lips.
                                               After Bernard and Huette.
        (154) 
i: 1: <   2 0


■~>?~*i0gf'
'**,
"W^.
niin.m \ 
 
DOUBLE  HARE-LIP.
155
fantum, of which the child died.   After the operation, as performed by the
scissors and the ordinary straight incision, I have seen several (five ?) failures.
As respects the  best period for the operation, I have generally selected the
earliest possible time after the tissues  seemed to be firm, usually soon after
the third week of infancy; and  I have always deemed it necessary to  con-
tinue the adhesive strips a week after the removal of  the pins.
   Mason  Warren, of Boston, as well as several  other surgeons, select an
early period for the operation; but resort to the interrupted suture in place
of employing  the hare-lip pins.
   Peirson, of  Salem, Massachusetts, has succeeded in  several cases, on which
he operated within the  first twenty-four hours after  birth;  and advocates*
this  early operation as being especially advantageous, from the tendency of
the infant to sleep at this period.
   Guersent, Surgeon of the  Children's Hospital in Paris, has also recently
performed the same  operation successfully on an infant only one day old.f
   Mason  Warren has  permitted nursing during the process of  healing, in
the case of an infant one month old,  on whom he had operated, and  em-
ployed three sutures without inconvenience, it being  evident that there was
no strain  on the lip during the  act of sucking. J  In two instances, I have
operated successfully within thirty-six hours after birth, resorting to the lead
suture and one hare-lip pin—the pin being placed on the level of the margin
of the  lip—but I always have the child fed.
                         § 2.—Double Hare-lip.

   In the variety of the disease known as Double hare-lip there is commonly a
double fissure in the lip and palatine portions of the mouth, together with a
tubercle  or intermediate  structure resembling and corresponding with the
intermaxillary  bone of animals, Plate XX. Fig. 4.   The  projecting ex-
tremity of this bone usually contains either  the germs of the incisor teeth
or the teeth themselves, according to the age of the patient, and is often a
source of difficulty, by causing the interruption of the circulation through
the middle flap.
   Ordinary Operation___If the central flap is to be preserved, it should  be
first freed from its attachment to the gum, but with judgment, lest its vitality
be impaired from want of base.  Then, one of its edges being freshened with
the scalpel and wooden spatula, the  opposite half of the fissure should  be
freed from its  attachment and  also freshened, as in the operation just de-
tailed, the  remaining portion of the operation being performed as in that
for simple fissure.  After a few weeks, when the union is firm, the remaining
half of the lip may be operated on in a similar manner; or, if circumstances
induce the surgeon  to think it advisable, both sides may be united at the
same time by transfixing them with  the pins, as represented  in  Plate XX.
Fig. 6.
  Remarks.—Some surgeons prefer, in double hare-lip, the  performance of
the operation on both  sides of the fissure at  the  same period;  but, in my
experience, this has seemed more  liable to failure:  1st. Because the stress
upon the pins, or upon the newly-formed cicatrices after their removal, is
much greater when both sides are  thus operated on.  2d.  From the inflam-
mation or compression of the middle flap by the  ligatures being more apt
* Bost. Med. and Surg. Journ., vol. xlvii. p. 134.
f South. Med. and Surg. Journ., vol. vii. p. 641.
X Amer. Journ. Med. Sciences, Oct. 1851. 
156           PRINCIPLES AND PRACTICE  OF SURGERY.
to induce sloughing.   To operate first on one side  and then repeat it on
the other will, it is thought, in most instances prove  preferable.   When the
incisor  teeth project  outwardly, it will  generally be  necessary to extract
them, or to cut off the inferior  anterior  extremity of  the  projecting inter-
maxillary bone before proceeding to the incision in  the lips.  But in chil-
dren, unless the portion of the alveolar process to be removed is limited, the
germ's of the permanent incisors will be entirely destroyed.  When the pro-
jection  necessitates interference, I  prefer, therefore, the plan proposed by
Blandin, of excising, with bone nippers or strong scissors, a triangular piece
of the septum,  with its base downward, behind the alveolar processes, and
then bending or forcing back the projecting portion,  as any attempt to push
back this end of the bone by bandages alone is very apt  to induce such in-
flammation in the  soft  parts as will necessitate their removal.
   The fissure so often seen in the hard palate, in connection with both simple
and double hare-lip, may subsequently require an operation, though  it will
often be much diminished or cured  simply by the contraction and constric-
tion of  the bones consequent on the union of the fissure in the soft tissues
of the lip, especially if the patient is operated on at the early  period  men-
tioned.   The treatment of the fissure in the soft palate will be referred to
under the head of Staphyloraphy.
                        \ 3.—Cancer of the Lip.

  When the surgeon is satisfied that the removal of the tumor will retard
the progress of the disease, he may excise it by an elliptical incision around
its base, in the* same manner that  he would remove a tumor in any other
part of  the body;  but  as these cancerous affections are apt to invade the
surrounding tissues, and the parts here involved possess much vitality, he
should be especially careful to  cut away such  an amount  of the adjacent
sound parts as will insure the entire removal of the complaint.  As the best
and simplest mode of operating, he may proceed as follows :—
  Ordinary Operation.—Make, either with the scissors or scalpel, a V  in-
cision of such a size as is necessary  for the entire  removal of the disease,
with its base corresponding to the free margin of the lip.   If the scalpel is
used, a wooden spatula should be placed so as to  support the portion cut
during  the incision; after which the wound may be united  as in hare-lip.
From the  great extensibility of the cheeks, very considerable portions  of the
lips, and especially of  the  lower one, may be  removed without deformity;
and I have seen two patients, in each of whom I had  removed a piece over
one inch in width  at the base of the V, three  years previously, for cancer,
and in both of whom it is difficult to see any deficiency.
  Should  the disease require the loss of more tissue  than can be supplied
by approximating the sides of the incision, resort must  be had to  the forma-
tion of  a new lip, or to the operation of Cheiloplasty, as hereafter shown.
                    \ 4.—Enlargement of the Mouth.

  The operation of re-establishing the orifice of the  mouth is one  that is
occasionally rendered necessary in consequence of its contraction or  closure
from  the cicatrices resulting from  ulceration  or burns.   Among the best
plans of operating in these cases is the very ingenious one  of Dieffeubach,
of Berlin.
  Dieffenbach's Operation.—Wishing to preserve enough of the mucous 
CHEILOPLASTY.
157
membrane to cover the edge of the incisions required in enlarging the mouth,
Dieffenbach introduced into the patient's mouth  the forefinger of one hand,
and, inserting the  point of one blade of the sharp-pointed scissors into the
cheek a line or two beyond the point at which he wished to make the new
angle of the mouth, he transfixed all the tissues except  the mucous mem-
brane, Plate XX.  Fig. 8.   On pushing the  point forward to the contracted
orifice, he was enabled to incise all this texture in the  line (3, 5) of the free
edge of the lower of the new lips; then, reintroducing the point of the scis-
sors at its first place (3) of entrance, he  divided these textures also, with the
exception of the mucous membrane, in a line (3, 4) corresponding with the
free edge of  the upper lip.
   The triangular piece (3, 4, 5)  being  then carefully  dissected off from the
lining  membrane of the mouth,  (1, 2,) the latter was  left uninjured, Plate
XX. Fig.  9.
   On dividing this membrane in  the middle, to within  two lines of the angle
of the first incision,  it only remained to attach it neatly by sutures to the
bleeding surface in order to complete the mouth.
   On two  occasions I repeated this operation—Plate XX. Fig.  7—with
entire satisfaction ; and many other surgeons have reported similar instances
of success.*
   After  union  has taken place,  the resemblance of  the new  mouth  to  a
normal one is often excellent.
                           \ 5.—Cheiloplasty.

   Plastic operations for the restoration of the  lips may be required in dis-
 eases of either of them, though it is most frequently demanded in that of the
 lower lip.  In  either case, the operation is termed Cheiloplasty.   In the
 upper lip it may be performed by adapting a flap, taken from the arm, to the
 deficient portion, as in the old Taliacotian  operation ; but the greater facility
 afforded by approximating the edges  of  the deficiency, as  in  the ordinary
 operation for hare lip, renders this mode of operating a rare occurrence.
   The Taliacotian  operation  has also been applied  to  the lower lip, but
 there is  as little to recommend  it in  this as in the former case, the loss of
 substance  from  cancerous degeneration or ulceration, when so extensive as
 to require any  plastic  operation, being more  readily  supplied by either of
 the following methods :—
   Operation of Pancoast.—Having excised the diseased margin of  the lip
 by an  incision which  entirely circumscribed  it, a vertical cut was made in
 the  middle line  of the  chin nearly down to the level of the os hyoides,
 and  crossed by a horizontal cut over the base of the lower jaw-bone.   The
 four angular flaps thus formed being now dissected up from  the jaw and
 the angles of the crucial incision, or the ends of the flaps removed so as to
 leave a lozenge-shaped space,  Plate XXI.  Fig. 3, the margins of the upper
 flaps were brought to the level of the angles of the mouth, and united on
 the  median line by the twisted  suture, after  which  the  lower  flaps were
 united so as to cover the point of the chin.f
  Operation of Chopart.|—Chopart,  in a case of cancer of the lower lip,
included all the diseased structure between  two parallel vertical incisions,
which, commencing at the margin of the lip, extended down to near the os
* See Bibliographical Index at the end of this part.
f Operative Surgery, p. 356.   Phila. 1844.
X Bernard and Huette, p.  179. 
PLATE   XXI.
       THE OPERATIONS OF CHEILOPLASTY AND  GENIOPLASTY.

  Fig. 1. A side view of Mutter's operation for the Formation of a New Cheek.
The edges of the ulcer, which resulted from extreme salivation, were first fresh-
ened, the useless teeth extracted, and four flaps formed by incisions in the course
of the dotted lines, so as to permit the approximation of the edges of the flaps.
                                                            After Mutter.

  Fig. 2. A three-quarter view of Mott's operation for the relief of Anchylosis
of the Jaw dependent on Cicatrization of the Mouth, with the restoration of a
part of the Cheek.  1. The cicatrix arising from an  ulcer.   This was entirely
excised, leaving an opening in the cheek.  2.  The tongue shaped flap, cut to fill
up the opening by being rotated upon its base.                    After Mott.

  Fig. 3. A front view of Pancoast's  operation for the removal of  an exten-
sive Cancer and the formation of a new Lower Lip.   The cancer is  shown as
circumscribed by a curvilinear cut.   A vertical incision in the median line of
the chin extended from  the curvilinear cut  nearly to  the  os hyoides,  and an-
other, which was horizontal and parallel to the base of the lower jaw, formed
four flaps.  The angles of the flaps  being removed, the upper flaps (1,  2) were
raised to the proper level, and united by the twisted suture on the median  line,
whgn the lower flaps  (3, 4) were also united on the median line so as to cover
the front of the chin.                                      After Pancoast.

  Fig. 4. A front view of Chopart's  operation for the  same object.  1, 5,  3, 6.
The vertical incisions.   2, 4. The horizontal cut circumscribiug  the disease.
2, 4 is to be raised to the level of 1, 3%            After Bernard and Huette.

  Fig. 5. Operation of Lallemand for closing  the gap  left by the excision of a
Cancer which involved the  angle of the Mouth and a portion of the Cheek and
Lower Lip.  1. The remaining portion of the lip, which is to be drawn over to
the angle of the  mouth at  2.  A flap, formed of the integuments of the neck,
having been dissected off,  is shown as being  partially rotated on its  base, and
about to be carried up to cover the deficiency.   The wound  on the  neck may
either be approximated at its edges, or left  to heal by the second intention.
                                              After Bourgery and Jacob.
       (158) 
 
 
CHEILOPLASTY.
159
hyoides.   These incisions formed a square flap, which was dissected off from
the chin from  above downward, Plate XXI. Fig. 4.   The  diseased por-
tion being then cut off by a horizontal incision, the head was  slightly flexed
and the flap drawn up to the level of the angles of the mouth, where it was
maintained by several stitches placed in the line of the vertical incisions.
  When the preservation of a portion of the mucous membrane can be ac-
complished, it will add much to the natural appearance of the new lip.
  Operation of Malgaigne.—This surgeon removed all the diseased struc-
ture either by a V incision or by two vertical incisions, which, starting on
each side of the cancer, reach to the  chin, and are there united by a hori-
zontal cut, as in the upper incision of the operation of Chopart.
  In the V incision, in consequence  of the triangular wound,  it is necessary
to prolong the angle of the mouth on each side by a transverse cut, and to
dissect the flaps so as to give them a  triangular shape.  Then, drawing them
forward, and  uniting their vertical edges by sutures upon the  median line, it
only remains to close  the horizontal incision, in order to obtain a proper
fullness for the  lip.
  In the two vertical incisions, the gap being square, it is necessary to make
two horizontal cuts, by which the angles of the mouth may be elongated.
Then, making another horizontal cut parallel to the base of the jaw, detach
the two square flaps thus formed, and unite them on the vertical or central
line, as well as  on the horizontal incisions, when the  cheeks will be made to
contribute to a lip which contains a portion of the orbicularis, as  well as the
lining membrane of the mouth.*
  Operation of Hamilton, of Buffalo, f—A lad, seven years old, having lost
his lower lip and corresponding portion of the jaw from salivation, mastication
became difficult, and the  saliva poured upon his chin so as to induce excoria-
tion of the face and neck and  wet his clothing.   To remedy this, Hamilton,
under the impression "that by attaching the skin directly to the periosteum,
its displacement by cicatrization and contraction would be  prevented," op-
erated as follows:—
  First Operation.—The upper edge of the skin corresponding to the lower
lip  being first abraded to the extent  of a quarter of an inch each way, from
the central line, a perpendicular cut of one inch was made from either end
of this horizontal abrasion.  Then, starting from the lower end of each per-
pendicular cut,  an incision was made outward and downward to the left, and
outward and downward to the right, to the extent of one inch and a half.
  The two lateral flaps, thus formed, being next dissected from the jaw and
slid upward, were  united by sutures above the  central piece, and their in-
ferior edges also stitched  to the upper and abraded edge of the central piece,
so that by leaving the central piece attached  to the jaw and uniting the
lateral flaps above it, the  new lip thus formed would be prevented from being
drawn down again by the contraction of the wound below.  This proved, to
some extent, successful, though the new lip, in process of time,  shrunk to such
an  extent as to become insufficient, and rendered another operation  neces-
sary in order to  increase the depth of the lower lip and enable it more
effectually to retain the saliva.
  Second Operation.—A single incision being made just under the chin, was
extended along the base  of the jaw about three inches from side to side, and
all the integuments between this  horizontal cut and  the  upper edge of the
lower lip being raised from the bone, the  entire  mass  was  slid up until its
lower edge corresponded with  a line just below the upper border of the jaw,
* Malgaigne, Op. Surg., p. 340, Philad. edit.
f South. Med. and Surg. Journ., vol. vii. p. 742. 
160            PRINCIPLES AND PRACTICE OF SURGERY.
when the edge of the flap was made fast to the periosteum by several points
of the  interrupted suture, the wound below  being healed by granulation.
The result was, that no disposition was shown  by the flap to draw downward
as the wound cicatrized, but, on the contrary, the skin from under the chin
and neck was somewhat drawn upward.
  Remarks.—This operation presents evidence of considerable ingenuity,
and was rewarded by success, as the lad obtained sufficient lower lip to cover
the gums and a part of the bodies of a set of artificial teeth.
  The  preservation of the periosteum, in such cases, is stated  by Hamilton
to have originated in his observation of the capacity  of  the periosteum to
form new skin, a suggestion  which may be doubted with our present knowl-
edge of elective cell action.  Periosteum has  never  been known  to form
anything but bone or fibro-ligamentous tissue.
                           \ 6.—Genioplasty.

   The application of the principles of plastic surgery to the restoration of
deficiencies in the cheeks must, like the operations already spoken of, depend
upon the peculiarities of the case.  The two instauces hereafter stated may,
therefore, suffice as illustrations of this class of operations.
   In a patient of Mott, of New York—see  Plate XXI. Fig. 2—in addition
to the loss of substance in the cheek consequent on sphacelus during an attack
of typhus fever, there was also some false anchylosis of the jaw.  To remedy
this, he operated as follows :—
   Mott's  Operation.—An  incision, commencing a little within the upper
angle of the mouth, was carried around the outer margin of the cicatrix to
a little within the lower angle of the under lip, so as to remove all the newly-
formed  tissues within it.  Then,  after overcoming the anchylosis, the lips
were brought together  at the angle of the mouth by a suture, and a portion
of integument, sufficiently large and of a corresponding shape to replace  the
portion removed, was taken from the side of the jaw  aud neck, Plate XXI.
Fig. 2.   This portion, being turned into the space it was  intended to  fill,
left a tongue  three-quarters of an  inch in breadth connected with the adja-
cent parts, and sufficient for all the purposes  of circulation.  The edges being
then  accurately adjusted by means of the interrupted suture and  adhesive
strips, and the lower wound drawn together as much as possible by adhesive
plaster, the whole  was  covered with lint, a compress,  and bandage.   On the
eighth day, adhesion appeared to have taken place at every point, when three
of the stitches were removed, and in about one month  the patient went home
cured.*
   Dieffenbach, in  cases where the sides of the ulcer could be at all  approxi-
mated by drawing upon the substance of the cheek, freshened the edges of
the opening and united them by sutures; then, in order to obviate the danger
of separation of the wound when  the sutures were withdrawn, or when  the
cicatrix was stretched, he made an incision across the base of the flap at  the
side  where the parts were most tense, and left this wound to heal by granu-
lation.
   Operation of Mutter, of Philadelphia.f—In order to relieve a  shocking
deformity of the face,  resulting from the sloughing consequent on profuse
salivation, Mutter  operated  as follows : Having first extracted the useless
teeth of the upper jaw, which would have prevented  the proper adjustment
of the flaps, or induced  their ulceration, and  freshened the edges of the ulcer
Am. Journ. Med. Sciences, vol. ix. p. 47, 1831.     f Ibid. vol. xx. p. 342. 
                          SALIVARY FISTULA.             ^        161

he detached the integuments from the side of the jaw, in order to permit some
approximation of the wound.  Two incisions above and below the ulcer were
then made so as to form four flaps, Plate XXI. Fig. 1, and these were united
to each other in  the line of the teeth, as far forward as the angle of the
mouth.   The edges of the remaining  ulcer, being partly approximated by
the hare-lip  suture, were subsequently caused to cicatrize  under the use of
the nitrate of silver.  The result was entirely satisfactory.*


               § 7.—Removal of Tumors from the Cheeks.

   From diseases of the buccal glands and other causes, it sometimes becomes
necessary to  remove tumors from the substance of the cheeks.  No  rules
need here be given, in reference to elliptical or such special incisions as the
case may call for, except two of a general kind: 1st, to make them  as much
as possible in the line of the zygomatici or levatores anguli oris muscles, so
as to couceal the  cicatrix by bringing it into  the direction of the natural
folds of the cheek; and 2d, if the tumor is far back, or toward the  angle of
the jaw,  to guard against injury of the duct of Steno.
                          §  8.—Salivary Fistula.

   As  the  position and  general anatomy of the duct  of Steno have been
 already given, (page 151,) it is only necessary at present to mention the
 operations  resorted to in cases where, from wound  or  ulceration, this duct
 has been opened and  the saliva flows out upon the cheek, and thus forms a
 Salivary Fistula.   Various plans have been suggested for the relief of this
 defect, but  the object of all of them is the same, to wit: to close the orifice
 on the external side of the cheek, and keep open that upon its inside.   The
 nearer the external opening can be made to approach the character of a sim-
 ple incised  wound, the greater will be the chance of its closure ; and the fol-
. lowing operation of Horner, by reducing the parts  to this condition, has,
 both in  his hands and my own, been  followed by perfect success.   In two
 patients on whom I have operated, the  cure  was readily accomplished by
 this method, the external parts healing by the first intention.
   Operation  of Horner, of Philadelphia.—The patient being seated with
 the head well supported by an assistant, the operator  introduces  a  strong
 broad wooden spatula within the cheek of the affected  side, where it should
 be firmly held by the same assistant.  The  wound being then slightly elon-
 gated by incising its sides in the line of the  zygomaticus major muscle, a
 round punch, like that employed by the saddlers, should be placed over the
 fistulous orifice, care being taken to avoid the  anterior  edge of the masseter
 muscle.   Then, on pressing the punch firmly against the spatula within the
 mouth, a piece of the entire thickness of the cheek will be removed by the
 instrument, and a fresh  opening made directly into the mouth, when the
 external wound, being accurately closed by sutures and adhesive strips, will
 asually heal kindly, and  the internal  opening be found to give free vent to
 the saliva.   The punch must have a keen edge, and the cheek be  well sup-
 ported by the spatula, in order to obtain a clean cut, Plate XXIV. Fig. 3.
  * Lecture on the Operations in Surgery, by Robert Liston;  with numerous additions
by Thomas D. Mutter, M.D.  Philad. edit. p. 244.
  VOL. II.—11 
162            PRINCIPLES AND  PRACTICE OF SURGERY.
 j 0.—Division of the Masseter Muscle for Immobility of the Lower Jaw,
                          (False Anchylosis.)

  This disease, which has been charged with being peculiarly an American
one, owing to its having frequently ensued upon the free salivation at one
time so common in certain sections of the United States,  was first treated of
as a distinct affection by xMott, of New York.*  The operation for its relief
is especially demanded in those cases where the anchylosis is dependent on
cicatrization or contraction of  the soft  parts, and was first performed by J.
W.  Schmidt, of  New  York, Oct.  1841.f   Subsequently, Carnochair, of the
same city, published an account of a similar operation performed by him in
1840; but, as his publication was after that of Schmidt, the latter has gener-
ally received the credit of priority.  In Schmidt's case, a young  lady, in
consequence of rigidity of one of the masseter muscles, caused by an exten-
sively ulcerated throat from which she  suffered when a child, had not  been
able for more than twelve years to open her mouth so  that the end of the
little finger could be inserted.   After dilatation and similar means had failed,
Schmidt  operated as follows :—
  Operation of  Schmidt, of New York.—A narrow bistoury being  passed
through the mucous membrane of the mouth immediately in front of the an-
terior edge of the masseter muscle, on a line with the alveolar process of the
lower jaw, the  integuments of the  cheek were raised from the muscle  with
one hand, while with  the other the bistoury was passed over the masseter
muscles between it and the integuments, but  without  cutting through the
latter, when the  muscle being completely divided  to the  bone, the mouth was
immediately  opened  by a lever.   Considerable hemorrhage followed,  and
some extravasation into  the cellular substance of the  cheek, but this  soon
subsided, and the case succeeded perfectly.  To prevent the union and sub-
sequent contraction of the muscle  to its former condition, pieces of soft wood
of a wedge-shape were kept in the mouth during the night, and occasionally
during the day. J
  The danger likely to ensue from inattention to the anatomical relations of
this region will be  readily foreseen by every anatomist, or may be recognized
by reference to  Plate XXIV. Figs. 1, 2, where  the position of the vessels
and of the salivary duct is shown  after the removal of the parotid gland.
  Mott's Operation.—In seventeen cases of false anchylosis of the jaw, re-
ported by Mott,§ forcible dilatation was practiced after, or in some instances
without,  division of the  contracted tissues.  To overcome the  contraction
and expand  the jaws, Mott employed only a screw and lever,  similar to
that of Heister, as depicted in the Armamentarium Chirurgicum of Scul-
tetus, and also in the  Surgery of  John Bell.   The  levers, being introduced
between  the teeth, are gradually expanded by turning the screw.
  An instrument suggested, and frequently employed by Rhea Barton, Plate
XXIII.  Fig. 1, will also be found to furnish an excellent means of relieving
anchylosis.   Its advantages over  the lever of Heister consist in  the breadth
of its plates, in their being covered by a  layer of caoutchouc, and in their
affording a better basis for the teeth, in consequence of which the latter are
less liable to injury.
  Remarks.—From  personal  experience, and from an examination of the
recent articles  published  by  American surgeons, I am satisfied that this
* Mott's Velpeau's Operative Surgery, vol. iii. p. 1139.
f Amer. Journ. of Med. Sciences, p. 516, Oct. 1842.
X Ibid.  loc. cit.                \ Mott's Velpeau, loc. cit. 
ANATOMY OF  THE  MOUTH.
163
complaint is comparatively common in this country, and also that it is fre-
quently very difficult to eradicate.  When the result of extended sloughing,
or when of many months' standing, the prognosis should be very guarded,
as it is not uncommon to find more or less reproduction of the stiffness after
the dilating means are  discontinued.  In more recent cases — say of six
months' duration—the prognosis will  be more  favorable.   As the immo-
bility, even when due to the  muscles in the first instance, generally  results in
more or less adhesion of  the condyles and glenoid cavities, it should be re-
membered that it is more important to preserve slight and constant motion
of the jaw, so as to favor the synovial secretion, than to rely upon great dila-
tation at an interval of several days.   Frictions with anodyne  liniments, or
the cold douche, applied by pouring water from a small pitcher  upon the
indurated region, will do  much toward facilitating the cure, as they will pro-
mote the  absorption of  effused  lymph, and favor an increased circulation
through the muscles of the part.  My experience, therefore, leads me to place
more confidence in gradual  dilatation, friction, etc., as  just stated, than on
subcutaneous or other incisions, as  I have found the  rigidity very apt to
return  to a greater or less extent, as cicatrization  goes on, in consequence
of the  uniting  medium being less extensible than  that consequent on the
division of a tendon.
                         CHAPTER  VII.

           OPERATIONS  PRACTICED  WITHIN  THE MOUTH.

  The operations that may be required in this region are those dependent
on diseases of the tongue, tonsils, and palate.
                            SECTION I.

                               ANATOMY.

   The description of the anatomical relations of the parts within the mouth
may at present be confined to such portions of that cavity as are found within
the line of the teeth, and require therefore but brief notice.
   The Tongue, being composed in a great measure of the genio-hyo-glossus,
hyo-glossus, and lingualis muscles, which connect it both with the os hyoides
and the lower jaw, is covered by a mucous membrane the reflection of which
to the floor  of the mouth constitutes  the Frsenum Linguae.  The general
arrangement of the fibres of the genio-hyo-glossus, and their expansion from
their origin  into the bulk of the tongue, may be understood by referring to
Plate XXII. Fig. 2.
   The Lingual artery is the main source of the blood supplied to the tongue.
Coming from the  external carotid, this artery penetrates the  hyo-glossus
muscle just above the os hyoides,  and of course lies too deep for any opera-
tion upon this organ except its extirpation, Plate XXII.  Fig. 2.   The sub-
lingual branch of this vessel, being more superficial, passes forward just
above the sublingual gland, near the median line of the tongue, between the
mylo-hyoid and genio-hyo-glossus muscles, to supply the floor of the  mouth
and its lining membrane.  Except in an attempt to extirpate the sublingual 
164
PRINCIPLES AND PRACTICE  OF SURGERY.
gland, it is  not  much exposed to injury in operations upon this part.   The
ranine artery and its accompanying vein are the continuation of the lingual
artery, and advance on each side of the median line of the tongue directly to
its tip, where there is an anastomosis of the vessels of each side.  The ranine
veins  are  especially superficial, and may be seen just beneath  the  raucous
membrane on  turning up the tip of  the  tongue.   They can, therefore, be
readily injured, and may give rise to  trouble, especially in children.   The
hypo-glossal nerve is shown in Plate XXII.  Fig. 2, and requires no further
reference, as it is not proposed to treat of the various wild operations that
have been recommended for the cure of stammering.
  The Glands of the mouth at present demanding notice are the sublingual,
submaxillary,  and the tonsil.  The Sublingual gland, being only covered by
the mucous membrane of the  mouth, may be readily seen on  turning up the
tip of the tongue.   Its duct or ducts open into the mouth on either side of
the fraenum below the tongue.   The duct of  the Submaxillary gland—Plate
XXIV. Fig.  1 —terminates  by  a small  projecting orifice  on the anterior
margin of the  fraenum.  The  obstruction of this orifice gives rise to  the dis-
ease termed Ranula,  and consists in  an  accumulation of saliva  within  the
duct, which, by distending the latter, or by forming cysts, creates a tumor.
The saliva also sometimes deposits  sabulous matter, and gives rise  to  con-
cretions which are usually situated in the duct itself.
  The Tonsil  glands—Plate XXII. Fig. 1—in a healthy condition, are six
or eight lines long, four or  five  wide,* and about  three thick.   They are
situated within and between  the  half arches of the  palate, and concur in
forming the isthmus of the fauces.  Immediately beneath or  outside of the
tonsils, or outside  of the cavity—that is, toward the skin of the neck—lies
the carotid artery, with the vessels found between the greater cornu of the
os hyoides and the angle of the lower  jaw.   The proximity of these vessels
should be remembered  by the surgeon when using a bistoury  upon these
glands, as there is only a thickness of about three lines of  tissue between
them and the artery;  and a case is reported by Beclard, in which the inter-
nal carotid was opened in an  operation upon this region.|
  The Palate is composed of two portions—the hard or bony structure,
formed by the palate plates of the palate and superior maxillary bones, and
the soft palate, which is composed of the raucous membrane and the muscles.
The soft palate stretches across the back of the mouth from side  to  side,
and obliquely downward and backward from the posterior  margin of the
hard  palate.  Its inferior  free margin  presents in its centre a projection
(uvula) from a half to three-quarters of an inch long in the healthy state.
   The Uvula—Plate XXII. Fig. 1—is composed of the azygos uvulae muscle,
which, arising from the posterior pointed termination of the middle palate
suture, goes down into the uvula, but the  point of the muscle stops half an
inch short of its inferior extremity.  The free end of the uvula is formed of
loose cellular substance covered  by  mucous  membrane, and in catarrhal
inflammations often becomes edematous, swollen, and elongated, so as occa-
sionally to require excision ;  but this  excision should never be extended to
the muscle, lest it  impair the voice,  and give it a nasal twang, from the
patient's inability to close the orifice of the posterior nares.
   From each  side of  the uvula proceed two crescentic doublings of the lin-
ing membrane, called the Half Arches, and designated as anterior and pos-
terior.   Within or beneath these folds lie the muscles of the part,  some of
which are important in connection with the  operations on this region.
* Horner's Anatomy, vol. i. p. 569.
f Blandin, Anat. Topographique. 
CANCER OF THE TONGUE.
165
  The Constrictor Isthmii  Faucium muscle is within the anterior half arch,
arises from the soft palate near the base of the uvula, and is inserted in the
side  of the tongue near its  root.  It will close the opening between the
mouth and pharynx.
  The Palato-Pharyngeus muscle is within the duplicature forming the pos-
terior half arch; it arises near the base of the uvula,  and is inserted into the
sides of the  pharynx, and into the posterior margin of the  thyroid carti-
lage.  It draws the soft palate  downward, or draws the  pharynx upward.
  The Tensor Palati  muscle arises from the spinous process of the sphenoid
bone ;  passes downward; winds around the hook of the internal pterygoid
process, and  is inserted into the soft  palate near its middle, and into the
posterior lunated edge of the  palate  bone.   It spreads out or extends the
palate.
  The Levator Palati muscle arises from the point of the petrous bone, and
passes downward  to  be inserted into  the soft palate.   It draws the soft
palate upward.*
  In the various operations for fissure  of the palate,  attention to the action
of these muscles is essential to a successful result, f
                            SECTION  II.

                    OPERATIONS UPON THE  TONGUE.

  The operations practiced on the tongue consist in such as are required for
the relief of cancer, ranula, or hypertrophy in the tongue.


                      § 1.—Cancer of the Tongue.

  When the development of cancer in the tongue is of a limited extent,
and shows itself as a circumscribed tumor, its removal may be accomplished
either by the ligature or by excision.
  Preliminary Measures.—In order to remove a cancerous  tumor, or be-
fore  attempting any operation  upon the  tongue,  the surgeon  will  find it
necessary to  obtain  entire control of the member, by inserting into its tip
a tenaculum, a needle  and ligature, or a  pair of hooked forceps; but the
former is preferable, both on account of  its  simplicity  and efficiency.   In
order to employ it, direct the patient to protrude the tongue, and spear the
tip of the organ by rapidly passing the  point of the tenaculum through its
structure, when its motions may be perfectly controlled without creating
any very great suffering, and the hand  of  the assistant  holding the  instru-
ment will then have this unruly member entirely in its power.
  Ligatures,  either of silk or of wire, may be resorted to for the removal of
cancerous tumors  when  the  disease is  slight.   When  the silk  ligature is
employed, the base of  the tumor  should  be  transfixed  by a  needle armed
with a double ligature, and then, on dividing this at its loop, each portion
of the tumor  may be strangulated by tying the ends firmly around its base.
As the tissue  to be constricted is  extremely dense, it is requisite that the
ligature should be drawn very firmly, in order perfectly to strangulate the
portion included in the loop.  Latterly the ecraseur of Chassaignac has  been
applied for this purpose, and is useful where  the position and shape of the
* Horner's Anat., vol. i. p. 490, eighth edition.        f See Staphyloraphy. 
PLATE  XXII.
       OPERATIONS PRACTICED ON THE TONGUE AND TONSILS.

  Fig. 1. A front view of the anatomical relations of the parts about the Fauces,
as shown  with the  Mouth widely open.  1. The dorsum of the tongue, as de-
pressed within the teeth.   2, 3. The tonsils in situ.  4. The uvula.  5.  The an-
terior half arch.  6.  The posterior half arch, with the tonsil between it and 5.
7. The soft palate.                              After Bernard and Huette.

  Fig. 2. A side view of a vertical section of the Mouth and Tongue,  showing
the anatomical relations of the Vessels  and  Nerves of the  Tongue.  1. The
lingual artery.  2. Its sublingual branch.  The veins accompanying the  arteries.
3. The hypo-glossal  nerve.  4. The ranine vessels, as seen near the tip of the
tongue.                                         After Bernard and Huette.

  Fig. 3. A front view of the Removal of the  end of the Tongue, as practiced
either for Cancer or Hypertrophy.  1, 2, 3. The lines of the V-shaped incision.
4. A pair of double-hooked tumor forceps, Plate I. Fig. 19, holding the portion
to be extirpated, and controlling the tongue until the  vessels are ligated.  The
incision  should, therefore, not be carried entirely to 3, until the hemorrhage is
checked and the flaps partially united by the applicalion of the first suture.
                                               After Bernard and Huette.

  Fig. 4. The operation of excising the tongue, as shown in  Fig. 3.  1.  Left
hand  grasping the flap of the right side.  2.  The forceps holding the tip.  3.
The right hand of the surgeon.                  After Bourgery and Jacob.

  Fig. 5. The preceding operation as completed.  1, 2. The sutures approxima-
ting the two flaps.                               After Bernard and Huette.

  Fig. 6. A three-quarter view of a Hypertrophied Tongue, (Lingua Vitula,) as
it existed in Harris's patient prior to the operation.             After Harris.

  Fig. 7. A vertical section of the Mouth and Pharynx, to show the  excision
of the Tonsil by means of the probe-pointed curved bistoury and tumor-forceps.
1. The forceps holding the gland.   2. The bistoury in the act of excising it.
                                       Modified from Bernard and Huette.

  Fig. 8. A similar view of  the parts in the Throat, showing the amputation of
the Tonsil by Physick's instrument.  1. The right tonsil, as excised and  about
to be removed in the instrument. 2. The Tonsilotome of Physick.
                                       Modified from Bernard and Huette.
        (166) 
Plate  22
Fi£. 1.
 
 
HYPERTROPHY OF THE TONGUE.
167
tumor admits of its being constricted at its base before its extirpation by
the ecraseur.
  The Double Canula and Wire Ligature.—When the wire ligature is em-
ployed, the double canula of Levret—Plate IV. Fig. 12—should be prepared,
as directed for polypus of the nose; the motion of the tongue be perfectly
controlled by the loop previously mentioned ;  a superficial circular incision
made around the base of the tumor ; a tenaculum passed through the diseased
structure so as to elevate it from that portion of the  organ  in which it is
deposited, and then the loop of the wire passed over the tenaculum and car-
ried around the tumor in the incision first made.  The wire being then drawn
as firmly as possible, should be fastened to the wing of the  canula, and the
latter left, wrapped with linen or tinfoil, protruding at the angle of the mouth
nearest  to it until sloughing occurs, when the instrument may  be removed.
  Extirpation.—Excision of these tumors maybe accomplished in this as in
other cases, by elliptical  incisions and dissection, the  anterior cuts being
made first, in order to prevent the  hemorrhage from  impairing  vision.
Subsequently, the wound should be closed by one or more stitches of the
interrupted suture.
  In more extended cases of disease, amputation  or  excision  of  the end of
the tongue by a V-shaped  incision, Plate  XXII. Figs. 3, 4,  as mentioned
under Hypertrophy,  may be required.
  The tongue may also be removed by  the ecraseur without  much hemor-
rhage ;  Choppin, of  New Orleans, having successfully accomplished it with
this instrument in fifteen minutes, in a  case of cancer.*
                    § 2.—Hypertrophy of the Tongue.

   Under the name of Lingua Vitula, authors have described an enlarge-
 ment of the body of the tongue, which sometimes has been so great as to re-
 quire the excision of the enlarged portion in order to enable the  patient to
 retract the tongue within the mouth.   The operation of Harris, of Phila-
 delphia, in 1830, which was  the  first  performed in the  United States, was
 of a  marked character.  His second operation, in  May, 1835, in which I
 assisted him, was of a similar character, and sufficiently  illustrates the ordi-
 nary proceeding in such cases.
  Amputation of the Tongue by Harris, of Philadelphia.—The patient,
 aged nineteen, had the tongue enlarged at birth.  A short time previous to
 the operation, it projected beyond the upper incisors three inches; its cir-
 cumference  was six  inches,  and its vertical thickness one inch and a half,
 plate XXII. Fig.  6,  and filled up the  jaws so completely that  it was neces-
 sary to have his food cut into small pieces and introduced at the side of the
 mouth.
  Operation. — The tongue  being  elevated, a  strong ligature was passed
through its tip, so  as to control its movements.   The under surface was then
dissected from the floor of the mouth  about three-fourths of an inch behind
the anterior part of the jaw, and a  strong straight bistoury introduced  into
the organ at the point where the dissection terminated, whence it was pushed
through between the  median line and the left ranine artery, and being drawn
forward and laterally, was made to cut a flap, which terminated  near the  first
bicuspid tooth.   The left ranine  artery being then secured with a ligature,
the bistoury was again introduced in a corresponding position on the right
side, and the opposite or right flap  made in a similar  manner.   The artery
* New Orleans Medical News and Hospital Gazette, Feb. 1860. 
168
PRINCIPLES AND  PRACTICE OF  SURGERY.
of this side being now secured, and the central portion, or space intervening,
divided by strong scissors, the incisions or flaps resembled the letter V, and
being approximated by three interrupted sutures, made a pointed, well-formed
tongue of the ordinary length.  A year subsequently, the patient articulated
distinctly, aud was relieved of all deformity.*
  Having had a favorable opportunity of witnessing  this operation, I could
not but notice the great advantage possessed by the  operator from the use
of the ligature in the tongue in  controlling the motions of this  organ ;  and
as but one-half of  the structure was  incised  at a time, the hemorrhage was
readily controlled by the immediate application of the ligature to the artery.
The flaps were then accurately adjusted by sutures without any difficulty.
  In a previous case, June, 1829, the same  surgeon applied a ligature  to
the  enlarged portion, in order  to cause it to slough off, but the irritation
was so great that he was  subsequently obliged  to amputate the end of the
tongue with a catlin.  In this patient, the tongue protruded beyond the teeth
four inches; its circumference was six inches  and three-fourths, and its ver-
tical thickness one inch  aud three-fourths.f
  In  a case, also congenital, operated on by H. S. Newman, of Pennsylvania,
the  enlargement was very great, the portion amputated measuring in length
two inches and three-fourths, circumference  seven inches and a half, thick-
ness one  inch and a half.|  J. C. Warren, of Boston, Mussey, of Cincinnati,
Wells, of Columbia, Hayward,  of Boston, and  Delaney, of the Navy, have
also operated for the same complaint.
                            SECTION III.

              OPERATIONS ON  THE UVULA  AND PHARYNX.

                      \  1.—Excision of the Uvula.

  When, in consequence of chronic inflammation, the mucous membrane  of
the uvula becomes infiltrated so as to resist the action of astringents, or when
it and the azygos uvulae muscle  become relaxed, the end of the uvula is apt
to fall upon the edge of the glottis, and produce a cough  and irritation of
the throat, accompanied by profuse expectoration, and  such  other natural
symptoms of  phthisis pulmonalis as have been  mistaken, on a slight inves-
tigation, for those of this complaint.  The effect of this state of  the parts,
and the mode of relief, were early suggested by Physick, of Philadelphia,§
who also reported a special instrument for the amputation of the  elongated
portion.   Various other  surgeons  have since  then  proposed  instruments
which they deemed advantageous, and calculated  to accomplish  their ob-
ject; but it will be found that a pair of dressing forceps to seize  the  point
of the velum pendulum, and scissors  or a bistoury to excise  it, are all that
are necessary.
   Ordinary Operation.—Seize the end of the uvula by the forceps held  in
the left hand, depressing the tongue with the shaft of  the  instrument, or  by
a spoon in the hands of an assistant.  Then, with  a pair of scissors hooked
at one end like  those  in  Plate XXVL  Fig. 1, or curved on the flat, and
held in the right haud, cut entirely through the elongated part, removing
the piece in the grasp of  the forceps.   If the mucoo*s  membrane is not cut
* Am. Journ. Med. Sciences, vol. xx. p. 15.
t Ibid. vol. vii. p. 17.
X Med. Recorder, vol. vii. p. 541.
\ Am. Journ. Med. Sciences, vol. i. p. 262, 1827. 
EXCISION OF  THE  TONSILS.                  169
entirely through at the first clip, or if it escapes from the grasp of the forceps,
the fragment will be apt  to  fall  into the glottis  and induce  such  violent
coughing as will render its subsequent excision  very  difficult.   Not more
than three-eighths  of an inch should be excised, and  it is of  great conse-
quence  to avoid amputating the muscle, as this will materially affect the voice,
as before mentioned, and cause the individual to speak in a nasal  tone.  All
that is essential in a primary operation is to cut off" the glove-like  end of the
mucous membrane, and thus give vent to the serum that has  elongated it.
The subsequent cicatrization will generally accomplish the cure.  If it does
not, the probability is that the apparent elongation of the uvula will be due
to a relaxed condition of the soft palate, and be relieved by stimulating ap-
plications, such as painting the parts occasionally with a strong solution of
the nitrate of silver, or with the tincture of iodine or tincture of the chloride
of iron.
   Uvula scissors, constructed for this operation,  are now generally kept by
the cutlers.
   After-Treatment.—Nothing more is requisite, after the operation, than
to gargle the throat several times a day with cold water, and to guard against
the use of hot,  or highly  seasoned, or salt food.  Should there be any hemor-
rhage of consequence, touching the end of the stump  with the nitrate of silver
will generally arrest it.
                     § 2.—Excision of the Tonsils.

   Chronic inflammation of  the tonsils, or repeated attacks of quinsy, some-
times  cause  such deposits  of  lymph in  the  parenchymatous structure of
these glands as results in induration and  permanent enlargement, or in the
condition sometimes, though improperly, designated as scirrhus.  The con-
tinuance of this  enlargement being a constant source of irritation, such pa-
tients are liable to inflammation of the throat on the slightest change of tem-
perature.
   To relieve this sensibility, after the failure  of other means, an operation
for their removal may become necessary.
   Operation of Physick.—In order to accomplish this  object without any
risk of hemorrhage, Physick proposed, and practiced for some years, the
removal of these glands by sloughing, induced by strangulating them with
the  double canula and  wire ligature before  referred  to.*   But in conse-
quence of the pain and inflammation which sometimes ensued, this  opera-
tion has justly been supplanted by that of excision.   Various instruments
have been recommended by different surgeons for this purpose, and for a list
of those suggested by surgeons in the United States, the reader is referred
to the Bibliographical Index at the end of this part.  At present,  one of
two instruments is most frequently resorted to in  this country, viz.,  that of
Physick, Plate XXVL  Fig. 3, and that of Fahnestock.
   The instrument of Physick consists of a ring, which  surrounds the part
to be excised, and of a triangular-shaped  knife, which, sliding  in the ring,
guillotines the gland.
   Fahnestock's instrument is also formed  of a ring, but his knife is of a cir-
cular shape, and excises the tonsil by drawing it toward the operator.  This
instrument has justly been objected to, by  many who have employed it, from
the diflSculty of  giving  a good edge to a circular blade, and  also from  its
tendency to cut by pulling  upon  the gland rather than  by dividing it with
* See Polypi in the Nostril, p. 145. 
170
PRINCIPLES AND  PRACTICE OF  SURGERY.
the clean incision of a knife.  That of Physick having none of these defects,
and  having its cutting  edge of such a shape as will enable the surgeon to
preserve or renew it himself, is preferred by others, and has much to recom-
mend it.  Velpeau  prefers the instrument of Fahnestock, but has modified
it  to  some extent;  and I have lately seen a further modification by Char-
riere, in which the knife  is only half a ring, and made to cut like a curved
bistoury.   This is,  however,  nothing  new, a similarly shaped knife having
been suggested and used by Rogers and Cox, of New York, nearly twenty
years since.
  Physick's  Operation of Excision.—The patient being seated before  a
strong light, the head supported against the breast of an assistant, and the
thumb of the latter made to press on the external parts just behind the angle
of the jaw, so as to render the  tonsil  prominent in the  throat, and force it
from between the half arches, the surgeon should introduce the instrument
flat upon the tongue, pass it rapidly back  to the fauces,  turn it on its side,
so as to place the tonsil in  its ring, transfix it with  the  needle  attached to
the instrument, and, pushing the  knife backward, shave  off all the  portion
included in the ring by a movement similar to that of a guillotine.   Then
removing the instrument, the excised portion will be brought out with it in
less  time than it takes to describe the  steps of the operation, Plate XXII.
Fig. 8.
   Should  this instrument  not be at  hand, a probe-pointed bistoury  and
dressing forceps may be made to answer by a  skillful  manipulator, Plate
XXII. Fig. 7 ; but the proximity of the carotid artery to the outer wall of
the pharynx at the seat of  the tonsil, should  induce the  surgeon to be cau-
tious, lest he open it by prolonging his incision to too great a depth.
  After-Treatment.—The only after-treatment that is requisite is that re-
ferred to in excision of the uvula.
  Remarks.—The simplicity of the operation of amputating the tonsil, as
performed by the tonsilotome, is such that it is difficult, at the present time,
to realize the anxiety and discussions of the surgeons of the period when
amputation of the tonsil was first suggested.  The fear of hemorrhage, which
was so generally entertained at that period, is now seldom  noticed, aud  out
of very many cases  upon  which I have operated, I can  only recall one in
which there was sufficient bleeding to demand  attention, and this yielded
readily to the application of a strong solution of the nitrate of silver.  When
a tonsil has been indurated for many  months, the effused lymph will cause
such a constriction of the blood-vessels in  the structure of the gland as  will
diminish their calibre, the  limited space in which the tonsil is placed  not
permitting any marked distention  of the structure, except in the line of the
thickening  of the gland.  It may, however, prove useful to state that under
no circumstance is it safe to attempt the excision of a portion of the tonsil
when its structure is acutely inflamed, as the  hemorrhage will then be very
free. 
CHAPTER VIII.
       DISORDERS  OF, AND OPERATIONS  ON, THE UPPER JAW.


                             SECTION I.

                  ANATOMY OF  THE PARTS  CONCERNED.

   The Superior Maxillary bone articulates with the frontal, nasal, and
 unguiform bones:  in front with the os frontis and nasal by its nasal process,
 by means of a firm regular suture; with the unguiform and ethmoid in  the
 orbit of the eye, by simple apposition;  and with the malar bone at its ante-
 rior external angle, by a firm suture.   To  the pterygoid process of  the
 sphenoid bone at its posterior inferior portion; to its fellow of the opposite
 side ;  to the vomer in the middle line of the  mouth, and to the palate bones
 in the same line posteriorly, it is also joined  by more or less close adhesions.
   The Inferior  Maxilla forms the lower outline  of the  face,  extending
 entirely around  it from ear to ear.   It  articulates with the glenoid cavity of
 the temporal bone, just in  advance of  the external meatus of  the  ear, by
 means  of its condyloid process.   This process is  a transverse  cylindrical
 ridge  directed inward  and slightly backward, and  springs  from  the ramus
 of the jaw by a  narrow neck.  The coronoid process is seated in  advance of
 it,  and has the temporal muscle inserted into its point.  It  is important  to
 notice that both processes are apt to be much enlarged by tumors or malig-
 nant deposits, which sometimes require the resection of the jaw.
   The Masseter Muscle, arising from the parts about the zygoma, is inserted
 into the base of the jaw at its angle.   The Muscles forming the  floor of the
 mouth are also attached along the base of the jaw on the inner side of the
 bone, and it is by this attachment that the tongue mainly maintains its posi-
 tion in advance  of the  glottis.  When  these attachments  are divided, the
 tongue may  be  drawn in upon  the glottis,  and induce suffocation, unless
 artificial means are employed to prevent it, though it is not  always the case,
 the connection of the  sterno-hyoid muscles with the hyoid bone having  a
 tendency to counteract the  action of the styloid muscles, which are those
 that mainly induce it.  The  Carotid  artery, in its connections with  the
 parotid gland, is found near the angle of the jaw, but, by drawing the bone
 well forward and downward, this artery will be separated to some extent
 from the bone, in consequence of the posterior adhesions of the parotid.


                             SECTION II.

                    DISORDERS  OF THE  UPPER JAW.

             \ 1.—Affections of the Antrum  Highmorianum.

  1. Effusions into the Antrum.—Etiology.—Effusions  into the cavity of
the antrum may be the  result of a simple increase in the mucous secretion of
the part, or they may  ensue on a  serous discharge  from  the lining  mem-
                                                          (1U) 
PLATE  XXIII.
          INSTRUMENTS EMPLOYED ON  THE JAWS AND EAR.

  Fig 1. A three-quarter view of  Barton's Dilator for expanding the Jaws in
cases of False Anchylosis.                                  Kolbe's pattern.
  Fig. 2. A view of the Dilator  of Jno. Bell, of England.  The screw causes
the blades to  separate.                                           After Bell.
  Fig. 3. A strong  Scalpel, with a Raspatory at one end of the handle, appli-
cable to all bone operations.                                 Kolbe's pattern.
  Figs. 4, 5. Strong double-edged  curved Scalpels for the same purpose.
                                                          Kolbe's pattern.
  Figs. 6, 7. Strong Knives or Scrapers for excising Carious or other diseased
Bones.                                                Charriere's pattern.
  Fig. 8. A pair of Hawk-bill Scissors, useful  in dividing the middle palate
suture in Resection  of the Upper Jaw.  The probe-pointed end is to be passed
into the nostril, and the other blade made to cut from the mouth upward. This
instrument is similar to that used by gardeners for lopping trees,  and is  the best
kind of bone-nippers I ever employed.                       Kolbe's pattern.
  Fig. 9. Horner's Triangular Vertical-Bladed Knife for dividing the transverse
portion of the Palate in Resection of the Upper Jaw.          Kolbe's pattern.
  Fig. 10. Itard's Ear Speculum.                After Bernard and Huette.
  Fig. 11. Bonafond's Ear Speculum.                    "           "
  Fig. 12. Itard's Catheter for the Eustachian Tube.      "           "
  Fig. 13. Blanchet's   "      "       "       "         "          "
  Fig. 14. Dupuytren's Forceps for Aural Polypi.        "           "
  Fig. 15. Fabrizj's Forceps for the removal of  Foreign Bodies from  the Ear.
                                               After Bernard and Huette.
  Fig. 16. A Curette for  the same purpose.               "          "
  Fig. 17. Horner's Knife for perforating the Membrana Tympani.
                                                          Kolbe's pattern.
  Figs. 18, 19. Deleau's Instrument for perforating the Tympanum.  In one the
perforator is concealed, in the other protruded from its sheath.
                                                       Charriere's pattern.
  Fig. 20. Homer's Syringe for washing out either the external or middle  Ear
either with air or water.                                    Kolbe's pattern.
  Fig. 21. The Nozzle of Fig. 20  passed through a  cork so as to plug up  the
external meatus when injecting the middle Ear.          From the  instrument.
  Fig. 22.  A Caoutchouc Bottle for washing out the Ear. Cliarriere's pattern.
  Fig. 23. Horner's Portable Air-Chamber  for Injecting the Ear.  1. The air-
pump.   2.  The tin chamber.  3. A cock which keeps  the  air in the chamber
when charged.   The opening of this tube being applied to the  catheter and the
cock turned, the current of air will pass as regulated ay the cock.
                                                    From the instrument.
       (172) 
Plate  23
Rgl
Fig. 8
 
 
RESECTION  OF THE UPPER JAW BONES.
173
brane, such as sometimes takes place from the Schneiderian or nasal mem-
brane as the result of catarrh.  These accumulations, owing to their being
circumscribed, will often give rise to very distressing symptoms, one of the
most painful of which is the neuralgic pain created by the pressure of the
effused fluid upon the dental  nerve, of which  mention has just been made.
Sometimes this fluid will continue to accumulate until, rising to the level of
the orifice, it is evacuated through the nostril, and relief is obtained.
   Treatment.—The treatment consists in the employment of such means as
are applicable to irritated conditions of the mucous membranes generally—
as warm  applications; but if  the accumulation of the  fluid  obstinately
remains, it may be gotten rid of by puncturing the antrum, precisely as one
would get rid of the pus in an abscess.
   2. Abscess of the Antrum.—Etiology.—Abscess of the antrum is a com-
plaint connected with  inflammation of  the lining membrane, and due to the
same causes as would  produce inflammation in the nose.   Any irritation of
the antrum, such as that created by exposure  to cold;  or the extraction of
teeth under certain circumstances, as where the violence done at the moment
of extraction produces fracture  of the alveolar process; or where the prongs
of the tooth, being unusually long, encroach upon the cavity of the antrum,
may also develop an abscess of this cavity.
   Symptoms.—From  these circumstances, and from many other unexplained
causes, inflammation of the lining membrane of the antrum is  developed,
from which an accumulation  of pus results, which, having no exit, gradually
increases in quantity and creates an abscess, thus producing severe  suffer-
ing, until it has sufficiently filled the antrum and begins to escape into the
nostril, when prompt relief follows, as  in the evacuation of abscesses else-
where.   These symptoms will also be frequently aggravated by the violent
neuralgia which is produced, as  in the serous effusions into the  antrum by
pressure  upon  the dental  nerve as it passes along the inferior wall of the
 antrum.
   Treatment.—The treatment is first to evacuate the pus as soon as possi-
ble ;  but, as it is  here  necessary to act upon  a bony structure, peculiar
means become necessary in order  to accomplish this.   If the  abscess has
been caused by the extraction of a tooth, the  pus may perhaps be evacuated
by puncturing the floor of the antrum  through the cavity in the alveolar
process by some suitable instrument, such as a small trocar and  canula, the
trocar  being withdrawn while the canula is  left to keep the orifice in the
 mucous membrane open to permit the escape of the pus through it.   After
the entire evacuation of the  matter, it will  often be useful to  inject the
 cavity of the antrum, through the canula, with tepid water, in order to wash
 it out thoroughly, as may be readily done by fitting the  beak of a syringe
 to the mouth of the canula.
   But  sometimes an  abscess of the antrum  occurs which is not  a result of
the extraction of teeth, and, under these circumstances, it becomes neces-
 sary to make an opening through  the sides or walls of the antrum, as may
 generally be done by turning  the  lip  forcibly upward  and puncturing the
 anterior and external walls of the superior  maxillary bone by means of  a
 strong trocar and canula, or by a sharp bistoury ; this  being a very simple
 operation, as the bones of the part are naturally thin, and, under the cir-
 cumstances described, are not unfrequently rendered yet thinner by disease.
   3.  Polypus  of the Antrum.—Polypus of the antrum may at times  occur,
though it is comparatively a rare disorder, unless found in  connection with
 polypi of the nostril.
   Treatment___If the polypus is benignant,  the treatment is to remove, by
ligature or otherwise, the polypi in the nostril, if there  be any, and to do 
174
PRINCIPLES AND  PRACTICE OF  SURGERY.
likewise with so much of the  polypus of the antrum as protrudes  into the
nostril, or can be  reached from it;  after which it will be necessary to act
upon  the diseased mass remaining in the antrum, by means of astringent
and alterative injections, which are to be thrown into the nostril.  But most
generally polypi of the antrum are either primitively malignant in their char-
acter, or become the seat  of malignant deposits, and then create  a  tumor
of the antrum, which has a disposition  to invade surrounding parts, the
neighboring bones being encroached  upon until  they become diseased, and
a peculiar condition results which requires extirpation of the superior max-
illary bone entire, as hereafter described.
                            SECTION  II.

                 RESECTION  OF THE  UPPER JAW BONE.

  The development in the bones of the face of tumors of  a malignant char-
acter, and their encroachment on the surrounding structures, has sometimes
created  such a condition as has rendered it desirable to remove either a
portion  or the  entire structure  of the  bones which  constitute the basis of
this  region.   As  the jaw bones are  generally deemed to be "essential to
speech as well  as  mastication,  it would  appear, at first sight, as if their
removal would necessarily impair the  nutrition and  also  the usefulness of
the patient, while  their close proximity to large blood-vessels and important
nerves indicates the necessity of great caution in any extended operations
that might be practiced upon them.   Such appears to have been the views
formerly entertained by surgeons, respecting the practicability of resorting
to resections of these bones entire;  and we accordingly find that the  earlier
operations were either of a limited character, or only performed after every
possible precaution had been taken to guard against hemorrhage, either by
preparing cauterizing irons, or  by ligating the main  trunk  of the carotids
previous to the operation.  The condition of patients who had suffered from
extensive  gunshot wounds of this region having shown, however,  that a
much greater amount of the face could be removed without loss of life than
had been supposed, surgeons gradually extended their efforts to  relieve the
diseases of these parts, until  they have at last succeeded in  removing the
entire upper jaw of each side,  and taken away all  the lower jaw from its
articulations forward.  Since the experiments  of Oilier, in reference to the
reproduction of bone when  the periosteum  alone  remains,  surgeons have
taken advantage of the principle thus enunciated to apply it to many resec-
tions, and especially to those of the bones of the face, where it has proved
most useful.   In an account of  the operations  of Langenbeck, as translated
by Holcomb, of New York,* several  operations are reported, Langenbeck
estimating highly  the importance  of  denuding the bone of its  thickened
periosteum and retaining it for future reparation, sub-periosteal resection
having  been performed  by him in two cases,  though  so  recently that the
results are not yet known.   Transplanting the frontal  periosteum, as in-
cluded in the tegumentary flap for Rhinoplasty with loss of the ossa  nasi,
has  also thus far been  satisfactory.    It is  evident, therefore,  that osteo-
plastic  operations are likely to  become a valuable addition  to our  present
means of relieving the diseases and injuries  of the bones,  and the preserva-
tion of the periosteum should, therefore, be  regarded as an important point
in all operations on the bones generally, and especially in those of the face.
* New York Monthly Review, April, 18G0. 
RESECTION  OF THE UPPER JAW  BONE.
175
   Iii reviewing the records of resection of the jaw, we find that Acoluthus,
a surgeon of Breslau, first removed a portion of the upper jaw for a tumor,
as early as 1693;  that Jourdan also removed a part of the antrum High-
morianum for the relief of a tumor, in May, 1768, and that Dupuytren re-
sected a considerable portion of the  alveolar cavities of the bone, in 1819.
These operations, though among the earliest of those recorded, did not reach
the extent of a resection of  either the entire body or even half of the bone;
and it may, therefore, be justly said that the most extensive and daring re-
section of either of the bones of the jaws were first  performed by American
surgeons ; that of Jameson, of Baltimore, upon the upper jaw,  having been
executed in 1820,* and that of Deaderick, of Kentucky,-)- upon the lower
jaw, performed in 1810.
   One of these operations—Deaderick's—was also performed nearly  ten
years prior to the operation  of Dupuytren, while the other—Jameson's—was
so near the  same period as to leave no  time for any communication of the
event  to this country.    I  have,  therefore, no  hesitation in  claiming for
American  surgeons the credit  of having been  the first to illustrate  the
feasibility of these extensive resections.
   The first  resection  practiced upon the bones constituting the upper jaw,
was performed in  the United States, for the  removal of a tumor from  the
antrum, by  Horatio G. Jameson, in November, 1820. J   From an inspection
of the  drawing which accompanied this case, as  well as from its history, it is
evident that this resection embraced  nearly the  entire body of one superior
maxilla, although  the roof  of the antrum, or floor of the orbit, which was
not diseased, was allowed to remain.
   The operation of resecting the superior maxillary bone of one side having
been thus   commenced,  the  resection was soon after—1824—carried  yet
further by David L. Rogers, of New Vork, who successfully removed nearly
the entire upper jaw, that is, both superior maxillae as far back as the  pos-
terior  external portion  adjacent to the pterygoid processes.   Lizars,  who
was the earliest of the British surgeons that  resorted to this resection, did
not operate until 1827,  and Gensoul, of France, whose subsequent proceed-
ings have so  intimately associated his name with the operation, did not
attempt it until about the same year.  Since 1827, the operation has been
very frequently performed in the United States—Stevens, of New York, in
1840, having successfully extirpated the entire superior maxillary and malar
bones with portions of the ethmoid and sphenoid of one side;  R. D. Mus-
sey,  of Cincinnati, and John C.  Warren, of Boston, having also successfully
removed the upper jaw in 1842.  A reference to the Bibliographical Index
at the end  of  this part, will  also show, that  since  this period many other
American surgeons have been equally successful;  so that this once doubtful
operation may be now considered as permanently established. The result of
the operation,  as shown by an analysis of many of those performed in Europe
since 1820, also indicates that an equally successful result has been obtained
elsewhere, Ried§—Die Resectionem der Knochen—having collected thirty-
five cases, in twenty-four of which the  patients were reported as cured—
meaning, probably,  cured  as to the operation, though not  preserved from a
return  of the disease when the tumor was malignant.
  As characteristic of the method  usually pursued in this operation, the fol-
lowing one,  performed by Warren, may  be first  referred to:—
* Am. Med. Record, vol. iv. p. 222, 1820.
f Ibid., vol. vi. p. 516, 1823.
X Ibid , vol. iv. p. 222, 1820.
\ Philadelphia Med Examiner, vol. ix. p. 595. 
PLATE  XXIV.
A  VIEW OF  THE  ANATOMY OF THE SIDE OF THE FACE, AND OF SOME
                OF THE  OPERATIONS PRACTICED ON  IT.

  Fig. 1. A side view of the Anatomy of the Face after the removal of the in-
teguments. 1. The shape and position of the parotid gland. 2. The duct of Steno.
3. The sublingual gland.  4. The facial artery, at the point where it passes on to
the face.  5. The facial vein.  6. The sterno-cleido-mastoid muscle.  7. The ex-
ternal  jugular vein. 8. The zygomatic muscle.  9. Branches of the portio dura
nerve emerging from the upper edge of the parotid; other branches are seen on
the face.                                       After Bernard and Huette.
  Fig. 2. The same Section after the removal of the Parotid Gland.  1. The
portio dura nerve at  its exit from the stylo-mastoid foramen.  2. The  duct of
Steno divided transversely.  3. The external carotid artery  when freed from the
parotid.  4. The temporal artery. 5. The facial artery after removal of the sub-
lingual gland.   6.  The sterno-cleido muscle.  7. Main trunk  of the external
jugular vein.                                    After Bernard and Huette.

  Fig. 3. A three-quarter view of Horner's  operation for  the cure of Salivary
Fistula.  A wooden spatula  supports the inside of the cheek ; a slight longitu-
dinal  incision is made at the external fistulous orifice, and the hand of the sur-
geon is seen pressing  the  punch against  the spatula so as to  cut out a piece
through the cheek.  The external incision, being closed by a point of a suture,
heals usually by the first intention, leaving the orifice, made by the punch, open
in the mouth.                                         Drawn from Nature.
  Fig. 4. A view of the operation of Resection of the Upper Jaw, as practiced
by the incision of Warren.  1, 2, 3.  The flaps everted, and turned over the nose
and eye so as to expose the bone.   The left  hand of the surgeon is holding, 4,
the bone at the moment of disarticulation by the knife, 5,  which is working at
the pterygo-maxillary  fissure. Velpeau's operation is nearly the same as that of
Warren.                                       After Bernard and Huette.
  Fig. 5. Represents  the completion of the  operation, the union of the wound
by the twisted suture,  and the line of the cicatrix, which extends from the malar
bone to the mouth near, but not at, the angle.     After Bernard and  Huette.

  Fig. 6. A view of the termination of Gensoul's operation, showing the  lines of
his incision. 1, 2. The first incision across the tumor.  3, 4.  The second incision.
1, 5. The third incision, forming flaps which are to be turned up and down upon
the face.  The sutures are seen as placed  at the termiuation of the operation.
                                                           After Gensoul.
        (176) 
Yiv
.^*s&?v»-*y_::.



K:-- .,.:' :"■'"■ 
 
RESECTION  OF THE UPPER  JAW BONE.
177
  Operation of Warren.—The patient being seated with his head well sup-
ported, an incision was made through the cheek down to the bone, from the
middle of the external edge  of the left orbit, to the left angle of the mouth,
and was  followed by a copious gush of blood.  The internal or nasal flap
being then quickly dissected forward  to the middle of the nose, the attach-
ment of the cartilage of the  left alas of the nose was cut off, thus freeing the
eyeball from the  inferior part of  the orbit,  by dividing the  inferior oblique
muscle, the fascia of the eye, and the periosteum.   The outer or lower flap
was next rapidly dissected from the osmalae and superior maxilla, and around
the latter bone as far as its union with the pterygoid process of the sphenoid ;
but the uniting  space was not penetrated  at this  time, on account of the
large pterygoid branch  of the internal maxillary, which it would have been
difficult to secure at this stage of the operation.
  The two flaps being separated, the anterior extremity  of the spheno-
maxillary fissure was perforated, and the  cutting forceps  applied  to the
broadest part  of the os  malse directly opposite to the perforation, by  which
it was smoothly divided in a few seconds.
  The same instrument was then  applied at the internal angle of the eye in
an oblique direction from the lower edge of the orbit, to the lower termina-
tion  of the os  nasi, and  the bone divided without difficulty.
  In the mean time  the  blood flowed in torrents;  one large artery required
immediate ligation, but the bleeding of the others was controlled by com-
pression  of the carotid artery.  The mouth of the patient filling  with blood,
frequent  pauses were required to afford him  an opportunity of ejecting it,
and occasionally he was recruited  with a little wine.
  The most difficult part of the operation remained, that of dividing the
sound from the diseased parts within the mouth, and  separating the maxil-
lary from the sphenoid and palate bones without injuring the latter, so as to
leave the patient the whole  of the soft palate,  with the palatine plate  of the
os palati to support it.
  In  order to accomplish this without dissection, an incision  was  made
through  the mucous membrane of the hard palate, beginning at  the edge of
the palatine plate of the os  palati, and extending forward to the front edge
of the jaw, and then upward across the alveoli into the bone.  To facilitate
this incision, the  central incisor within the  left  side was extracted so as to
break the anterior part of the alveolus.   Then, by a single stroke of the cut-
ting  forceps, the upper maxillary was  separated  from its fellow, and its
palate plate cut through as far as its junction  with the os palati.  In order
to separate the palatine plates of the maxillary and palate  bones, the fore-
finger of the left hand  was passed into  the mouth to the last molar  tooth,
and its pulp turned forward to receive and support the cutting instruments,
the flow  of  blood preventing anything being seen.  A strong pointed knife
was then stuck through the hard palate at the union of the maxillary and
palate bones,  so as to separate them, and  also free the maxillary from the
pterygoid process of the sphenoid, thus accomplishing the disunion of all the
bones concerned.
  Finally,  the knife was passed externally behind the upper maxillary bone
into the space between this and the pterygoid  process, and, seizing the bone
with the  left hand by its orbitar and alveolar portions, it was, by a  gradual
movement, started from its situation,  Plate  XXIV. Fig. 4, and, aided by a
few touches of the  knife, freed from its  remaining periosteal attachments.
The hemorrhage was arrested by ligatures and lint.   Eight weeks afterward
the patient went home, and  three months from that time continued well.*
         * Boston Med. and Surg. Journ., vol. xxvi. p. 9, 1842.

VOL. II.—12 
178
PRINCIPLES AND PRACTICE  OF SURGERY.
  Homer, in a case of scirrhus of the  antrum, succeeded in removing the
whole of the  upper jaw icilhout any  external incision, thus saving the
patient the scar in the face.   The removal of a considerable portion of the
same bone was also successfully performed by Stevens, of New York, in 1823,
and published  in the New York Journal of Medicine and Surgery for 1849.
The publication  of this case having been delayed for several years, from mo-
tives of delicacy to the patient, who was widely known, Stevens did not
receive that general  credit to  which  his  ingenuity  entitled  him, and  I,
therefore, now call attention to it.  Horner was  ignorant of Stevens's suc-
cess at the time of his operation.
  Removal of the Superior  Maxillary Bone without any external Inci-
sion in the  Cheek.—Horner having determined to avoid cutting through
the cheek, as commonly practiced, the patient was seated in a chair, with his
head well supported, and partially etherized.  The assistant, supporting the
patient's head, then raised the angle of the mouth on the left side, and held
it widely open, while the upper lip and cheek were dissected from the superior
maxilla as far  back as possible,  in a line parallel with the superior margin
of the buccinator muscle.   The two incisor teeth on the left side being then
drawn, the corresponding alveoli were  cut through in the middle line by a
narrow saw, Plate V. Fig.  7,  which worked its way from the mouth into the
left nostril;  then a pair of strong hawk-bill scissors, Plate XXIII. Fig.  8,
such as are used by gardeners for lopping off twigs, took out the two vacated
alveoli at a clip.
  A thin,  flat,  well-tempered  knife, with a  strong, round handle, Plate
XXIII. Fig.  5, was now  struck through the roof of the mouth  into the
nose, at the junction of the  palatine processes of the palate  and superior
maxillary bones, (posterior middle palate suture,) so as to cut forward and
separate the maxillary bones  from each other in the middle ; when the nar-
row saw was again used to cut through the root of the nasal process of the
maxillary bone, and strong scissors, curved on the flat, made to cut through
the orbitar plate at its margin, the incision being carried  back  to the ptery-
goid process o" the sphenoid, around and below the malar bone.
  The base  of the soft  palate being then detached by a short  triangular
knife, Plate XXIII. Fig. 9, curved on the flat, so as to leave the soft palate
attached to the palate bone, a few touches of the knife freed the remaining
attachments.
  The pterygoid process,  malar bone, and  the  orbitar  plate  of the upper
maxillary were not disturbed.  The tumor, besides its bony connection, was
also attached  to the posterior part of the cheek, and to the external ptery-
goid muscle.  The gouge and scissors, however, sufficed to remove every part
that could be detected.
  The bleeding was profuse, especially from what was believed to  be the pos-
terior palatine artery; but the vessel was readily secured  by means of a liga-
ture and Physick's needle,  and a few other ligatures, with charpie, arrested
the remainder of the hemorrhage.   The drawing—Plate XXV. Fig. 1—
shows the appearance of the mouth immediately after the removal of the bone,
though  representing it on  the right instead of the left side of the face, in
consequence of its being daguerreotyped, this peculiarity having been over-
looked by the engraver.  The amount of the jaw which was removed in this
operation is accurately shown in Plate XXA1".  Fig.  2.
   The additional time required for this mode of operating is probably fifteen
or twenty minutes; but it saves the patient a scar for life.*
   Three years afterward the patient presented  no appearance  of the return
* Philadelphia Med. Examiner, No. 1, p. 16, 1850. 
RESECTION  OF BOTH SUPERIOR  MAXILLA.
179
of the tumor;  and  his  daguerreotype—Plate  XXV. Fig. 3—shows  the
small amount of deformity.
  Stevens, of New York, in August,  1823, extirpated a fungus from  the
antrum raaxillare, and removed a considerable portion  of the bone also,
without any external incision.
  Operation of Stevens, of New York.—The second incisor and the last
molar tooth but one being  first extracted, the upper lip was dissected off
from  the jaw as high as  the infra-orbitar foramen.   The bone being then
bored through by means of a trocar, which was carried backward and down-
ward till it perforated the palatine membrane near the junction of the left os
palati with  the palatine process of the left superior maxilla, the palatine
membrane was incised from this point to  the  external edge of the first  left
incisor tooth.  The palatine  process of the superior maxilla was next divided
by a saw, with its  teeth directed downward, passed through the route made
by the trocar;  and the bone, both above and  below, between the socket of
the last molar tooth and  the perforations of the trocar, was also divided by
a fine flexible saw, seven inches long, made of watch-spring, and having
teeth only in its middle for the extent of three inches, the division  being
made in the direction of a curved line, which extended from the point  where
the trocar first entered to the alveolar cavity of the molar tooth extracted.
No bad  symptom followed, and in six months the  opening in the antrum
was completely closed.
  The patient, seven years subsequently,  was in perfect health.*
  Mott,  in an operation  for a large polypus of the  nose, was compelled to
make a partial section of the upper jaw,  by an incision through the integu-
ments from below the internal canthus, down the side of the nose, and through
the upper lip about three lines from the angle of the mouth.   Then, dissect-
ing back the two flaps  thus made, he divided the necessary portion of the
bone  with a saw.f
  Remarks__It will be found to be  a matter of some consequence, in these
resections of the upper jaw, to leave the os unguis and the superior extremity
of the nasal process of the  superior  maxillary bone untouched, in order to
preserve the lachrymal sac from injury.  When attention is not given  to the
preservation of this sac and its  duct, the  patient will be liable to  a constant
edematous condition of the  lower lid, and suffer also from stillicidium lach-
rymarum.  If the orbitar plate can also be left, it will diminish  the  de-
formity.
  In  tumors requiring the entire amputation of the jaw, the incision of Mott
will be found to expose the bone freely, aud may be advantageously resorted
to;  and in the case of a very large tumor, whose removal would be imprac-
ticable by the plan of Horner, this incision would probably open the parts
sufficiently, and yet create a scar that would hardly be noticed.


                            SECTION IV.

               RESECTION OF BOTH SUPERIOR MAXILLA.

  The Resection of both Superior  Maxillary Bones, which was  first at-
tempted by Rogers, of New York, J in 1824, was repeated by Heyfelder, in 1844,
and again in January, 1850, both operations succeeding, though the disease
  * Velpeau's Surgical Anatomy.  Appendix, by John W. Sterling, M.D., vol. ii. p. 518.
New York, 1830.
  f Velpeau's Surgery, by Mott, p. 907.
  X Velpeau, M6d. Op^rat., tome ii. p. 628. 
FLATE  XXV.
            RESECTIONS  OF TIIH UPPER AND LOWER  JAW.

  Fig. 1. A view of the inside of the  Mouth, immediately after the removal of
the left superior maxillary, as performed  by Horner, without any external in-
cision in the cheek.  The soft palate is shown as preserved, but the engraving
has reversed the side from which the bone was taken, making it appear as if per-
formed on the right side.                                    After Nature.

  Fig. 2. A side view of the portion of bone removed from  the mouth.
                                                           After Nature.

  Fig. 3. A likeness of the patient three years after the operation.
                                                            After Nature.

  Fig. 4. An outline of a Skull, showing the relative size aud position of the
Tumor in Barton's patient.                                   After Barton.

  Fig. 5. An outline of an  Inferior Maxilla, showing the line of incision in the
Jaw.                                                        After Barton.

   Fig. 6. A front view of Barton's operation for Resection of the Lower Jaw
without destroying  its  base, thus preserving the outline of the Face.  In the
original operation, the lower lip was divided vertically at its left angle, but this
has not been done  in the drawing, in consequence of its not  being universally
necessary.   When the tumor permits it, the  simple horizontal cut in the integ-
uments, as shown  in the figure, brings the cicatrix under the chin, where it is
hardly perceptible.                                           After Nature.

   Fig. 7. A side view of Lisfranc's operation for Resection and Disarticulation
of half of the Lower Jaw, at the moment of removal, the jaw being everted and
drawn forward and downward in order to  avoid any injury  to the artery at this
point.                                          After Bernard and Huette.

   Fig. 8. A front view of  the Resection  of the Chin or middle  portion of the
Inferior Maxilla, as practiced by Dupuytren.  A vertical incision in  the median
line of the chin enables the operator to turn back two flaps (1, 2) and expose the
bone, which may then be readily divided by Hey's saw, if it is desirable to cut
 from before backward, or by the chain-saw passed around the  bone and made to
 cut from behind forward.   The latter is preferable, in most instances.
                                                After Bernard and Huette.
        (180) 
Plate  25
He. ^
Fid. 2
M
n
^   is
">d
/**
fig.
Jllm/ifi X  ,*,>,>,'.> 
 
RESECTION  OF BOTH SUPERIOR MAXILLA.          181
had reappeared in one case at the last account.  It has also been performed,
unsuccessfully, by Maisonneuve, of Paris, on a man sixty-nine years of age,
who suffered from cancer of these bones, and, successfully, upon a  young
girl affected with necrosis from the vapor of phosphorus, or, as one account
says, polypus.  The first case was operated on as follows:—
  Maisonneuve's  Operation for Resection of both Superior Maxillae.—A
vertical incision being made in the middle line, so as to divide the nose from
its root, and terminate in the upper lip, a transverse incision was made from
the internal angle of the right to that of the left eye, leaving two large quad-
rilateral flaps,  which were  dissected  along  the  edges of the  orbit  to the
external angle on each  side.  These  flaps being  inverted, the disease was
exposed.   One end of a chain-saw being then passed by its needle through
the spheno-maxillary fissure, and  the other through the root of the nose, so
as to traverse the os unguis of each side, the  bones were detached  laterally
and superiorly, the velum palati freed transversely and posteriorly by a bis-
toury,  and the entire mass  of the bones detached by the help of Listou's
forceps.*
  Heyfelder's Operation.f—Both the superior maxilla; being involved in  a
malignant tumor, an operation  for their removal was  performed  as  fol-
lows:—
  The patient being seated  in a chair,  with his head supported against the
breast of an assistant, an  incision was made on each side of the face, from the
external angle of the eye to the labial commissure, and the included parts
reflected upward toward  the internal angles of the  eyes, the nasal bones, and
also toward  the forehead, until the infra-orbital  ridge was exposed.  The
chain-saw of Jeffrey being then passed through the spheno-maxillary fissures,
the malar bones were divided, the maxillae separated from the ossa nasi, and
the vomer and the thinner bones cut with strong scissors, when the applica-
tion of the chisel to the upper part of the tumor was sufficient to effect its sep-
aration by the employment of slight force.  Very little blood was lost,  torsion
and compression sufficing to arrest the hemorrhage.   Two hours afterward, the
edges of the wounds, from the angles of the eyes to the corners of the  mouth,
being uuited by twenty-six points of the interrupted suture, cold lotions were
applied; there was no reaction or swelling, and  the patient could swallow
water  and broth.   Four days subsequently, the wounds had nearly healed
by the  first intention, and in six weeks the patient was exhibited to the Med-
ical Society of Erlachen.   At this time there was no deformity of the feat-
ures ;  a fissure, thirteen  lines long and three lines wide, was seen along the
median line in his mouth ; the soft palate and uvula were in their natural place;
deglutition was free ; the nose had resumed its usual form and direction, and
the face, which, before the operation, was like that of a monkey, again pos-
sessed  a human expression;  a firm and solid tissue replaced the extirpated
parts.
  Remarks.—In  resection  of the upper jaw, as in all other surgical oper-
ations, the circumstances of  the case exert so great an  influence on  the de-
cision of the means to be employed, that  an estimate of their value must
necessarily be only an approximation.  Where the tumor will permit it, there
is, however, no question  that the operation of Horner, for the removal of
the bone without an external incision,  is  the best for the patient, as  it pre-
serves  the functions of the  portio dura nerve, saves him a most unsightly
scar, and, when the cheek can be freely dissected  off from the surface of the
tumor, exposes the part with considerable freedom. But if the development
of the  disease requires a more free opeuing of the integuments, in order to
* New York Journ., vol. v. N. S. from Med. Gaz.
f Med. Examiner, vol. ix. N. S. p. 595, from Rev. M6d.-Chir.  Paris. 
182            PRINCIPLES AND PRACTICE  OF SURGERY.

afford space for acting  in the various steps of the disarticulation, then the
simple curved incision from the outside of the malar bone to near the angle
of the mouth, so as to avoid the main trunk of the portio dura, as practiced
bv Warren and Mussey, and subsequently by  Velpeau, or the vertical cut of
Mott, will probably answer  better ; but it is always advisable to make these
incisions terminate near and not precisely at the angle of the  lips, as  the
cicatrix, from its stiffness, is then less apt to interfere with the expansion or
contraction of the mouth, and  consequently with the expression of  the face
when the patient is engaged in conversation.  In all external incisions, and
especially those near the masseter muscle, the operator should bear in mind
the position of  the duct of  Steno, and so  arrange  his  incisions and dissec-
tions as to leave it uninjured in the lower flap of the integuments.   When-
ever  the disease has  not  encroached  upon the  orbit,  it is also desirable to
leave the orbital plate for the support of the eyeball.   But as this can
seldom be told unless  by opening  the front of  the antrum  and  removing
the mass of the tumor,  at the commencement of the operation, the proceed-
ing will, in many cases, prove dangerous from the  hemorrhage  that it will
induce.
  Statistics of Resection of the Upper Jaw.—Resection of the superior
maxilla has been  twice  performed  by Jno. C. Warren, one patient being
cured, and the  other lost;  the  same surgeon  has also  performed partial re-
section many times with  perfect success.* By a reference to  the Biblio-
graphical Index of this part,  it will also be seen that the cases reported
by Jameson, Rogers, Warren,  Mussey, Stevens, Mott, and  other  American
surgeons have often been followed by a successful result.  From an  analysis
of these cases, we have the following facts :—
  Of eighteen  cases reported,  ten  were cured  and eight died,  or nearly
three-fourths were  cured, that is, the patients were doing well  at periods
varying from six weeks to  five years  after the operation.  But, to prevent
misapprehension in relation to the effects of this operation upon the disease,
I would state that several of those above reported as cured, are so referred to
by the operators solely  in connection with the results of the operation, some
of them being expressly mentioned as dying subsequently of the disease.   In
prognosticating the result of the operation, it should, therefore, be remem-
bered that, though its happy termination is more marked than that of other
great operations, (nearly  three-fourths recovering,) yet the tendency to ulti-
mate death from the disease is but slightly diminished  by removing it from
the  point in which it was first  apparent.  According to the experience of
every surgeon, it may be anticipated that in  every instance of encephaloid
tumor the disease will return, no matter how thoroughly the abnormal struc-
ture  has been extirpated, but  that  in the fibrous  or other non-malignant
tumors there is no reason  to  apprehend a relapse.   The results of Ried's
examination of the  history of this operation also shows that out of  thirty-five
cases treated in Europe, there  were  twenty-four cures.
                            SECTION V.

                 RESECTION OP THE INFERIOR  MAXILLA.

  The Inferior Maxilla may be resected either partially or entire, the former
having been  performed by Deaderick, of Kogersville, (now of  Athens,)
Tennessee, in Feb. 1810, and subsequently by Mott, of New York, in 1821,
* Manuscript of Warreu. 
RESECTION  OF THE INFERIOR MAXILLA.
183
and the latter having been successfully performed by George M 'Clellan, of
Philadelphia, who, in 1823,* removed  all the bone, anterior to its angles,
and was the first  surgeon who  attempted so extended  a resection of this
portion of the face.  Walther, of  Bonn, and Graefe, of Berlin, have since
then resected  and also  disarticulated  the entire bone, and  Carnochan, of
New York, once  repeated the operation in  order to relieve  a  patient who
was  suffering from  an  extensive  necrosis.   Ackley,  of Cleveland, Ohio,
is also reportedf to  have succeeded, in July, 1850, in  removing  the bone
entire, in  a case of osteo-sarcoma, the patient being alive and in good
health two years subsequently.   The partial resection  of the jaw has  now
been so often accomplished as to render it difficult to register all the cases.
  Whether the evils  resulting from the  loss of the entire lower jaw bone are
not such as will forbid  its repetition, is at  present a  question that expe-
rience has not settled.   They  should,  however, be  deliberately considered
by every surgeon before attempting the operation, the difficulties of accom-
plishing the operation not being so  great as the evils likely to  ensue to the
patient on its completion.
           § 1. — Resection of one Side of the Inferior Maxilla.

   Operation of Deaderick—An incision was commenced under the zygo-
 matic process, and continued over the tumor—which  almost entirely envel-
 oped the left portion of the jaw, and occupied nearly the whole mouth—
 in the direction of the bone, to nearly an inch beyond the centre of the chin.
 A second incision was then begun  about midway and at  right angles with
 the first, extending a short distance down the neck.   The integuments being
 now separated  from their connection with the tumor, and the jaw sawed
 through near its angle, as well  as  at the  centre of the chin, there was no
 difficulty in freeing  it from its  other attachments.   The  wound was then
 closed in the usual manner, and  the boy had a speedy and happy recovery.
 Thirteen years subsequently, there  was no  connecting medium between the
 ends of the divided  bone.| The description of the tumor shows it to have
 been enchondroma.
   Remarks.—As the account of this  operation was not published by Dead-
 erick until  nearly one year after Mott's operation, and  as  the latter  sur-
 geon had performed his operation before he heard of that of Deaderick, the
 credit of  priority has  been strongly  urged, and  by many  accorded to the
 former  gentleman.  But as the case  of Deaderick,  though not published
 until 1823, contains the  evidence of those  who know it to have been per-
 formed in 1810, justice would seem  to demand that Deaderick should obtain
 the renown which has been so frequently attached to those who only followed
 in his footsteps,  especially as claims to the credit of originating the opera-
 tion have been advanced in Europe both  by  the English and French sur-
 geons.  The decision of the priority of the operation of Deaderick is now
 generally received in the United  States as correct, though there are yet some
European surgeons who assign the credit of the first operation  to  Dupuy-
tren in 1812.  It is, however,  but just to state, in connection with the vary-
ing claims of Mott and Deaderick to the originality of their operations, that
the operation  of Deaderick was a  resection  of a portion  of the jaw, the
  * Am. Med Review, vol. ii. p. 153, 1825.   Also, Cooper's First Lines, p. 16, edited
by Samuel M'Clellan.  Philadelphia, 1830.
  f N. Y. Journ. Med., vol. x. N. S p. 288, 1853.
  X Amer. Med. Recorder, vol. vi. p. 516.  Philadelphia, 1823. 
184
PRINCIPLES AND PRACTICE  OF SURCERY.
ramus of the same side being left, while that of Mott was the  resection of
the entire half of the bone, and necessitated a disarticulation at the temporo-
maxillary joint.  Though the credit of the first resection of this bone there-
fore belongs  to  Deaderick, Mott was certainly the first American or Euro-
pean surgeon who, while  resecting, also disarticulated  half of the lower jaw.
  In  the  early operations performed by Mott, it was deemed  essential to
success to ligate the carotid artery a few days  prior to removing the bone;
but many cases,  since operated  on  by others, as well as that of Deaderick,
have proved that this step is only a complication  of  the  proceeding;  it is
therefore now seldom resorted to.
  Ordinary  Operation  for  Resection and  Disarticulation  of Half of
the Jaw.—The  patient  being  seated on  a chair, so that his feet will  not
touch the ground and enable  him to tilt himself backward, and having  his
head  supported  by an assistant, make a horizontal incision over the tumor,
from the  angle to the symphysis, along the base of the inferior maxilla.   A
vertical cut over the  symphysis, from the lip to the end of the first incision,
will then free the flaps, which  should be dissected back from the tumor, one
being turned up on the cheek, and the  other downward and backward.
After sawing through the bone at the symphysis from without inward, shave
off  with a strong good scalpel  all the soft parts on the inside, as far as  the
angle of the bone;  then,  drawing the bone outward and forward, use it as a
lever, Plate XXV. Fig. 7 ; and, while its upper attachments are  upon  the
stretch, insert behind  the coronoid  process, and just  below the zygomatic
arch, a bistoury, so as to  detach the temporal muscle from its insertion.   At
the  same  time, while depressing the bone so as to dislocate the condyloid
process, draw it forcibly  forward so  as  to  remove it  from the  artery, and
divide the  capsular  ligament and  pterygoid muscles, which will  generally
free the jaw entirely, when the wound may be closed with a few  stitches and
adhesive  plaster.
  Removal of the  Middle of  the Bone.—The patient being arranged as
before, seize one angle of the  mouth with the  left hand, while  an assistant
does the  same with the  other,  and, while  drawing the lip tense, divide it
immediately in its middle by a single vertical incision   The two flaps being
then shaved off from the  bone to the desired extent, let them be held by  the
aids, while the teeth at the points of division are extracted, when the bone
may be cut through, either by  Hey's or the  chain saw, the latter cutting from
behind forward, after being passed around  the jaw by means of a needle.   If
it is desirable to divide the bone from before backward, a saw similar to that
of Hey must be  employed, Plate XXV. Fig. 8.
  The point of the tongue being now held, either by a ligature introduced
through it, or by means of a  tenaculum, so  as to prevent its being  drawn
back upon the pharynx, shave off the muscular attachments from the inside
of the bone, and close the wound by sutures.
  Should the portion of  bone to be removed be the entire chin, it will, per-
haps, be  necessary to attach the tongue to the  side of the  cheek  for a  few
days, by means of a suture, iu order to prevent its retraction upon the glottis,
lest this should  induce suffocation.
  Barton's Operation for Removal of  Half the Jaw, by a Longitudinal
Section, without destroying the base of  the bone, so as to  preserve the line
of the face.—The patient had a tumor, (epulis,) which  had taken entire pos-
session of the mouth, forcing the tongue  into  the pharynx, and stretching
the jaws  widely apart.  It also rose up outside the superior maxillary bone
Plate XXV.  Fig. 6, protruding the lips, cheek, and neck on the left side.
  Operation—An incision,  which  commenced over the  left angle of  the
lower jaw, being carried on a line with the  under edge  of the base around to 
RESECTION  OF THE INFERIOR  MAXILLA.
185
near the edge of the masseter on the opposite side, through the integuments
and muscles of the cheek and lip, so as to open the cavity of the mouth, the
under lip was cut through vertically toward the left commissure of the mouth,
so as to  meet the first incision at a right angle, when the tumor, being thus
exposed, was found to be adherent to the anterior and posterior surfaces of
the bone.  These adhesions being  detached from  the  anterior face of the
bone as  high up as it  was sound, Plate XXV. Fig. 6, the  bone  was cut
through  longitudinally  with a small narrow saw  from without  inward, in a
line parallel to the base of the jaw, and just below the maxillary canal, this
section  being extended as far back as the roots of the  last  molar tooth  on
the left, and the second  molar on the right side.  A vertical  cut being then
made through the alveoli between these teeth, so as to meet at a right angle
the horizontal division of the bone, Plate XXV. Fig.  5, the portion thus
insulated was found to contain the  diseased mass, so that, after separating
the attachments of the soft parts, the operator was  enabled to take it away
entire,  Plate  XXV. Fig. 6, leaving the base of the  bone in a healthy state,
except at one point on the surface, which was readily taken off with the nip-
pers.   No  blood-vessels required the ligature, except  the  left facial and
right coronary  arteries.   The flap  being replaced, the vertical  cut through
the lip was closed by the hare-lip suture, and  the remainder of the wound
united  by the  interrupted  suture  and adhesive plaster.  In  a month  the
patient was well, the contour of the face  was preserved, and he was able to
masticate his food with  the three remaining molars and  their antagonists of
the upper jaw.*
  Resection  of a Portion of the  Lower  Jaw, and Extirpation of the In-
ferior Maxillary Nerve, for the  Cure of Neuralgia.—Operation of  J. M.
Warren, of Boston.—An  incision  being  made from the sigmoid  cavity of
the temporal  bone down to the edge of the jaw, the parotid gland was raised
and turned to the outside, when  the lower portion of the masseter muscle
was  dissected  up, and  a portion of the  ramus removed by means of the
trephine  and chisel.   The nerve being thus fully exposed, about half an inch
of its main trunk was excised.  The inferior maxillary artery was cut and
tied, and there was also a slight discharge of saliva through the wound, from
interference with the parotid.
       § 2.—Resection of the  Inferior Maxilla Entire, or nearly so.

   Operation of M'Clellan, of Philadelphia.-f—The entire substance of the
lower jaw, in front of its angles, being affected with osteo-sarcoma, and the
tumor having extended in all directions  and pushed the tongue back into
the pharynx, so as to impede  deglutition and  respiration, M'Clellan  oper-
ated as follows:—
   Operation.—Making  an  incision  through the  integuments, from the  left
commissure of the lips obliquely downward and backward, he carried it over
the anterior edge of the stemo-cleido-mastoid muscle, so  as to command the
internal carotid  artery, if  necessary.  Having ascertained  that the artery
need not be touched, he  next exposed the tumor by dissecting up the integu-
ments, and, paying no  attention  to  the  small vessels, at once secured  the
facial artery, when the bleeding immediately ceased.   After dissecting up the
insertions  of the masseter a little way behind  the tumor, he divided the bone
on each side with a metacarpal saw, turned the tumor out of the mouth, and
* Am. Journ. of Med. Sciences, vol. vii. p. 331, 1831.
f Cooper's First Lines, edited by Sam. M'Clellan, p. 16. Phila. 1850. 
186           PRINCIPLES AND PRACTICE OF SURGERY.
dissected from the under surface of the tongue such portions of the submax-
illary glands as were sound, when the remainder, and especially a portion of
the left submaxillary, were removed with the tumor.  Only three small arte-
rial twigs required a ligature, and the wound was closed  by sutures and ad-
hesive plaster, the large cavity under the  tongue being filled with lint, to
support the skin.  This patient recovered and lived  some months subse-
quently,  and the preparation  is now the  property of  his son, J. H. B.
M'Clellan, of Philadelphia, who has deposited it in the  Museum of Pennsyl-
vania College, Philadelphia.
  Remarks.—This operation was a very bold and successful one, but appears
to have been generally overlooked by the profession, though its performance
at so early a date should have given it a prominent position, especially as no
surgeon had then attempted so  extended a resection.
  Resection of .the Inferior Maxilla Entire.—Operation of Carnochan, of
New  York.—A patient in  the Emigrants' Hospital having  long  suffered
from a necrosis, which had loosened the teeth in the lower jaw, partially de-
nuded the alveolar ridge, and caused great suffering and depression, it  was
decided to remove the inferior maxilla.  The patient being seated, an incision
was first made, commencing opposite the  left condyle ;  then passing down-
ward to the  angle of the jaw, about two lines in front of the posterior border
of the ramus, it was extended along the base  of the jaw,  and made to term-
inate by a slight  curve on the  mesial line, half an inch below  the free mar-
gin of the lower lip.   The flaps being dissected off, the bone was laid bare,
and the tissues forming the floor of the mouth separated from their attach-
ments, from  the mesial line back as far as the  angle of the jaw.   The attach-
ments of the buccinator being  next divided, and the facial aud sublingual
arteries tied, the bone was found to be partially separated at the symphysis,
and  completely necrosed from  this  point  to  the  inferior portions  of  the
ramus, the latter  being also diseased.  A double  ligature having now been
passed through the anterior part of the tongue, and intrusted to an assistant
in order to prevent its falling back upon the orifice of the larynx, the bone
was broken at the symphysis and at  the angle, and this portion readily re-
moved ; when, by pulling on the ramus, it was disarticulated  and removed,
after  being  freed from the  soft tissues by  the use of the knife  and bluut-
pointed scissors, without any injury to the  internal maxillary  artery.   The
same incision and dissection being practiced on the opposite side, the bone
was  disarticulated in a similar  manner at this joint, also without injury to
the blood-vessels, and the amount of  blood  lost was inconsiderable.   Union
of the wound occurred in forty-eight hours, and  the patient  afterward re-
covered, articulation  being  sufficiently distinct to render  words intelligible,
while his food was broken up by the pressure  of the tongue against the roof
of the mouth.
  Remarks.—Although so important a portion of the general  outline of the
face and of the organs of mastication is necessarily removed in  the resection
of the lower jaw, the deformity which results from the  operation is by no
means such as might be  anticipated.   In the  case of a gentleman, formerly
an Interne of Lisfranc's at  the hospital  of La Pitie, who I  saw  in Paris
in 1839, the deficiency was  admirably concealed  by his  whiskers;  and in
the modification proposed  by Barton, of Philadelphia, where  a rim of  the
base of the jaw was left, it is very slight.   In all cases, where the amount of
the disorder will  permit it, Barton's  method of operating will  be found to
be the most advantageous ; but it is essential to a successful  result that as
much as possible of the  base of the bone below the orifice of the nutritious
artery be preserved, in order to obviate the risks of necrosis from the want
of circulation. 
STAPHYLORAPHY.
187
  In reviewing the various methods of operating, it is therefore apparent
that, as the object of all is the same, the  modifications will be chiefly such
as are demanded by the peculiarities of the case.
  Statistics.—When we remember the character and extent of the parts
involved in this operation, it must be admitted that the success attending
resection of the lower jaw, and the relief afforded by it from a painful and
loathsome complaint, is such  as  is highly creditable to the surgery of the
nineteenth century.
  Out  of about one hundred and sixty cases collected from various sources
by Velpeau, there  have only been forty deaths, or one-fourth of the whole
number operated on, a success wdiich is very great when compared with the
serious character of the operation.*   By  referring  to the Bibliographical
Index of this part, it will also be seen that the operation is one which has
been frequently resorted to by American surgeons, the whole number of re-
sections of this jaw there referred  to, and doubtless reported as those  of
special  interest, being  forty-two.   As many others have been performed
within  my knowledge, which have not been reported.   The whole number of
cases  operated on, including those reported by Velpeau, now amounts  to
more than two hundred.
                           CHAPTER IX.

                    OPERATIONS  ON THE PALATE.

   The occurrence of a fissure, either in  the hard or soft palate, or in both,
 is most frequently the result of a congenital defect, and often coexistent with
 a similar fissure in the alveolar processes of the upper jaw as well as in the
 lip, as was mentioned when treating of the operation for hare-lip.  In con-
 sequence of the effect of this fissure upon the  tone of the voice, as well as
 upon the enunciation of words, it becomes desirable to attempt its closure
 by uniting the two halves, or by performing a plastic operation at as early
 a period as will be  permitted by the  patient, or rather so soon as the indi-
 vidual is willing and able to assist the operator in the efforts required for its
 execution.   If the case is seen during infancy, the cure of the hare-lip will
 often diminish the size of the fissure in the palate, or materially aid the sub-
 sequent operation ; but if both hare-lip and fissure of the palate are present
 in an adult, the operation must first be performed upon the lip, and then, if
 necessary,  repeated  upon the  palate,  the operation of staphyloraphy, or
 union of the fissure of the palate, being  very much the same in principle as
 well as means of treatment  as that resorted to for the relief of hare-lip.


                             SECTION  I.

                            STAPHYLORAPHY.

  The operation of refreshing the edges of a fissure in the palate, and then
uniting them by a suture, was suggested  by a French  dentist, Le Monier, in
 1764, and  termed staphyloraphy—<rza<puXrj, the palate, and  payt], suture.
* Velpeau, M6d. Ope'ratoire, vol. ii p. 620. 
PLATE  XXVI.
A VIEW OF THE INSTRUMENTS EMPLOYED IN OPERATIONS UPON THE
           THROAT, AND ESPECIALLY IN STAPHYLORAPHY.

  Fig 1. Scissors for Excising the Uvula.                     Kolbe's pattern.

  Fig. 2. Gibson's Spatula, to depress the Tongue.            Kolbe's pattern.

  Fig. 3. Physick's  Tonsilotome for excising the Tonsil Gland.  The ring sur-
rounds the tonsil, the needle transfixes it, and the angular knife shaves it off.
                                                           Kolbe's pattern.

  Fig. 4. A long-handled double-edged Scalpel, for freshening the edges of the
fissure in the operation of Staphyloraphy.                     Kolbe's pattern.

  Fig. 5. Curved Scissors, with long handles, for the  same purpose.
                                                           Kolbe's pattern.

  Fig. 6. Physick's  Forceps,  with long handles, and  holding a small needle of
the proper curve, to facilitate  its passage  through the side of the Uvula.   This
curve maybe readily given to the ordinary curved needle, simply by pressure and
gentle heat.  The catch on the handle of the forceps enables the operator to free
the needle in a moment, after transfixing the part, and again to seize its point with
the same instrument, so as to  draw it through the  opposite side of the fissure.
                                                           Kolbe's pattern.

  Fig. 7. Gibson's Forceps for inserting the ligatures in  Staphyloraphy, at the
moment when the needle is passed through the palate.         Kolbe's pattern.

  Fig. 8. The same  instrument drawing the ligature into its position.
                                                           Kolbe's pattern.

  Figs.  9, 10. Needles of different sizes, as adapted to Gibson's Forceps.  The
shoulder near the spear-point  facilitates  the grasp of the forceps, which close
around  it in consequence of a little split in the top of the  first upright portion.
                                                           Kolbe's pattern.
        (188) 
Illman ScSons 
 
STAPHYLORAPHY.
189
After being  for a time forgotten,  it was  revived  by Graefe,  of Berlin,  in
1817, but methodized and first published, with the rules for its  performance,
by Roux, of  Paris, about 1819.   In 1820, a nearly similar operation was
invented and  executed by John  C. Warren, of Boston, he  being, at the time,
ignorant of the  views or  operations of the  other surgeons.   In many re-
spects, the steps proposed by Warren and  Roux corresponded, though the
means suggested by Warren were  the simplest.   The operation of Roux
being, however,  generally regarded as the basis of the various  modifications
that have since perfected the proceeding, his plan may be  first referred to.
   Operation of Roux,  of Paris.—Four  different objects, which are to  be
attained in four different  stages of  the operation, have been laid down  by
Roux as  likely to facilitate  the surgeon's  manipulation,  and the success of
the means employed.
   1st. The paring off the edges of the fissure.
   2d. The introduction of the  ligatures at equal distances through its mar-
gins.
   3d. The knotting of the ligatures and the approximation of  the freshened
sides of  the fissure.
   4th. The relief of any tension in  the parts consequent on the suture.
   Instruments___The instruments proposed  by Roux  for accomplishing
these objects are sufficiently complicated, consisting of three silk ligatures,
made of two or three  strands, and waxed; of six small, curved but flat
needles,  each end of the three  ligatures  receiving one needle; of a porte-
aiguille or needle-holder ; of dressing forceps ; and of a  probe-pointed bis-
toury, and curved scissors.
   Operation.—The patient being seated before a strong light, with the head
thrown back and supported against the chest of an assistant, the mouth is
to be kept widely opened  by means of a  cork placed between the molar
teeth.  The  surgeon, being placed  in front, then seizes, with the forceps
held in  his left  hand, the right lip  of the  fissure,  and, with his right hand
armed with the needle-holder, introduces the point of the  needle from before
backward  behind the uvula, in order to traverse the flap from behind forward,
Plate XXVII.  Fig. 1, at three or four lines from the free edge of the fis-
sure.  The needle, being now thrust in as far as its head,  is then to be freed
from the needle-holder, and  seized at its point by forceps, which draw it and
the ligature through into the mouth.   After resting a few seconds, the same
manoeuvre is practiced on the left half of the fissure with the other needle of
the same ligature, the two ends of which are  thus brought out into the mouth.
In passing three ligatures, the operator should commence by the lowest, then
pass the highest, and lastly apply the third in the middle of the fissure.
Plate XXVII. Fig.  1 shows the ligatures as the last is being passed through
the  right side of the fissure.
   The extremities of the ligatures, 3, 3, 4, 4, 5, 5, being brought outside the
mouth, and their loop or central portion depressed toward the pharynx, the
surgeon  proceeds to
   Freshen the Edges of the Fissure.—To accomplish this—Plate XXVII.
Fig.  2—he should seize the lower end of the left margin with the forceps, 1,
held  in  the  left hand, and  cut off  the edge from  behind forward  with  the
probe-pointed  bistoury, 2, or curved scissors, Plate XX VI. Fig. 5, held in
the right hand, cutting from below upward, and prolonging the incision a
little beyond the centre or angle of union of the two sides of the fissure.
The  other margin is then to be incised in  the same manner by cutting a
little beyond the angle of union, in order to free the flap.
   In order to tie the ligatures, Roux commences  by knotting the middle
ligature—Plate XXVII. Fig. 1—with the  fingers, and, after making a sim- 
PLATE  XXVII.
       A FRONT VIEW OF THE OPERATION OF STAPHYLORAPHY.

  Fig. 1. The operation as practiced by Roux.  1. The needle-holder (porte-
aiguille) in the act of carrying  the last ligature through the right  side of the
fissure.  2. Dressing forceps holding this  margin.  3. The first ligature  as
placed, the ends being brought out through the angles of the mouth, and the loop
being loose behind the palate.  4. The second ligature as introduced.  5. The
third ligature.                                   After Bernard and Huette.

  Fig. 2. The three ligatures, 3, 4, 5, as before shown, being accurately placed,
the surgeon  proceeds to freshen the edges of the fissure with a probe-pointed
bistoury, taking care not to cut the loops of the ligatures.  1. Forceps holding
the free end of the palate.  2.  The bistoury paring off a strip.
                                                After Bernard and Huette.
  Fig. 3*. Operation of Warren.   1. The knife freshening the edge of the fissure
from above downward.  2. The forceps steadying the margin so as to favor  its
regular incision.                                  Modified from Pancoast.

  Fig. 4. The introduction of the Suture by means of Physick's Forceps and a
curved needle.  1. Physick's forceps introducing the needle.  2. Dressing for-
ceps seizing its point at the moment when it is liberated from the instrument of
Physick.  3,  4, 5. Position of the sutures.  They should all be introduced at
equal  distances and as nearly parallel as possible.            After Pancoast.

  Fig. 5. The operation of Staphyloplasty, as practiced by Dieffenbach. 1,2, 3.
The sutures as tied, and closing  the fissure.  4, 5. The two longitudinal incisions
made  on each side of the soft palate, so as to remove the strain from the line of
union.                                           After Bernard and Huette.
(190) 
Plate   27
FiS.i
Fi(5.2

 
 
STAPHYLORAPHY.
191
 pie knot, confides it to an assistant, who holds it with a serre nceud (knot-tier)
 while  he ties the second and then the first ligature, drawing them tighter
 than is necessary to approach the edges of the wound, in order to prevent
 any separation.  This being completed, the ends of the ligatures should be
 cut close to the knots, and toe patient kept from eating, drinking,  or speak-
 ing during two or  three days ;  the ligatures being removed on the third or
 fourth day, and the lowest ligature being left twenty-four hours longer than
 the others.
   It  is  essential that the ligatures be placed  at equal distances;  that the
 points of each one be on the same level, and that they be at a proper and
 equal distance from the free edge of the  fissure.*   If, on knotting the lig-
 atures, the  strain upon  the parts seemed to be too great, or such as might
 excite an apprehension of their tearing out, Roux made an incision in the
 sides  of the soft palate, Plate XXVII. Fig. 5,  and allowed these wounds to
 heal by granulations.
   Operation of Jno. C. Warren.—In the case of a young girl, aged seven-
 teen years, who from birth had suffered from a cleft on the left side of the
 uvula, extending as far as the ossa palati, where the fleshy membrane was so
 thin as to be transparent, the operation of staphyloraphy was performed by
 Jno. C. Warren, of Boston, as follows :—
   "The patient  being well supported and secured, a piece of wood an inch
 wide, a little curved at the end, and with a handle to be held by an  assistant,
 was placed between the molar teeth on one side, to keep the mouth  open.  A
 sharp-pointed curved bistoury was then thrust through the top of the palate,
 above the angle  of the  fissure, and carried down on one edge of the cleft to
 its extremity, Plate XXVII.  Fig. 3 ; and the same was done on the oppo-
 site side, so as to cut out a piece in the form of the letter V, including about
 a line from each edge.  Next, a hook, or curved needle, fastened in  a handle,
 with an eye on its extremity, and a movable point armed with a triple thread
 of strong silk, was passed double  into the mouth through the fissure, and
 behind the palate, and the latter pierced by it at one-third the length of the
 fissure from the upper angle of the wound, so as to include about three lines
 of the edge of the soft palate.  The eye with the ligature, being  seen, was
 seized by a common hook and drawn out.   The eyed hook was then drawn
 back, turned behind the palate, and the  other edge transfixed in  a similar
 manner.  A second and a third stitch were now passed in the same way, the
 third being as near as possible to the lower end of the fissure. Then, seizing
 the upper ligature  with the fingers, the knot was tied without  using a serre
 nceud,  and placed on one side of the wound iu order to prevent its pressing
 on the fissure, the others being tied in a like manner, and the fissure closed.
 The  patient  was exhausted  by the  operation, but soon revived; remained
 twenty-four hours without speaking or taking a drop of liquid into her mouth,
 then used a little water.   In seven days the stitches were removed, and she
■left the hospital a day or two  after.   Two years subsequently she swallowed
 perfectly and spoke well."f
  In 1826  a similar operation was  successfully performed on a boy, aged
 eleven.   The cure was perfect.^
  Remarks on the American Operations—The first of these operations is
 stated by Warren to have  been original with himself, as he was not at that
 time acquainted with the operations performed in Europe.  From the sim-
  * Bernard and Huette, p. 207.  Paris, 1850.
  f Amer. Journ. of Med. Sciences, vol. iii. p. 1, 1828; and MS. Records of/Mass..Hos-
pital.                                                    X Ibid. 
192
PRINCIPLES AND  PRACTICE OF  SURGERY.
plicity of the instruments employed, and the freshening of the edges from
above downward, his method has advantages over that of Roux, from the fact
that the incision of the soft tissues is facilitated by the traction, while the flap,
being left adherent above until  the completion of the opposite edge, is less
likely to cause irritation about the fauces.   That these two surgeons should
devise similar expedients at the same time, and yet each be ignorant of  the
proceeding of the other, only shows the uniform tendency of different minds
when devoted to the same object.
  After the operation of Warren, A. II. Stevens, of New York, Sept. 1826,
also operated successfully by first inserting the  ligatures, and then paring
the edges.*
  Alettaner, of Virginia, in  1827, operated for staphyloraphy, and  in 1837
published an excellent essay, f from which the reader may  gain much that is
of  practical value.   He employed the leaden  ligatures  recommended  by
Dieffenbach.
  Wells, of Columbia, South Carolina, (1832,) in a case of recent wound, was
enabled to  apply the sutures by heating a surgeon's needle in  a lamp, bend-
ing it to a proper  curve, and passing it  through the fissure by the aid of
Physick's forceps. J  This simple  contrivance seems to have answered per-
fectly, and  is certainly capable of  supplanting all the more complicated  in-
struments,  and  has  been successfully used in staphyloraphy by various sur-
geons  of Philadelphia.
  Gibson,§ of  Philadelphia, operated  with instruments  of a useful kind,
some of which have been transferred to these pages.
  Hosack, of New  York, also published, in 1833, a memoir npon this sub-
ject, with illustrations of his own instruments;  and Smith,  of Baltimore, em-
ploys a peculiar hook  or needle for the suture.   L. A. Dugas|| in 1860 cured
a case of cleft palate, by employing the metallic  suture, introducing  five
metallic threads and simply twisting them.
   In fact, there are few operations in which surgeons seemed to have felt  the
necessity of more perfect instruments than in that of staphyloraphy.  Each
one has, therefore,  endeavored to improve on those of his  predecessor, and
especially in reference to the introduction  of the needles, thus showing that
placing the ligatures  is the most  difficult step in the operation.   The sim-
plicity and efficiency of Physick's  forceps removes,  however, this great  ob-
stacle to the rapid performance of the operation.
   The advantages resulting from the transverse incisions suggested by Roux,
or the lateral sections practiced by Dieffenbach, have recently been more sys-
tematically presented  and specially urged on account of their anatomical rela-
tions,  by Ferguson, of London, in the Transactions of the Royal Medical
and Surgical  Society  for 1845.^f  By many, the views  of  Ferguson  are
regarded as original; but the following facts show that he had been antici-
pated.
   In connection with  the history  of an operation for fissure of the palate, J.
Mason Warren published, in the New England Quarterly Journal of Medi-
cine and Surgery, No. IV. p. 544, April, 1843, on account of the division
of  both pillars of the  palate,  and of  its  happy influence upon the union
of the freshened edges of the fissure.  Ferguson's paper did not appear until
December  21, 1844, when, in  the Medical Times, he  published an accouut
* Nonli American Medical and SurgicalJournal, vol. iii. p. 233, 1827.
t Amer Jour, of Med. Sciences, vol. xxi. p. 309, 1837.
X Ibid., vol. x. p. 32, 1832.
I Instil and Pract. of Surg., vol. ii. p. 40.        || Dugas, in MS.  April, 1860.
* Ferguson, Practical Surgery, p.  506. Philadelphia edition, 1848. 
STAPHYLOPLASTY.                       193
of the dissection, from which he was led to suggest the special division of the
levator palati and palato-pharyngeus muscles.  As he entered minutely into
the anatomy of the structure concerned, and also demonstrated the import-
ance of dividing  these muscles, he has doubtless aided  the progress  of the
operation; but it  is apparent,  from the references just  made, that the  idea
was not  a novel  one, having been put in execution nearly two years  pre-
viously by Warren.   Froriep also appears to have been fully aware  of the
value of this muscular division, having described and figured the part in his
Notizen, early in 1823.*
  Mettauer, of Virginia, in 1837  also recommended the section of the mus-
cles by repeated lateral incisions, as a preparatory step to the operation in
cases of great loss of substance, allowing the parts to heal by granulations,
as suggested by Velpeau in staphyloplasty.f
  To Ferguson, however, is certainly due the credit of demonstrating, in a
scientific manner, the  special effects upon the fissure, of each of these muscles,
though they had  been previously divided without any reference to the  ana-
tomical details of the region.
                             SECTION II.

                            STAPHYLOPLASTY.

   In the  operation of staphyloraphy, as just detailed, the attempts of sur-
geons have generally been limited to cases in which the fissure was only in
the soft palate, the opening in the bony structure  being left untouched  or
covered up by a metallic  plate.   The following ingenious operation, by J.
Mason Warren, of Boston, presents a plan of closing  the opening in  the
bones, as  well as that in the soft tissues, by means of a portion of the neighbor-
ing  structure.   As the opening is thus closed by a flap taken from the  ad-
joining soft parts, and made to slide over the fissure, as in plastic operations
elsewhere, the operation has been termed Palatoplasty, Staphyloplasty, or
Uranoplasty, according to the position of the opening, either of which names
is sufficiently applicable to the operations on any part of this structure.
   Operation of J. Mason Warren, of Boston.—The patient being placed on
a low seat, in a strong light, has his  head firmly supported against the breast
of an assistant, who raises or depresses it, as circumstances may require. The
patient is then  directed to keep  the jaws  widely  separated, to retain any
blood which may collect, as long as possible,  so as not to embarrass the opera-
tor, and restrain all efforts at coughing, in all which he should be encouraged
by the surgeon. The use of a speculum oris is deemed by Warren altogether
inadmissible, as it obscures the  light and prevents the proper manipulation
of the instruments.   The mucous membrane of the hard palate, being now
carefully separated from the bones with a long double-edged bistoury, curved
on the flat, should be rather peeled than dissected off, in consequence of  the
diflSculty of making any sawing motion with the knife in this  confined posi-
tion, the obstacles being always greater in proportion to the obliquity of the
palatine vault.  As the dissection approaches the connection of the soft parts
with  the  edges  of the palate  bones, where the muscles are attached and
the union  most intimate, great care must be  taken lest the mucous membrane
be perforated; and as soon as this dissection is terminated, it will generally
be found that, by seizing the soft palate with the forceps, it can be brought
         * Chirurgische Kupfertafeln.  Weimar, 1823.
         f Am. Journ. Med. Sciences, vol. xxii. p. 309, 1838.
VOL. II.—13 
104
PRINCIPLES AND PRACTICE OF SURGERY.
into the median line.   If the fissure is wide, and this cannot be effected, then
the soft parts being forcibly stretched, a  pair of long powerful French scis-
sors, curved on the flat, should be carried behind the anterior pillars of the
palate, and its attachments to  the tonsil and to the posterior pillar carefully
cut away, when the anterior soft parts will at once be found to expand and
an ample flap be provided.
  The edges of the palate may now be freshened by seizing them on either
side with  hooked forceps, and removing a slip  with the  scissors or sharp-
pointed bistoury.  A small  curved  needle, armed with a strong silk thread,
confined in forceps with a movable slide, (Physick's,) should then be intro-
duced at the  upper edge of the fissure, and carried from before backward on
the left side,  and from behind forward on the right,  or vice versa.  Three or
four ligatures being thus introduced, the patient should clear his  throat of
mucus and blood, the  ligatures be wiped dry, and tied with deliberation, be-
ginning at the  upper and proceeding gradually downward, waiting a little
between each ligature in order to allow the throat to accommodate itself to
this sudden and almost imperceptible tension of the soft parts.   No forceps
are required  for holding  the first knot while the second  is tied, the  object
being better effected by making two turns of the thread instead of one, and
by enjoining  perfect quiet on the patient until the second  knot is tied.
  Warren has always  arrested the hemorrhage consequent on the incisions
by iced water and the finger, and does  not wait before introducing the liga-
tures.  The ligatures also were generally removed in forty-eight hours, or on
the third  day; drinks were employed with caution from an early period,
and the patient was nourished by oatmeal gruel in injections.*
  Velpeau operated successfully, and closed  an opening in the hard palate
three-quarters of an inch long and half  an  inch broad,  by the following
means :—
  Operation.—Having noticed that the fibro-mucous membrane of the pal-
ate, in consequence of its firmness and slight vascularity, was very apt to
mortify and slough, either in whole or part, the operation  was performed as
follows :  Two  flaps, six to ten lines long, of a triangular shape, were cut,
one from in front, the  other  from behind the opening, and dissected off,  and
brought down toward each other.  These being united by  means of a suture
at their apices, a wound was left, which gradually  closed up the  fistula in
every direction  by the approximation  and cicatrization of its  borders, the
cure being aided by a longitudinal incision, made from time to time upon the
two sides of the opening, as well as by occasional transverse ones upon the
root of each flap.
  Statistics.—The results of this operation are shown by the following cases  :
Of twenty-four cases  operated on by Warren, it appears that he has suc-
ceeded in  twenty-three of them; and  Roux, in 1842, obtained a success of
two out of three in simple fissure, but of  only one out of three when it was
complicated with a fissure in the hard  palate.
  From a recent statement by  Warren  to the Boston Medical Society, it ap-
pears that this surgeon " has latterly  performed five operations, in two of
which the hard palate was badly fissured, and that all had  proved successful.
In one of these, where the fissure extended through the hard palate and alveo-
lus, the soft palate and a portion of the mucous membrane, which was peeled
off the palatine arch,  united.   In  regard to  the result of these operations
Warren also  states that he has recently seen a young lady on whom he had
  * Operations for Fissures of the Soft and Hard Palate, (Palatoplasty,) by J. Mason
Warren, M.D.   New England Quarterly Journal of Medicine and Sureerv No TV «
338.  Boston, 1843.                                            *'        P> 
ANATOMY OF  THE  EAR.
195
operated some years since, and that the power of speech was quite restored, so
that she enunciated with great distinctness.  In almost every case the speech
improved, the deglutition was easier, and the fauces were relieved from  the
dryness and inflammatory attacks to which they were formerly liable."
                           CHAPTER  X.

                       DISORDERS OF THE  EAR.

   The importance of studying the derangement of an organ so essential to
individual comfort and usefulness as the ear,  is  so evident that it might, at
first, be thought that it would naturally attract the attention of every sur-
geon.   Impressed with the idea that its structure is complicated, its dis-
orders  difficult  to  recognize, and the remedies advised  often unavailing,
there has long been, on the part of many, a disinclination to investigate these
affections thoroughly, or a disposition to turn over patients  thus afflicted
to any one who would undertake  their treatment.  In consequence of this
general professional  neglect,  the public have been gradually led  to  think
that aurists belonged to a special class of practitioners, and  quackery has
readily taken  advantage of the idea to advance its  own  selfish interests.
That difficulties attend the attainment of a thorough knowledge  of  aural
surgery must be admitted.  Yet these difficulties are not greater than  those
met with  in other  affections, and can be readily mastered, while the result
of a judicious  treatment will  frequently be entirely satisfactory,  and  oc-
casionally so prompt, that both patient and surgeon will be gratified  at
the success.
  After many  years' experience, under favorable circumstances, I am fully
convinced that aural diseases are not more difficult to diagnose or treat sat-
isfactorily than are those of the eye or many other organs  of the body; and
though my present space must limit the consideration of the subject, it is
thought that enough can be presented to serve the purposes of the general
practitioner, and induce him to continue the investigation of these disorders,
by consulting some of the excellent monographs written by the few whose
attention  has been specially devoted to them.*
                             SECTION I.

                        ANATOMY OP  THE EAR.

  Of the two portions of the ear, one is external, being the Ear of popular
language, while the other, or the Internal Ear, embraces the structures mainly
concerned in hearing.  The  external ear consists  of  a fibro-cartilaginous
and fleshy substance,  covered by the  skin and attached to the side of the
skull by ligaments and muscles, and of a cartilaginous tube which  leads
from the external to the  commencement of the internal ear.
  The lobus or soft and  fleshy portion of  the external ear is at the  inferior
  * Among these, I would name as especially useful and easily obtainable, Kramer on
Diseases of the Ear, 1844;  Wilde,  Aural Surgery, 1853; Toynbee, Diseases of the Ear,
1860. 
196
PRINCIPLES AND PRACTICE  OF SURGERY.
extremity of the organ ;  when lost, it may be replaced by a plastic operation
—Otoplasty—as hereafter described.   The meatus  auditorius externus, or
the orifice of the cartilaginous tube, is at the bottom of a depression in the
external ear known as the concha.  Its orifice is about three lines in diameter.
The canal itself is,  in the adult, about one inch and a quarter long from the
external meatus to the membrane of the  tympanum, and is narrower in its
middle than at either of its extremities.  It is also  more expanded down-
ward than it is transversely, consequently foreign bodies may be most readily
seized by forceps passed above and beneath the object, while the bivalve aural
speculum should be opened in the vertical rather than in the transverse line.
  As the cartilaginous tube runs inward  with a slight inclination forward,
and a convexity upward in its curvature, it is  requisite to pull the external
ear upward and backward when it is wished to look to  the bottom of the
canal.
  The  diameter of the cartilaginous tube varies, sometimes readily admit-
ting the end of the little finger, and at others being only of  the  size of a
quill.
  The  cartilaginous tube is covered by the epidermis and dermis, these being
continuous with the same tissues on the external ear.   The osseous canal is
part of the temporal bone.  Between the osseous canal  and the cartilaginous
tube are found the periosteum of the bone, and  an areolar  tissue that is often
the seat of abscess, as well as the ceruminous glands.
  By straightening the cartilaginous tube by drawing  the  external ear up-
ward and backward, dilating the external meatus, and  so inclining the head
that a  strong ray of light can enter the canal, its condition throughout its
entire length may be readily noted.  The  membrana tympani  is a complete
septum—Plate XXVIII. Fig.  1—which is found at the deepest extremity of
the cartilaginous tube.  It is placed very obliquely across the tube, so that its
upper edge inclines outward, and its lower edge inward,  the latter forming
a very acute  entering angle with the floor of the cartilaginous tube,  and
gives it an additional depth.  With a good ray of light, a  speculum like that
of Wilde, Fig. 400, or some other, and the manipulation hereafter described,
Fig. 399.                        Fig. 400.
A view of the vessels of the membrane
       of the tympanum.
it is easy to recognize the condition of this membrane.  The membrane of
the tympanum or the drum of the ear is composed,  according  to the ex-
tended researches of Toynbee, of the following layers: 1, an epidermis, which
is continuous with the epidermis of the external meatus  and the cartilag-
inous tube; 2, of the derm, which is also continuous with that  lining the
tube; 3, of a fibrous layer composed of radiating and circular  fibres, and
continuous with  the periosteum of the osseous canal; and, 4, of a mucous
membrane, that is continuous with that lining the  internal ear and  throat. 
ANATOMY OF  THE  EAR.
197
Though appearing as a bluish or gray semitransparent membrane, the mem-
brana tympani contains a fine network of vessels, as shown by Arnold in his
anatomical plates, as well as in Fig. 399, copied from Wilde.   " The outer
circle of the figure is the bony ring, and the central body is the cut-off  ex-
tremity of the malleus."  Inflammation will make the vascularity of this mem-
brane quite apparent, and the pulsation of its vessels may be seen, as proved
by Wilde.*
  The function of the membrane thus constituted is to convey the sonorous
undulations from the meatus to the  ossicles, through  which the impression
of sound is made on the labyrinth.  Any disorder of the drum becomes, there-
fore, a source of deafness, on the same principle that a change in the laminae
of the cornea impairing the transmission of the rays of light becomes a source
of blindness.   The healthy characteristics of the tympanic membrane should,
consequently, be carefully studied before any attempt is made to treat its
disorders, and, where its normal appearance is  thoroughly impressed upon
the observer, one great obstacle to a correct knowledge  of a common cause
of deafness will be removed.
   Appearance of the Healthy Membrana Tympani.—When fully exposed
to a ray of strong light, by some of the means hereafter mentioned in con-
nection with  the treatment of myringitis, the membrana tympani appears as
a bluish  or grayish  semi-transparent membrane, stretched across the  car-
tilaginous tube about one inch and a quarter from the external orifice of the
ear.   Its  surface is slightly curved, and divided near its upper half by a white
streak, which is caused by the  attachment of the handle of the malleus, this
streak corresponding with the insertion of the malleus into the  fibrous layer
of the membrane.   The anterior portion of the membrane of the tympanum,
when carefully exposed by  straightening the  auditory canal,  looks like a
thin  tissue, of the appearance of fine gold-beaters' skin, reflecting a point
of light from its most prominent portion.  The posterior and inferior portion
is also thin and glistening, but not so transparent as the anterior.   The upper
portion is thicker, whiter, and concave in a line with  the superior  wall
of the cartilaginous tube, the epidermis and derm being reflected from this
canal over the membrane of the tympanum.
   If air  is forced  from the throat and cavity of the tympanum against
the  membrane,  the  anterior  portion will become  more  convex and  the
upper portion pinkish from the congestion of the vessels in  the line of the
handle of the malleus.   Congestion, which is one of the  earliest pathological
conditions of this membrane, may change the character of the epidermis cover-
ing the membrana tympani, and cause its scales to be thrown off, thus creat-
ing a white, parchment-like  appearance, resembling the dura mater of the
brain, or rendering the membrane as pink as the fingers held before a candle
in a dark room, while inflammation may render the anterior portion especially
thick and opaque, like  an inflamed arachnoid membrane, ulceration some-
times developing an opening  with  a corresponding  change in  the tension
and concavity of the surface of the drum.  A careful study of the appearances
of this membrane is of great consequence; and if the student of aural surgery
will  only  frequently examine the healthy ear of a friend, he will soon recog-
nize,  in disease, variations of color and translucency that language cannot well
designate, and find the subject of aural disorders as readily recognizable as dis-
eases of the thorax are by auscultation and percussion.   Behind or within the
membrane of the tympanum is the Cavity of the Tympanum or the internal
ear, composed of various structures essential to hearing,  as the labyrinth,
* Op cit. p. 217.  Phila. edition. 
PLATE  XXVIII.
                     OPERATIONS  UPON  THE EAR.

  Fig. 1. A vertical Section of the Head, in order to show the  angular  course
of the Eustachian Tube and of the External Auditory Canal.   1. The inferior
turbinated bone.  2.  The middle  turbinated bone.  3. The pharyngeal orifice
of the Eustachian tube, directly behind  the posterior extremity of the inferior
turbinated  bone.  4. The angular direction of this tube.   5. The membrana
tympani.  6.  The external  auditory  canal; its direction completes the arch
formed by the Eustachian tube.  7. The carotid artery.
                                               After Bernard and Huette.

  Fig. 2. A coil of silver wire forming a Spring for the retention of a Catheter
in the Eustachian Tube, and attached to the nostril.
                                               After Bourgery and Jacob.

  Fig. 3. Itard's Frontlet for the same purpose.                 After Hard.

  Fig. 4. A view of the Frontlet as applied.

  Fig. 5. Perforation of the Tympanum  by Deleau's  Instrument.  1, 2. The
instrument.   3. The membrana  tympani at  the point  of perforation, so as to
avoid the handle of the malleus.                   After Bernard and Huette.

  Fig. 6. Eemoval of a  Polypus, by the Forceps, from the External Auditory
Canal.                                         After Bernard and Huette.

  Fig. 7. Fabriji's mode of  strangulating Aural Polypi by the repeated appli-
cation of the ligature with its canula.   1. The hand of an assistant holding the
canula. 2. The second canula and ligature about to be applied below the first.
3. The fingers of the surgeon passing its loop over the  first canula by means of
a probe.                                        After Bourgery and Jacob.

  Fig. 8. A vertical Section of the Ear, showing the subsequent constriction of
the base of the  tumor.                           After Bourgery and Jacob.
(198) 
I'latr  2 8
i^i.:$*^**
..§ssii-r
.,,L.i.
 
 
          OPERATIONS  ON THE EXTERNAL EAR—OTOPLASTY.       199

cochlea, etc., all lined by a mucous membrane which is continuous with that
seen in the pharynx.  At the fore part of the cavity of the tympanum is the
Eustachian tube, a cartilaginous canal that runs for six or eight lines in the
petrous portion of the temporal bone, and terminates in a cartilaginous and
membranous portion that opens  into the pharynx at  the posterior nares,
Plate XXVIII. Fig. 1.   The orifice of the Eustachian tube is found in the
upper part of the throat, on a line with the posterior end of the inferior tur-
binated bone.   It is rounded, oval, or trumpet-shaped, and large enough to
admit the tip of the little finger, Plate XXVIII. Fig.  1.   The canal in its
whole length measures nearly two inches,  and  its course from the pharynx
is nearly horizontal backward and outward toward the  membrana tympani,
diminishing as it goes backward, so as to receive with difficulty a small probe.
It is lined in its whole extent by a fine and extremely delicate mucous mem-
brane, which is continuous with that in the throat.  In  catarrhal affections,
the mucous secretions of this  membrane sometimes fill  the whole  cavity of
the tympanum.  The Eustachian tube is also liable to adhesions of its  side,
as well as to stricture, though both are rare.
                            SECTION  II.

        DISORDERS OF, AND OPERATIONS ON, THE EXTERNAL EAR.

  Composed of the  tissues already alluded to, it may be readily supposed
that the External Ear would be liable to the diseases of the skin seen in this
tissue elsewhere, and to the development of tumors, the production of wounds,
etc.   It is therefore unnecessary here to do more than mention that Eczema,
Erysipelas, and Burns, of the external ear, are to be treated on general prin-
ciples, care being taken that no permanent obstruction of the external meatus
results therefrom.  When the external ear is wounded so  as  to risk its at-
tachment to  the side of the  head, the skin should  be neatly fastened by a
stitch or two of the lead suture, or, if possible, retained in its position by col-
lodion, isinglass plaster, adhesive  strips, a bandage, or some similar means.
When the lobus has been removed, it may be replaced by otoplasty.
                            \ 1.—Otoplasty.

   The formation of a  new lobe for the  ear is a plastic operation, invented
by Dieffenbach,  in which a proper-shaped flap is taken from the side of the
head, or rather from the lateral portion of the neck, and, being slid from its
original position, is fastened by sutures upon the deficient part.  After union
has taken place, the flap is cut free at its  base, as in the operations of Rhi-
noplasty.
   Another mode of operating will  be found in the following method :—
   Operation of Pancoast.—A piece of integument, rather  larger than the
natural size of the lobe, being marked out by  an  incision  in  front of the
ear, a semicircular portion of  larger size, but narrowed where it touched
the cicatrix,  was dissected up from behind  the ear or  over the insertion
of the sterno-cleido-mastoid  muscle.   A  sharp-pointed bistoury being then
passed under the front portion of the ear, it was freed from its attachments
by a single sweep of the instrument, and the  everted edge of the  tragus
loosened with the knife, leaving a raw surface, which was  of  considerable
size, and bled freely, but without requiring ligatures.  The margins of the
wound in front  being  closed with the  hare-lip suture and adhesive plaster, 
200            PRINCIPLES AND  PRACTICE OF  SURGERY.
the posterior flap was brought round over the lobe to the anterior portion of
the ear, where it was  fastened with two stitches of the interrupted suture;
the parts presenting a good appearance, though the lobe was purposely made
larger than natural, in order to admit of the shrinking which always  ensues
upon operations of the plastic class.   The lower point of the ear, which had
been  strained downward by the cicatrix, retracted, when loosened during the
operation, to nearly the natural length, and the success was perfect.
  Remarks.—This operation, which is only a slight modification of that of
Dieffenbach, was  performed  to relieve the cicatrix from a burn, the pinna
being drawn close to the head, and the lobe  lost in the common covering of
the face and neck.
  Any operation for the restoration of the lobe is, however, one of doubtful
utility.   At best, the  restored portion cannot aid or affect the  hearing, and
will not much resemble the lobe, after a few months, while the removal of the
flap produces cicatrices upon  the neck, which are apt to cause a greater de-
formity than that arising from the original defect.
  The removal of tumors from the lobe requires the same steps as those de-
manded by tumors elsewhere.   In several cases reported by Norris, of Phila-
delphia, they resembled Keloides,  and, as appears from his statement,  are
most common in the negro race, being the result of perforation of the  lobe
for the use of ear-riDgs.


        \ 2.—Foreign  Bodies in the  Meatus Auditorius Externus.

  Foreign Bodies, as found in the external meatus of the ear, are very varied,
and may consist of insects, beads, coffee-grains, or similar articles, accident-
ally introduced into the meatus, or of collections of hardened wax, combined
with epithelial  scales,  wool,  hair,  or  other  substances, either  naturally or
accidentally  collected in the tube itself
  Extraction of Foreign Bodies.—Operation.—Whenever it  is desired to
remove an insect from the ear, the head of the patient should be inclined to
one side, and the  meatus filled with any mild oil or tepid mucilage, which is
to be retained in  the ear a few minutes, by keeping the patient's  head in an
inclined position.   The oil or liquid thus occupying the tube closes the res-
piratory pores of the  creature, and soon  either kills  it or causes it to  seek
the orifice, to obtain air or to escape, when it may be seized, or subsequently
washed out with a syringe and tepid water, especially if inflammation  exists,
as this increases the sensibility of the part.

                                Fig. 401.
                               Ear forceps.

  If the foreign body should  be  a hard substance, and one not capable of
absorbing water, the removal  may be attempted by the use of forceps  like
those shown in Fig. 401; but if  the foreign substance cannot be removed
without violence by this means, then the best plan will be to wash it out by
the force of a stream of water gently thrown in on one side of it, and made to 
      FOREIGN BODIES IN THE MEATUS  AUDITORIUS  EXTERNUS.   201

fly outward through the resistance created  to its entrance by the surface of
the membrane of the tympanum, as in the following plan :—
  To Wash out  Foreign Bodies.—Introduce the point of a large-nozzled
syringe as near  as  possible to one side of the foreign body, there  being
very few that will distend the meatus so completely as to prevent the pas-
sage  of a  stream of water on  one  side.  Then  inject gently a  full stream
from  the syringe, and  the recurrent stream will  generally bring  the foreign
substance to a point where it may be seized with the forceps or curette.

                                Fig. 402.
      Wilde's ear basin—the perforations are intended to act as a sieve. (From the instrument.)

  As the  necessity of washing out the ear is often noticed in the treatment
of deafness, the removal of hardened wax, or for the examination of the mem-
brana tympani, the following method is given, as, though a simple operation,
I have often seen patients soiled and annoyed by its imperfect performance:—
  To Wash out the Auditory Canal.—Direct the  patient to hold  a large
teacup, or basin, shaped as proposed by Wilde, Fig. 402, close under  the lobe
of the ear, and press it firmly against the mastoid cells.   Then, while the
ear is  drawn upward and backward  by the  left hand,  hold  the  body of  a
good two or four ounce ear syringe, Fig. 403, between the thumb and second

                                Fig. 403^
                               Ear syringe.

finger, while the forefinger forces in the stream from the syringe by pressing
on the piston.   If the force of the stream is not too great, the water will
all pass into, and not over the cup, and the patient's neck  and clothing
will  not  be in  the least soiled, or  even  dampened, Fig. 404.   Another
method of  protecting the patient  in  washing out the ear is shown in Fig.
405, where a tin or gutta-percha spout is attached to the head by a spring,
and  carries the water off into  a cup held underneath it. 
202
PRINCIPLES AND  PRACTICE  OF SURGERY.
  The syringe of Hullihen, of Wheeling, I have found to be objectionable,
because it is apt to bruise the meatus.

                                  Fig. 404.
A view of the process of washing out the auditory canal. (After Nature.)
  Remarks.—In  introducing any instrument  into the  ear of an adult, the
peculiarity of the shape of the external  canal should  be  recollected.   The

                                 Fig. 405.
           A view of Toynbee's ear spout for washing out the meatus. (After Nature.)

operator should, therefore, pass it either from the top or bottom of the mea-
tus, so that it may correspond with  the largest dimensions of the canal its 
POLYPI IN  THE  MEATUS EXTERNUS.
203
vertical diameter being greatest in this direction;  but in a child it should be
directed either toward the front or back of the meatus, as the transverse meas-
urement is here the greatest.  Hardened wax may be  softened by warm oil
or water applied twenty-four hours previously, and then washed out with the
syringe, the  ear being  drawn  upward, outward, and backward, in order to
facilitate its escape, by straightening the cartilaginous  tube.
   Should every other means  fail, the surgeon may resort to the plan of
Paulus ^Egineta, and, perforatiug the cartilaginous tube from below, intro-
duce a probe behind the foreign body, and thus push it  outward; but most
frequently perseverance with the use  of the syringe will suffice.
                  \  3.—Polypi in the Meatus Externus.

   Like other mucous membranes, that lining the external meatus and cover-
ing the membrana tympani may be the seat of those various morbid growths
which pass under the common name of polypi, and which may here be pro-
duced  under the same conditions and in the same manner as polypus else-
where, whether in the  nostril, uterus, rectum, or urethra.   Polypus  of the
Ear generally arises from  the walls of the meatus, near the orifice  of the
ceruminous gland, or from the surface of the tympanum, where, by filling the
tympanic  cavity, it  causes the membrana  tympani to ulcerate, when the
polypus forces its way through, and shows itself at the external meatus.
   Symptoms.—When a polypus forms in the ear, the patient begins to com-
plain of frequent  earache, for which he is  unable  to  assign any cause, not
being subject to neuralgia, and not having been exposed to cold, etc.  Soon
after this,  a running from the ear, of a sero-purulent character, will be noticed,
this discharge  being the same as that which accompanies polypi, wherever
situated.   Next, he may  suffer more or less  from  deafness, because the
growth from the polypus obstructs the passage, and the altered character  of
the membrane  itself,  interferes with the transmission of the sonorous undula-
tions; or, if the polypus has arisen from the side of the meatus, it may act  as
a foreign body, and plug up the canal.
   The slightest ocular examination of the meatus will  now at once reveal the
true character  of the disease, as in looking into it a  fleshy-looking, smooth
tumor can be seen, varying from  the size of a pea to  that of a  tumor that
fills the meatus.

                               Fig. 406.
Ear polypus forceps. (From the instrument.)
  Polypi in the ear, like polypi elsewhere, may be of different kinds, that is,
either soft, mucous, fleshy, or carcinomatous.   Generally, these tumors arise
from the cartilaginous tube near the seat of the orifices  of the ceruminous
glands, though they also spring from the tympanum, and project externally,
Plate XXVIII. Fig.  6.   If of the soft kind, they may be removed by seiz-
ing them with forceps, Fig. 406, and rotating the latter until the polypus is
twisted, when  simple  traction will suffice to remove it;  or, if it  is possible
to pass a loop around the growth, its strangulation  may be effected by a fine 
204
PRINCIPLES AND  PRACTICE OF SURGERY.
wire ligature in a small double canula like that of Levret, or by the "snare"
of Wilde, of Dublin, Fig. 407, which is a neat and useful instrument, and em-

                                 Fig. 407.
Wilde's snare for polypus. (From the instrument.)
ployed by holding the instrument on the thumb and drawing the wire noose
with the fore and second fingers, as in  Fig.  408.   If more firm, the polypus

                                 Fig. 408.
                    Mode of employing Wilde's snare. (After Nature.)

may require excision  in  pieces, the  hemorrhage being readily arrested by
compression in the meatus, or by the application, with a camel's-hair pencil,
of the liquor ferri persulphas.   In all cases, however, it is usually desirable
to apply the nitrate of silver to the  seat of the tumor after its removal;  to
keep  the meatus clean, by  repeated syringing, and to  employ astringent
washes occasionally.  The best mode of cauterizing the external auditory
canal in cases of polypi is by means  of the porte-caustic of Wilde, as shown
I,.Ill) ■ HI III -II- ,llll~.
■ w/M^
Porte-caustic of Wilde, for cauterizing the auditory canal or membrana tympani. (From the instrument.)

                               Fig. 410.
                              Curette for the ear.

in Fig. 409, the flexibility of the  instrument preventing  injury.  Fig. 411

                                 Fig. 411.
represents a cup for fusing the crystals of the nitrate of  silver, in order to
coat the flexible porte-caustic.
  Where the polypus is very large, and entirely fills up the meatus externus
the repeated applications of the wire ligature will often enable the surgeon to 
EXTERNAL  OTITIS.
205
remove it entirely, but if not, it may be pared off from the tube by means of
a narrow knife, Fig. 413.

               Fig. 412.                               Fig. 413.


  Fig. 412.—Knife for perforating the membrane of the tympanum, or excising a polypus. (From the instru-
ment.)
  Fig. 413.—Knife for excision of aural polypi from the external auditory canal. (From the instrument.)

   Operation of Fabrizji, of Modena.*—The patient being so seated as to
throw the  light into the meatus, the surgeon should pass the loop of a wire
ligature, contained in a double  canula, around the  polypus, passing it by
means of a probe as far  as  possible into the auditory canal and toward the
base of the tumor.   Then, after firmly constricting it  with this loop, let him
next pass the loop of a second ligature in its canula, over the first, drawing
upon the latter so as to carry the second ligature  as deeply as possible, and,
constricting the tumor by this, remove  the first ligature and canula.  If the
second thread does not cause the tumor to come away, carry a silk or buck-
skin ligature in  a flexible canula below it, and twist it until the tumor is cut
off, Plate XXVIII. Figs. 7, 8.
   Astringent washes are  of  but  little value in checking the development of
aural polypi, but I have derived benefit from applying, by means of a camel's-
hair pencil, the finely-powdered  sulphate of zinc, and allowing it to remain
on the polypus, while the patient's  head is inclined so as to favor the escape
of that which is  dissolved, repeating the application as required.


                          \ 4.—External Otitis.

   By  the general term External Otitis is designated an inflammation of the
skin and areolar  tissue connected with the external meatus and cartilaginous
tube that is liable to result in thickening and a diminution of the calibre of
the tube or in the formation  of an  abscess exterior to it.
   Etiology.—The causes of otitis are blows upon the ear, pulling of the ex-
ternal ear so as rudely to stretch the auditory tube, foreign bodies left in
the meatus or roughly extracted, exposure to cold draughts of air, bathing
in cold water or  exposure to a current of cold air while  the body is warm,
scrofula, and extension of inflammation from adjacent parts.
   Symptoms.—The  symptoms of  external otitis are  those of inflammation
in similar tissues elsewhere—as violent pain, (described as earache,) with red-
ness, swelling, and ultimately free suppuration.
   Diagnosis.—When the inflammation is superficial, the heat and redness of
the part render the diagnosis easy, but when the disorder is seated in the areolar
tissue  between the cartilaginous tube and the osseous canal, the distention
of the  tissue will be difficult, while the pus can only escape through the normal
fissures of the cartilaginous tube,  or find its exit through the meatus.  In these
cases an examination of the  external canal may show redness and tumefac-
tion about a half inch within the  meatus, from which inflammation may be
suspected.   But  if it does not, the chief diagnostic sign between otitis and
otalgia is to be found in the fact  that in otitis motion of the  external ear
upward and backward by straightening the canal will greatly augment the
suffering,  while it will not do so in  simple otalgia.
   Prognosis.—Acute external otitis requires usually three to five days before
* Bourgery, M6d. Op6rat., tome vii. 7me, p. 33. 
206
PRINCIPLES AND PRACTICE  OF SURGERY.
suppuration gives relief.   If seen early, its progress may be more promptly
checked.
  Treatment.—The treatment of otitis should be based on the general prin-
ciples of  inflammation elsewhere—the redness and congestion of the early
stage beiug arrested by leeches applied just within the meatus, and the sup-
puration, if possible, prevented; or when  pus is  formed, by  evacuating it
promptly.
  The  best means of accomplishing the first is  by a  prompt  and thorough
leeching,  four to six European leeches being applied in front, below, and around
the meatus, by means of a curved glass tube, Fig.  414, so as to draw  two or
                                    three ounces of blood from the adult—
              Fig. 414.               the  mouth  of the patient  being kept
                                    open so as to relax the tissues around
                                    the  meatus, and  the latter filled with
                                    cotton  to prevent the  entrance of a
                                    leech, after which cloths wrung out of
                                    warm water and  covered by oiled silk
                                    should be kept constantly  applied, or
                                    a wet  cloth may be wrapped around
                                    a hot stone  or  flat iron, and the head
 A glass tube for applying leeches within the orifice  placed On it, SO that the moist, Warm
     of the meatus. (From the instrument.)       *                ,,             /-v„
                                    vapor  may  enter the  meatus.   Ul
course, proper precautions must be taken to have sufficient cloths, to prevent
burning.   When blood accumulates in the  meatus after leeching, it should be
gently washed out by syringing.   When the throbbing and buzzing is marked,
and the slightest motion of the ear is painful, the  gentle injection of warm
mucilage—as warm as can be borne—is very soothing.  Laudanum and warm
oil, so often employed in domestic practice,  should be especially forbidden, the
alcohol of the laudanum being an increased source of irritation,  and tending to
inflame the membrane of the tympanum. While  no one would  think of pour-
ing warm oil and laudanum into  an eye, every by-stander is ready to recom-
mend it for the ear.  Trousseau, of Paris,  speaks well of the extract  of bel-
ladonna,  rubbed up with a little water and glycerin, and then applied within
and around the external meatus by means  of a pellet of charpie  or lint sat-
urated with it. A morsel of lint moistened with chloroform and placed within
the bowl of a tube or pipe, the  stem of which may be introduced into  the
meatus, will afford a simple mode of applying anaesthetic vapor.  Blowing
into the  bowl of the pipe will cause  the vapor  to enter the ear.  As thus
applied, the anodyne effect is obtained without  there being such increased
vascular  action as follows the use of laudanum when poured into the ear.
Gentle friction within, around,  and below the meatus with  an  ointment con-
taining one grain of aconitia to the drachm of cold cream, will also allay
the pain.  The  popular remedies of the core of  a roasted onion, or a  hot
fig, should be avoided,  heat and  moisture being better  applied by the warm
water-dressing.  When pus has  evidently  formed  beneath the cartilaginous
tube, it should be evacuated, if possible, near the meatus; if not, it had better
be left to nature.   When the abscess  breaks, frequent and gentle washing of
the canal with warm water will be very useful.
  But while attention is thus given to the  local  remedies, the  general treat-
ment must not be overlooked, smart purging with mercurials,  or the admin-
istration  of a few grains of the blue mass, followed by a saline cathartic, prov-
ing  highly advantageous.   In some  instances, after the  evacuation of  an
abscess, or after the acute stage of otitis has passed, an eczematous eruption
will be noted extending within the meatus. At  other times desquamation of
the epidermis lining the tube follows, both  being liable to impair the hearing, 
      MYRINGITIS AND INJURIES OF  THE  MEMBRANA  TYMPANI.  207

as will be again alluded to under the head of deafness.   In chronic external
otitis, as in many other forms of aural inflammation, counter-irritation close
beneath, in front, and  behind the external meatus will be found highly ser-
viceable. This may be best accomplished by painting the part with pure
creosote, or with cantharidal collodion.
         § 5.—Myringitis and Injuries of the Membrana Tympani.

   In the  account of the structure of the ear, the composition and position
of the membrane of the tympanum were alluded to. As the epidermis as well
as the derm of the external cartilaginous tube are continued upon the drum,
inflammation of the former is very apt to be followed by that of the latter,
and the consideration of the disorders of this membrane thus follow naturally
those of the external meatus, and Myringitis—myringa, the membrane of
the drum—is the name well applied by Wilde, of Dublin, to indicate inflamma-
tion of  this  structure.
   Causes.—Though frequently consequent on  external  otitis, myringitis
often exists independently of it,  and may  be due to the  accumulation of
hardened  wax in the  external tube, to the extension of an eczematous
irritation, to sudden concussion by blows on the ear, by the firing of can-
non, etc.,  or to  the extension of  inflammation from the cavity of  the tym-
panum, to rheumatism, catarrh.  Myringitis may exist either in the acute or
chronic form, corresponding, in many points, with corneitis or inflammation
of the cornea, in diseases of the  eye,  the  chronic variety being the most
common.
   Symptoms.—Severe, often intense  pain within the head, which is increased
by coughing, sneezing, or any act that will cause the air to distend the mem-
brane of the tympanum is usually  noted, the pain, if due to a rheumatic at-
tack, being  also complained  of in the  temples, eyes, and brain.   As  the
acuteness  of the pain diminishes,  the patient also complains of dizziness,
buzzing in the head and ear, while  the temper is irritable in the  extreme,
the slightest noise or attempt to speak, or an effort to swallow, causing loud
complaint.  When  consequent on  a catarrhal affection, there  is also usually
present  the ordinary symptoms of a catarrh, while fever, a disordered diges-
tion, with irregular chills, and not  unfrequently  slight  delirium, are often
seen in marked cases.
  Diagnosis.—As the condition of the membrana tympani can only be rec-
ognized by  examination, the  proper mode  of proceeding  will be that now
given.

                                Fig. 415.
Wilde's instrument for depressing the tragus. (From the instrument.)
  Examination of the Membrana Tympani.—In a large open meatus with a
strong ray of light, draw the external ear upward and backward, and with
the little instrument of Wilde, Fig. 415, or a pencil, or the finger, push the
tragus forward ; then, keeping the observer's head out of the way, incline the
patient's head to  a proper angle to throw the light into it, and the mem- 
208
PRINCIPLES  AND  PRACTICE OF SURGERY.
brane may be  readily seen.  But as the meatus is often  small, it is better
that a speculum should be used, and the examination made as shown in Fig.
416.
  Light.__The sunlight is the best in  all cases, but as this cannot always
be obtained  in a room, in consequence of its position, the following plan, as
proposed* by  A.  Young, Jr.,  of Maine, will be highly useful:—

                                Fig. 416.
 Position of the surgeon and patient in an examination of the membrane of the tympanum by sunlight with
T>ynbee's speculum, the surgeon carefully keeping his head so as not to obstruct the rays of light as he lcoks
through the speculum into the ear. (After Nature.)

  Young's Mirror, or  "Solarscope."—"To  a foot,  or  base-board, about
eight inches square, attach a rod two feet in length, bearing a sliding ring with
thumb screw, and an  armature twelve inches long, having at the  end  a  ball-
and-socket joint with a thumb-screw, and another short armature to  hold a
mirror six inches square.
  " To use the instrument, raise the lower sash of the window and place it upon
the sill, resting the beam of the sash upon the top of the rod.   Swing the  arm-
ature out of the window, and by means of the thumb-screw adjust the mirror
so as to direct the rays  of the sun to any part  of the room you please."
  Various other plans have also been suggested to throw the rays of  light
upon the drum of the ear, of which Hutchinson's, which consists of a mirror
so arranged as to  transmit the rays of a  lamp, will be found to be a good
one;  while  that of Grant,  of Newark,  New  Jersey,  which  is adapted for
the rays of the  sun, though  artificial  light may also  be  employed, will  be
useful.  The appearance of the healthy membrane of the tynrpanum has been
already described, p. 196.
  When the room has a south exposure, the rays of the sun will often so fall
as to render a mirror unnecessary,  yet even then it will sometimes be useful
to employ one.  A strong light being essential, when circumstances prevent
the use of the sunlight, that of  a wax or spermaceti  candle  may be substi-
* New Orleans Med. News, Feb. 1860, from Boat. Med. and Surg. Journ. 
      MYRINGITIS AND INJURIES  OF THE MEMBRANA TYMPANI.  209

tuted, a little mirror being attached by a wire to the candlestick; or Miller's
lamp, Fig. 417, may be resorted to, as advised by Toynbee.  The bivalve, or
Itard's  speculum,  Plate  XXIII. Fig. 10, though useful, sometimes causes
pain if incautiously expanded, and requires  more attention in manipulating
than that of Toynbee, Fig. 418, or that of Wilde before shown, either of
which I regard as the best of those at present made by the cutlers.

             Fig. 417.                               Fig. 418.
A medium size Toynbee specu"
 lum. (From the instrument.)
        Miller's lamp. The cover of the candle
      when not in use is seen on the right side of
      the cut. (From the instrument.)

   The  mode of  examination  is graphically shown in Fig.  419.   When,  by
 these means, the membrana  tympani is fully exposed  in  a  case of acute
 myringitis, we  may note  a tumefaction of the external auditory canal, with
 more or less edema and  redness, a bright pink or damask hue of the mem-
 brane of the tympanum, especially on its circumference, like the vascular circle
 around the cornea in a case of iritis; or the color may be of a dull orange-yel-
 low, according to the acuteness of the attack and the character of the con-
 gestion, the  vessels sometimes inosculating all over the surface of the mem-
 brane in a manner analogous to that seen in ulceration or chronic inflammation
 of the cornea. Indeed, acute myringitis, in its appearance, course, and changes,
 closely resembles corneitis; when ulceration results, the ulcer  will usually be
 found in the portion anterior and inferior to the handle of the malleus.
   Prognosis.—The  prognosis of acute myringitis should be guarded, as the
 result in reference to the  hearing of the patient is very uncertain.   Some-
 times myringitis, especially if slight, is followed  simply by desquamation  of
 the epidermis covering the membrane ; at other times fibrin is effused between
 the two laminae of the fibrons coat, which  will leave an opacity and thickening
 that will greatly impede hearing, and be almost as difficult to remove as sim-
 ilar opacities in the cornea; or ulceration may leave a permanent loss of tissue
 and consequent destruction of the function (vibration) of the membrane •  or
the myringitis  may be complicated with tympanitis, (inflammation of the
     VOL. II.—14
 
210           PRINCIPLES AND  PRACTICE OF SURGERY.

cavity of the tympanum,) and this be followed by polypus, otorrhcea, necrosis of
the ossicles, and eutire destruction of the ear as an acoustic instrument.  The
termination of the acute stage of the disorder varies from a week to ten days ;
the deafness, etc. may last indefinitely.

                                Fig. 419.
Position of the surgeon and patient in an examination of the membrane of the tympanum by
                     artificial light. (After Nature.)
  Treatment.—The treatment before advised as applicable to external otitis
is equally useful in acute myringitis—purgatives, diaphoretics, and anodynes
being actively employed.  The general principles applicable to corneitis are
also  applicable to acute myringitis, except that mercurialization, which is
liable to prove injurious in corneitis, and to induce sloughing of the cornea,
is advisable in the treatment of myringitis.  A mercurial purge, followed by
small doses of Dover's powder, will often prove  an important part of the
treatment of acute myringitis; counter-irritation near the meatus, by the ap-
plication of creosote, as advised  in the treatment of otitis, being also very
serviceable.
  Subacute and chronic myringitis will be  referred to under the section on
Deafness.

                            SECTION  III.

                   DISORDERS OF THE  INTERNAL EAR.

                          \ 1.—Internal Otitis.

  The cavity of the tympanum,  being formed in  the petrous portion of
the temporal bone, is  lined by periosteum,  and this  again is covered  by a
mucous membrane which is continuous through the Eustachian tube with the
mucous lining of the throat, and is reflected over the posterior or inner face
of the membrana tympani.   The  inflammation of either or both  of these
tissues is  designated as Internal  Otitis,  or, more correctly, Tympanitis__ 
INTERNAL OTITIS.
211
thongh, as usage has assigned the latter terra to flatulent  distention  of the
belly, Internal Otitis is the best terra.
  Causes of Internal Otitis.—Exposure to cold  and dampness, so as  to
check perspiration, wet feet, and all such causes as develop a  catarrh, are
liable to create congestion of the  mucous membrane lining the cavity of the
tympanum, and  at a later period periostitis in this cavity.   In children a
slight congestion caused by cold is the usual condition known as "earache."
Scarlet fever, rheumatism, gout,  scrofula, syphilis, or  small-pox  may also
create such  inflammation of the mucous lining  of the tympanum  as will
develop internal otitis.
   Symptoms.—The  symptoms of internal otitis depend greatly on the
extent, degree, and duration  of the  inflammation.   In  catarrhal otitis, and
in the milder form seen in children, there is usually more or  less sense  of
obstruction or stuffing, with buzzing and now and then a bursting or crack-
ling sound in the ear, with  more or  less  pain, often of a severe character,
and especially violent at night.   In  this  form we recognize the  results  of
congestion, increased secretion of mucus, edematous thickening, and some-
times suppuration of the mucous lining of the cavity of the tympanum.  When,
as in scarlet  fever, the irritation of the mucous membrane of  the pharynx
extends to that lining the cavity of the tympanum, suppuration is quite com-
mon.  Examination of the  membrana tympani at  this period will show a
color like that of chronic inflammation of the skin,  a peeling or desquama-
tion of the exterior layer  of the  membrane, and sometimes a distention of
the  membrana tympani  outward, in  consequence  of  the accumulation  of
matter within the cavity of the tympanum, while the Eustachian tube is ob-
structed by edematous inflammation.   Ulceration of the membrana tympani
giving exit to the pus, the symptoms of otorrhoea, as hereafter described, will
become  apparent.   When internal  otitis is well developed, more or less
constitutional disturbance,  as fever, partial delirium, slight coma, moaning,
tossing of the head and general restlessness, may be noticed.
   Diagnosis.—Internal otitis, if present for a few hours, generally develops
more or less  myringitis;  but the  latter may be told from the former, if exist-
ing  separately,  by  the greater acuteness of the pain, by its  increase  on
straightening the cartilaginous  tube,  by the permeability of  the Eustachian
tube to inflation by the patient, and  by the marked bright  congestion of the
membrane of the tympanum, as compared with the browner  hue of internal
otitis.
  Prognosis.—The prognosis of  internal  otitis depends greatly on the vio-
lence and duration of the inflammation.   In the simpler form a  discharge of
serum or mucus  into the throat, with relief of pain and the catarrhal symp-
toms, is  the usual result;  while in the form  consequent on scarlet fever and
scrofula, the  destruction of the membrana tympani, necrosis and  discharge of
the ossicles, permanent thickening and obstruction of the  Eustachian tube,
thickening of the lining  membrane of the labyrinth, are very apt to super-
vene, and thus induce permanent deafness.
  Treatment.—In the treatment of acute internal otitis prompt measures are
necessary to arrest the progress of the disorder, such as free leeching around
and within the external meatus, warm and  moist cloths to the side of the
head, mild gargles, painting the pharynx with a moderately strong solution
of nitrate of silver, a brisk  purge, and the measures before alluded to in the
treatment of  myringitis.
  When an examination of the membrana tympani shows its distention, its
early puncture and the evacuation of the contained liquid will greatly expe-
dite  the  cure, an incision of this membrane healing more readily than  an
ulcer.   The treatment of the disorder, when otorrhoea  is developed, will  be 
212           PRINCIPLES AND  PRACTICE OF SURGERY.

given hereafter.   As suppuration in internal  otitis, with closure of the orifice
of the Eustachian tube by pharyngitis, converts the cavity of the tympanum
into a circumscribed chamber, no hesitation should be felt in puncturing the
membrana tympani, giving exit to the pus, and  preventing the development
of caries or necrosis of the ossicles, or the extension of the suppuration to
the mastoid cells.
   The  puncture  may  be made by  a  needle,  Fig. 412, a  short, straight-
pointed bistoury,  or, still better, by means of Deleau's instrument, prepared
especially for the  purpose, Plate XXIII. Figs. 18, 19;  taking  good care,
however, whatever be the instrument employed, to avoid striking the handle
of the malleus, as hereafter shown.  Having thus got rid of the pus, tepid
water may be carefully injected  into the meatus, with the view of thoroughly
washing it out, when the symptoms will generally be much alleviated.   The
after-treatment is  the  same as that of any  other abscess, the little wound
in the tympanum  healing rapidly like any  other incised wound, and with
the greater rapidity because the previously distended membrane having now
collapsed, the edges of the punctured wound are brought into accurate juxta-
position.  Indeed, this is sometimes so readily effected after  perforation of
the membrane of the tympanum, that  in  those cases where it is  desirable
from any cause to keep the wound open, a  free crucial incision or the use
of caustic is necessary to obtain that result.
   Should the timidity of the practitioner lead to a neglect of these measures
and the pus be not evacuated, the membrane will not be saved, as its disten-
tion by  the pus will terminate in ulceration, the ulcer that is  left  being diffi-
cult to heal and often destroying the whole  membrane, while the luxuriant
granulations from its edges may give rise to a fungus that will fill the meatus.
Or if ulceration does not take place, or if the membrane of the tympanum
does not rupture, still  the irritation will  impair its usefulness  by leading
to a deposit of lymph  and  the formation of adhesions  that will limit  the
vibrations of the stapes; or the membrana tympani will  become so thickened
that it will cease to vibrate.   If pus  collects and the membrane is ruptured,
the ossicles may also be loosened from  their connections and  be  discharged
with the pus that  escapes, the patient being thus rendered permanently deaf,
a condition not unfrequently seen in children  as one of the sequela? of scarlet
fever.   When the membrana tympani is ruptured, a patient can generally be
made to show it by directing him to close his nose and mouth and expel the
air from his lungs, when, if the Eustachian  tube is  still patulous and  the
membrane is ulcerated,  the air  will escape from the external ear.   Ulcera-
tion or perforation of the membrane, from any cause, will also account for the
power sometimes observed in certain individuals of expelling tobacco smoke
from their ears; a most dangerous practice, as the irritation of the smoke
is liable to lead to inflammation of the internal ear, and thus result in per-
manent  disorganization  of the organ.
   The treatment of the internal  otitis which  arises during scarlatina, or
as a sequel to it, is plain.  As the irritation and inflammation started
originally in the pharynx, the first remedies  should  be addressed to  the
throat, careful treatment of the pharyngitis during this fever  often  pre-
venting the condition of the ear under consideration.   But should  internal
otitis occur notwithstanding these precautions, it should be promptly treated
by perforating the membrana tympani and evacuating the pus. 
OTORRHOEA.
213
                          2 2—Chronic Otitis.

  Chronic Otitis is, as its name imports, a variety of the affection just de-
scribed.   It is similar in its relative results to chronic inflammations in other
mucous membranes, as chronic conjuctivitis, chronic gleet, etc., and is to be
treated on the same principles, the greatest service being  obtained  from
counter-irritants  and slight mercurial  alteratives, this treatment  being
steadily persevered in for months in order to obtain benefit.
  Cases of chronic deafness, in which  the  patient hears  imperfectly under
ordinary circumstances, though he can  hear distinctly the ticking of a watch
wheu placed between his teeth or against his  mastoid cells, so as to  receive
the reverberation of sound that passes  through the bones of the cranium to
the ear, are usually cases  of chronic otitis.   They are  by far the  most fre-
quent forms of deafness, and are sometimes spoken of as cases of nervous
deafness, and pronounced incurable, though  really due to chronic inflamma-
tion and  thickening of the  mucous membrane of the  internal ear.   They
will hereafter  be alluded to under the section on Deafness.
                             § 3.—Otorrhoea.

   Otorrhoea is the name applied to any irritation which results in a puriform
 discharge from the external ear.   It is often a sequel of external  as well as
 of the internal otitis most frequently seen in children, and consists in the free
 discharge of pus, ichor, or sanies from the external meatus, accompanied by
 eczema of the meatus, and more or less deafness.  If there is caries or ne-
 crosis of the small bones of the ear, or of the mastoid cells, the  discharge
 will be exceedingly offensive,  presenting the ordinary characteristics of dis-
 charges from dead or diseased bones, the sulphuretted hydrogen contained in
 the  discharge  under these circumstances  not unfrequently  blackening  the
 parts around the ear,  and producing  appearances which are quite charac-
 teristic, especially when  lead-water  has been used as  a  wash.   Otorrhoea
 supervenes on  ulceration of the membrane of the tympanum, as a result of
 scarlet or other fevers.    It  may also be due to inflammation in the  ex-
 ternal laminae  of the membrane  of the  tympanum,  or to that lining  the
 external meatus and cartilaginous tube.
   Diagnosis.—The escape of the matter renders the diagnosis easy, though,
 until the external ear is thoroughly cleansed, it is often impossible  to tell
 the precise origin of the suppuration.
   Prognosis.—The prognosis depends on the cause, otorrhoea being gener-
 ally  only a symptom of inflammation in some of the tissues lining the bony
 cavities of the ear.
   Treatment.—In all  cases of otorrhoea it is important to wash out the  ear
 thoroughly, and examiue the  canal  and membrana tympani by means of a
 speculum.   Syringing  the ear should be practiced, as  previously directed,
 with tepid water, or tepid soap and water.   After thoroughly washing out
 the meatus, the membrane of the tympanum should be examined by means of
 the speculum auris, described in myringitis.   This examination will at once
 show whether the tympanic membrane is thickened or diseased, and whether
 it has been destroyed by  ulceration, or is distended by pus.
  The alterative local treatment  of otorrhoea should  be conducted upon
general principles, whether the disease involves merely the external meatus
or the  whole internal structure of the ear.   When otorrhoea has existed for
a length of time, there is the same indication for the application of astringents 
214
PRINCIPLES AND PRACTICE  OF SURGERY.
 that exists for their employment in chronic inflammations of mucous mem-
 branes  elsewhere.  Injections, therefore, may be thrown into the ear, con-
 sisting  of solutions of sulphate of zinc or  nitrate of silver,  of the strength
 of one grain to the ounce of water, or the liq. plumb, subacetat. may be ad-
 vantageously substituted in the proportion of gtt. vj to two or three ounces of
 water, the quantity being augmented in accordance with the chronic char-
 acter of the discharge.  When the membrane of the tympanum is not involved
 in the disorder, it will be better, however, to apply these washes by means of
 a pellet of charpie saturated with them, and to leave the pellet in the canal,
 loosening it  by syringing before attempting  its removal.   In this way the
 wash will be prevented from irritating the membrane of the tympanum.  The
 practice of pouring liquids into the ear, unless they  are intended  to come in
 contact with the drum of the  ear, is highly improper, and may develop
 myringitis.
  The  constitutional treatment of otorrhoea is also important,  as the dis*
 ease is  very common, perhaps most  common  among tuberculous children.
 Here, the general treatment of the tuberculous diathesis  must be adopted,
 as the use of the  iodide of potassium, cod-liver oil,  tonics, etc.
  The  inflammation of the mucous  membrane, which  produces otorrhoea,
 sometimes also results  in  ulceration of the  membrane of the tympanum,  in
 consequence of which  fungous granulations sprout from the ulcerated sur-
 face, so that upon looking iuto the ear  these fungous  granulations can be
 readily  seen, their appearance being such that they  may readily be mistaken
 for polypus  of the ear.   The former, however, possess  a mulberry-like sur-
 face, which is quite characteristic, while polypus presents the appearance of
 a fleshy tumor, with a surface that is generally smooth and even.
  In the adult, otorrhoea  is  sometimes caused  by  the  presence of foreign
 bodies in the meatus, and not unfrequently from accumulations of the secre-
 tion of the ceruminous  glands, mingled with dirt, dust, epithelial  scales, and
 other matters.   Many individuals, who are very cleanly in  other respects,
 are not  unfrequently careless in regard to the condition  of the external ear,
 never washing it out, and merely removing  the wax  from time to time with
 an earpick.   When a person of such  habits goes on a journey, the dust and
 cinders  of the road collect in the ears, and, becoming adherent to the wax,
 the patient soon  finds himself quite  deaf,  a condition which he generally
 ascribes to the effect of the noise of the cars instead  of its true cause.  This
 accumulation of dirt and wax in the external  ear, if allowed  to remain, will
 soon act as an irritant, precisely as any other foreign body would, and mauy
cases of otorrhoea in healthy adults who have  not suffered previously from
 an attack of otitis, will be correctly attributable to  this cause, and relieved
 by simply syringing the meatus, with the subsequent  use  of mild astringents.
  Perhaps  few disorders  are more  amenable  to a  judicious treatment, or
 likely to result in permanent injury,  than  that just alluded to  under the
general  term otorrhcEa; a term only expressive of a  symptom, not  of a
pathological condition, and yet one that usage has rendered so popular that
it cannot be  advantageously discarded.
  The  following  points connected with otorrhoea  may be  remembered  in
connection with its treatment:—
  1st. All discharges from the ear, or "running from the head," should be
regarded as evidence of the existence of acute or chronic inflammation  of
 some of the tissues entering into the composition of the ear.
  2d. All inflammations of the  ear should  be arrested  as soon as possible
 in order to prevent a change of structure.
  3d. All discharges from the ear should be promptly arrested, provided as
in other discharges, they are not a natural effort to relieve congestion.  When 
DEAFNESS.
215
this is the case, the reduction of the inflammatory action  will arrest  the
discharge.
  In few points of aural surgery will there be more evidence of ignorance
presented to the surgeon than in this of otorrhoea;  many practitioners, and
a yet  greater number of patients, insisting that the arrest of a discharge from
the head will expose the patient to an attack of congestion, or some other dis-
ease of the brain.  Such an opinion is the result of ancient prejudices and of
the influence of the humoral doctrine, though altogether inconsistent with
our present anatomical and pathological knowledge of the ear.  How judi-
ciously  arresting an external or internal otitis, and  thus  curing  an otor-
rhoea, can act on the  brain, is not apparent.   When, then, otorrhoea is
present, let the ear be carefully examined; let the inflammation of the dermis
lining the cartilaginous tube, or that of the membrani tympanum, be checked;
let polypi be removed, and  inflammation of the mucous lining of the cavity
of the tympanum be arrested, and the discharge will cease.   Who ever hesi-
tates  at  arresting, judiciously, a gonorrhoea or diarrhoea ?  Who now hesi-
tates  at  curing a fistula  in ano, or  a herpes,  or eczema, under any circum-
stances?  Why, then, should  prejudice be allowed  to arrest the cure  of a
discharge whose existence is evidence of the presence of an inflammation that
is a source of danger to the organ  so  long  as it is permitted to continue ?
Let no  surgeon, then, delay in removing, as soon as possible, an eczema or
intertrigo behind the ear, or in checking otorrhoea when inflammatory action
can be arrested at the same moment, as numerous little  patients can  be found
in whom permanent deafness has resulted from the fears of friends and others
being excited  about "checking a running from the head."
                            SECTION IV.

                               DEAFNESS.

   Deafness is the  general  terra under which, in popular language, any im-
pairment of the organ of hearing is described.   In the varied structures of
the ear, a variety of changes may be noted, all of which may be referred to
the general head  of  Inflammation, the consequences  of which impair the
usefulness of the ear as  an  acoustic instrument.  Now, although it would be
a  more scientific  arrangement  to  allude to deafness only as a symptom of
certain inflammatory changes in the tissues concerned, yet it will probably be
more practically useful to call attention to the defect of hearing as the great
point to be overcome, and then allude in a general way to such  pathological
conditions as have been already referred to, and which are especially import-
ant as causing deafness.
   The natural perfection of the ear varies greatly;  some persons having the
sense of hearing very acute, others being  more dull, and  each  having it
greatly influenced by the  mental  process  of  attention, or listening.   In
order to establish some general standard,  the  departure from which  shall
indicate the degree of disease, it may be assumed  that a healthy ear of  an
intelligent person  will  readily recognize the ticking of a lever watch  at a
distance of three feet from his head, or at his arms' length.   Some can  hear
at a greater distance, but this is a good average. Any marked inability to
hear at this  distance may therefore be regarded as constituting deafness, or
impaired hearing. 
216
PRINCIPLES AND PRACTICE  OF SURGERY.
                  \ 1.—Deafness from Excess of Wax.

  Deafness may be produced by any cause that will interrupt the vibration
of the rays of sound upon the membrana tympani, and the several conditions
of the ear before described are liable  to create it;  the most  common, and
the first to which attention should be given, being the accumulation of wax
or of the secretion of the ceruminous glands, which, when allowed to collect
within the meatus, becomes mingled with  particles of  dost and dirt and
other foreign matter, so as to obstruct the canal, not only producing at times
the otorrhoea already referred  to, but also creating more or less dullness of
hearing.   There is also a true increase  of activity in the ceruminous glands,
leading to a considerable  augmentation in the quantity of wax produced,
which creates a  similar condition.   When from either of these  causes wax
accumulates in the meatus, and becomes hard and inspissated, it acts like a
plug, and  produces very marked  symptoms, of  which the imperfect hearing
is usually  that which most attracts the  patient's attention.
  Symptoms.—In the  deafness from accumulated and inspissated wax the
patient complains not only of loss of hearing, but of roaring and ringing in
the ears.  When the meatus is examined with a speculum under these circum-
stances, it will generally be found to be  diminished in depth, and to have at
its  bottom, say within three or more lines of the external  meatus, a dark-
brown  or  blackish body which blocks  up the passage completely.   If this
wax has become very dry from evaporation, or any other  cause, it will  be
movable, and sometimes rattle in the ear; but if it is yet soft, and adheres to
the sides of the meatus, it will often be found adhering firmly to the epithelial
covering of the  canal, and sometimes  to the epidermis  covering the mem-
brane of the tympanum.  As in the attempts of nature to get rid of this mass,
inflammation is not unfrequently developed, pus is soon secreted, as already
shown  in connection  with otorrhoea.
  Diagnosis.—Inspection with a speculum, after washing  out the canal,  as
far  as is possible, renders the diagnosis easy.
  Prognosis.—The prognosis, as regards the removal of the wax, is certain.
As  respects  the  cure of the  deafness caused by it, this will depend mainly
on the degree of inflammation that it has developed in the membrana tym-
pani.
  Treatment.—As this wax is a foreign body, and as such requires removal
by such means as will at once free the passage and thus  enable  sound  to
reach the  membrane of the tympanum, the plan of treatment should  be
conducted as follows: Drop into  the ear, at bedtime, some  glycerin or warm
oil of sweet almonds,  for the purpose of softening the wax  as  much as  pos-
sible, and then, next morning, wash out the canal with plenty of warm water
and a syringe, throwing in about  twenty syringes full, or injecting in all one
pint of tepid water, as advised in the removal of foreign bodies.  It ib a good
plan, however, not to wash  the ear too much at the first time, but to desist
when some impression appears to have been made upon the hardened wax, and
to resume the washing next day, repeating the operation as often as is neces-
sary until the whole is removed.   Sometimes the outer crust of the wax is  so
hard, that liquids make no impression on it.  Under these  circumstances, it
is useful cautiously to drill a hole in the plug of wax by means of a sharp
needle, Fig. 412, taking care not to use  such pressure as might force the plug
against the membrane of the tympanum.   After the wax has been completely
removed, the condition of the tube should be examined, and if it is fouud to be
red  and inflamed near the bottom, as it will often be, owing to the removal of
the  epidermis and the existence of an eczematous inflammation, it should  be 
DEAFNESS  FROM DRYNESS OF THE EAR.           217
treated as similar inflammations elsewhere.   Sometimes the condition of the
auditory canal is such as to require the  use of a weak  solution of sulphate
of zinc, of acetate of lead, half a grain to the ounce, or the nitrate of silver,
one-fourth of a grain to the ounce, the surgeon being careful to apply these
washes by moistening a small portion of charpie and allowing it to remain in
contact with the diseased portion of the canal.   When these liquids are
injected, or  poured into  the ear, they necessarily come in contact with the
membrana tympani, and may thus become a source of irritation.  Having
completed the application of the wash, a little carded wool should be tempo-
rarily kept in the orifice of the meatus.   In  a few days the disorder will be
cured, after which the ears should be kept scrupulously clean, or if the accu-
mulation of wax appears to depend upon increased activity of  the cerumin-
ous  follicles, counter-irritation should  be applied behind and  beneath the
auditory canal near the meatus.
                \ 2.—Deafness from  Dryness of the Ear.

   Sometimes  deafness is the result  of excessive  dryness  of the external
 meatus and of the membrane of the tympanum,  evidence of which is noted
 in a diminished secretion in the epithelial  layer of the lining membrane.
   Symptoms.—The general symtoms of  this condition  are, in connection
 with the function of hearing, similar to the symptoms produced by an accu-
 mulation of wax in the ear;  thus there is  the same dullness of hearing, and
 the same sensation of ringing and roaring in the ear.
   Diagnosis.—A  diagnosis may be made between these two conditions by
 means  of  a very  simple test, as an  examination with a speculum  and a
 good light will at  once show that  the canal  is free.   Then, again, in  most
 instances of deafness from dryness of the tympanum, the patient hears better
 when there is a  good deal of noise.  Thus a  conversation which, under
 ordinary circumstances, would not be heard,  will often be noted  quite dis-
 tinctly, when riding in an  omnibus, or sitting in a mill, the noise of which
 would perhaps make the voice quite  inaudible to a person with a perfectly
 healthy ear.   This same peculiarity, here  mentioned, is also found in what
 is called nervous deafness,  a disease which is  now believed to be much rarer
 than was generally supposed by the majority of the profession. A diagnosis
 of deafness from dryness, and that due to nervous disorder, may, however,
 be very readily made, from  the fact that  in  deafness  from  dryness of the
 tympanum, the patient can  often hear the ticking of a watch perfectly well if
 it is placed in his mouth, or against his mastoid cells; while in deafness from
 disease  of the nerve this will not be  the case.   Dryness of the tympanum
 can also be recognized by means of the speculum, the membrane of the tym-
 panum, which in  health is  translucent, being now observed to be whitish,
 opaque, and presenting more or less the  appearance of damp parchment,
 although not quite so thick.
  Prognosis.—The prognosis of the  cure of deafness caused  by deficient
 secretions in the canal and  thickening of the drum should be guarded, much
 depending on the duration  of the deafness, the age of the  patient,  etc.   But
not unfrequently a judicious and continuous  treatment will, in a few weeks,
render the improvement of the hearing quite evident, and these  cases are
often susceptible of being improved.
  Treatment.—The treatment of this form of deafness is  based on the
principles regulating that  of deficiency of secretion elsewhere,  the  lining
membrane of the  caual and the  membrana  tympani being stimulated into
activity by means  of  various irritants.  During the interim the  necessary 
218
PRINCIPLES AND  PRACTICE  OF SURGERY.
moisture of the parts may, however, be temporarily restored by means of the
oil of sweet almonds, or pure  and fresh glycerin dropped into the ear, this
being the best  substance known for  preserving moisture on a dry surface;
but if this is not at hand, melted chicken-fat may be  substituted.  AVith a
view of stimulating the part to an increased  secretion, the nitrate of silver
may be  very properly employed, the solution  being  applied on  the sides of
the canal, or to the  surface of  the drum,  with a camel's-hair  pencil,  the
external meatus being  first oiled to  protect the skin from  discoloration.
The solution may be used in the proportion  of from one to four grains to
the ounce of water.   External irritants may also be  applied in  the  neigh-
borhood of the ear, and are very useful, either directly in front of the meatus,
or,  still better, behind it, and over  the  mastoid  cells.   Among these  we
may employ blisters,  or inflame the skin by means of adhesive plaster mixed
with tartar  emetic, or by  tartar emetic ointment, or croton oil, or collodion
containing cantharidin, or by blistering tissue, or by creosote painted on the
integuments and the  mastoid cells ; the last-named remedy being generally
preferable.
  The popular plan  of treatment, by warming salt upon a shovel and rub-
bing it while hot behind the ear, is not a bad  one,  as the salt  acts like
any other stimulant,  and some patients find  the sensations  produced by it
extremely agreeable.   Or the external membrane of the tympanum may be
painted with pure citrine ointment  applied  with  a camel's-hair pencil, if
the patient can bear it, or if not, by its being diluted with lard.  At the same
time, the general health should  be attended to, the patient taking a foot-
bath every two or three nights as a revulsive.  When the membrane of the
tympanum is thickened,  as well as dried, the treatment should be precisely
that which has been  stated under the head  of simple  dryness, except  that
the stimulating washes which are introduced into the ear must now be care-
fully applied by the pencil or mop  directly to  the membrane of the tym-
panum.  When this  membrane has been thickened for a considerable length
of time, benefit will be derived from the continued use of T'6th of a grain of
the bichloride of mercury twice or thrice daily after meals.   But when  the
disease resists the treatment stated, and we are satisfied that this dried  and
thickened membrane is the true cause of the patient's deafness, the operation
of puncture  of the membrane, as before alluded to, p. 212, may be advan-
tageously resorted to.
   Thickening  of the Membrana Tympani.—As illustrative of the appear-
ance and treatment of thickening of the membrane of  the tympanum, Cowl-
ing* published a case of deafness, of at least four years' standing, due to a
thickened state of the cuticle  of the membrane of the tympanum, in which
this membrane appeared convex instead of concave, was not sensitive to the
touch of a probe, and was white and  dry, there being no wax in the meatus.
   His treatment consisted in the application, every  second day, of ungt.
oxyd.  hyd., with  a  brush, to  the  membrane,  after  syringing  previously.
After  two or three  applications this was  discontinued, and a  solution of
cupri sulph.,  grs. xxx  to aquae f^ss,  applied  with a brush,  instead—still
syringing previously to each  application.   After continuing this treatment
some weeks, the ear  was daily  syringed with warm water, and injected occa-
sionally with a small quantity of a solution of argent, nit. grs.  xx to aquae
f^ss.   After several applications of this, " a thick flaky exfoliation " came
away from the membrane, when  the nitrate of silver was stopped, and an
ointment of the biniodide of  mercury directed to be applied with a  brush
* New Orleans Med. and Surg. Journ., vol. xi. p. 463, 1855. 
CATARRHAL  DEAFNESS.
219
every second day.   The secretion of wax was soon resumed, and the patient
recovered perfectly.
  Duration of Treatment.—Four months.
  If no benefit is derived from this operation, the wound may then be allowed
to heal, which it generally does very readily ; but if  the hearing is improved,
a free crucial incision should be made, and  the wound kept open by the oc-
casional  application of the nitrate of silver, until a permanent opening is
established, which will permit the waves of sound to act directly on the in-
ternal ear.
                       \ 3.—Catarrhal Deafness.

  Deafness may also be  due to a catarrhal inflammation of the mucous
membrane lining the internal ear;  this having arisen either in the cavity of
the tympanum, or had its origin in the throat and  been transmitted to the
cavity of the tympanum through the Eustachian tube.
  Symptoms.—The symptoms, as might be expected from the seat of this
disorder,  are those simply of chronic  internal otitis, already described, the
inflammation being liable to result in internal  suppuration and the destruc-
tion of the small bones of the ear.  As the inflammation of the mucous lining of
the Eustachian tube is usually accompanied by a serous infiltration of the sub-
mucous areolar  tissue, a thickening follows, which diminishes the calibre of
the tube, or causes such a  fibrinous secretion as partially strictures it so that
it will generally be found, at a very early period, that the patient is unable to
blow air  into the ear, and that the  tick of a watch is not heard with distinct-
ness, unless in contact with the cranium.
                                Fig. 420.
Toynbee's Otoscope. (From the instrument.)
   Diagnosis.—The sudden occurrence and history of catarrhal deafness, with
the loss of the patulous condition of  the Eustachian tube, and the existence
of catarrhal and throat symptoms, render the diagnosis easy.
   Prognosis.—The prognosis is usually favorable.
   Treatment.—The treatment of this form of deafness is that of mild inter-
nal otitis, as already described.  If the inflammation has originated in the
pharynx, and that  structure is yet in  a  state of chronic inflammation, as
shown by its congestion, etc., the  remedies should be  addressed to the
throat, by swabbing it  out with a probang or sponge wet with a strong solu-
tion of the nitrate of silver, say thirty grains to the ounce.  After which, the
inflammation of the ear should be  treated as was directed under the head of
internal otitis. 
220
PRINCIPLES  AND  PRACTICE OF SURGERY.
  Permanent obstruction of the Eustachian tube as a cause of deafness is, how-
ever, a much less common disorder than was formerly supposed, this  tube
being by no means so small or so easily obstructed as was at one time thought,
while the angle at which it is placed, as well as  the size  of its orifice, favors
the escape  into the  throat of any secretions of serum or  mucus that may ac-
cumulate within it.  Obstructions in the  Eustachian tube may be tested  by
directing the patient to close the nose  and mouth and making a full expira-
tion, as already mentioned, so as to  force the air from the pharynx into the
ear.   In order to judge of the effect of this self-inflation of the Eustachian
tube, an "otoscope" has been proposed by Toynbee, consisting of a tube, the
form of which is shown in Fig. 420.  If the Eustachian tube is  patulous,
the drum will be acted on by the air forced  into the cavity of the tympanum
and rendered more convex, its vascularity being temporarily increased. Then,
when the otoscope is held in the position represented in Fig.  421, care being

                                Fig. 421.
 View of the application of the Otoscoj>e, the patient distending the internal tympanum by forcing his breath
into it as he closes his mouth and nostrils.  The bulging of the membrana tympani can be plainly heard by
the tube which enters the ear of the surgeon. (After Nature.)

taken that it shall not touch anything except the ears of the patient and sur-
geon, and the transmission of the sound interrupted, the bulging of the mem-
brana tympani will be readily heard if the Eustachian tube is pervious.  As
catarrhal inflammation may extend to the membrana tympani,  the condition
of this  membrane, and any change in its transparency, should always be care-
fully noted.

                         \ 4.—Nervous Deafness.

   Nervous  Deafness, or that due to a paralysis of the auditory nerve, is a
disorder often alluded to, though really a rare  affection.  It, however, some-
times occurs, and may arise from organic changes in the portio mollis, from
tumors  pressing upon the nerve, and from organic changes in the cerebral
centres  which may or may not result in paralysis.   But it should be remem-
bered that it is very seldom met with, and when it does exist, is generally 
        DEAFNESS  FROM SUBACUTE AND CHRONIC  MYRINGITIS.    221

coexistent with some other disease in the ear.   When, however, true nervous
deafness is present, very little can be done for the patient.   Cases which ap-
pear to be due to mere paralysis of the portio mollis, in which there is no pain
in the head, no cerebral disturbance, in which the existing condition appears
to be a mere loss of power, and which sometimes suddenly ensue on the con-
gestion  induced by the too free or  improper administration of the sulphate
of quinia, may sometimes be benefited by transmitting a current of electricity
through the ear, as hereafter directed.
   Counter-irritants behind the ear or to the nucha may  also be employed, and
will sometimes prove useful.   But before  a case is pronounced to be one of
nervous deafness, and before such measures as those suggested are adopted,
a most careful examination should be made of both the external  and  the in-
ternal ear,  to ascertain  whether disease exists in them.  If the  patient can
hear a watch tick when  placed against his  head, it may be safely asserted
that some power yet exists in the nerves of the organ of  hearing.
   Kramer  advises, in cases  of paralysis or  atrophy of the tensor tympani
muscle,  that magneto-electric currents should be applied  by passing one
electrode through the nostril or throat, near  to the orifice of the  Eustachian
tube, and the  other into the  external meatus.   Garratt,* of Boston, also
recommends the application of the  "primary current of galvanism," by a
special method, in cases of paralysis of the auditory nerve.  When the diagnosis
can be certainly established, Kramer's plan might be usefully resorted to, but
I have had no experience in it.
          § 5.—Deafness from Subacute and Chronic .Myringitis.

   Patients being entirely ignorant of the structure of the ear, and unable, as
in inflammation of the eye, to note the  redness, opacity, etc. of the drum of
the ear, not unfrequently suffer from a subacute myringitis as the result of a
so-called "earache, " or external or internal otitis of a mild form; or, being
relieved from an  acute attack of myringitis, as caused in the manner before
stated, continue to suffer from the changes of structure in the membrana tym-
pani consequent  on inflammation  without  consulting a surgeon, until deaf-
ness is well  developed.
   Symptoms.—Deafness as a consequence  of subacute or chronic myringitis
is usually accompanied by a sensation of stuffing in the  ear, attended or not by
tinnitus aurium.  When the nose is blown, or air is forced into the Eustachian
tube, the latter is found to be patulous,  and the passage  of the air "bursts
something," or there is a sense of crackling.  If one ear only is affected, the
sensation differs in the  affected  ear from  that on the sound side.   Exam-
ination of the membrana tympani  by the speculum and strong sunlight also
shows a change in its character,  the translucency and color  being  changed,
the entire membrane presenting a dull-white, parchment-like hue, or opacity
in spots, especially anterior to the malleus, like the opacities seen in the cornea
in glaucoma.  Should ulceration  have existed, the opening in the  tympanic
membrane will be quite apparent, and the act of  inflation through  the Eus-
tachian tube will  cause the air to escape through the external meatus so as
to act on the flame of a candle, if it is employed in the examination, or make
a rushing sound that is quite perceptible as it escapes.
  Diagnosis.—The diagnosis of deafness from this cause is not difficult, if
the examination is carefully made and a full knowledge gained, by a com-
parison of the disordered with the healthy  membrana-tympani.
* Electro-Physiol., Boston, 1800. 
222
PRINCIPLES  AND PRACTICE  OF SURGERY.
  Prognosis.—The prognosis should be guarded, especially in reference to
the time required for the treatment.   Subacute  and chronic myringitis are
both likely to  be relieved if not cured, when they are seen early.   But if of
long standing, the opacity of the membrane of the tympanum is difficult to
core, though it may be much diminished, the hearing improving in a degree
corresponding with the progress toward health.
  Treatment.—The  treatment of deafness due  to subacute myringitis  con-
sists in the local abstraction of blood by leeches,  as directed in acute myrin-
gitis; in perseverance in purging, and especially in the administration of  one-
sixteenth of a grain of corrosive sublimate immediately after each meal, to act
as a gentle stimulant  of the secretions; in counter-irritation around the mea-
tus, by the application of creosote every second  or third night; by the  con-
tinned nightly use of a stimulating foot-bath, and by such attention to the gen-
eral health as the symptoms would indicate.  When met with, as is often the
case, as a sequel of otorrhoea in tuberculous children, or as the consequence
of a syphilitic pharyngitis, remedies appropriate  to these conditions of the
system must be resorted  to.  In fact, a constitutional treatment  adapted to
a case of debility would  be here equally useful—such as good diet, fresh air
exercise, and chalybeates, with  cod-liver oil, etc.   When the membrane of the
tympanum is destroyed, the ossicles will very frequently be found to have  also
been affected, especially in those cases consequent on an attack of measles or
scarlatina.   If the ossicles have not suffered from nercrosis or  anchylosis,

       Fig. 422.                               Fig. 423.
Toynbee's artificial membrana tym-   Introduction of an artificial membrane for ulceration of the drum
  pani. (From the instrument.)                  of the ear. (After Toynbee.)

the simple ulceration  of the  tympanic  membrane will  not create  positive
deafness ; the  malleus and stapes being apparently acted on  directly by
the vibrating current of air.   In these  cases of perforation, Toynbee has
highly recommended the  application of a  thin piece of caoutchouc as an arti-
ficial  membrane, Fig. 422.  This is to be introduced in the  manner  repre-
sented in Fig. 423.   The introduction  of a thin layer of wool, so as to
close the orifice in the drum, has also  been highly recommended by Toynbee •
but I  have never  been able to obtain from either the benefit claimed by the
advocates of each.  The artificial membrane of Toynbee I have also found to
be a source of irritation. 
        PERFORATION OF THE MEMBRANE OF THE  TYMPANUM.    223

  It is in the deafness  consequent on chronic myringitis—which is  the
condition often met with  in old age, where the membrane of  the tympanum
often  undergoes a  fatty degeneration  and opacity, like that  seen in  the
arcus  senilis—that the use of  ear  trumpets and auricles has been  so much
lauded. The use of a flexible  tube to convey the rays of sound more directly
to the  drum is, in  some cases, a source of comfort.  The "auricles," or ear
trumpets  more permanently  attached to the  head, and lauded by various
quacks as a "cure  for deafness," are by no means superior  to the flexible
tube.   They act, it is true, in  collecting the sound, and thus are temporarily
useful; but the constant  presence of the tube  in  the ear often develops an
irritation of the  skin lining the cartilaginous canal, and thus  keeps up an
irritation  that extends to the membrane of the tympanum  and  eventually
does serious injury.
  When chronic myringitis has left the membrane  opaque,  I have derived
benefit from the application of local stimulants—as passing into the external
ear, with a tobe, the vapor  of ether as it escapes  from a bottle surrounded
by a warm cloth, or the vapor  of the  red sulphuret of mercury heated beneath
a funnel, so as to carry the vapor into the external meatus, for a few seconds.
  The cold water douche on the side of the head and neck every day, for ten
or twenty seconds, and gentle syringing of the ear daily, so as  to stimulate
the circulation of  the membrane,  combined with some of the means before
mentioned, may also be employed.
  " Scarpa's  acoustic oil," " Harlem oil," and similar stimulants, are uncer-
tain and dangerous articles, and had better be avoided.
  Perforation of the drum,  as hereafter described, has, in my experience,
benefited cases of chronic myringitis with marked  opacity and thickening of
the membrane.
          \ 6.—Perforation  of the Membrane  of the Tympanum.

   Perforation of the Membrana Tympani as a cure for deafness was sug-
 gested  by Sir A. Cooper, in 1800, in order to  permit  the  entrance of air
 into the middle ear when the Eustachian  tube was  permanently closed, or
 when the  membrane was too  much thickened and changed  to  vibrate.
 Although a simple operation, it has not been much practiced, owing, appar-
 ently, to a want of confidence in  its utility, or from  fear lest injurious con-
 sequences should result.  Such fears are, however, groundless; the puncture
 being readily made, not productive of  great  pain, and often healing with
 great facility.
   Operation of Sir Astley Cooper.—After inclining the head, so that a
 strong  light  shall fall directly into the meatus, introduce a small trocar, or
 the instrument of Deleau, Plate  XXIII. Fig. 19, or the knife of  Horner,
 Plate XXIII.  Fig.  17,  at the anterior  inferior side  of  the  membrane, and
 transfix it so as to avoid the handle of the malleus.
   Remarks.—In the rare cases in which the Eustachian tube is closed by
 mucus,  and the surgeon  finds it difficult  to clear or dilate it by  catheterisra
 through the nostril, or when he wishes to assure himself positively that this
 tube is patulous,  and cannot do so with the  otoscope as before described,
 perforation of the membrane of the tympanum will enable him  to act upon
 the cavity of the tube  very advantageously,  and to test with  great cer-
tainty the condition of the inner portion of the ear,  by  forcing  a current of
air from a syringe through the meatus externus against the puncture  in the
membrana tympani.  As the wonnd in the  membrane will heal  readily, the
patient  runs no risk of injury if the Eustachian tube  prove to be totally im- 
224           PRINCIPLES AND  PRACTICE OF SURGERY.

pervious; while,  if choked, it  can be thoroughly cleansed  by driving  the
mucus into the throat in the natural course of the tube.  By thus demon-
strating the pervious condition of the tube, the diagnosis of the character of
the deafness will be much simplified.
  Operation of Horner, of Philadelphia.—A method which  Horner prac-
ticed on many occasions enabled him to pass a stream of water or air from
the meatus  externus  into the throat, and thus  clear the Eustachian tube
more effectually than can possibly be done by means of a catheter passed into
its orifice from the nose. It is accomplished as follows : Perforate the inferior
half of the membrana tympani by a sabre-shaped knife, one line in breadth,
the edge of which is on the convex margin, Plate XXIII. Fig. 17, by first
plunging the cutting  edge upward, and then revolving it on its axis, so as
to make the incision either angularly or of the shape of a V, as this will
leave  a flap  easily  moved.   A  small pipe, surrounded  by  a cork, Plate
XXIII Fig. 21,  being then introduced tightly into the  meatus externus so
as to plug it up, and a  small syringe, holding an  ounce and  a  half, being
adapted to the  pipe, the water  may be forced through the hole  pierced  in
the membrana tympani, as just  directed, and thus pass into the internal  ear
and out of the pharyngeal orifice of the tube. The stream thus carefully thrown
in will now be found to wash out the tympanum and Eustachian tube with
great  facility, as may be readily  ascertained by seeing the water escape from
the throat or nose.   The air douche may also be most  perfectly accomplished
in the same  manner; in any other way it is very defective,  and not to  be
relied on for what it professes to do, viz., to  open the  Eustachian  tube, as a
very little reflection will prove.   For  example, let the same  cork be fitted
into a phial, and then let the operator try to  inject air from the syringe into
the bottle, and he will  have a representation of the real effect of the  air
douche by the catheter introduced into the Eustachian tube from the nostril,
as usually practiced.
  Remarks.—Though Horner  often  performed this operation,  he never
knew  it to do harm, but has, on the contrary, known it to do good.  The
principal idea of the profession, at one time, in regard to the cause  of deaf-
ness, was, as evolved by the assertions of leading aurists, the  fact of there
being an obstruction of the Eustachian tube.   This Horner proved to be an
error, the obstruction of this tube  being, in his experience, very unusual as
a simple form of disease. I can also add the personal experience of numerous
cases in support of  this opinion.
  In the air  douche, by the catheter  passed into  the Eustachian  tube, as
usually advised, the introduction of the air may be regulated  by a column of
water acting on a large reservoir of air, or by means  of the cock in the can-
ister, Plate XXIII. Fig. 23, or by simply resorting to the caoutchouc bot-
tle, Plate XXI11. Fig. 22.
               \ 7.—Catheterism of the Eustachian Tube.

  When the position of the orifice of the tube in the pharynx is recollected,
Plate XXVIII. Fig.  1, it will  be  seen  that  the introduction  of the  ear
catheter through the nostril and pharynx is also a simple operation, though
the verbiage in which  it has often been described tends to create a belief in
its being difficult.  Aurists have  recommended various instruments for  the
performance of this operation, and the catheters  most in repute  are  those
figured in  Plate XXIII. Figs. 12, 13.
  Ordinary Operation—The  patient being seated, with the head slightly
thrown  backward and firmly supported, take the catheter in the right  hand 
               CATHETERISM  OF THE EUSTACHIAN  TUBE.            225

and, after oiling it, introduce it into the nostril on the  side to be sounded.
Then, keeping the point of the instrument upon the floor of the nostril, and

                                 Fig. 424.
 Inflation of the cavity of the tympanum by the breath of the operator; the tube being attached to the'
       Eustachian catheter previously introduced into the nostril of the patient. (After Nature.)

 its convexity upward and inclined against the septum  narium, slide it back-
 ward until it reaches the soft palate, as may be readily told by the sense of
 touch, or by the patient making a slight gulp or effort to  swallow.   At this
 moment, turn the point of the catheter upward and outward by rotating it a
 quarter  of a circle, and then, by a slight movement forward and backward,
 slip it into the orifice of the tnbe, when it will pass as easily as a catheter can
 be  made to enter the bladder.   The proper position of the instrument may
 be  at  once known  by its steadiness, as well as  by  the sensation of the
 patient.
   When it is desired to inject air or liquids through the instrument, compress
 the nostrils and catheter in the fingers of one  hand, and employ the syringe
 or gum-elastic bottle  with the other, or resort to a little wire spring, Plate
 XXVIII. Fig. 2, or to a frontlet, Plate XXVIII. Fig. 3.
   The frontlet, forceps, air-drum, etc.  will  all  be found useful in  the oper-
 ations of those who may wish to devote themselves specially to aural sur-
 gery ; but, for the general operator, the instruments figured in PJates XXIII.
 and XXVIII., and the use of the tube inflated by the operator, as suggested
 by Toynbee, and represented in Fig. 424, will prove sufficient.
  Cases  of deafness have been occasionally met with in which the aurist has
 found it  impossible to pass the catheter into the  pharyngeal orifice of the
ear, and  the cause of the difiBculty has  been either  unknown or undescribed,
in consequence of the  rarity  of a post-mortem examination of this  region.
  Neill,  of Philadelphia, has published* the results of several post-mortem
examinations, in which he has noticed a peculiar condition of this orifice of
              * Medical Examiner, vol. ix. p. 626, 1853.
VOL. II.—15  • 
226
PRINCIPLES AND  PRACTICE OF  SURGERY.
the Eustachian tube, it being overhung at its superior and posterior border
by a thickening and hypertrophy of the  mucous  membrane with enlarged
follicles, which is doubtless the occasional cause of deafness.  Neill thinks it
probable that the  enlargement of the tonsils, which have so frequently been
supposed to be the cause  of deafness, may be real, owing  to  the  condition
which he has thus  described.
   General  Estimate of  the  Operations for the Relief of Deafness.—
The almost  universal necessity that exists  in the United States for every
surgeon to practice several distinct portions of his profession, as well as the
absence of definite instruction in these complaints,  usually noted in the ordi-
nary courses of education in  our  medical  schools, have, for many years,
induced the majority of the profession to  shun the treatment  of aural com-
plaints, and forced patients into the  hands of empirics.   All these opera-
tions  are, however, so  easily practiced, and the variety of the complaints
requiring thera so very  limited, that this  condition of things  may now be
readily  remedied by any surgeon.
  In order to prove this, an effort has therefore been made to describe all the
ordinary operations required for the relief of deafness, as  folly as is neces-
sary, and if the reader follows the foregoing descriptions, in connection with
the plates, he will, it is hoped, find them full enough for all general points of
practice connected with aural surgery.   Washing out the external and inter-
nal auditory tubes, with perforation of the membrana tympani, or perhaps the
mastoid cells, really constitute the entire portion of aural operative surgery,
and are operations which  can be easily executed by any.  I thiuk, therefore,
that it is to be regretted that the difficulties of aural operations are so greatly
overrated by physicians generally.  The prognosis of the complaints requiring
these operations is, it is true, often doubtful, or decidedly unfavorable ; yet it
should  be  remembered  that, even when unable to cure, a  medical  adviser
may effect much good by assuring the patient of the impossibility of his being
relieved, and every one should, therefore,  gain such an amount of practical
skill as will enable  him to  give an opinion.   By washing out the meatus ex-
ternus, and examining the condition of the membrane  of the tympanum;  by
catheterizing the Eustachian tube, or by  perforating the membranum tym-
pani, and  testing  the permeability of the passage to the  throat, as  above
described, much advantage will often be gained by the patient, while the pro-
fession will be able to rescue many persons from the hands of unprincipled
men, who, in the majority  of cases, only do them harm.
  If the general practitioner would only give these cases the attention that
they deserve, or place them in the hands of a judicious surgeon, he  would do
much  to banish the wretched quackery in aural complaints  now so often
seen.   When deafness cannot be cured by  a scientific course of treatment, it
becomes the duty of the practitioner to  exert his influence in preventing the
patient from wasting his time and money among charlatans, whether profess-
ing to cure by " Scarpa's acoustic oil," or by the magnetic,  electropathic, or
chronothermal plan of treatment. 
PAPERS ON  DISORDERS  OF  THE HEAD AND FACE.        227
AMERICAN  PAPERS ON THE SURGICAL DISORDERS OF THE  HEAD
                               AND  FACE.
ON TREPHINING  AND  INJURIES  OF
             THE  HEAD.
Use of the Trephine in Epilepsy, being the
  sixth  successful case, by Benjamin W.
  Dudley, M.D.   Lexington, Kentucky.—
  Am. Journ. Med. Sci.,  vol. xi.  p.  542.
                                 1832.
Compound Camerated Fracture of the Cra-
  nium,  successfully treated by  the re-
  moval  of  three  pieces  of the external
  table of the Skull, by Paul F. Eve, M.D.
  Georgia.—Am. Journ. Med. Sciences, vol.
  xii. p.  549.                     1833.
ExoBtosis of the Frontal Rone removed, by
  R. D. Mussey, M.D. New Hampshire.—
  Amer. Journ. Med.  Sci., vol. xxi. p.  377.
                                 1837.
Epilepsy successfully treated by Trephin-
  ing, by George Hay ward, M.D.  Boston.
  —Am. Journ. Med. Sci.,  vol. xxii. p. 517.
                                 1838.
Researches on Hernia  Cerebri  following
  Injuries of the Head.  Essay, read before
  N. Y. Med. and  Surg. Society, by Gur-
  don Buck, Jr.,  M.D.   New  York.—AT.
  Y. Journ.  Med. and Surg., vol. iv. p.  348.
                                 1840.
Cases of Injury of the Head, by A. B. Ship-
  man, M.D. Cortland County, New York.
  —Am.  Journ. Med. Sci., vol. ii. N. S. p.
  66.                             1841.
Cases of Injury of the Head, by A. B. Ship-
  man, M.D.—Am. Journ. Med. Sci., vol.
  ii.  N. S. p. 373.                 1841.
Operation for the removal of a large bony
  Tumor, called Spina Ventosa, by George
  M'Clellan, M.D.  Philadelphia.—Medical
  Examiner,  vol. iv. p. 44.         1841.
Cases of Injury of the Head, by A. B. Ship-
  man, M.D.  Indiana.—Boston Med. and
  Surg. Journ., vol. xxxviii. pp. 353,  373.
                                 1848.
Trephining for Epilepsy  of twenty years'
  standing,  successful, by  J. G.  F.  Hol-
  ston, M.D.  New Concord, Ohio.—Amer.
  Journal Med. Sci., vol. xvii. N. S. p.  541.
                                 1849.
Compound Comminuted  Fracture of the
  Skull, removal of a large portion of the
  right  Parietal  Bone,  Recovery, by  Geo.
  Fox, M.D.   Philadelphia.—Am. Journ.
  Med. Sci., vol. xvii. N. S.  p. 43.   1849.
Fracture  of the Cranium, with Depression,
  Epilepsy, Operation, Recovery, by Chas.
  A. Pope, M.D.   St. Louis.— St. Louis
  Med. and Surg. Journ.,  vol. vii.  p.  298.
                                 1850.
Fracture of the Skull and Wound of the
  Brain, (cured after the application of
  the Trephine,) by  John Syng Dorsey,
  M.D.   Philadelphia.—Philadelphia Med.
  Museum,  vol. ii. p. 282.           1806.
Memoir on the Subsequent Treatment of
  Injuries of the Head, illustrated by Cases,
  by Valentine Mott,  M.D.  New York.—
  Trans, of the Physio-Med. Soc.  of N. ¥.,
  vol. i. p. 223.                   1817.
Fungus Cerebri, successfully  treated by
  Excision, by  Jonathan  A. Allen, M.D.
  Brattleboro', Vermont.—New  England
  Med. Journ.,  vol. viii. p. 323.     1819.
Fractured  Skull, successfully  Trephined,
  by Andrew Park, M.D.  Eaton, Georgia.
  —Phila.  Journ. of Med. and Phys. Sci.,
  vol. viii.                         1824.
Epilepsy from  Depressed  Bone,  cured by
  Trephining, by David  L.  Rogers, M.D.
  New York.—N. Y. Med. and Phys. Journ.,
  vol. v. p. 79.                    1826.
Observations on Injuries of the  Head, by
  Benjamin W. Dudley, M.D.  Lexington.
  —Transylvania Journ. of Med., vol. i. p.
  9.                              1828.
Case of Epilepsy, cured by Trephining, by
  James Guild, M.D.  Alabama.—Amer.
  Journ. Med. Sci., vol. iv. p. 96.    1829.
Chronic Injuries of  the Brain,  relieved by
  an Operation with the Trephine, by Wm.
  Judkins, M.D.  Mount  Pleasant, Ohio.
  —Transylvania Med. Journ., vol. ii.  p.
  135.                            1829.
Case in which the  Osseous Disk, removed
  by a Trephine, was regenerated.—Mary-
  land Med. Recorder, vol. i. p.  152.  1829.
Case of  Hernia Cerebri, cured by Sponge
  Compress, by J.  W. Heustis, M.D.  Mo-
  bile.— Am. Journ. Med. Set., vol.  iii  p.
  349.                            1829.
A Case of Depressed Fracture  of the Cra-
  nium, successfully  treated without re-
  sorting to the Trephine, by  Thomas F.
  Dale, M.D. Pittsburg.— North American
  Med. and Surg. Journal, vol. x. p. 164.
                                  1830.
Report of Cases of  Injuries  of the Head,
  treated in  the Pennsylvania  Hospital,
  by George W. Norris,  M.D.   Philadel-
  phia.—Am. Journ. Med.  Sciences, vol. ix.
  p. 304.                          1831. 
228             PRINCIPLES  AND  PRACTICE  OF  SURGERY.
Trephining  for an old Depression of the
  Cranium,  causing  Idiocy, (died on the
  ninth day from Hemorrhage from Longi-
  tudinal Sinus,) by J. M. Warren, M.D.
  Boston.—Am. Journ. Med. Sci., vol. xix.
  N. S. p. 72.                     1850.
Surgical Treatment  of Epilepsy, (7 cases
  operated on  by a Trephine,  etc.,)  by
  John G. F. Holston, M.D.   New Con-
  cord, Ohio.—  Western Lancet, vol. xi. p.
  700.                            1850.
Epilepsy, cured by  dissecting  Cicatrices
  in Scalp free from Cranium,  by  F.  H.
  Hamilton, M.D.  Buffalo.— Western Lan-
  cet, vol. xi. p. 321,  from Buffalo Med.
  Journ.                          1850.
Abscess  in  the  Substance of the Brain,
  Hernia Cerebri, the  Lateral Ventricles
  opened by an Operation, (died,) by Wm.
  Detmold, M.D.  New York.—Am. Journ.
  Med. Sci.,  vol. xix. N. S. p. 86.   1850.
A Case of Epilepsy, cured by  Trephining
  the Skull, by E. L. Dudley, M.D.  Lex-
  ington, Kentucky.— Transylvania Med.
  Journ., vol. i.  N. S. p. 84.        1851.
Injuries of Cranium, Trepanning, by Henry
  F. Campbell, M.D.  Augusta, Ga.—South-
  ern Med. and Surg. Journ., vol. vii. p. 279.
                                  1851.
Report of Trephining for  Compression of
  the Brain, cured, by J. W. H. Trugien,
  M.D. Portsmouth,  Va.—Stethoscope, vol.
  i. p. 647.                        1851.
Fall from a Height of  Fifty Feet, without
  serious Injury, by  L.  A. Dugas, M.D.
  Georgia.—Southern Med. and Surg. Journ.,
  vol. vii. N. S. p. 271.             1851.
Fall from a Height  of Twelve  Feet, pro-
  ducing excessive Concussion of Brain,
  by L. A. Dugas, M.D. Georgia—South-
  ern Med. and Surg.  Journ., vol.  vii. N. S.
  p. 271.                          1851.
Case of Compression of the Brain from Ef-
  fusion, Trepanning, Recovery, by C.  G.
  Catlett, M.D.    St.  Joseph,  Mo. — St.
  Louis Med. and Surg. Journal, vol. xiv.
  p. 319.                          1851.
Case of Fracture of the Cranium, with De-
  pression, followed by Traumatic Tetanus,
  in which  Trephining was  successfully
  practiced, by E. Geddings, M.D. Charles-
  ton.—Charleston Med. Jour., vol. vii. p.
  505.                            1852.
Trephining the Cranium,  and Ligature of
  the  Carotid Artery,  in Epilepsy,  but
  little  relieved, by Willard Parker, M.D.
  New York.—N. Y. Journal of Medicine,
  vol. viii. N. S. p. 418.            1852.
Remarks on  Fracture of the Cranium, (6
  cases,  showing results  of Trephining,)
  by John Harden, M.D.  Louisville, Ky.
  — Western Journ. Med.  and Surg., vol.
  ix.  3d S. p. 203.                 1852.
The Surgical Treatment of Epilepsy, with
  Statistical Tables of all the recorded cases
  of Ligature of the  Carotid Arteries, and
  also Trephining  the  Cranium, as  per-
  formed by American Surgeons, by  Ste-
  phen Smith, M.D.  New  York.— N. Y.
  Journ. Med. vol. viii. N. S. p. *--°-  1852.
A  Description  of,  and  Remarks upon, a
  newly constructed Trephine, with a  Cut,
  by Samuel S. Purple, M.D.  New York.—
  N.  Y. Journal of Medicine, vol. x. N. S.
  p. 419.                          1853.
Successful  Case of Trephining, by J. J.
  Chisolm,  M.D.   Charleston, S. C —
  Charleston Med. Journal., vol. ix. p.  597.
                                  1854.
Trephining in  Infancy, by  Jas. L.  Van
  Ingen, M.D.  Schenectady, N. Y.—N.
  Y. Journ. of Mid., vol. xii.  N. S. p.  378.
                                  1854.
Remarkable Case of Gunshot  Wound of the
  Head, by H. V.  M. Miller, M.D.  Au-
  gusta,  Ga.—Southern Med.  and Surg.
  Journ., vol.  ii. N. S. p. 555.      1855.
Exostosis of the Orbit, by Mark Stephen-
  son, MD. New York. — Am. Journ.  Med.
  Sci., vol. xxix. N. S. p. 139.      1855.
On Wounds of the Brain, by M. A. Pallen,
  M.D. St. Louis.—St. Louis Med.  and
  Surg. Journ., vol. xiv. p.  325.     1856.
Gunshot Wound of the Brain, by Drs.  Hu-
  bert and Culver. Warrenton, Ga.—South-
  ern Med. and Surg. Journ., vol. xii. N. S.
  p. 79.                           1856.
Compression of the Brain, Trepanning, Re-
  covery, by G. C. Catlett, M.D. St. Louis,
  Mo.—N.  O.  Med. and Surg. Journ., vol
  xiii. p. 192.                      1856.
Report of  two Cases of Fracture  of the
  Skull,  and  one  of Concussion of the
  Brain without Fracture, treated  in the
  Pennsylvania Hospital, reported by Jno.
 - H. Packard, M.D.  Philadelphia.—Am.
  Journ. Med. Sci., vol. xxxiv. N. S. p 51.
                                  1857.
Caries of Temporal Bone, by G. C.  Black-
  man, M.D. Cincinnati.— Western Lancet,
  vol. xviii. p.  571.                1857.
Meningeal Tumors, with sundry Complica-
  tions, by Bennet Dowler,  M.D.   New
  Orleans.—Ar. O. Med. and  Surg. Journ.,
  vol. xiv.  p. 192.                  1857.
Fracture of Skull, with Depression,  Tre-
  phining,  Recovery,  by  J. G. Adams.
  Putnam County, N. Y.—N. Y. Journ. of
  Medicine,  vol. v. 3d S. p. 252.     1858.
Report of a Case of Trephining, Recovery,
  by M. E.  Winchell, M.D.—N. Y. Journal
  of Medicine,  vol. v. 3d S.  p. 250.  1858.
Two Cases of Trephining, (one recovered,
  one died,) reported by J.  M. Farrington,
  M.D., House-Surgeon of Rellevue Hos-
  pital.  New  York.—N.  Y.  Journal of
  Medicine, vol. v. 3d S. p. 249.     1858.
Five Cases of Trephining,  (all  died,) re-
  ported by J.  J. Campbell, M.D., House-
  Surgeon  of  Bellevue Hospital.    New
  York.—N.  Y. Journal of Medicine,  vol
  v. 8d S. p. 244.                  1858; 
PAPERS  ON  DISORDERS OF THE  HEAD AND FACE.          229
Case of Epilepsy, Trephined  three times,
  with relief, by Warren Stone, M.D.  New
  Orleans.—2V. 0. Med. and Surg. Journ.,
  vol. xv. p.  433.                  1858.
Thirty-one  Cases  of Hernia Cerebri of
  Traumatic  Origin,  occurring in  New
  York Hospital, by Robert F. Weir, M.D.
  New Yfork.—N~.  Y. Journal of Medicine,
  vol. vii. 3d S. p. 291.            1859.
Four  Cases of Trephining, (two deaths,
  two recoveries; operator, J. Watson. M.
  D.,) reported  by Geo. F. Shrady, M.D  ,
  late Resident Surgeon New York Hospi-
  tal.—Ar.  Y. Journal of Medicine, vol. vii.
  3d S. p. 380.                    1859.
Inter-Cranial Suppuration following a La-
  cerated Wound of the Scalp, application
  of the Trephine, Death, Autopsy, by T.
  G.  Richardson, M.D.  New Orleans.—
  N.  0. Med. and Surg. Journ., vol.  xvi.
  p. 680.                          1859.
        ON HYDROCEPHALUS.

 Case of Hydrocephalus Tapped, by P. S.
   Physick.  M.D.  Philadelphia,  1801.—
   Phila. Journ. Med. and Phys. Sci., vol.
   iv. p. 316.                       1826.
 Account of an accumulation of eight  ounces
   of fluid between the Cranium and  the
   Scalp, by Robert Lebby, M.D.—Amer.
   Journal Medical Sci., vol.  xvi. p. 250.
                                   1835.
 Case of Congenital Hydrocephalus, form-
   ing a Cyst on the back of the Head, con-
   taining the Posterior Lobes of the Cere-
   brum, in which the water was evacuated
   by Puncturing the Brain, (died,) by Wm.
   E. Horner. M.D.   Philadelphia.—Am.
   Journal Medical  Sci., vol. xx. p. 536.
                                  1837.
 Case of Hydrocephalus treated by Tapping,
   (operation performed seven  times, and
   sixty-one  ounces of fluid drawn off;  pa-
   tient  lived near two months  after  the
   first  tapping,)  by  L. A.  Dugas, M.D.
   Georgia. — Am.  Journ.  Med. Set., vol.
   xx. p. 536.                       1837.
 Case of Hydrocephalus repeatedly Tapped,
   (died,) by J. B. Whitridge, M. D. Charles-
   ton.—Am. Journ.  Med. Sci., vol.  xx. p.
   538.                            1837.
 Case of Chronic  Hydrocephalus  Tapped,
   (died sixth day,) by Wm.  Pepper, M.D.
   Philadelphia.—Amer. Journ. Med. Sci.,
  vol. xix. N. S. p. 552.            1850.
Operation of Paracentesis Capitis (relieved)
  in  a  Case of  Hydrocephalus,  by  M.
  Howard, M.D. Louisville.—Transylvania
  Medical Journ., vol.  iii. p. 373.    1852.
Case  of Hydrocephalus  Tapped,   (died,)
  with Remarks on the Nature and  Treat-
  ment of this Disease, by H. L. Byrd, M D.
  Savannah, Ga. — Charleston Med.  and
  Surg. Journ., vol. viii. p. 774.    1852.
ON  DISORDERS OF THE  EYELIDS.

Case of Irritation of the Tarsi Cartilages,
   caused  by Pediculus  Pubis, by J.  D.
   Godman,  M.D.  Philadelphia. —Amer.
   Journ. Med. Sci., vol. i. p. 241.    1827.
Encysted  Tumor of the Orbit of the Eye
   removed, by H. G. Jameson, M.D.  Balti-
   more.—Phila. Med. Recorder, vol. xii. p.
   340.                            1827.
Observations on Entropium, with  a Case,
   by Samuel Jackson,  M.D. Northumber-
   land, Pa.—Am. Journ.  Med. Sci., vol.  iv.
   p. 297.                          1829.
Scirrhus of the Lachrymal Gland success-
   fully removed, by George  Bushe, M.D.
   New York.—Medico-Chirurgical Bulletin,
   vol. i. p. 38.                     1832.
Dissertation  on  Fistula  Lachrymalis,  by
   Robert W. Haxall, M.D.  Richmond, Va.
   (Boylston Prize Essay.)—Medical Maga-
   zine, Boston, vol. i. p. 129.        1832.
On Anchylo-blepharon,  by Isaac  Hays,
   M.D.  Philadelphia.—Am. Cyclopsedia of
   Practical Med.  and Surg., vol. i.  p. 464.
                                  1834.
Remarks on Encysted Tumors of the Eye-
   lids, with a Case, by  E. J. Davenport,
   M.D.  Boston—Boston Med.  and Surg.
   Journ.,  vol. xviii. p.  413.         1838.
Blepharo-plastic  Operations for Restora-
   tion of the Lower Eyelid,  by J. Mason
   Warren, M.D.  Boston.—Boston Med.
   andSurg Journ., vol. xxiv. p.  149. 1841.
Case of  Congenital  Hypertrophy  of  the
   Upper Eyelids and  Mucous  Membrane
   of the Upper Lip, with an  Inversion of
   the Eyelashes, by H.  H. Toland, M.D.
   Columbia, S.  C.—Am. Journ. Med. Sci.,
   vol. ii. N. S. p. 244.              1841.
Blepharo plastic Operation  for Ectropium,
   by A. C Post,  M.D.   New York— Am.
   Journ. Med. Sci., vol.  iv. N. S.  p. 258.
                                  1842.
Plastic Operation for Ectropium, by Daniel
   Brainard, M.D.  Chicago.—Am. Journ.
   Med. Sci., vol. x. N.  S. p. 356.    1845.
Congenital Inability to  raise the   Upper
   Eyelid, cured by an Operation, by Charles
   A. Hall, M.D.  Vermont.—Am. Journ.
   Medical Sciences, vol.  xii.  p. 143.   1846.
Symblepharon successfully treated by a
   Plastic Operation, by Isaac Hays, M.D.
   Philadelphia.—Am. Journ. Med. Sci., vol.
   xiv. p. 263.                      1847.
Case of Fungus Hsematodes  of the Eye,
   Extirpation, by Edward Delafield, M.D.
   New York.—N. Y. Journal of Medicine,
   vol. v. N.  S. p. 199.              1850.
Carcinoma of the Eyelid, Blepharoplasty
   after Dieffenbach's Method, by C. Theo-
   dore Meier. M.D.   New  York.—N.  Y.
   Journ. of Medicine, vol. ix. N. S.  p. 205.
                                  1852.
Case of Carcinoma Oculi  and Extirpation
   of the  Eyeball, by Henry W. Williams, 
230
PRINCIPLES AND PRACTICE  OF  SURGERY.
  M.D.  Boston.—Boston Med. and Surg.
  Journ., vol. xlvii. p. 202.         1852.
Strumous Ophthalmia, by  S.  D. Gross,
  M.D.  Louisville.— Western Journ.  of
  Med. and Surg., vol. i. N. S. p. 103. 1854.
Scirrhus of Lachrymal Gland, Extirpation,
  Cure,  by  James  Cowling, M.D.  New
  Orleans.—N. 0. Med. and Surg. Journ.,
  vol. xii p. 319.                  1855.
Exostosis occupying Orbit and Nasal Cav-
  ity successfully  removed, Vision  Re-
  stored, by A. R. Mott, M.D. New York.
  —Am. Journ. Med Sci., vol. xxxiii. N. S.
  p. 35.                           1857.

   DISORDERS OF THE EYEBALL.

Observations on Cataract and the various
  Modes of  Operating for its Cure, by G.
  Fricke, M.D.   Baltimore.—Medical Re-
  corder, vol. iv. p.  26.             1821.
Artificial Pupil and Modes  of Operating,
  by G.  Fricke, M.D.  Baltimore.—Medi-
  cal Recorder, vol. vi.  p.  36.        1822.
Artificial Pupil, by Edward Delafield, M.D.
  New York.—N. Y. Med. and Phys. Journ.
  vol. iv. p.  145.                   1825.
An   Account of  a new Instrument   for
  making Artificial Pupil and cutting up
  the Lens, by  John  Hill,  M.D. South
  Carolina.—N. Y. Med. and Phys. Journ.,
  vol. iv. p.  490.                   1825.
Case of Wart on the Adnata, removed by
  Nitrate of Silver, by P. S. Physick, M.D.
  Philadelphia.—Phila. Med. Journ.,  vol.
  v. N. S. p. 187.                  1827.
Extirpation  of a Cancerous  Eye, by  Har-
  vey Lindsly, M.D.  Washington, D. C.—
  Am. Journ. Med. Sciences, vol. vi. p. 349.
                                  1830.
Operation for the Formation of  Artificial
  Pupil,  by  E. J. Davenport, M.D.  Bos-
  ton.—Boston Med. and Surg. Journ.,  vol.
  xix. p. 165.                     1839.
Extraction of Foreign Bodies from the Eye,
  by Isaac  Hays,  M.D.  Philadelphia.—
  Am.  Journ. Med.  Sciences,  vol.  xxiv. p.
  514.                             1839.
Case of Osseous  Formation in the Eye, by
  J. Jeffries, M.D.  Boston.—Boston  Med.
  and  Surg. Journ.,  vol. xxiii.  p.  302.
                                  1841.
Cases of Strabismus,  (division of the In-
  ternal  Rectus,) reported by J. H. Dix,
  M.D.   Boston.—Boston Med. and Surg.
  Journ., vol. xxiii. 265.            1841.
Cases of Operations for Artificial Pupil, by
  John Jeffrie*,  M.D.   Boston.— Boston
  Med.  and Surg. Journ.,  vol. xxv. p. 249.
                                  1841
On the Operation for the Cure of Strabis-
  mus, by Joseph Pancoast,  M.D.  Phila-
  delphia.—Medical Examiner, vol. iv. p.
  390.                             1841.
Subconjunctival  Method of Operating  for
  Strabismus, by  E.  J. Davenport, M.D.
  Boston.—Boston Med. and Surg. Journ.
  vol. xxv. p. 89.                   1841
Case of Congenital Tumor of the Eyeball,
  by  W. T. Taliaferro, M.D.   Kentucky.
  —Am. Journ.  Med. Sciences, vol. ii. N. S.
  p. 88.                            1841.
Operation for Artificial Pupil, and  subse-
  quent section of the Rectus Superior, by
  J. Kearney Rogers, M.D.  New York.—
  Am. Journ. Med. Sciences, vol. iv. N. S.
  p. 248.                           1842.
Operation for Artificial Pupil, by  Isaac
  Hays, M.D. Philadelphia.—Am. Journ.
  Med. Sci.,  vol.  iv. N. S.  p. 371.    1842.
Two Cases of Malignant Ophthalmic Dis-
  ease, (Colloid  Tumor of the Orbit and
  Melanosis of Globe,) by Geo. A. Bethune,
  M.D.   Boston.—Boston Med. and Surg.
  Journ., vol. xxxvi. p. 509.         1847.
Dislocation of the Crystalline Lens from a
  Blow, by Francis West, M.D.  Philadel-
  phia.—Phila.  Med. Examiner, vol. vi. p.
  241.                              1850.
Dislocation of the Crystalline Lens beneath
  the Conjunctiva, Extraction at the Inner
  Canthus, by Charles  A. Pope, M.D.  St.
  Louis.—St Louis Med. and Surg. Journ.,
  vol. vii. p.  289.                   1850.
Exophthalmia, caused  by Tumor in Orbit,
  by L.  A. Dugas,  M.D. Georgia.—South-
  ern Med. and Surg. Journ., vol. viii. N. S.
  p. 404.                           1852.
Eye Destroyed by a Birdshot, by L. A.
  Dugas, M.D.  Georgia.—Southern Med.
  and Surg. Journ., vol. viii. N. S. p. 404.
                                   1852.
Extraction of Cataract, (the patient being
  under the  influence of Ether,) by H. W.
  Williams,  M.D. Massachusetts.—Boston
  Medical  and Surgical  Journal, vol. xlix.
  p- 338.                           1853.
Cataract in  the  Aged, with Physiological
  and Pathological Remarks, by B. Dowler,
  M.D.—N. O. Med. and Surg. Journ., vol.
  xi. p.  1.                          1854.
Fungus Haematodesof the Eye, Extirpation,
  Recovery, by James  Bolton, M.D.  New
  York.—Am Journ. Med. Sci., vol. xxix.
  N. S. p. 577.                     1855.
Knife Needle for  the Operation for Cataract
  by  Solution  or Absorption,  by  Isaac
  Hays, M.D.—Am. Journ. Med. Sci., vol.
  xxx. N. S.  p. 81.                 1855.
Case of  Laceration of  the Cornea of both
  Eyes during a Convulsion, by J. W. Mc-
  Kinney. M.D.  Illinois.— N. O. Med. and
  Surg. Journ., vol. xiii. p. 197.     1856.
Amaurosis relieved by Cataract Operation,
  by G. A. Hunkler, M.D.  Madison, Ind.
  — West. Lancet, vol. xvii. p 334.    1856.
Opacity of the Cornea removed by an Oper-
  ation, by C. R. Agnew, M.D. New York.
  —N Y. Journal of Medicine, vol. iii 3d S
  P- 200.                          "i857; 
PAPERS  ON  DISORDERS OF THE  HEAD AND FACE.          231
Black Cataract, by G. C. Blackman, M.D.
  Ohio.— Western Lancet, vol. xviii.p. 722.
                                   1857.
Spontaneous Rupture of the Eye, by Andrew
  Fleming, M.D.   Philada—Am. Journal
  Med.  Sciences, vol. xxxv.  N. S. p. 373.
                                   1858.
Remarks  on Cataract,  by C. S. Fenner,
  M.D. Memphis, Tenn.—Am. Journ. Med.
  Sciences, vol.  xxxv. N.  S. p. 565.   1858.
Rupture of the  Cornea, with Dislocation of
  the Crystalline Lens aud Capsule, by J.
  Cowling, M.D.   Houston, Texas.—New
  Orleans Med. and  Surg. Journ., vol.  xv.
  p. 78.                           1858.
Five cases of Cataract in one Family, by
  H.  W.  Williams,  M.D.   Boston— Am.
  Journ.  Med.  Sciences,  vol. xxxvi.  N.  S.
  p. 580.                           1858.
Remarks on Artificial Pupil, with Cases, by
  M.   A.  Fallen,  M.D.   St.  Louis.— St.
  Louis Med. and Surg.  Journ., vol. xvii.
  p. 289.                           1859.
Extirpation of  the Eye,  by C. R. Agnew,
  M.D.  New York.—Am. Journ. Med. Sci-
  ences, vol. xxxvii. N. S. p. 578.    1859.
Extirpation of  the Eye, by C. R. Agnew,
  M.D.  New York.—N. Y. Journ. of Med-
  icine, vol. vi.  Third  Series,  p.  67.
                                   1859.
Remarks on Operations for Cataract, by J.
  C. Nott, M.D.   Mobile, Ala.— New  Or-
  leans Med. and Surg.  Journal,  vol. xvi.
  p. 1.                            1859.
The Clinical use of the Ophthalmoscope in
  diseases of the Eye, by Laurence Turn-
  bull, M.D. Philadelphia.—Med.andSurg.
  Reporter, vol. ii. N. S. No. 13, p. 261.
                                   1859.
     OPERATIONS  ON  THE FACE.

Tic Douloureux, (cured by dividing the Infra
  and Supra-orbitar Nerves,) by  Jeremy
  Stimpson. M.D.  Boston.—New England
  Journ. Med.  and  Surg.,  vol.  vi. p.  14.
                                   1817.
Case of Anastomosing Aneurism of the In-
  ternal Maxillary  Artery,  by  Granville
  Sharpe Patteson,  M.D.    Baltimore.—
  Philadelphia Med. Recorder, vol. v. p. 108.
                                   1822.
Facial Neuralgia,  cured  by Acupunctura-
  tion, by J.  Hunter Ewing,  M.D.—North
  American Med. and Surg. Journ., vol. vi.
  p. 77.                            1826.
Cases illustrative  of Remedial  Effects of
  Acupuncturation,  by  Franklin  Bache,
  M.D.   Philadelphia.—North Am. Med-
  ical and Surgieal Journal, vol. i. p. 311.
                                   1826.
Cases of Neuralgia, treated by division of
  the Nerves, (Infra-orbitar, Submaxillary,
  Portio Dura, and Supra-orbitar,) by John
  C. Warren, M.D.  Boston.—Boston Med.
  and Surg. Journ., vol. i. p. 1.      1828.
Excision of  the  Submaxillary Nerve, (for
  Tic Douloureux, cured,) by John C. War-
  ren, M D.   Boston.—Boston  Med. and
  Surg. Journ., vol. i. p. 2.         1828.
On  Acupuncturation, by Franklin  Bache,
  M.D.  Philadelphia.—Am. Cyclopedia of
  Practical Medicine and Surgery, vol. i. p.
  200.                            1834.
Anaplastic Operation for removal of a de-
  formity caused by a hole in the forehead,
  left  by Syphilitic Necrosis of the whole
  external table of the Os Frontis, by John
  Watson, M.D.   New York.—Am. Journ.
  Medical Sciences, vol. viii. N.  S.  p. 537.
                                  1844.
Rhinoplasty, Blepharoplasty, and  Cheilo-
  plasty, in the  same  patient, by F. H.
  Hamilton, M.D.   Buffalo.—Buffalo Med.
  Journ., vol. iv. p 549.           1849.
Erectile Tumor of the Face, successful liga-
  ture of the Primitive Carotid, use of thirty
  needles heated to a red heat,  (relieved,)
  by James D. Trask, M.D.  White Plains,
  N. Y.—Am. Journ. Med. Sci.,  vol. xviii.
  N. S. p. 86.                      1849.
A Horn (seven inches long and five broad
  at the base) excised from  the Face, by
  Frank H. Hamilton, M.D.   Buffalo.—
  Buffalo Medical Journal, vol.  vi. p. 13.
                                   1850.
Gunshot wound of face, by L.  A.  Dugas,
  M.D. Georgia.—Southern Med. and Surg.
  Journ., vol.  viii. N. S. p. 404.      1852.
Tic Douloureux, Relief by removing a por-
  tion of the Infra-Maxillary Nerve  by Tre-
  panning the Lower  Jaw, by J.   Mason
  Warren, M.D.  Boston.—Am Journ. Med.
  Sciences, vol. xxv. N.  S. p.  85.     1853.
Excision of a portion of the Inferior Maxil-
  lary Nerve for Neuralgia, by S. Parkman,
  M.D.  Boston.—Am.Journ.Med.Sciences,
  vol. xxv. N. S. p. 95.             1853.
Salivary Fistula, by F.  H.  Badger, M.D.
  Tenn.— Western Journ. of Med. and Surg.,
  vol. ii New  Series, p. 439.        1854.
Deformity of the face,  by J. F. Sanford,
  M.D.  Keokuk, Iowa.—New Orleans Med.
  and Surg. Journ., vol. xi.  p.  217. 1854.
  From the Trans, of the Iowa State Medical
  and Chirurgical Society.            1854.
Salivary Calculus, by  H. H. Pusey, M.D.
  Kentucky.— Western Journ. of Med. and
  Surg., vol. iii. N. S. p. 339.       1855.
Exsectionof thetrunk of theSecond Branch
  of the fifth pair of nerves, beyond the gan-
  glion of Meckel, for sev ere neuralgia of the
  face, with three Cases, by J. M. Carnochan,
  M.D.  New York.—Am. Journ.  Medical
 - Sciences, vol. xxxv. N. S. p. 134.   1858.
Trephining the Lower Jaw for Neuralgia, by
  J. Mason  Warren, M.D.   Boston.—Am.
  Journ. Med. Sci., vol. xxxvi. N. S. p. 574.
                                   1858. 
232
PRINCIPLES AND PRACTICE  OF SURGERY.
   OPERATIONS ON THE EXTERNAL
                  NOSE.

  Rhinoplastic Operation, (being t he first suc-
   cessful Case in the United States,) by J.
   Mason Warren, M.D.  Boston.—Boston
   Med.  and Surg. Journ., vol. xvi.  p.  69.
                                    1837.
  Rhinoplastic Operation, by J. Mason War-
   ren, M.D.  Boston.—Am. Journ. Medical
   Sciences, vol. xx. p. 269.           1837.
  Rhinoplastic Operation, by Thomas D. Mut-
   ter, M.D.  Philadelphia.—Am. Journal
   Med. Sciences, vol.  xxii. p. 61.      1838.
 Rhinoplastic Operations, by J. Mason War-
   ren, M.D.  Boston.—Boston Medical and
   Surg.  Journ.,  vol. xxii. p. 264.   1840.
 Autoplastic Operations, by J.  Mason War-
   ren, M.D. Boston.—Boston Med. Journ.,
   vol. xxii. p. 268.                 1840.
 Taliacotian Operation, flap divided seventy-
   two hours afterthe Operation, (successful
   two years afterwards,) by J. Mason War-
   ren, M.D.  Boston.—Boston Medical and
   Surg. Journ., vol. xxviii. p.  69.   1843.
 Rhinoplastic Operations, by J.  Pancoast,
   M.D.  Philadelphia.—Operative Surgery,
   p. 345.                          1844.
 Exostosis of Nasal Bones; successfully re-
   moved, by William E. Horner, M.D. Phil-
   adelphia.— Philadelphia Med. Examiner,
   vol. vii. N. S. p. 33.              1851.
 Rhinoplastic Operation, (covering  alas of
   one side.) by B.J.Raphael, M.D.  Louis-
   ville,  Kentucky.—Trans. Med. Journ.,
   vol. i.  N.  S. p.  28.                1851.
 Cases  (two) of Plastic Surgery (Rhino-
   plasty) successfully performed, by David
   Gilbert, M.D.   Philadelphia.— Philadel-
  phia Medical Examiner, vol. vii. N. S. p.
   238.                             1851.
 Rhinoplastic Operation, (Indian method,)
   successfully performed, by Joseph Pan-
   coast, M.D.  Philadelphia.—Medical Ex-
   aminer, vol viii. N.  S. p. 341.      1852.

      ON POLYPI  OF  THE NOSE.

 Inquiry into  the Pathology and Treatment
  of Polypous Tumors of the Nasal Fossas,
  with Observations  on other Tumors in
  various parts of the Body, by John Wat-
  son, M.D.   New York.—Am.  Journ. Med.
  Scienoes, vol. iii. N.  S. p. 325.     1842.
Case  of  Gelatinous  Polypus,  cured with
  Sanguinaria Canadensis, after Extrac-
  tion had twice failed,  by Lewis Shanks,
  M.D.  Tennessee.—Am. Journ. Med. Sci-
  ences, vol.  iv. N. S.  p.  368.        1842.
A Nasal  Operation  for  the  removal of a
  large Tumor, filling up the  entire Nostril
  and extending into the Pharynx, by Val-
  entine  Mott,  M.D.   New  York.— Am.
  Journ.  Med. Sciences, vol. v. N. S. p. 87.
                                  1842.
Removal of a large Polypus from the Nose,
  through the Pharynx, (by a t ape,) by Paul
  F. Eve, M.D.  Georgia. —S»u//t'-rn Med.
  and Surg. Journal, vol. v. p. 466.    1849.
Malignant Polypus of  the Nose. Ligature
  of the Common Carotid Artery,  Death
  with Cerebral Symptoms, by William H.
  Van Buren, M.D.  New York.—New York
  Journ. Med., vol. ii. N. S. p. 297.   1849.
      OPERATIONS  ON THE LIPS.

 Case  of Double Hare-Lip, operated on by
   Isaac Cathrall, M.D.  Philadelphia.—
   Med. Recorder, vol. ii. p. 372.      1819.
 Double Hare-Lip, with Fissure through the
   Hard and Soft Palate, by J. C. Warren,
   M.D.   Boston.—Boston Med. and  Surg.
   Journ., vol. i. p 140.             1828.
 Remarks on the Operation of Hare-Lip, by
   ZadocHowe, M 1). Massachusetts.—Am.
   Journ. Med. Sciences,yol.\\i. p. 414.  1831.
 On the Operation of Hare-Lip, (within the
   week, two cases successfully treated,) by
   A. L. Peirson,   M.D.  Massachusetts.—
   Transylvania Journ. Med., vol. ix. p. 780.
   1836; also, Boston Med. and Surg. Journ.,
   vol. xv. p. 293.                   1836.
 Two Cases  of  Congenital Division of the
   Lip and Palate,, occurring in  the  same
   family, in which Operations were per-
   formed, by Isaac Parrish, M.D.  Phila-
   delphia—Am.  Journ. Medical  Sciences,
   vol. xxii. p. 97.                   1838.
 Insect l'ins  in Cases of Hare-Lip, by Geo.
   Hay ward, M.D.  Boston.—Boston  Med.
   and Surg. Journ., vol. xix. p. 153. 1838.
 Case of Congenital Double Hare-Lip, with
   both Fissures  extending  through the
   Roof of the Mouth and Palate, by  N. S.
   Davis,  M.D.   New  York—Am. Journ.
   Med. Sciences, vol. ii.  N. S.  p. 371. 1841.
 Three  Cases of Hare-Lip, in one of which
   the Operation resulted in Death, reported
   by  F.  H.  Hamilton,  M.D.  Buffalo.—
   Buffalo  Medical Journ., vol.  iv. p. 603.
                                   1849.
 Hare-Lip, Nursing during the  process of
   Union, (without any Strain on the Lip,)
   by J. Mason Warren, M.D.  Bostou.—
   Am. Journ. Med. Sciences, vol. xix. N. S.
   P- 74.                            1850.
On an early Operation in Hare Lip, (within
   24 hours,) by A. L. Peirson, M.D.  Sa-
   lem, Massachusetts.—Boston  Med. and
   Surg. Journ., vol. xlvii. p.  134.    1852.
Mouth Ripped  Open by a Cow's Horn, by
   L. A. Dugas,  M.D.   Georgia.—South-
   ern Med. and Surg. Journ.,  vol. ix  N  S
   P- 209.                           1853!
Cheiloplastic Operation, by Mark Stephen-
   son,  M.D.   New York.   (For  relief of
   Deformity  of  Upper  Lip.)—Xew   York
  Journal of Medicine, vol. xiii. N. S. p. 359.
                                  1854!
New Operation for Labial  Fissures, by 
PAPERS  ON  DISORDERS OF THE HEAD  AND FACE.        233
   J. F. Sanford,  M.D.  Keokuk, Iowa.—
   New  Orleans Medical and Surg. Journ..
   vol. xi. p  217, 1854.  From the Trans, of
    the Iowa State Med. and Chirurg. Society.
                                    1854.

  OPERATIONS  ON THE UPPER  JAW.

 Case of huge Tumor of Superior Maxillary
   Bone, Operated on by Resection, Nov.,
   1820, by H. G. Jameson, M.D.  Balti-
   more.—Am. Med. Record, vol. iv. p. 222.
                                    1821.
 Osteo-sarcoma of  the Upper Jaw, with a
   successful Operation  for  its  removal
   nearly entire, (that is, of both  Superior
   Maxillae as far back as the posterior ex-
   ternal portion, adjacent to the Pterygoid
   Processes,) by David L. Rogers,  M.D.
   New York.—New York Medical and Phys.
   Journ.,  vol. iii. p. 301.            1824.
 Tumor  in the Antrum Highmorianum  ex-
   tirpated, by Clarke Wright, M.D. New
   York.—New York Med. and Phys. Journ.,
   vol. iv.                          1825.
 A Case of Fungus of the Antrum, (carotid
   tied,) by Michael A. Finley, M. D.  Mary-
   land.—Maryland Medical Recorder, vol. i.
   p. 97.                            1829.
 Observations on Tumors of the Upper Jaw,
   by  Horatio G. Jameson,  M.D.  Balti-
   more.—Maryland Med. Recorder,  vol. i.
   p. 102.                          1829.
 Exostosis  of the  Upper Jaw, treated suc-
   cessfully, by  B. A.  Rodrigues,   M.D.
   Pennsylvania.—Am.  Journ.  Med.  Sci-
   ences, vol. xxiv. p. 516.           1839.
 Case of Osteo-sarcoma of the Upper Jaw,
   successfully treated by Extirpation of
   the whole of the Superior Maxillary and
   Malar Bones, and portions  of the Eth-
   moid  and  Sphenoid  Bones,  with  Re-
   marks, by Alexander H. Stevens, M.D.
   New  York.—New York Journ.  of Med.
   and Surg., No. iv. p. 249.          1840.
 Excision of the Upper Maxillary Bone,  by
   R. D.  Mussey, M.D.   Cincinnati.—Am.
   Journ Med. Sciences,  vol. iv. N. S. p. 509.
                                   1842.
 Removal of Upper Maxillary Bone,  success-
   fully  performed, by  J. C. Warren, M.D.
   Boston.—Boston Med. and Surg. Journ.,
   vol. xxvi  p. 9, 1842;  also, Am. Journ.
   Medical Sciences,  vol. iii. N.  S.  p.  506.
                                   1842.
Removal of the Upper Maxillary Bone for
  Cephalomatous  Disease, by J.  C. War-
  ren,  M.D.  Boston.—Boston Med. and
  Surg.  Journ., vol. xxvi. p. 9.       1842.
On Muco-purulent Secretion of the  Antrum
  Highmorianum, by S. P. Hullihen, M.D.
  Wheeling, Virginia.—Boston Medical and
  Surg.  Journ., vol. xxvi. p. 94.      1842.
Amputation  of  the Superior  Maxillary,
  Malar, and Palate Bones, for Disease of
  the Antrum, Recovery, by Daniel Brain
   ard, M.D.   Chicago.—Am. Journ. Med.
   Sciences, vol. xiii. N. S. p. 250.    1847.
 Removal of Superior  Maxilla and apparent
   Cure, Return of  the  Disease,  second
   Operation,  (patient died,) by J. Marion
   Sims,  M.D.  Alabama. — Am.  Journal
   Med. Sciences, vol. xiii. p. 340.    1847.
 Modified Operation for Excision of the Up-
   per Jaw, cured, (without  any incision
   through the cheek,)  by W.  E  Horner,
   M.D.  Philadelphia.—Medical Examiner,
   vol. vi. N. S. p. 16.              1850.
 Observation on Excision of the Superior
   Maxillary  Bone,  illustrated  by  seven
   cases,  by  S.  D. Gross,  M.D.  Louis-
   ville.— Western  Journ.  Med.  and Surg.,
   vol. x. 3d series, p. 185.          1852.
 Resection of Left  Half of the Upper Jaw,
   (successful at the  time, but  disease re-
   turned in 19 months after the operation,)
   by Henry H. Smith, M.D.  Philadelphia.
   —Philadelphia Med. Examiner, vol.  viii.
   N. S. p. 226.                    1852.
 Resection of the Superior Maxillary Bone,
   by  D.Gilbert, M.D.,  Philadelphia, re-
   ported by W  H. Gobrecht, M.D.  Phila-
   delphia.—Medical Examiner, vol. viii. N.
   S. p. 790.                       1852.
 Resection of the Superior Maxillary  and
   Malar Bones, (not malignant, cured,) by
   Daniel Brainard, M.D.  Chicago.—Am.
   Journ. Med.  Sciences,  vol. xxiv. N. S. p.
   131.                            1852.
 Phosphoric Necrosis  of  Maxillary Bones,
   peculiar  to  lucifer  match makers, its
   Pathology and Hygienic Treatment, by
   Hirtley Ryland,  M.D.  St. Louis.—St.
   Louis Med. and Surg. Journ., vol.  xii. p.
   28.                              1854.
 Resection of Superior Maxillary  Bones for
   Medullary Fungus, by M.   Shuppert,
   M.D.  New Orleans.—New York Journ.
   of Medicine, vol. xv. N. S. p. 435.   1855.
 Excision of the Superior Maxillary Bone,
   Recovery, Removal of the Inferior Max-
   illary  Bone, Recovery, by  C. A. Pope,
   M.D.  St. Louis.—St.  Louis  Med.  and
   Surg.  Journal, vol. xv. pp. 339,  340.
                                   1857.
 Resection of the Superior Maxilla for Osteo-
   sarcoma,  Recovery, subsequent Return
   of the Disease and Death, by J. J. Mc El-
   rath, M.D. Arkansas.—New Orleans Med.
   and Surg.  Journ., vol. xv. p. 178.  1858.

   ON IMMOBILITY OF THE JAW.

Case  of  Immobility of the Jaw success-
   fully treated, by Valentine  Mott,  M.D.
   Rutger's College.—Am. Journ. Med. Sci-
   ences, vol. v.  p. 102.              1829.
Case of Immobility of the Jaw, and Talia-
   cotian  Operation, by  Valentine  Mott,
   M.D.  New York.—Am. Journ. Med. Sci-
   ences, vol. ix. p. 47.               1831.
Case of Immobility of the Jaw successfully 
234             PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  treated by Mott's complicated Lever, and
  a Modification of his Operation, by Jesse
  W. Mighels, M.D.  Maine.—Am. Journ.
  Med. Sciences, vol. ix. p. 60.       1831.
On Immobility or incomplete Muscular An-
  chylosis of the Jaw, by William E.  Hor-
  ner, M.D.  Philadelphia.—Am.  Cyclope-
  dia  of Med. and  Surg., vol. i. p.  470.
                                  1834.
Subcutaneous Division  of  the  Masseter
  Muscle, (for Anchylosis of the Jaw,) by
  J. W.  Schmidt. M.D.   Newr York.— Am.
  Journ. Med. Sciences, vol. iv. N. S. p. 516.
                                  1842.
Two Cases  of  Immobility  of the Lower
  Jaw   successfully  treated,  by  Daniel
  Brainard, M.D.  St. Louis.—Am. Journ
  Med. Sci.. vol. vi.  N. S. p. 374.     1843.
Claims to Priority in the  Division of the
  Masseter  Muscle, etc., in Immobility of
  the  Inferior  Maxilla, by John  Murray
  Carnochan,  M.D.   New York.—Mott's
  Velpeau by Townsend, vol. ii. p. 20, Ap-
  pendix.                         1847.
Immobility of the Jaw  relieved by Mott's
  Dilator, by Paul F Eve,  M.D.  Georgia.
  —South. Med. and Surg. Journ., vol. vi.
  p. 257.                          1850.
Case of  Immobility of the Lower Jaw from
  Adhesions, the Result of Salivation, re-
  lieved by an Operation, by P. Calhoun,
  M.D.  Louisiana —Charleston Med. Journ.,
  vol. v. p. 43.                    1850.
Case of Immobility of the Lower Jaw cured
  by the Division of the Masseter Muscles,
  by James R. Wood, M.D.   New York.—
  New York Journ. Med., vol. v. N. S.  p.
  423.                             1850.
Cases  of Immobility of the Inferior Maxil-
  lary Bone produced  by the Abuse  of
  Mercury, by H. H. Toland, M.D.  Cali-
  fornia.— Charleston Med.and Surg. Journ.,
  vol. iii. p. 145.                   1853.
Operation  for  Immobility  of the Lower
  Jaw,  by  J.  F.  Gaston, M.D.  South
  Carolina.—Charleston Med. Journ., vol.
  viii. p. 895.                     1853.
Case of False  Anchylosis  of the Lower
  Jaw, by C. S. Fenner, M.D.  Memphis,
  Tennessee.—Am.  Journ. Med. Sciences,
  vol. xxviii. N. S. p. 131.          1854.
Immobility of the Jaw, of  fourteen years'
  standing, cured by extensive section of
  the  muscles, by  J.  F.  Sanford,  M.D.
  Keokuk, Iowa.—New Orleans Med. and
  Surg.  Journ., vol. ii.  p. 217, 1854, from
  the Trans, of the Iowa State Med. and Chi-
  rurg.  Soc.                       1854.
 OPERATIONS ON THE LOWER JAW.

Excision of nearly one-half of the Inferior
  Maxillary Bone  for Osteo-sarcoma,  in
  1810, by W. H. Deaderick, M.D.  Athens,
  Tenn., (claiming justly to be the first
  operation of the  kind ever performed,
  being two years before that of Dupuy-
  tren.)—Med. Recorder, vol.  vi. p. 516,
  1823, also Am. Journ. Med. Sciences, vol.
  xiii. N. S. p. 521, published in 18 17, but
  done in                         1810.
Case  of Fracture of the Inferior Maxilla
  successfully treated by the Seton, by P.
  S. Physick, M.D.  July, 1822 —Philada.
  Journ. Med.  and Phys. Sciences, vol. v. p.
  116.                            1822.
Case of Osteo-sarcoma, in which the right
  side of the Lower Jaw was removed suc-
  cessfully after tying the Carotid, by Val.
  Mott, M.D.  New York, 1821.—New York
  Med and Phys. Journ.,vol. i. p. 385. 1822.
Second Case of Osteo-sarcoma,  in  which
  the left Carotid was  tied, and a portion
  of the Lower Jaw removed successfully.
  March, 1823, by V. Mott. M.D., N. York.
  —New York Med. and Phys.  Journ., vol.
  ii. p. 157.                        1823.
Third Case of  Osteo-sarcoma on the right
  side of  the  Lower Jaw removed at the
  Articulation, the Carotid tied, (died the
  fifth day,) by Val. Mott,  M.D , N. York,
  1823.—New  York Med. and Phys. Journ.,
  vol. ii. p. 401.                   1823.
Removal of nearly one-half of the Lower
  Jaw,  by  Thos. Hunt,  M.D.  Natchez,
  Miss.—Phila.  Med. Recorder, vol. vii. p.
  682.                            1824.
Case of Amputation of part of the Lower
  Jaw,  by Jno. Wagner,  M.D.  Charles-
  ton, S.  C.—New York Med. and Phys.
  Journ.,  vol. v. p. 533, 1826;  also, Am.
  Journ. Med.  Sciences.              1824.
Removal of half of the Lower Jaw Bone for
  Osteo-sarcoma, cured, by J. C. Warren,
  M.D.—Boston Med. and Surg. Journ., vol.
  i. p. 90.                         1828.
Amputation of the  Lower Jaw for  Osteo-
  sarcoma, cured, by J. Randolph,  M.D.
  Philadelphia,  July, 1829.—Am. Journ.
  Med. Sciences, vol. v. p. 17.       1829.
Extract from  a  Report of a Committee
  upon the subject of Osteo-sarcoma of the
  Lower Jaw, to a Medical  Society in New
  York, April  1,1830, by David L Rogers,
  M.D , Chairman.—Am. Journ. Med. Sci-
  ences, vol. vi. p. 533.             1830.
Longitudinal Section of the Lower Jaw for
  the removal of a Tumor,  by J.  Rhea
  Barton, M. D. Philadelphia.—Am. Journ.
  Med. Sciences, vol. vii. p. 331.      1831.
Case  of Osteo-sarcoma of the Lower Jaw
  successfully treated  by  Amputation of
  the Bone, by W. W. Anderson, M.D.  S.
  Carolina.—Am. Journ. Med. Sciences, vol.
  x. p. 315.                        1832.
Case of Exsection of half of the Lower Jaw,
  (disarticulated,) by George W. Campbell,
  M.D.  Tenn.—Trans. Journ. Med., vol.
  vi.  p. 400.                       1833.
Amputation of nearly  half of the  Lower
  Jaw, by Paul F. Eve, M.D.  Georgia.__ 
PAPERS  ON  DISORDERS OF THE HEAD AND FACE.         235
   Am. Journ. Medical Sciences, vol.  xxiii.
   p. 261.                          1839.
Osteo-sarcoma and Excision of a large por-
   tion of the Lower Jaw, by J. Wort, M.D.
   Indiana.—Am. Journ. Med.  Sciences, vol.
   xxvi. p. 260.                     1839.
Osteo-sarcoma of the Lower Jaw, removed
   by Dr. Batchelder,  June,  1825.  Re-
   ported by S. W. Williams, M.D.   Deer-
   field.—Boston Med. and Surg. Journ., vol.
   xxii. p. 39.                       1840.
Case of  Excision of  a portion of the Infe-
   rior Maxillary  Bone, by H. H. Toland,
   M.D.   S. Carolina. — Am.  Journ. Med.
   Sciences, vol. i. N.  S. p. 534.      1841.
Osteo-sarcoma of the Lower  Jaw, Ampu-
   tation and Cure, by Charles Bell Gibson,
   M.D.  Baltimore.—Am. Journ. Med. Sci-
   ences,  vol. iv. N. S. p. 277.        1842.
Osteo-sarcoma of the Lower Jaw, Excision
   and Cure,  by James P. Jervey.  M.D.
   Charleston.—Am.  Journ. Med. Sciences,
   vol. viii. N. S.  p. 111.            1844.
Exsection of the Inferior Maxillary Bone,
   by Valentine Mott, M.D.  New York.—
   Am. Journ. Med. Sciences, vol. ix.  N.  S.
   p. 525.                          1845.
Excision of a portion of the Lower Jaw, by
   N. Pinkney,  M.D., U.S. Navy. — Am.
   Journ. Med. Sciences, vol. xii.  N.  S.  p.
   335.                             1846.
Osteo-sarcoma of the Lower  Jaw, Resec-
   tion of the Bone and Cure, by J. Marion
   Sims, M.D. Alabama.—Am. Journ. Med.
   Sciences, vol. xi. N. S. p. 128.      1846.
Osteo-sarcoma of the Lower Jaw, removal
   of the Body of the Bone anterior to its
   angle, without  external incision,  by  J.
   Marion  Sims,   M.D.  Alabama. — Am.
   Journ. Med. Sciences, vol. xiv. N. S.  p.
   370.                             1847.
Fibrous  Tumor of the LowerJaw, in which
   the left half of the Bone was  successfully
   removed, (disarticulated,) by S. D. Gross,
   M.D.  Louisville.—Am. Journ. Med. Sci-
   ences,  vol. xvi.  N.  S. p.  344.       1848.
Exsection and Disarticulation  of the Lower
   Jaw for Osteo-sarcoma, by Geo. C. Black-
   man, M.D.  New York.—Am. Journ. Med.
   Sciences, vol. xvii.  N. S. p. 93.     1849.
Exsection of three inches of  the Inferior
   Maxilla  for Spina  Ventosa,  cured, by
   Paul F. Eve, M.D.— South. Med. and Surg.
   Journ., vol.  vi. p. 261.            1850.
Case of Elongation of the Lower Jaw and
   Distortion of the Face and Neck, caused
   by a Burn, successfully treated by Oper-
   ations, by S. P. Hullihen, M.D.  Wheel-
   ing, Va.—Med.  Examiner, vol. vi. p. 188.
                                   1850.
Resection of  two-thirds  of the Inferior
   Maxilla, (successful,) by Carter P. John-
   son,  M.D.   Richmond.—Med.  Examiner,
   vol. vii. N. S. p. 644.             1851.
Resection of half the Lower Jaw, (success-
  ful,) by  Wm.  Gibson, M.D.  Philadel-
  phia.—Medical  Examiner, vol. vii. N. S.
  p. 30.                           1851.
Resection and Disarticulation of half of the
  Lower Jaw for  Spina Ventosa, by Chas.
  Bell Gibson.  M.D.  Richmond,  Va.—
  Stethoscope, vol. i. p. 144.         1851.
On  the Claims of priority in the Exsection
  and Disarticulation of the Lower Jaw, by
  George C. Blackman,  M.D.    N. Y.—
  N. Y.  Journal  of Med., vol. viii. p.  280.
                                  1852.
Observations on  Excision of the Inferior
  Maxillary Bone, illustrated by five Cases,
  by S. D. Gross,  M.D. Louisville.— West.
  Journ. Med. and Surg., vol. x. 3d series,
  p. 277.                         1852.
Resection of the Chin, with a portion of the
  Body of the LowerJaw, by Isaac Greene,
  M.D.  N. Y.—N. Y. Med. Gazette, vol. iii.
  p. 266.                         1852.
Extirpation of more  than half the Lower
  Jawfora Cancerous Degeneration,(died,)
  by F. II. Hamilton,  M.D.  Buffalo, N. Y.
  —X. Y. Journ. Med.,  vol. viii. N. S. p.  289,
  from Buffalo Med. Journ.
Amputation of the entire Lower Jaw, with
  Disarticulation of  both  Condyles, by J.
  M. Carnochan, M.D. N. Y.—N. Y. Journ.
  Med., vol. viii.  N. S. p. 9.         1852.
Extirpation of the left half of the Lower
  Jaw, with the  Submaxillary Gland  and
  Anterior Lobe of the Parotid, by Jno. G.
  F. Holston,  M.D.   Zanesville,  Ohio.—
  West. Lancet,  vol. xiii. p. 15.      1852.
Amputation of the entire Lower Jaw for Os-
  teo-sarcoma, (patient lived two years  sub-
  sequently, and died of another disease,)
  by J. Ackley.   Cleveland, Ohio.— N. Y.
  Journal of Med., vol. x.  N. S. p. 288.
                                  1853.
Resection of a  portion of the Lower Jaw,
  cured, by Drs. Gaines and  Henry. Hop-
  kinsville, Ky. — West.  Journ. Med.  and
  Surg.,  vol. xi. 3d series, p. 217.   1853.
Excision of a portion  of the  Inferior Max-
  illary Bone for Caries, by W. G.  Bullock,
  M.D.  Savannah.—Am. Journ. Med. Sci-
  ences, vol. xxvi. N.  S. p. 129.      1853.
Cartilaginous Exostosis of Condyle, Ramus,
  and Angle of the Lower Jaw, for which
  Resection,  with removal of the Parotid
  Gland  and Zygomatic Arch, was success-
  fully performed, by Daniel  Brainard,
  M. D.  Chicago.—Am. Journ. Med.  Sci.,
  vol. xxvi. N.  S. p. 397.           1853.
Extensive  Enchondroma  of the  Inferior
  Maxilla, removed by section of  the bone
  from the Symphysis to the angle on the
  right side,  by  D. Gilbert, M.D.  Phila-
  delphia.  Reported by  W. H. Gobrecht,
  M.D.—Med. Examiner,  vol. ix. p.  746.
                                  1853.
Osteo-sarcoma of the  Lower  Jaw,  by C. S.
  Fenner,  M.D.  Memphis,  Tennessee.—
  New Orleans Med. and Surg. Journ.,  vol.
  xi. p. 22.                        1854. 
236
PRINCIPLES AND PRACTICE  OF  SURGERY'.
Necrosis of the Lower Jaw, by G. R. Henry,
   M.D.  Burlington, Iowa. — Am. Journ.
   Med.  Sciences, vol. xxix.  N.  S. p. 126.
                                  1855.
Resection of  the  Inferior Maxillary,  by
   Stanford Chaille, M.D.  New Orleans.—
   New Orleans Med.  and Surg. Journ., vol.
   xii. p. 339.                      1855.
Necrosis of the Lower Jaw, by  J. C. Nott,
   M.D.  Mobile,  Ala. — American  Jour-
   nal Medical Sciences,  vol. xxx.  N. S. p.
   77.                             1855.
Tumor of the Lower Jaw Extirpated, by Ju-
   riah Harris, M.D.  Augusta, Ga —South-
   ern Med. and Surg.  Journal,  vol. xi. N. S.
   p. 406.                          1855.
Necrosis of the Inferior Maxilla from Va-
   por of Phosphorus, by James R. Wood,
   M.D.   New York.—Am.  Journ. Med. Sci-
   ences, vol. xxxii. N. S. p. 288.    1856.
Removal of the Entire Lower Jaw for Os-
   teo-sarcoma, by Prof. G. C.  Blackman,
   M.D.  Cincinnati.—Am. Journ. Med. Sci-
   ences, vol. xxxii. N. S. p. 334.     1856.
Extirpation of the Lower Jaw, by M. Cos-
   grave, M.D   Columbia,  111.—Charleston
   Med. Journ., vol. xiii.  p.  676.      1858.
Resection of the Lower Jaw for Necrosis
   caused by  Inhalation of the fumes  of
   Phosphorus, by Wm.  S. Halsey, M.D.
   Philadelphia.—Am. Journ. Med. Sciences,
  vol. xxxv. N. S.  p. 356.           1858.
Disarticulation and Removal of nearly half
  of the LowerJaw, by C. E. Isaacs, M.D.
  New York.—Am. Journ. Med.  Sciences,
  vol. xxxv. N. S. p.  295.           1858.
    OPERATIONS ON THE MOUTH.

Operation for  the Removal of a large Tu-
  mor on the  Face, by Jas. Webster, M.D.
  Philadelphia.—Phila. Med. Recorder, vol.
  viii. p. 275.                      1825.
Case  of Deformity of  the  Mouth  from a
  Burn, successfully  treated by Dieffen-
  bach's Method,  by T. D. Mutter, M.D.
  Philadelphia.—Am. Journ. Med. Sciences,
  vol xx. p. 341.                  1837.
Plastic  Operations, by J.  Pancoast,  M.D.
  Philadelphia.—Am.  Journ.   Med.  Sci.,
  vol. iv. N. S. p. 337.             1842.
Plastic  Operations, by J.  Pancoast,  M.D.
  Philadelphia.- Am.  Journ.  Med. Sci.,
  vol. v. N. S. p. 99.               1843.
Genioplasty, by  Geo. C. Blackman,  M.D.
  New  York.—Am. Journ. Med. Sciences,
  vol. x. N. S. p. 327.              1845.
A  Case  of  Cheiloplastic  Operation,  by
  Abraham  Stout, M D.  Easton,  Pa.—
  Med. Examiner, vol. vi. p. 13.     1850.
Syncope from  the entrance of Air into the
  Facial Vein during removal of small
  Tumor below the Jaw, by Moses Gunn,
  M.D.    Michigan.—N.  Y. Journ. Med.,
  vol. viii. N.  S. p. 356.            1852.
    OPERATIONS ON THE  TONGUE.

 Amputation of the Tongue for Enlargement,
   (the   portion  amputated  measured—
   length 2|  inches,  circumference  7J
   inches, thickness  H  inches,) cured, by
   H. S.  Newman, Ml).  Warren  County,
   Pa.—Medical  Recorder, vol. vii. p. 541.
                                   1824.
 Case of  Glossitis, attended with Alarming
   Symptoms of  Suffocation, removed  by
   Deep Incisions made into the Substance
   of the Tongue, by Abner Hopton, M.D.
   N. Carolina.—Am. Journ.  Med.  Sci.,
   vol. iv. p. 533.                   1829.
 Operation for Cancer of the Tongue, (cured,)
   by J. C. Warren,  M D.   Boston.—Bos-
   ton Med. and Surg. Journ., vol. ii. p. 157.
                                   1829.
 Chronic Intumescence of the Tongue, (very
   large,) treated bv Amputation,  (cured,)
   by Thos. Harris, *M.D.  Philadelphia.—
   Am. Journ.  Med. Sciences, vol. vii. p. 17.
                                   1830.
 Case of Hypertrophy of the Tongue, (oper-
   ated on,)  by Thomas  Wells, M.D.   Col-
   umbia, S. Carolina.—Am. Journ. Med.
   Sciences, vol. x. p.  35.             1832.
 Carcinoma of  the   Tongue, successfully
   treated with the ligature, by M.  Donnel-
   lan, M.D.   Louisiana.—Am. Journ. Med.
   Sciences, vol. xvii.  p. 540.         1835.
 Case of  Congenital   Enlargement of  the
   Tongue, (Lingua Vitula,) by Thos  Har-
   ris, M D.    Philadelphia.—Am. Journ.
   Med. Sciences, vol.  xx. p. 15.       1837.
 Case of Enlarged Tongue, operated on by
   R. D. Mussey,  M.D.  Fairfield,  N. Y.—
   Am. Journ. Med. Sciences, vol. xxi. p. 394.
                                   1837.
 Removal of Cancer of the Tongue, (believed
   to be rarely successful,) treated  by Geo.
   Hay ward, M.D. Boston. — Boston Med-
   ical and Surgical  Journal, vol.  xix.  p.
   158.                            1838.
Case of Congenital Glossocele,  amputated
   successfully by M. G. Delaney, M.D.,
   U. S. Navy.—Am. Journ. Med. Sciences,
  vol. xvi. N.  S. p. 294.             1848.
Removal of a Foreign Body (Pin) from the
   Duct of Wharton,  by  H. F.  Campbell,
   M.D. Georgia.—Am. Journ. Med. Sciences,
  vol. xv. N. S. p. 572.             1848.
Observations on Ranula, with Cases, Treat-
  ment, and Cure, (iodine injected into tu-
  mor,) by Jas. M. Gordon, M.D. Georgia.
   —Southern Med. and Surg. Journ., vol. v.
  P- 65.                           1849.
Ranula successfully treated by Lead Liga-
  ture, by J. J. Peele, M.D.   Tennessee.—
  Am. Journ. Med. Sciences, vol. xxxvi N S
  P- 283.                          V858!
Obstinate Hemorrhage following division of
  the Fraenum Linguae,  by  A. R. Jackson,
  M.D. Stroudsburg, Pa.— Am. Journ. Med.
  Sciences, vol. xxxvii. N. S. p. 141.   1859. 
PAPERS  ON  DISORDERS OF THE  HEAD AND FACE.
237
   OPERATIONS ON THE THROAT.

 Obstinate Cough, caused by Elongation of
   the  Uvula, in which a portion of that
   Organ was cut off, with a Description of
   the  Instrument employed for that pur-
   pose, and also for Excision of Scirrhous
   Tonsils, by P. S. Physick, M.D.  Phila-
   delphia.—Am. Journ. Med. Sciences, vol. i.
   p. 262.                          1827.
 Case of Consumption (?) relieved by Trun-
   cating the Uvula, by Augustus W. Mills,
   M.D.   Kentucky. — Trans. Journ. Med.,
   vol. ii. p. 530.                   1829.
 Extraction of a Thimble from the Ptery-
   goid Fossa, by IsaacParrish, M.D. Phila-
   delphia.—Am. Journ. Med. Sciences, vol.
   xvii. p. 540.                      1835.
 Cancer of the Throat — Operation — Reco-
   very—but the patient subsequently died
   of Peritonitis, (remarkable transposition
   of all the organs,) by J. Mason Warren,
   M.D.  Boston.—Am. Journ.Med. Sciences,
   vol. xix.  p. 120.                 1836.
 Snoring prevented by excision  of Uvula,
   by L. A. Dugas, M.D.  Georgia.—South-
   ern Md. and Surg. Journ., vol. viii. N. S.
   p. 612.                          1852.
 Extirpation of Pharyngeal  Tumors,  by L.
   A Dugas, M.D. Georgia.—Southern Med.
   and Surg.  Journ., vol. ix. N.  S. p. 264.
                                   1853.

   OPERATIONS ON THE TONSILS.

 The Double Canula and Wire Ligature, re-
   commended  in Extirpating Tonsils and
   HaemorrhoidalTumors, by P. S. Physick,
   M.D.  Philadelphia.—Phil. Jour, of Med.
   and Phys. Sciences, vol. i. p. 17.     1820.
 Treatment of Enlarged and Indurated Ton-
   sils, with a New Mode (ligature) of Re-
   moving these and Polypous Tumors, by
   Alexander H. Stevens, M.D. N. York.—
   N. Y. Med. and Phys. Journ., vol. vi. p.
   523.                             1827.
 On an Improved Instrument for Excising
   the Tonsils and Uvula, by C. B. Matthews,
   M.D.  Philadelphia.—Phil. Medical Re-
   corder, vol. xiii. p. 309.           1828.
 Remarks  on the various Modes generally
   adopted for the Removal of the Tonsils,
   by Alex. E. Hosack, M.D.  New York.—
   N.  Y.  Journ. Med. and Phys.  Sciences,
   vol.  i. p. 262.                   1828.
Description of a Forceps used to facilitate
   the Extirpation of the Tonsils, and  In-
   vented by  P. S. Physick,  M.D.   Phila-
   delphia.—Am. Journ. Med. Sciences, vol.
   ii. p.116.                       1828.
Remarks on Enlarged Tonsils, with a new
   Instrument  for excision,  by Abroi. L.
   Cox, M.D.  New York.— N. Y. Med. and
  Phys Journ., vol. ii. N. S. p. 52.  1830.
New Instrument for Excising the Tonsils,
  by David L. Rogers, M.D.  New York.—
  N Y. Med.  and Phys. Journ.,  vol. ii.
  N. S. p 13.                     1831.
A new Instrument, for Extirpating the Ton-
  sils, by J. K  Mitchell, M.D.  Philadel-
  phia.—North Am. Med. and Surg. Journ.,
  vol. xi. p. 239.                  1831.
An Essay on Excision of the Tonsils with
  an Instrument, by George  Bushe, M.D.
  New York.—Med.  Chirurg. Bulletin,  vol.
  ii. p.  161.                       1832.
Description  of an  Instrument for the Ex-
  cision of the Tonsils, by Wm. B.  Fahne-
  stock, M.D. Pennsylvania.—Am. Journ.
  Med. Sciences,  vol.  xi. p. 249.     1832.
Instrument for the Excision of Tonsils, by
  N. R. Smith, M.D.   Baltimore.—North
  Am. Archives, Med  and Surg. Sciences,
  vol. i. p.  88.                    1835.
On  the Common Induration of the Tonsils,
  and a Description  of an  Instrument for
  their Excision, by JohnC. Warren, M.D.
  Boston.—Suryical  Obs. on Tumors,  with
  Cases and Operations, Boston.     1839.
Remarks on the  Enlargement of the Ton-
  Bils, attended  by certain Deformities of
  the Chest,  by J. Mason Warren, M.D.
  Boston.—Am. Journ. Med.  Scitnces,  vol.
  xxiv.  p. 523.                    1839.
Tonsilotomy,  Profuse  Hemorrhage,   by
  F. H. Hamilton, M D.  Buffalo.— Buffalo
  Med. Journ., vol. iv. p. 217.       1849.
Case in which a large Thimble remained
  for two weeks in the Posterior Nares with-
  out detection, (removed,) by Richard L.
  Howard,  M.D.   Columbus, Ohio.—Ohio
  Med.  and Surg.  Journ., vol.  v. p. 245.
                                  1853.
Excision of the Tonsils, by C. Green, M.D.
  New York.—New York Journal of Medi-
  cine, vol.  xii. N.  S. p. 153.        1854.
On  Excision  of the  Tonsils, by J. Mason
  Warren, M.D.—Am Journ Med. Sciences,
  vol. xxxiv. N.  S. p. 287.          1857.

        ON  STAPHYLORAPHY.

Suture of the Palate in Infancy, believed
  to have been successfully performed by
  Nathan Smith,  M.D.  Yale  College.—
  N. Y. Med. and Phys. Journ., vol. v. p.
  525.                             1826.
Staphyloraphy successfully performed, by
  A. H. Stevens, M.D.  N. Y.—North Am.
  Med. and Surg. Journ.,  vol. iii.  p. 233.
                                  1827.
Operation in May, 1824,  for the Cure of
  Natural Fissure of the Soft Palate, (the
  first in America, and performed without
  knowledge of  the operations of  Roux,)
  by J. C. Warren, M.D.  Boston.—Am.
  Journ. Med. Sciences, vol. iii. p. 1.   1828.
Extensive Division of the Soft Palate (from
  a wound)  sewed with Physick's Needle,
  etc.,  by Thos. Wells, M D.   Columbia,
  S. C.—Am. Journ. Med. Sciences,  vol. x.
  p- 32.                           1832. 
238
PRINCIPLES  AND  PRACTICE  OF  SURGERY.
Observations on Staphyloraphy with a new
   Instrument, by N. R. Smith, M.D.   Bal-
   timore.—North Am. Archives,  vol. i. p.
   27.                             1835.
Congenital Fissures of the Palate operated
   on, by James Deane, M.D.  Greenfield,
   1837.—Boston Med. and Surg. Journ., vol.
   xvi. p. 333.                     1837.
On Staphyloraphy, by Jno. P. Mettauer,
   M.D.  Va.—Am.  Journ.  Med. Sciences,
   vol.xxi. p. 309.                  1837.
On the Use of the Interrupted Suture in
   Cases of Cleft Palate, (with a description
   of a needle for it and hare-lip,) by E. H.
   Dixon, M.D.  New York.—Boston Med.
   and Surg. Journ., vol. xxv. p.  329.  1841.
Cases of Cleft Palate, (treated by Physick's
   Needle,)  by Thos.  D.  Mutter,  M.D.
   Philadelphia.—Am. Journ. Med. Sciences,
   vol.  ii. N. S. p.  74.               1841.
On Staphyloraphy, by Jos. Pancoast, M.D.
   Philadelphia.—Am. Journ. Med. Sciences,
   vol.  vi. N. S. p. 66.              1843.
Operations for Fissures  of the  Soft  and
   Hard Palate, by J. Mason Warren, M.D.
   Boston.—Am. Journ. Med. Sciences,  vol.
   vi. N. S. p. 257.                  1843.
Operation for Fissure of the Hard and  Soft
   Palate, with the result  of 24 Cases, by
   J. Mason Warren,  M.D.   Boston.—Am.
   Journ. Med. Sciences, vol. xv. N. S. p. 329.
                                  1848.
On Fissure  of the Palate,  by J.  Mason
   Warren, M.D. Boston.—Am. Journ. Med.
   Sciences, vol. xxv. N. S.  p. 95.     1853.

     OPERATIONS ON THE  EAR.

Extraction of Foreign Substances from the
  Ear, (by means of  a thread  attached to
  the article by gluing with shell-lac,) by
  Charles Hooker, M.D.  New Haven.—
  Boston Med. and Surg. Journ., vol. x. p.
  317.                            1834.
Polypi of the Meatus Auditorius Externus
  removed  by Ligature,  by E. J. Daven-
  port, M.D.   Boston, 1837.—Boston Med.
  and Surg. Journ., vol. xvii. p. 235.   1837.
 Congenital Absence of the Meatus Audito-
  rius Externus of both Ears without much
  impairing the hearing, by R. D. Mussey,
  M. D.  Fairfield, N. Y.— Am. Journ. Med.
  Sciences, vol. xxi. p. 377.          1838.
 On the Extraction of Foreign Bodies from
  the  Meatus Auditorius Externus, by J.
  Marion  Sims,  M.D.  Alabama.—Am.
  Journ. Med. Sciences, vol. ix. N. S. p. 336.
                                   1845.
 Fibrous Tumor removed from the Lobe of
  the Ear, by Geo. W. Norris, M.D.  Phil-
  adelphia.—Am. Journ. Med. Sciences, vol.
  xx. N. S. p. 557.                 1850.
 Maggots, probably  40, in the  Ear,  (from
  previous entrance of a fly,) removed, by
  Frank H.  Hamilton,  M.D.   Buffalo.—
  Buffalo Med. Journ., vol. vi.  p. 10.   1850.
 Contributions to Aural Surgery, Analysis
  of 140 Cases of Diseases of the Ear, by
  Edward H. Clark, M.D.  Boston.—Am.
  Journ. Med. Sciences, vol. xxiv. N. S.  p.
  31.                              1852.
 On  Obstruction of the Pharyngeal Orifice
  of the Eustachian  Tube, by Jno.  Neill,
  M.D.   Philadelphia.—Med.  Examiner,
  vol. ix. p. 626.                    1853.
 Thickening of Membrana Tympanum, by
  James Cowling, M.D.  N. O.—New Or-
  leans Med.  and  Surg. Journ.,  vol.  ii.  p.
  463.                             1855.
 On  the Remote Causes  of  Deafness,  by
  Dudley Peet, M.D. N. Y.—Southern Med.
  and Surg. Journal, vol. xii. new series,  p.
  680.                              1856.
Observations  on  the Causes,  Effects, and
  Treatment  of Perforation of the Mem-
  brana Tympani, by  Edward  H.  Clarke,
  M.D. Mass.—Am.  Journ. Med.  Sciences,
  vol.  xxxv.  N. S. p. 13.            1858.
Foreign Body in the Ear,  by Jas. Corse,
  M.D.  Philadelphia.—Am. Journ. Med.
  Sciences, vol. xxxvi. N. S. p. 408.   1858.
Removal of Foreign Bodies from the Ear,
  by W. L. Archibald, M.D.   Miss.— Am.
  Journ. Med. Sciences, vol. xxxviii.  N.  S.
  p. 281.                           1859. 
                      PAET   XIII.

DISORDERS OF, AND OPERATIONS ON, THE NECK AND
                              TRUNK.
                          CHAPTER  I.

                 SURGICAL ANATOMY OF THE NECK.

  The Neck is that region of the body which is situated between the head and
the trunk, being bounded above by the base of the jaw, mastoid portion of
the temporal bone, and occipital part of the skull, and below by the clavicles,
sternum, and scapula?.   In  its general outline, this region is  cylindrical or
cylindroid, with the base upon the shoulders.   On the front and sides it is
decidedly convex, presenting certain well-marked prominences, which, by
establishing fixed  points of  reference, are highly useful to the surgeon.  On
its posterior face it is flat and regular, presenting nothing demanding special
notice.
  The prominences and depressions seen on the front of a well-formed neck
indicate the position of certain important organs which are often objects of
solicitude to an operator.  Thus immediately above the sternum, in the me-
dian line of the neck, is a depression called the supra-sternal fossa, near or in
which are usually found the roots of the large blood-vessels directly connected
with the heart as well as several important nerves.  Above this, in the me-
dian line, is the prominence caused by the  larynx and trachea; and a little
outwardly on each side of this line may be seen the elevation caused by the
sterno-cleido-mastoid muscle.   In front of this muscle, or between it and the
trachea, is the carotid fossa or depression, where, from the superficial  posi-
tion  of the vessel, its pulsations may be readily felt.  At the base of the neck,
near the clavicles and exterior to  the sterno-cleido-mastoid  muscle, is the
supra-clavicular  depression or fossa, containing  part of the subclavian
artery and vein, together with some other vessels of importance; and at its
upper portion, in the space adjoining the base of the jaw, are the parotid and
supra-hyoid regions, which contain several important parts  that will be here-
after referred to more in detail.
  The cylindrical shape of the neck, and the enlargement at its base, render
the smooth application of a broad bandage around it nearly impossible, and
it  will hence be generally found  necessary either to make  all such pieces of
dressing quite narrow, or to give them a curved  shape on the lower edge like
that  seen in the stocks worn by men as an article of dress, in order to enable
them to fit the clavicular portion of this region.  A similar shape will also
                        %                                (239) 
240
PRINCIPLES AND  PRACTICE OF SURGERY.
be requisite to  adapt them to the upper and lateral parts of the neck, and
especially to the outline of the chin and sides of the jaw.
  Owing to the great importance of the various organs contained within the
neck, and the necessity of an accurate knowledge of their relations to each
other, it has been found advantageous to divide it into numerous sections or
departments, either by imaginary  lines or by following the course of well-
known muscles.   Each of these  sections demands special attention, the ad-
vantages of such a subdivision being found in the facility as well as accuracy
with which the  position of the contents may  be recognized.  Of the various
regions thus created by anatomists, none seems to  me to present points of
greater practical  utility than that employed by Blandin, in his  Anatomie
Topographique,  and the following  descriptions will, therefore,  be  based
mainly on the accounts furnished by him. In mapping out the regions  of the
neck, Blandin has divided its anterior or Tracheal surface into those parts
which  are above  and those below the os hyoides, and into such as are more
or less closely connected with the course of the sterno-cleido-mastoid muscle.
Of  the portion  above the os hyoides, he makes two regions, one of the Su-
pra-Hyoid or Hyo-glossal region, being the portion near the chin, and the
other that about the parotid gland or the parotid region.   The parts  below
the os hyoides, on the front of the neck, he divides into the Laryngo-Tra-
cheal and the Supra-Sternal regions, while those on the sides are designated
as the Sterno-Mastoid, Carotid, and Supra-Clavicular regions.  The bound-
aries of these regions being, however, purely conventional, we  find that in
mapping them  out  there is  some difference  in the descriptions of different
writers.
  By some of the English anatomists* the disposition has been shown to ap-
portion the neck  into regions of a more mathematical character than  those
adopted by Blandin.   Thus, on the  neck being extended,  one-half of it is
made to take the form of an elongated square, which square is divided by the
course of the sterno-cleido-mastoid muscle into two triangles, one near the
clavicle and the other near the jaw, in both  of which are parts of vital im-
portance.   But though  upon the subject such a formation  of regions may
answer the descriptive purposes of the anatomist, it will not prove as  useful
to the surgeon as that adopted in the following pages, from the fact that any
difference in the extension of the neck must  cause the diagonal line to vary,
and thus render the relations of the various parts incorrect, unless the utmost
possible tension of the muscle is always obtained.   As considerable experi-
ence has satisfied  me of the practical utility of the system adopted by Blandin,
it is recommended to the study of those who desire to obtain such a minute
knowledge of this important section of the body as will fit them for the  duties
of the operator.

                             SECTION I.

        THE STJPRA-HYOID OR GLOSSO-HYOID REGION OF THE NECK.

  The Glosso-hyoid portion of the  neck is  bounded above by the inferior
part of the tongue or base of the lower jaw; below, by the os hyoides ; and
laterally by a line drawn from the  angle of the jaw to the extremity of the
greater cornu of the hyoid bone, or by the expansion of that process of the
fascia superficialis cervicis which is attached  to the stylo-maxillary ligament
and angle of the jaw, Plate XXIX. Fig. 1.  The skin of this part presents
nothing requiring special description.   Its muscles consist of a portion  of the
* Surgical Anatomy, by Joseph Maclise.  Philadelphia, edit. 1851. 
THE PAROTID  REGION.                     241
platysma-myodes, of the  anterior belly of the digastric, of the mylo-hyoid,
genio-hyo-glossus, hyo-glossus, and a part of the  stylo-glossus, all covered by
a fibrinous expansion or fascia.   This fascia—being the second tegumentary
covering of the neck, as of several other portions of the body—is attached in
this  region to the os hyoides and  base of the jaw.  It sends  a triangular
process over the muscles at this part,  surrounds the submaxillary gland, and
then, by attaching itself to the stylo-maxillary ligament and angle of the jaw,
places the submaxillary gland in a kind of pouch, which separates it by a per-
fect  septum from the anterior and inferior portion of the parotid gland, Plate
XXIX.  Fig. 1.   This reflection of the fascia superficialis and its attachment
to the stylo-maxillary ligament is a valuable point of reference in  operating
on this and the adjacent  regions.  It also exercises a material influence on
the disorders of the part,  by preventing suppurations in the neighborhood of
the parotid or submaxillary  glands from communicating or traveling either
forward or backward; it has also considerable influence on the development of
tumors and their subsequent  shape  and condition.
  The principal Arteries  found in this region are the facial, lingual, and sub-
lingual, Plate XXIX.  Fig. 5.
  The Veins generally follow the course  of  the arteries, except the lingual
vein, which, it should be  remembered, is  separated from its corresponding
artery by the hyo-glossus  muscle.
  The  Nerves  are the hypo-glossal, lingual, glosso-pharyngeal,  and their
branches, Plate  XXIX. Fig. 3.
                             SECTION II.

                          THE PAROTID REGION.

   The Parotid region of the neck comprises its superior and lateral portions,
 and, though limited in extent, is  of the  highest importance to the surgeon.
 Bounded in front by the ramus of the inferior maxillary bone ;  behind, by the
 mastoid  process of the temporal as well as by the meatus externus of the ear ;
 above, by the zygomatic arch; below, by a horizontal line drawn a little be-
 low the level of the angle of the jaw; and within, or in its deeper points, by
 the styloid process of the temporal bone, as well as by the stylo-maxillary and
 stylo-hyoid ligaments ; this region  is closely circumscribed by dense tissues,
 and is generally accurately filled up by the parotid gland and its vessels.
 The muscles near the gland are the sterno-cleido-mastoid behind,  to which,
 when enlarged, the posterior edge of the gland is  often firmly attached, and
 the posterior belly of the digastric; the styloid muscles are within, or at the
 deepest side of the gland.
   The Parotid Gland, in its normal condition, being seated between the an-
 gle of the jaw and the mastoid process of the temporal bone, is limited to
 these points; but, when diseased,  will be found  to encroach considerably
 upon the surrounding parts.  Owing, however, to the expansion of the super-
 ficial fascia, and its attachment to the angle of the jaw, as before stated, the
 parotid is separated from the submaxillary gland,  and  cannot, therefore,  ex-
tend itself to any great degree forward.   The styloid process  and  ligaments
limiting its deeper progress, and  the sterno-mastoid muscle resisting its pos-
terior development, nothing is left it but to enlarge outwardly or toward the
skin; and, as its progress  in this direction is resisted  by the portion of the
fascia superficialis, which covers it and forms its capsule, the engorgement of
this gland generally causes severe pain by pressing on the neighboring nerves.
The dense character of the  fascia, and its strong adhesions around the gland,
     vol. n.—16 
PLATE   XXIX.
               THE SURGICAL ANATOMY  OF  THE NECK.

  Fig. 1. A side view of the arrangement of the Fascia of the Neck.  1. Parotid
gland. 2. Masseter muscle. 3. Submaxillary gland.   4. Os hyoides.  5. A por-
tion of the fascia superficialis, dissected from the side of the face, and  held down
to show  its relations to the stylo-maxillary ligament and  angle of the jaw,
together  with  the  septum which separates the parotid from the submaxillary
gland. 6. Deep process of  the fascia superficialis which forms the septum just
spoken of.  7. Internal jugular vein just beneath the angle of the jaw.  8. Deep
cervical fascia.  9. Sterno-hyoid muscle partly displayed.        After Nature.
  Fig. 2. A view of the Superficial Vessels of the Neck.   1. Inferior maxillary
bone.  2. Lingual artery.   3. Os hyoides.  4. Superior thyroid artery.   5. De-
scending branch.  6. Position of the carotid artery.   7. Sternal  origin of the
sterno-cleido-mastoid muscle.   8. Clavicle.  9.  External jugular  vein.   10. Its
anterior branch.  11. Parotid gland and veins near the angle of jaw.
                                                After Bernard and Huette.

  Fig. 3.  A view of the Deep-seated Parts of the Neck.  1. The oesophagus.  2.
Omo-hyoid muscle.   3. Par vagum nerve.  4. Internal jugular vein.   5.  Carotid
artery. 6. Digastric tendon. 7. Hypo-glossal nerve.  8. Facial artery. 9. Facial
vein.  10. Occipital and internal maxillary veins.  11. External carotid artery
seen after the removal of the parotid gland.  12. Masseter muscle.  13. Pectoral
muscle and clavicle.   14. Hook holding aside the external jugular vein.
                                                After Bernard and Huette.

  Fig. 4. A front view of the Veins of the Neck.  1, 1. Base of the lower jaw.
2. Os hyoides.  3, 3. Internal jugular vein.  4.  Omo-hyoid muscle.  5.  Larynx.
6. Sterno-hyoid and thyroid muscles. 7, 8. Superficial veins.  9. External jugu-
lar vein.  10. Sterno-cleido mastoid muscle.        After Bernard and Huette.

  Fig. 5. A side view of the oesophagus and adjacent parts.  1.  Facial artery
and vein  passing on to the face.  2. Lingual artery.  3  Os hyoides. 4. Superior
thyroid artery.  5. (Esophagus.  6. Trachea.  7.  Inferior thyroid artery.  8. Ster-
no-cleido-mastoid, cut across.   9. Primitive  carotid.   10. Internal jugular vein.
11. Upper portion of the sterno-cleido-mastoid muscle.
                                               After Bernard and Huette.
       (242) 
Plate  29
Fig.l
Fig.3.
 
 
       THE  LARYNGO-TRACHEAL  AND  SUPRA-STERNAL REGIONS.   243

have also an important influence upon the blood-vessels connected with it.  In
two cases which occurred under my observation, it led to the entire oblitera-
tion of the carotid artery, and in one, to that of the internal jugular vein, as
well as the artery.  When enlarged by scirrhus or similar deposits, the shape
of parotid tumors is always at first more or less flattened in consequence of
this expansion of the fascia over the surface of the gland, though ultimately
they may attain considerable size and a globular form.  Having no proper
capsule,  in the normal  condition, the parotid gland owes its shape, and the
continuity of its  structure, to connective tissue, the  induration of which, as
well as its adhesion to the fascia just alluded to, renders the extirpation of the
gland  much more easy when diseased than it is in the healthy condition.
   The Arteries of the parotid region are numerous, and among the most im-
portant of those found in the neck.  The External Carotid,  entering at the
inferior and  internal  portion of the gland, passes through its substance not
far from  its internal or deeper-seated surface, and extends between the ramus
of the jaw and the ear to near the level of the  neck of the jaw-bone, when it
gives  off the internal maxillary and the temporal arteries.   The  Internal
Maxillary, winding around the neck of the bone between the pterygoid mus-
cles, is hence difficult to ligate,  and sometimes  gives rise to considerable re-
current hemorrhage, even after the application of a ligature to the external
carotid of  the same side, as I have seen  in three instances.  The Veins fol-
low pretty generally the course and distribution of the arteries; but, owing
to their direct connection with the internal jugular vein, caution is requisite
in opening them,  lest air be introduced into the latter vessel, whence it may
readily pass to the heart and cause death.
  The principal Nerve  of this part  is the portio dura, which, emerging at
the stylo-mastoid foramen, penetrates the substance of the gland'from above
downward and forward.    Lymphatic glands are also found, in considerable
numbers, Plate XXXIII. Fig.  1, around as well as beneath the structure of
the parotid, and the disease of  these glands has occasionally rendered the
diagnosis of tumors in the parotid region difficult, and led to mistakes in re-
spect to the structure involved in the complaint.
                            SECTION III.

         THE LARYNGO-TRACHEAL  AND  SUPRA-8TERNAL REGIONS.

   The middle of the front of the neck, presenting points directly connected
 with  the  trachea  and  larynx, has  been  named the Tracheal region, and is
 formed by that portion which is bounded laterally by the anterior edges of
 the sterno-mastoid muscles.  The part of this surface above the os hyoides
 has already been spoken of as the supra-hyoid region.   The region immedi-
 ately  below it constitutes the Laryngo-Tracheal, the lower portion of which,
 or that nearest the sternum, has been called the Supra-Sternal region.
  The Laryngo-Tracheal region presents several useful points of reference,
 which are apparent outside of the skin.  Thus, in  passing from the os hyoides
 to the sternum in the median line, there is the prominence of the hyoid bone,
 the thyro-hyoid depression or space between the os hyoides and the thyroid
 cartilage, and indicated chiefly by the notch in the top of the cartilage.  Next
 may be felt or seen  the crico-thyroid space, the prominence  caused by the
 development of the thyroid gland ;  then  the rounded surface of the trachea •
 and, lastly, the supra-sternal  fossa or depression, the depth of which is gen-
 erally increased when the patient expands the chest, as in taking a full inspi-
ration.  On the external or lateral  portious of the region, near the anterior 
244
PRINCIPLES AND  PRACTICE OF  SURGERY.
 edge of the sterno-mastoid muscles, may be felt the pulsations of the primi-
 tive carotid arteries;  and this, as before stated, has led some anatomists to
 designate this portion of the neck as the Carotid region, instead of viewing
 it as merely the lateral boundary of the preceding  part.
   Examining the structures concerned in  these portions of the neck, but
 little time need be given to the skin, which differs in nothing that is import-
 ant from the same tissue  elsewhere.  Beneath it is seen the common Fascia
 Superficialis,  and beneath this, but separated by sparse  cellular substances,
 is the fascia known  as the Cervical  Fascia of Allan Burns, or the Fascia
 Profunda, a laminated expansion which exercises a  most important  influence
 on the diseases of this region.   This fascia, arising from the larynx, forms a
 thin capsule to the thyroid gland,  and, being then closely attached to the in-
 ferior margin of  the gland, descends to the  sternum in two laminae, so as to
 form a perfect sheath for the sterno-hyoid  and thyroid muscles.  At its in-
 ferior extremity it is firmly attached to the sternum, sternal ends of the cla-
 vicles, and cartilages  of  the adjoining ribs, for about  one  inch below the
 upper edge of the breast-bone, thus forming an elastic  and resisting mem-
 brane from the top of the  sternum to the larynx. Directly above the sternum,
 it surrounds the arteria innominata and brachio-cephalic vein ; and beneath
 it are the trachea, roots of the large arteries of the head  and upper extremi-
 ties, and the trunks  of their veins,  as well as important  nerves.*   Between
 these organs and the fascia there is  much loose connective tissue filled with
 lymphatic glands, the former being liable to  serous infiltration, and to ex-
 tensive suppuration in the disorders of this and the adjacent portions of the
 neck.   The external border of the  fascia profundi colli  is continuous with
 the sheath of  the carotid arteries, while it  and the fascia superficialis are
 united together along the anterior  edge of the sterno-cleido-mastoid muscle.
   The sterno-hyoid and  thyroid muscles, on  the median  line of the neck,
 are the only muscles useful as points of reference in this region.
   The Arteries are among the most important of the body.   Counting from
 the sternum upward, we find the innominata passing obliquely from left to
 right,  and from below upward.   As it is only about eighteen lines in length,
 its position is limited chiefly to the supra-sternal fossa.   Next to this may
 be mentioned  the carotids which are in the lateral boundaries, and extend
 usually to a level  with  the os hyoides without giving off any branches; but,
 on reaching this level,  they give origin to the two superior thyroid  arteries.
 These, in connection with the two inferior arteries of the same name, run to
 supply the thyroid gland and adjoining parts, and are the only arteries which
 can be especially  referred to as restricted to this region.
  The accompanying Veins are very numerous, being both superficial  and
 deep seated, and  bring the blood from the thyroid gland and the surround-
 ing organs into the jugular vein.  The deep-seated veins have three principal
 directions : the superior follow the course of the superiur thyroid  arteries,
 and  empty into the internal jugular vein; the  middle come out at the sides
 of the thyroid gland, and also enter the internal jugular vein; but the sub
 or inferior thyroid pass down in numerous anastomoses toward the  left sub-
clavian vein, crossing the inferior portion of the trachea iu an opposite course
from that taken by the arteria innominata, and being also more superficial
 than this vessel, Plate XXIX. Fig. 4.
  The superficial veins are more variable, and anastomose in various ways
with the deep  veins, f
  The irregular size and direction  of these  veins render a minute and accu-
* Special Anatomy and Histology, by Wm. E. Horuer, vol. i. p. 378, eighth edition
f Bland, Anat. Topographique, p. 191. 
THE SUPRA-CLAVICULAR REGION.
245
rate  description of them impossible, though their position in regard to the
operations of tracheotomy and others practiced on this region would render
it desirable.  The surgeon should, therefore, be upon his  guard, in all inci-
sions made upon this part, and especially as he approaches the supra-sternal
fossa.  The relations of the veins and nerves  connected with the course of
the carotid artery, or those on the borders of this region, will be referred to
hereafter.
  The other tissues  of this portion of the neck may be briefly mentioned at
present in their relations to each other, as well as to those which surround
them.   Commencing with the skin, there may be noticed, first,  a loose con-
nective tissue, on which it moves readily; a layer of the superficial fascia;
an anterior layer of  the deep fascia, with some veins; the sterno-hyoid and
thyroid muscles; a  posterior  lamina of the deep fascia; the thyroid gland,
covered by each layer of this fascia, and thus placed in a capsule ;  the larynx
and trachea, with the condensed connective tissue around them, which latter
has been designated* as the tracheal fascia;  then the oesophagus ; and last
the muscles on the front of the vertebrae.  In this enumeration, no reference
has been made to the great vessels and nerves of the neck, as their relations,
variable  disposition, and  arrangement can be better understood  in connec-
tion with the special operations practiced upon them.

                            SECTION IV.

                    THE SUPRA-CLAVICULAR REGION.

  At the base of the neck, immediately above the clavicle, being bounded
internally by the posterior  edge of the  sterno-mastoid muscle, and exter-
nally by  the anterior borders  of the trapezius  and splenius muscles, is the
region designated as the Supra-elavicular.  Being triangular in its outline,
with the base below, the  clavicle, together with  the trapezius and sterno-
mastoid muscles, form its three sides.   The skin and fascia covering this re-
gion, with a small portion  of the platysma-myodes muscle, require  little
notice, as they present nothing of importance, and  are chiefly noted by the
surgeon as indicating the coverings that he may expect  to find on tumors
in this neighborhood.   Of the numerous lymphatic glands situated  about
this part, some are superficial, and some deep seated, Plate XXXIII. Fig.
1, as in other regions of the neck.  When enlarged, the movable character
of the swelling, and  its greater development when superficial, will generally
enable  an operator to tell whether the tumor  is seated above or below the
fascia,  a matter of much  importance to decide when extirpation  is contem-
plated.
  The  Arteries usually found  in the supra-clavicular region are such as sup-
ply the upper extremities and the adjacent parts of the neck.  Among the
first is the Subclavian artery, which, in the course taken from its origin to its
escape  through  the  subclavius muscle—whence to the edge of the axilla it
is called axillary—forms a curve, the concavity of which surrounds the cul-
de-sac  made  by the expansion of the pleura above the first rib.f   The
branches given off by the  subclavian artery may be  divided into those which
run horizontally with, and  those whose  course  is perpendicular to, the line
of the clavicle,  Plate XXXIII. Fig.  1.   Among the first are the Posterior
Cervical, which is two fingers'-breadth  above the clavicle; the Superior-
Scapular, which runs close along the posterior margin of the  bone, and is
often in  the  way of the operator in attempting to ligate the subclavian;

                * Porter, Surg. Anat. of Larynx and Trachea.
                f Blandin, Anat. Topographique, p. 206. 
PLATE   XXX.
   INSTRUMENTS EMPLOYED  UPON THE CESOPHAGUS AND TRACHEA.

   Fig. 1. Stomach-pump of Goddard.                       Kolbe's pattern.

   Fig. 2. Physick's  (Esophageal Catheter for the evacuation of the contents of
 the stomach.                                              Kolbe's pattern.

   Fig. 3. Ordinary (Esophageal Probang.                    Kolbe's pattern.

   Fig. 4. (Esophageal Hook and Probang of DupnytreD.      Kolbe's pattern.

   Fig. 4'. (Esophageal Hook of Nathan Smith.               Kolbe's pattern.

   Fig. 5. Blunt Hook, made of annealed wire, for the removal of foreign bodies
 from the oesophagus.                                         After Bond.

  Fig. 6. (Esophageal Bougie for dilating stricture.             After Horner.

   Figs. 7, 8.  Bond's  (Esophageal Forceps.                     After Bond.

   Fig. 9. Sponge for cauterizing the Larynx, as advised by Trousseau.
                                                          Kolbe's pattern.

  Fig. 10. Instrument employed by Green  for the same purpose.
                                                          Kolbe's pattern.

  Fig. 11. Tongue Depressor; by which a patient can depress bis own  tongue
without incommoding the operator.                          Kolbe's pattern.

  Fig. 12. A ring made of watch-spring, so  as to be readily adapted  to  any
neck, and employed by the  author to hold open the sides of the  trachea after
the operation of tracheotomy.                                  After Smith.

  Fig. 13. Ordinary tracheal tube or canula, intended to be placed in the trachea
immediately after the operation of tracheotomy.              Kolbe's pattern.
(246; 
luiic  :v*.
F10.2
HS-:«
 
 
            DISEASES OF, AND OPERATIONS ON, THE NECK.        247

and the Transversalis Colli, all of which run toward  the  back of the neck
and top of the shoulder; while the Vertebral, Inferior Thyroid, and others,
coming off within the scaleni muscles, run more or less perpendicularly.  The
perpendicular arteries, constituting the Thyroid Axis, arise at the inferior
internal angle of this region, or at the space which exists between the sternal
and clavicular origins of the sterno-cleido-mastoid muscle.
  The Veins follow the course of the  arteries, being generally in advance of
them, or between them and the skin.  The Subclavian Vein, however, does
not pass between the scaleni muscles, but in front of them.
  The External Jugular Vein terminates toward the inner side of the supra-
clavicular fossa, after receiving the superficial veins from the shoulder, by
emptying into the subclavian vein in  front of the  scalenus anticus  muscle.
Sometimes, instead of one  trunk, there are two or  three which  unite  at
variable  distances above the clavicle.
  The Nerves of this region belong chiefly to the brachial plexus ; the four
lower cervical and the first dorsal nerves forming a plexus, which is more or
less closely connected with  the subclavian and the commencement  of  the
axillary arteries,  Plate XXXIII. Fig. 1.
  The other details of these parts will be given in connection with the oper-
ations practiced on the artery.
  In dissecting this region, the layers are usually presented as follows: First,
the skin, then the superficial  layer of the fascia, as well  as the platysraa-
myodes muscle.   Next, loose connective tissue, containing numerous venous
and arterial branches, the  principal of  which have just been referred to as
connected with the subclavian vessels.  Around these vessels is a fibrinous ex-
pansion from the deep fascia,  which forms for them a sheath, close to which
is the cul-de-sac of the pleura, as it rises above the first rib.  But the eleva-
tion or depression of the shoulder, by moving the inferior boundary of the
region, will increase or diminish the apparent depth of these vessels, as well
as relax or stretch the various layers which cover them.
                           CHAPTER  II.


    DISEASES OF, AND OPERATIONS  ON, THE  NECK ABOVE THE
                             OS HYOIDES.

  In the portion of the neck above the os hyoides  we find two regions, the
Supra-hyoid and Parotid, both of which may require surgical operations in
order to relieve their different disorders.  But as the importance of all the
parts  contained within the limits of the  neck renders it difficult to make a
selection of any one as specially worthy of attention, it has been deemed ad-
visable to refer to these operations in  the order which has been adopted as
the plan of the work;  and,  commencing at the  portion  which is nearest the
head,  proceed from above downward,  according to the natural arrangement
of the tissues.  The surgical affections of the skin and fascia in this section
of the neck, presenting nothing requiring special operative interference, the
disorders connected with  the salivary glands become the  first subject to which
attention should now be directed. 
248
PRINCIPLES AND  PRACTICE OF  SURGERY.
                             SECTION I.

               OP THE DISEASES OP THE PAROTID GLAND.

  The diseases of the Parotid Gland, independently of the affections of its
duct,  of which  mention has been already made in connection  with the oper-
ations practiced on the face, consist either in  such simple departures from a
healthy state as yield readily to medical treatment, or in such degeneration
of the connected tissue and proper structure of  the gland as may necessi-
tate its removal.
  The position of several of the superficial lymphatic  glands of the neck,
and the enlargement consequent on their diseased condition, sometimes also
creates such a tumor in the parotid region that any one who  is not cautious
in forming a diagnosis, or who does not  accurately examine the anatomical
relations of the surrounding  structures,  may readily be led to  suppose the
enlargement to be due to an affection of the parotid itself.
  As caution is necessary in deciding on  the structure involved in the tumors
of this region, a guarded prognosis should always be given.
  Pathology.—That the salivary glands, as a general rule, are less liable to
abnormal deposits or to degeneration of structure than other glands, is a
point on which most  pathologists seem  to agree.  Velpeau* expresses the
decided opinion that all malignant growths, when seated in  the parotid or
submaxillary gland, commence either by a deposit in the lymphatic glands in-
corporated with these glands, or by a change in the parenchyma of the glands
themselves, rather than by a  degeneration of the proper secretory portion.
Whether this opinion is based upon microscopical examination, or is solely
the result of close  observation, it has a  special value in connection with the
question of the propriety of  extirpating these glands when diseased, which
should be noted;  because,  admitting  that  the  deposit commences  in the
parenchyma of the  gland, it is evident that it cannot long be limited to its
original seat, but must encroach on the surrounding structure, so as either to
cause its absorption or disintegration.   In the case of parotid tumors, such
a change  must modify very materially the natural relations of the part, and
marked departures from the normal condition may, therefore, be looked for
when the  removal of the diseased mass is attempted.   Particles of  a gland,
which, in the original  state, were separate and  distinct, or very loosely at-
tached, will often, when  diseased, be found  to  be blended in one  common
mass; and portions which were deep seated and  difficult of access in health,
prove to  be  superficial, in consequence  of their close and  condensed union
with  tissues  nearer  to  the surface.  It  has, therefore, been  noticed that a
diseased parotid is often surrounded with a dense capsule,  formed chiefly at
the expense of the adjacent connective tissue and fascia, while its  conglom-
erate parts are so fused into  one conglobate  mass, that the deepest portion
of the gland has been pried entirely out  from the deep fossa  around the sty-
loid process by the attachment of the exterior of the tumor to  the  muscles
and parts about the  angle of the jaw, as I have seen in several instances of
well-marked scirrhus.   That surgeons have  been misled in relation  to  the
difficulties of the removal of the parotid, from comparing  the  operation in
the diseased structure with that attempted on  it in health, is certain ;  and
daily experience is leading  many to place confidence in the  views of those
* M6d. OpSratoire, tome iii. p. 644. 
                EXTIRPATION OF  THE  PAROTID GLAND.            249

operators of  the eighteenth century who advocated  the  practicability  of
accomplishing by an operation the entire removal of a diseased parotid.
   When, therefore, circumstances induce the belief that the removal of the
diseased structure can add to the patient's days, the operation should be per-
formed, as the entire gland has been extirpated beyond all doubt; though it
should be remembered, in cases of malignant degeneration, that the patient
will only be  subsequently placed in the same  condition  with  those who
submit to an operation for the removal of a scirrhus or encephaloid deposit
elsewhere.

                 I 1.—Extirpation of the Parotid Gland.

   For many years, the removal of the parotid gland entire was a vexed ques-
tion, the possibility of accomplishing it being denied by high authority, among
whom were Boyer, Richerand, and others, who, though dead, seem yet to influ-
ence a few surgeons of the present day, there being some who continue to speak
of the matter in terms of doubt, notwithstanding the most positive proofs
of its feasibility and execution.   Informed of the existence of these doubts,
and yet fully aware of the error of those who entertained them, Geo.  M'Clel-
lan, of Philadelphia, exerted himself to  prove that the extirpation of the
parotid gland was not only justifiable, but also capable of being thoroughly
accomplished ; and to his skill and  energy, more than to that of any other
surgeon, is  due, I think, the credit of having demonstrated the  reasonable
character of the attempt; while by recalling attention to the means of treat-
ment advocated by Heister, Von Swieten, Garangeot, and others, who had
preceded him, in Europe, he secured for the operation a degree of confidence
which has since led to its more frequent performance.
   Extirpation of the parotid gland was, however, an operation  which had
previously been frequently performed in the United States, being first done
by Warren, of  Boston, who, as early as 1798, removed  the entire gland;
in 1805, M'Clellan, of Franklin County,  Pennsylvania, did  the same thing;
in  1808, it  was also successfully performed by S. White,  of Hudson, New
York; and  in 1811 and 1814, and again in  1841, Sweat,  of Maine, success-
fully repeated it.
   But though it is evident from these facts that the operation was well known
to a few, it was  not until the time of Geo. M'Clellan (1826) that it was gen-
erally regarded  as feasible, and that the  difficulties attendant on  the entire
removal  of the gland in a diseased  state were found to be  much less than
those experienced in accomplishing  the same end when it was in a healthy
condition.   Since this period, the removal of the  entire gland has been suc-
cessfully accomplished in numerous instances.
   Operation of George M'Clellan, of Philadelphia.—The patient, Dr. John
Graham, at  that time a student of medicine in Philadelphia, had  a tumor  in
the parotid region, the removal of which  had been attempted in Dublin, but
desisted from,  in consequence of the opinion of the surgeons engaged in it,
that, as the  parotid was involved, the attempt was unadvisable.   M'Clellan,
thinking otherwise, proceeded to the operation,  February  27, 1826, as fol-
lows :—
  Operation.—Two curvilinear incisions were made from a little  above the
zygoma to a point two and a half inches below the angle of the jaw, so as  to
include nearly the whole of the old cicatrix between them.   After reflecting
the integuments from the surface of the tumor, the dissection of the mass
was continued down to the zygoma and masseter muscle in front,  and to the
cartilaginous tube of the ear and mastoid process  behind.   Being unable to
dissect any further in these directions, progress was  made beneath the tumor 
250            PRINCIPLES AND PRACTICE OF SURGERY.

by burrowing under its  lower edge.   The posterior belly of the digastric
muscle being then divided, the fingers passed readily under the whole body
of the tumor, and an effort was made to wrench it from its bed,  but without
success.  Before proceeding further, the  trunk of the external  carotid was
insulated, just as it was entering the tumor together with the descending
veins;  and  then, instead of cutting them across, they were torn out from the
body of the tumor with the thumb  and  finger.  An instantaneous gush of
blood deluged the eyes and face of the operator; but, before a ligature could
be placed around the vessels, the hemorrhage altogether  ceased  in  conse-
quence of the retraction and  contraction of the lacerated vessels.   After
powerful and repeated efforts at wrenching, aided by an occasional  use of
the knife, to divide the strong bands of connective tissue, and  some  of the
fibres of the styloid muscles which adhered to  the tumor, the mass was ele-
vated above the ramus of the jaw and the mastoid  process.  The trunk of
the portio  dura, which was very much enlarged, being then seen  mounting
over the posterior margin of the tumor to enter its substance, was divided,
and the upper portion of the tumor  separated from the zygoma  by the scal-
pel, as the layers of fascia were too strong to be lacerated.
  In this step,  the main trunk of the temporal artery was necessarily cut,
and a profuse hemorrhage coming from the recurrent circulation,  a ligature
was placed on the vessel, this being the only one which was ligated  during
the operation.   The internal maxillary was not discovered, having probably
been ruptured in the act of wrenching the deep-seated portion of the tumor
from behind the angle and ramus of the jaw.  After waiting some time to
see if  hemorrhage would occur,  the edges  of the  wound were  united by
three stitches of the interrupted suture, in order to prevent their being re-
flected inward;  adhesive strips,  a compress and head bandage completing
the dressing.  The patient recovered, with less deformity than existed before
the operation.*   The gentleman is believed to be yet alive, and residing in
the City of New York.f
   Operation of Mott, of New York.—Determining to ligate  the external
carotid artery before attempting the dissection, the  operation of  Mott was
commenced by  an incision about three inches  long,  which was carried from
the posterior angle of  the lower jaw downward and  inward,  so as  to lay
bare  the artery.  Owing to the tumefaction, this vessel  was  found to be
nearly three inches from the surface, and was tied immediately  below  the
digastric muscle, or a little above the upper border of the thyroid cartilage.
   An  incision  was next commenced above the jugura temporale, and car-
ried downward in a semicircular direction, until it  terminated  upon the os
occipitis, when  the incision  on the  neck  was extended upward to intersect
the one over the tumor.
   On  detaching the integuments in the form of a double flap, the gland was
found in a melanotic condition.   In order to free it, the adipose aud  areolar
tissue along the inner edge of the tumor  was divided until the masseter was
exposed.   The  finger being then introduced  into the mouth and cut upon,
in order to avoid the division of the buccal  membrane, the tumor was sepa-
rated  for some  distance from the masseter, to  which it closely adhered, and
then  separated  from the jugum, which  had become carious  from pressure.
The mass  was next dissected entirely free  from the digastric and masseter
 muscles, as well as from the angle of the jaw;  but, as the  patient complained
of excruciating torture when the tumor was raised from below upward, the
* New York Med. and Phys. Journ., vol. v p. 650.
t Priuciples and Practice of Surgery, by the late Geo. M Clellan, M. D., edited by J.
. B. M Clellan, M.D., p. 335, note. 
EXTIRPATION OF  THE  PAROTID GLAND.
251
dissection was continued from above downward, and the adhesions being
separated, with a few rapid  strokes of the knife, from the capsular ligament
of the lower jaw, the bulk of the mass was removed.  The portion filling up
the space between the styloid and  mastoid processes  was then cautiously
detached with the handle of the scalpel, and the portio dura rapidly divided.
Several arteries were tied during the operation, and the trunk of the tempo-
ral yielded a profuse retrograde hemorrhage.   After waiting to see if  there
should be further hemorrhage, the wound was dressed  by sutures,  adhesive
strips, lint,  a  compress and  bandage.*
   At first the wound did well, the ligature on  the carotid separating on the
fourteenth day,  but  the disease promptly showed itself, and  the patient died
of constitutional disturbance on the  fifty-fourth day after the operation.
   Operation  of Randolph, of Philadelphia.—The disease  being seated in
the left parotid gland, the head was inclined to the right side, and an incision
made from the zygoma down to the  edge of the  sterno-cleido-mastoid mus-
cle ;  a second one  was then made  at right  angles  to  this,  and  the flaps
dissected back.   The facial artery being secured, an attempt was  made to
raise the lower edge of the  tumor and  to secure the carotid artery  where it
enters the gland;  but this being very difficult, in consequence of the  close
adhesions, the tumor was dissected from its attachments, from above down-
ward.  In doing  this, the  temporal and  internal maxillary arteries with
some smaller  ones were secured, and the deep dissection being continued, the
carotid was divided with the last adhesions of the tumor, and instantly se-
cured by  Physick's needle and forceps.   The internal jugular vein  was also
cut and secured at each end.  The operation  lasted fifty-nine minutes: but
little blood was lost.  Rhea Barton, Horner, Norris, Coates. and the author,
who  witnessed and  assisted in the  operation, all coincided  in the opinion
that the entire gland was extirpated.f  Having subsequently had the charge
of this patient,  I  am  fully persuaded that Randolph succeeded in removing
the entire gland.
   The wound healed readily, and the patient left the hospital well; but about
ten months subsequently I heard of his death  from a return of the disease.
The  tumor is now in  the Wistar and Horner Museum of the University of
Pennsylvania.
   Operation of Horner, of Philadelphia.—A  crucial incision over the cen-
tre of the tumor being freely continued along the base of the jaw,  so  as to
include some  enlarged lymphatic glands,  and also down the neck in the
course of the carotid artery, the flaps were turned back and  the fibres of the
platysma-myodes and the fascia of  the neck  freely divided.  Commencing
behind, the  tumor was then dissected from the anterior edge of the sterno-
cleido-mastoid muscle, to which it closely adhered, and, by working gradually
forward, the gland, which was  surrounded  by a firm capsule, was gradually
freed from its posterior and  inferior attachments.   The primitive carotid ar-
tery being then fairly brought into view by the  progress of the dissection, was
found to have been so much involved in the disease as to show considerable
thickening of its coats, having the  appearance of the vessel when injected in
the subject.   A ligature was therefore placed around  it, nearly on a level
with  the larynx, but not tied, the  upper and  anterior attachments of the
tumor divided, the artery tied, and the tumor removed from its deep adhe-
sions.  These were  by no  means as  close as  in  the healthy condition, the
adhesion of the tumor to the angle of the jaw  having caused the exit of the
gland from its deepest points. The division of the internal maxillary giving
rise to considerable hemorrhage, the internal aud external carotids were also
* Am. Journ. Med. Sciences, vol. x. p. 17.
f Ibid., vol. xxiii. p. 517. 
252           PRINCIPLES AND  PRACTICE OF  SURGERY.

tied, lest,  in their patulous condition, recurrent  hemorrhage  should ensue
through them  also.  The submaxillary gland, and the lymphatics leading to
and adhering  to the thyroid gland, were also  removed, leaving the deep-
seated parts of this region perfectly exposed; but, on a close examination, it
was impossible to find either the internal jugular  vein,  or the par vagum, of
this side.   The wound was then filled lightly with lint;  the flaps closed by
sutures, and covered with adhesive plaster, a compress, and bandage.  On the
eighth day all  the ligatures separated spontaneously,  and the patient started
for his home six weeks after the operation.* When last heard from, the dis-
ease had returned  and caused his death by exhaustion.
   Statistics.—Of eleven oases in which the parotid gland was  extirpated by
M'Clellan, ten recovered from the operation, seven of whom were living in
1848, one died on  the fourth day, from coma consequent on the ligation of
the carotid artery, and one died three years subsequent to the  operation.-}-
Three cases have been  operated on  successfully by John C. Warren, of Bos-
ton ; one  by John II.  B.  M'Clellan, of Philadelphia, successfully, although
the pneumogastric  nerve  was divided in the  operation;  and one  each  by
Mott, Horner, Randolph, Nathan R. Smith,  Wheeler,  Shipman,  Toland,
Wedderburn, and J. Mason Warren.  Three cases were also operated on by
Bushe, of New York.   The history of these cases is, however, too extended
to permit more than a brief enumeration, though it is right  to say that in
all of them there was more or less  of cancerous degeneration  which had in-
volved the entire structure, or which, if  limited to the areolar tissue in  the
first instance, had  produced such  a change in  the gland that the  original
growth  could  not be recognized.   From  the account of the operations fur-
nished by Velpeau,| it appears  that there are  over thirty-five cases of this
operation in which it was reported that  the entire  gland  was  extirpated;
though  he seems to doubt the  fact,  because of the rarity of degeneration of
the salivary glands as a class.  But this general statement, when met by  the
positive assertion  of the  diseased  condition of the  gland  by surgeons and
anatomists of  good standing, and recognized as such even  by  Velpeau him-
self, only  shows the diversity of sentiment that  may  arise, when surgeons
have not seen  the same  cases.   Walshe§  says,  in  speaking of this  opinion,
that "it is certain  that scirrhus and encephaloid do occasionally  originate in
the parotid, and run their ordinary course."
   As regards  the possibility of accomplishing the extirpation of the entire
parotid  gland, there is, therefore, in my mind no doubt.  The  fact, however,
is equally well established that the  ultimate result  to the  patient in these
tumors,  where  the  tumor is of a cancerous character, will be found to corre-
spond with the operations performed for the removal of malignant growths in
other portions of the body.
   Remarks on the Operation.—In the  descriptions of the operative pro-
ceedings just referred to, we see several varieties, each of them  being  more
or less modified by the peculiarities of the case.   Certain  general  precepts
may, however, be applied  to every instance in which the removal of the gland
may be  deemed proper.
   1st.  All external incisions should  be free enough, at first, to enable the
operator to work readily around the tumor.
   2d. The tumor  should be first loosened at  its posterior part, then at its
superior and anterior borders, and lastly  at its inferior.
* Medical Examiner, vol. vii. N. S. p. 30, 1851.
f M'Clellan's Principles and Practice of Surgery, p. 332.
X Velpeau, Op. Surg., by Mott and Townsend, vol. iii. p. 443.
\ Walshe on Cancer, p. 267. 
EXTIRPATION OF  THE  PAROTID GLAND.
253
   3d.  The attachments of the tumor to surrounding parts should be stretched
or torn as much as possible, instead of being dissected, as the laceration pre-
vents hemorrhage.
   4th.  The edge of the scalpel should  be directed toward the tumor  as
much as possible.
   5th.  The external carotid  artery should be taken up, as nearly below the
tumor as may be  necessary, at the moment  of removing the gland from its
deepest and inferior connections.
   The  propriety of ligating, or even of passing a ligature around the primi-
tive carotid previous to acting on the tumor, is a question that the majority
of operators have decided in the negative;  and when it is remembered that,
in some instances, the external  carotid alone is cut, while  the  internal re-
mains uninjured, and that, in others, the compression of the surrounding
structures by the diseased mass has caused great diminution of the calibre of
the  vessels, or even their obliteration, this decision seems  to be based on
sound principles.  In three  instances,  it  has been my duty to attend to the
hemorrhage during this  operation, and in all it was readily controlled by
pressure upon the main trunk of the artery when the course of the dissection
seemed likely to injure the external carotid, or by the  direct application of
the  ligature to the divided end  of  the  artery, when it was cut free from the
tumor.
   In the operation performed by Horner, and in that of John H. B. M'Clel-
lan,* the internal jugular vein was entirely obliterated;  and in the  others
that have fallen under my observation, the artery has either been much thick-
ened in its coats or diminished in its calibre, the most troublesome hemorrhage
having been that which arose from  the recurrent circulation.   The paralysis
arising from division of the portio dura, in one case, was subsequently  very
much relieved, and in the others, during the short period  when they were
under my charge, did not produce  as  marked deformity as that created by
the  presence of the tumor. In a case reported by Warren, it had nearly dis-
appeared a  few months after the operation, f   That the  division of this nerve
was the cause of the intense suffering described by some of the earlier oper-
ators, is a point on which every surgeon of the present day must have his
doubts, the pain then noted being doubtless due to the division of the branches
of the third branch of the fifth pair, or of the cervical nerves involved in the
disease.  Mott, of New York, yet advisesj that the carotid should always
be tied first.   He also recommends that an incision should be made  in a
vertical direction over the tumor in the course of its long axis, and that an-
other should cross this, but not at  a right angle; and that, after dissecting
back the flaps, the operator  should begin the separation of the gland from
below, and not from the zygomatic arch.  In  connection with this operation,
as well as in others upon  the neck,  he also cautions the surgeon against the
dangers of the entrance of air into veins that may be wounded, and espe-
cially the jugular vein.
   In reviewing the opinions  thus stated in relation to the performance  of
the operation of extirpating the  parotid gland, it may, I think, be safely said
that, though the operation is one which involves a  high responsibility,  it is
yet one which every good anatomist may succeed in performing. But whether,
after accomplishing this  much,  the patient  will be benefited for any long
period, is a  point which the statistics of operations for malignant growths
elsewhere alone can settle.  Certain it is that the removal of the tumor has
often relieved the individual of the  distressing neuralgic pains and cesopha-
* Principles and Practice of Surgery, p. 336.      f Warren on Tumors, p. 290.
X New York Register of Med., vol. i. No. x. p. 153. 
254
PRINCIPLES AND  PRACTICE OF  SURGERY.
geal difficulties under which he  formerly labored; and, as an euthanasial
measure, or one capable of prolonging life for even a limited period, its pro-
priety should, therefore, be  calmly considered  in  every case where its per-
formance may be demanded.  My individual opinion is favorable to it when
other general or local means have failed to check the progress of the disease.
   \ 2 —Relief of Enlargement of the Parotid Gland  by obstructing the
                               circulation.

   In order to avoid the necessity of resorting to extirpation of the parotid
 gland in  cases of scirrhus, various  other  local means have been  tried, as
 leeches, friction, blisters, electricity, iodine, and  pressure, though the latter
 can  only  be applied very imperfectly.   Such means can, however,  only act
 as palliatives.  A more certain method of  checking the development of the
 tumor, or inducing atrophy of its structure, will be found in the interruption
 of the supply  of blood through the nutrient vessels of  the parts, by ligating
 the carotid artery.   This operation has been successfully performed, in two
 cases, by Hosack, of New York, and, in a third, absorption had visibly com-
 menced.   In the first case, the patient was a woman, aged fifty-five years, the
 tumor of considerable size, and of  three or four years' growth, and had been
 treated with iodine internally and externally for two months, without benefit.
 After ligating the vessel, the tumor not only disappeared, but left a depres-
 sion of the same form as the gland in its natural state.
   But, in estimating the value of this operation, one difficulty evidently ex-
 ists, and  that is the utter impossibility of deciding whether the tumor is
 formed by the parotid.  In one of the cases reported by Hosack, the account
 certainly justifies us in doubting whether the tumor was a cancer of the pa-
 rotid, as these tumors are seldom very large; while if it was of the size of the
 encephaloid degeneration it would hardly have taken three or four  years to
 have developed itself without inducing the death of the patient.   When the
 tumor is formed of the parotid, or even the adjoining lymphatics, there would
 also be great difficulty in preventing the return of the blood through the re-
 current branches of the opposite side, even when the carotid was tied.   As,
 under ordinary circumstances, any surgeon who could accomplish the ligation
 of the artery  could also remove the  tumor, and thus render the  removal of
 the diseased structure certain ; while under the use of  anaesthetics he would
 cause his  patient  but  little additional suffering, I should much prefer  the
 chances of the extirpation in effecting a cure, or even temporary alleviation
 of suffering, to those presented in any other plan of treatment, except an ap-
 propriate  constitutional one.   When this had failed, I  would certainly oper-
 ate, if only to alleviate the patient's suffering, and enable him to obtain an
 easier death.


                            SECTION  II.

        OPERATIONS PRACTICED ON  THE SUBMAXILLARY GLAND.

  Owing to the remarks made in connection with the  degenerations of  the
parotid gland, there is but little necessity to  occupy much space in consid-
ering the disorders of this body.   Like the parotid,  the  submaxillary gland
is rarely or never the starting-point of malignant disease, while the lymphat-
ics in its neighborhood are often involved.   But, should circumstances induce
the surgeon to attempt its excision,  he may accomplish it by the following
plan :— 
         SURGICAL ANATOMY  OF THE LARYNX AND TRACHEA.     255

  Operation.—Direct the patient to  shut the mouth and throw back  the
head, inclining  it to the side opposite to  that which is affected.  Then, by
any incision which is adapted to the size of the tumor, cut through the integu-
ments, aud dissect back the  flaps thus created, so as to expose the disease.
Applying two ligatures to the facial  vein, and dividing the vessel between
them, and also ligating the facial artery near its entrance into the gland, or
near the jaw, pass a needle and ligature through the tumor, and forming a
loop with the  ligature, remove the needle.  Then drawing upon the loop,
either downward and backward while the dissection is prosecuted in front of
the gland, or outward  and upward when it is carried below and behind the
gland, free the  latter from its pouch,  avoiding all injury to the surrounding
parts, by directing the edge of the knife constantly toward the tumor,  and
keeping its adhesions upon the stretch, by  drawing firmly on the loop of the
ligature which was passed through it.
   The other tumors of this  region will be referred  to in  the chapter on
diseases of the  lymphatic glands of the neck.
                          CHAPTER  III.

 DISEASES OF, AND OPERATIONS  PERFORMED  ON, THE LARYNX AND
                              TRACHEA.

   The operations practiced on this  portion of the neck are cauterization of
 the larynx from the mouth, and the  opening of the larynx or trachea, either
 for the removal of foreign bodies, or in cases of membranous croup.


                             SECTION  I.

           SURGICAL ANATOMY OF THE  LARYNX AND TRACHEA.

   The upper extremity of the Trachea or the Larynx is formed by five car-
 tilages.  These cartilages, of which the thyroid, cricoid, and epiglottis—
 Plate XXXI. Fig. 2—are the most important to  the surgeon, as connected
 with the operations on this part,  extend  from  immediately below the os
 hyoides and root of the  tongue to  the first ring of the trachea, being lined
 throughout by  a  mucous membrane,  between  which and  the cartilaginous
 structure is a sparse cellular tissue, liable in certain forms of disease to drop-
 sical or serous infiltration.
   The Trachea is four or five inches  long in its entire length, though not more
than two and a half inches in the portion which is situated between the top
of the sternum and the cricoid cartilage.  It is about nine lines in diameter,
and composed of  sixteen or twenty  distinct rings, each of  which is  deficient
in the posterior third, being completed in this portion of the canal as well as
united  to each other by elastic ligamentous matter.
   The structures covering the trachea are the skin, superficial fascia, sterno-
hyoid and thyroid muscles, and deep cervical fascia, together with the thyroid
gland,  which  latter, or rather its isthmus, sometimes extends as low as the
fifth ring.  Beneath these parts is the areolar tissue, immediately around the 
PLATE  XXXI.
     A VIEW OF THE OPERATIONS PERFORMED ON  THE TRACHEA.

  Fig. 1. A front view of the Surgical Anatomy of the Trachea.  1. Os hyoides.
2. Thyroid cartilage.  3. Thyro-hyoid muscles.  4. Crico-thyroid muscles. 5. Thy-
roid gland and veins in front of crico-thyroid ligament.  6. Rings of the trachea.
7.  Common carotid artery.  8. Superior thyroid  arteries.  9. Inferior thyroid
artery.  10. Carotid  artery, as divided.  11.  Outline of  the  top  of the  chest.
12. Innominata artery.  13.  Inferior thyroid vein.  14.  Transverse vein.
                                                After Bernard and Huette.

  Fig. 2. Relative position of the Larynx, Trachea, and  Blood-vessels.   1. Os
hyoides.  2. Thyro-hyoid ligament.   3. Thyroid  cartilages.   4.  Crico-thyroid
ligament.  5. Cricoid  cartilage. 6. Trachea. 7. Internal jugular vein. 8. Trans-
verse vein.   9. End of inferior thyroid vein.  10. Veins.
                                                After Bernard and Huette.

  Fig. 3. Relative positions of the great vessels  concerned in operations near
the top of the sternum.  1, 1. Internal jugular vein.  2, 2.  Subclavian veins.
3.  Subclavian artery.  4. Transverse vein.  5. Inferior  thyroid  vein.  6. Ex-
ternal jugular vein.  7. Arch of the aorta.  8, 8. Primitive carotids.
                                                After Bernard and Huette.

  Fig. 4. A view of the operation of Tracheotomy, as performed by Mr. Liston.
1.  The tenaculum inserted into the trachea.  2. Position of the  bistoury in in-
cising the rings.  3. Line and termination of the external  incision.
                                                              After Liston.

  Fig. 5. Extraction of a foreign body by Tracheotomy, the head being thrown
back and lowered, so as to facilitate the gravitation of the object.  1, 1.  Blunt
hooks holding open the wound. 2. Hand of the surgeon in the act of extracting
the foreign body, by drawing it upward from the bronchia.
                                                 After Bourgery and  Jacob.

   Fig. 6. A front view of the position and mode of retaining a  canula  in the
Trachea, as usually practiced.  1. The incision.   2, 2. A tape attached to the
wings of the canula and passing around the neck.   After Bernard and Huette.

   Fig. 7.  The appearance of the parts concerned in Edema of the Glottis.
1.  The epiglottis cartilage, much  swollen by serous infiltration of  its submucous
cellular tissue.                                     After  Gurdon Buck, Jr.
   Fig. 8. The operation of scarifying the Glottis for the relief of Edema.  1. The
forefinger in its position  as a director.  2. The knife in the act of  scarifying the
part.                                             After Gurdon Buck, Jr
        (256) 
Plate 31
 
 
          DISORDERS OF, AND OPERATIONS ON, THE LARYNX.      257

tube which has been spoken of by Porter as the Tracheal Fascia, and which
is liable to become emphysematous when an opening is made into the trachea,
unless it is specially attended to.   But the most important of the surgical
relations of this portion are the numerous blood-vessels, whose varying posi-
tion renders them especially troublesome to the surgeon.  Between the isth-
mus of the thyroid gland and the top of the sternum are usually seen several
veins. Of these, the superficial veins are distributed on the front of the sterno-
hyoid muscles, Plate XXIX. Fig.  4, and  cause but little trouble in opera-
ting ; but the plexus formed by the deep veins, and especially  by the inferior
thyroid, together with an  artery, (middle  thyroid,) all of which  are behind
the muscles,  will often prove to be  sources of trouble in tracheotomy.
   There are  also certain variations in the  arrangement of  the larger vessels
of the neck which may embarrass the surgeon when operating on this part.
Thus, the  superior thyroid artery occasionally sends a large  branch to  the
crico-thyroid  ligament, and then turns  down to  supply the thyroid gland;
sometimes the inferior thyroid arteries are  giveu off by the primitive carotids
on a level with the thyroid gland ;  or the left carotid may  arise from the in-
nominata and pass across the  front  of the trachea, as has been  seen in several
instances by  Blandin.*
   As the trachea follows the shape of the vertebral column, it is most super-
ficial at  its upper portion, where the vertebras are convex in  front, but  be-
comes deeper as it approaches the  chest, so that near the sternum it is over
an inch beneath the integuments, or even more, in short, fat necks ; while the
changes produced by edema, congestion, and the other consequences of dis-
ease of the windpipe, especially in  children, frequently add to the depth of
this canal from  the surface of the neck,  at this point.


                             SECTION  II.

             DISORDERS OF, AND OPERATIONS ON, THE  LARYNX.

   The operations practiced on  the Larynx consist in such as are required
for the relief of the results of inflammation, and those demanded by the pres-
ence  of foreign bodies.
   Before  deciding on the propriety of these operations, it will  be well  to
employ the Laryngoscope as  an additional means of investigation.
   The Laryngoscope of Czermak consists of a large concave mirror of about
eight to twelve inches focal  distance,  and three or four  inches  diameter,
arranged with a central aperture on the well-known principle of the ophthal-
moscope, which  serves to reflect the light of an argand-burner, or gas-flame,
upon a small metallic mirror attached to a long, flexible handle, which is in-
troduced into the cavity of the pharynx, and held there at a proper angle.
The flexibility of the handle  allows of  the adjustment of the mirror under
different angles; and to avoid the condensation  of vapor on its surface, it is
previously gently heated in a lamp, or by dipping it into warm water.  The
image is observed through the central aperture in the concave mirror, which,
if the operator desires to use his hand as a spatula, probang, etc., may be
attached to a support of soft wood or  orris-root, by which it may be held
between the operator's teeth, and be furnished with screws for adjusting it in
any position.
  If the  patient protrude the tongue as far as possible, the  mirror can be
readily held in the pharynx, the epiglottis will be lifted from the aperture of
                    * Anat. Topograph, p. 196.
VOL. II.—17 
258
PRINCIPLES  AND  PRACTICE OF  SURGERY.
the glottis, and when  the patient  pronounces forcibly certain  sounds, the
chorda? vocales will be brought into full view.  On pronouncing a long, (as
in fate,) these will be seen to open, allowing the inspection of the parts be-
neath.  With this instrument, after a little practice, there will be no trouble
in bringing into view the back of the tongue, the  epiglottis, the arytenoid
cartilages,  the true  and  false  vocal chords, the  ventriculus  Morgagni, the
anterior walls of  the  larynx and trachea,  and  even,  though with  greater
difficulty, the bifurcation of the trachea.
   The instrument, in a slightly modified form, has  also been used by Prof.
Czermak for examining the posterior wall of the soft palate,  the upper wall
of the pharynx, the nasal cavities, and the orifice  of the Eustachian tubes.
   Stangenwald reports* that he has frequently used this instrument, in con-
junction with Green, of New York, and with satisfactory results.  It can be
obtained at the cutlers.


                    \ 1.—Cauterization of the Larynx.

   The  cauterization of the larynx  is an operation  which  may be demanded
in the treatment of various forms of inflammation, and especially in mem-
branous croup.
   The credit of suggesting and applying this remedy  is due to Trousseau,
of Paris, f  who first  introduced a strong  solution freely into the canal, both
by means of a sponge as well as by a syringe; while in the  United  States
particular attention has been called to the advantages of its employment by
Green, of New York.|  The operation is simple, and may be readily per-
formed  as follows:—
   Operation.—Place the patient before a strong light, with the mouth widely
opened, and the head  supported, and, depressing the tongue by any means
that is found most convenient, pass the sponge directly into the larynx, Plate
XXXII. Fig.  2, on either side of the epiglottis, and immediately withdrawing
it, much less inconveuience will be caused to the patient than might have
been anticipated.
   The  instruments adapted to this purpose  may  be  seen on  reference to
Plate XXX. Figs. 9,10, 11, and include both those of Trousseau and Green,
the difference  between them not being very marked.
   Remarks.—Cauterization of the  larynx  is an operation of so simple a
character that reference to it in these pages might seem  unnecessary, were
it not that it  is an important preliminary step in  the  treatment of  croup,
and one that should always be employed before  tracheotomy is resorted to.
Although this remedy had been known to the profession for several years,
incredulity, and a knowledge of the irritation usually created by the presence
of even a small particle of any substance in the trachea, prevented very many
in this country from attempting it;  and there are yet to be found practi-
tioners  who deny the  possibility of introducing a  sponge into  the  glottis.
To Green,  of  New York, is therefore due the credit  of having done more
than  any other surgeon in the United  States toward establishing profes-
sional confidence  in an operation which has since  proved to be both easy
and useful in many instances.   The tendency to quackery, so  often observed
  * The Laryngoscope of Prof. Czermak, by Hugo Stangenwald, M.D., (read before
the New York Medico-Chirurgical College, June 14, 1858.)  From the Southern Medical
and Surgical Journal, vol. xvi. N.S. p. 871.
  f Traits' de la Phthisie Laryng6e et des Maladies de la Voix. Paris, 1836.  Me"m. de
l'Acad., etc.
  X Diseases of the Air-passages.  New York, 1846. 
EDEMA OF THE GLOTTIS.
259
 in the treatment of affections of the windpipe, dependent on chronic inflam-
 mation, has, however, shown itself in this as in other rational plans of treat-
 ment; and a measure which is capable of doing much good, when judiciously
 directed, seems likely to be underrated by many, on account of its liability
 to be misemployed.

                       § 2.—Edema of the Glottis.

   Pathology.—In the rare form of disease  of the upper extremity of the
 larynx, which  has been designated as Edema of the Glottis, there is com-
 monly found an infiltration of the submucous connective tissue of the aryteno-
 epiglottic cartilages, in consequence of the development of such a  degree of
 inflammation as results either in the deposit of pure serum or of a gelatinous
 serum or lymph, or of pure pus, or of pus mixed with shreds of the membrane
 consequent on sloughing of the tissue, though this  last condition  is said to
 be rare.   Owing to these changes, the mucous membrane lining the opening
 or edges of the cartilages at the top of the larynx becomes distended and
 formed into folds, or doublings, which, rising  upward, and also extending
 downward as far as the vocal chords, Plate XXXI. Fig. 7, render the epi-
 glottis thick and  stiff, greatly diminishing, or even closing the opening of
 the larynx, so as to prevent the  entrance of air into the lungs.
   Originally named by Bayle, in 1808, Edema of the Glottis, this complaint
 has been described as if it were  limited  to that portion of the  larynx which
 is anatomically described as the glottis, whereas it is  really, as shown  by
 Bouillaud  and others, an edematous inflammation  of the  larynx itself, con-
 sequent on, or  accompanied by, a similar condition of the surrounding parts.
 Though often the  result of the extension of inflammation  from the pharynx
 to the larynx,  this complaint sometimes occurs spontaneously, three out of
 the forty cases reported by Valleix having suffered from  it while  otherwise
 in good health; it is  also most common  during the convalescence from slow
 fevers or after  pneumonia.  In most instances, however, it  is the result of an
 inflammatory affection of the laryngopharyngeal membrane, wnere it is ex-
 panded over the tonsils, uvula, or soft palate, at which  points the membrane
 is seen increased in color, and accompanied by all the symptoms consequent
 on tonsillitis, though at other times it is unnaturally pale and swollen in this
 affection.   Such a condition of parts, it is now believed, existed in the case
 of General Washington, who, without presenting marked symptoms of croup,
 yet died asphyxiated.   That the difficulty of respiration in his case was not
 alone due to the angina, must be admitted  by all who  recall the anatomical
 relations of the parts; and as  edema of the glottis was not thoroughly un-
 derstood at the period of his death, the  explanation thus advanced is due to
 the observation of more modern pathologists, as may be seen by referring to
 the views of various writers on this subject.*
  Sometimes edema of the glottis,  instead of being an acute  complaint, is
 merely a subacute  affection, and is, therefore, difficult to recognize  solely  by
inspection, in consequence of the natural appearance of such portions as can
be discovered by the  eye.   Under  these circumstances, the sense  of touch
should be most confided  in, as it alone  will often enable the surgeon to re-
cognize the condition  of the top of the larynx, and enable him correctly to
appreciate  the diminished  state of  an orifice  which has sometimes been  so
completely closed as scarcely to permit the passage of light into the trachea,
even when it was  removed from the body.  Edema of the Glottis appears
  * See Cyclopaedia Pract. Med., vol. iii., art. Laryngitis; Diet, des Sciences Medicales,
tome xvii.; Pract. of Med., by George B. Wood, M.D., vol. i. p. 743. 
260            PRINCIPLES AND PRACTICE  OF SURGERY.
to be much more common in males than in females, twenty-nine out of the
forty reported by Yalleix* being males, and only eleven females.  Without re-
ferring to the medical treatment which would be proper as preliminary to,
or as an  adjuvant of, the operation demanded for its relief, and, with the
simple mention of the utility of tracheotomy as a last resort, this account will
be limited mainly to the operation, and  especially to the means  employed,
with great success, in several cases, by Gurdon Buck, Jr., of New York.
   Operation of  Buck.—The patient being seated on  a chair, with the head
thrown back, and supported by an assistant, should be first directed to keep
the mouth as wide open as  possible, or  if unable to do so,  should have  it
kept open by means  of  a plug introduced between the molar  teeth.   The
forefinger of the surgeon's left hand being then introduced at the right angle
of the mouth, and passed down over the tongue till it encounters the epiglot-
tis, the end of the finger may readily be made to overlap this cartilage by
being carried above it,  as there is  usually no difficulty in drawing  the epi-
glottis forward toward the root of the tongue.  The finger thus serving as a
guide, Plate XXXI.  Fig. 8,  a curved knife—Plate XXXV. Fig. 15—should
be conducted along it, the concavity of the instrument being directed down-
ward till  its point reaches the finger nail.  Then, by elevating the handle
so as to depress the blade an inch or an inch and a half further, the cutting
extremity will be placed in the glottis between its  edges, when the instru-
ment, being slightly rotated  from one side to the other, so as  to give it  a
cutting  movement, may be made to incise the mucous membrane by  with-
drawing it from  the  larynx.   After repeating  this two or three times, on
either side, without  removing the finger, the  margin of the  epiglottis, and
the swelling between it  and  the base of the  tongue, as well  as  the  margins
of  the  larynx,  will  be freely scarified;  or scissors curved flatwise—Plate
XXXV. Fig. 16—may be used in the same manner.  Though a disagreeable
sense of suffocation  and  choking  is  at  first caused  by the  operation, the
patient  soon recovers, and submits  to a repetition of the incisions after  a
short interval.   In all the cases operated on  by Buck, the  scarification was
performed twice, and in some instances three times, the hemorrhage  which
followed it being encouraged by the use of warm gargles.f
   Operation of  Lisfranc.—The patient  being placed in a similar position
to that just referred  to, a slightly curved bistoury with a  long and narrow
blade, guarded with  lint to within one line of its point, should be held as a
pen in the right hand.   Then passing the first and second fingers of the left
hand through the isthmus of the  fauces to the edematous swelling,  pass the
bistoury flatwise on the fingers down  to  the part, and when it has reached
the larynx, turn its edge upward and forward, elevating  or  depressing the
handle so as  to  make gentle  pressure with its point,  and scarify  the  tissue,
when a little pressure of the fingers will readily evacuate the serum. J
   In milder cases, resort may be had to  the use of the nitrate of silver.
   Cauterization.—Green, of New York, has obtained  much  success from
cauterizing the parts with a strong solution of the crystals of the nitrate  of
silver, 9ij or 3i  to £i of water, and applied by means of the  probang,  Plate
XXX. Fig. 10.  A weak solution, Green  thinks, is injurious, five or ten grains
to the ounce only tending to increase the inflammation.   His treatment is  as
follows:—
   Apply the sponge probang wet with the strong solution first to the pha-
rynx and top of the epiglottis, and, after a delay of  ten  or fifteen  minutes,
* M£m. de l'Acad. Royale de M6d., tome xi. p. 121.
f Transact. Amer. Med. Associaiion, vol. i. p. 137.
X Malgaigne, Operat. Surg., Philad. edit., p. 869. 
POLYPI IN THE  LARYNX.                   261
apply it freely to the base  of the  epiglottis and over the edematous lips of
the glottis.   Repeat this application  every hour  or  two according to the
urgency of the disease and the effect produced by the operation, attempting
each time to  introduce the  sponge into the glottis, which may be the more
readily accomplished as the edema subsides.*  Should this fail to arrest the
disease, resort must be had to Tracheotomy.
   Statistics.—Of six cases reported by Lisfranc, five were cured.  Of eight
reported by Buck, all terminated favorably, though in one tracheotomy was
also resorted to;f and in six additional cases reported lately! as occurring
in the hands of Buck, or in that of other surgeons in New York, all were
likewise cured.   R. A. Kinlock, of Charleston, has also lately cured one case
by scarification, making  twenty cures out of  twenty-one  cases.     '
   M. Sesticr, in a recent  number of the Archives  Generates, gives the
result of  168 cases, of which 127 died.   In  132  cases  the ordinary treat-
ment was adopted, and of this number 104 died.   In  36  cases the operation
of bronchotomy was performed, and of these  13  recovered and  23 died.§
   Remarks.—Previous to the year 1821, there  seems to have been no op-
eration practiced for  the  relief of this  complaint excepting  tracheotomy,
though MarshaliHall had suggested the  idea of  scarification  at that time.
This suggestion was, however, generally discountenanced  till Lisfranc, in
1823, resorted to punctures and pressure.  His idea seems also to have been
forgotten, or at least not generally resorted to, being  viewed as a "fantastic
operation," until Buck, of  New York, called  the  attentiou  of  the surgeons
of the United States to the result of his operations.   When we recollect the
serious nature of  the complaint,  and the fact that, without  opening the
trachea, the danger of death is imminent,  the benefits  conferred upon society
by such a paper as that  of Buck, cannot be too highly estimated.
   Among many points,  on which  he  lays especial stress, is  the  means of
diagnosis previously pointed out  by the  French writers, and  especially by
Tuilier, who proposed it in 1815,  in his inaugural thesis. ||   In seven  cases
out of the eight treated  by Buck, there was ample evidence to the  touch of
the puffy condition of the  parts, and  in the eighth there was no proof that
they were not swollen.   Of seventeen other cases which  Buck  has collected,
the edema was present  in fifteen, giving  in  all of them the sensation of  a
soft pulpy structure.   That a practice so long advised in severe cases  of
edema of the limbs, should not sooner have  been resorted to in a similar
condition of so important  an organ as the larynx, can only  be  explained by
the fact that the true nature of the disease has only  been accurately known
within  the  last fifty years.  As  a substitute for tracheotomy, and as a ra-
tional means of affording relief from a distressing  and dangerous complaint,
the operation of scarifying the glottis and epiglottis may be regarded as one
of the  most useful of those suggested  by the  surgeons of the nineteenth
century.
   Cauterization is only  likely to prove useful in the earlier stages.
                       \  3.—Polypi in the Larynx.

  In a valuable monograph by Ehrman, of Strasburg,^" professional atten-
tion has been called to the occasional presence of polypi upon the laryngeal
  * Surgical Treatment of Polypi of Larynx and Edema of Glottis, by Horace Green,
A.M., M.D.   New York, 1852.
  f Transact. Amer. Med. Association, vol. iv. p. 277, 1852.        J Op. cit., p. 145.
  g Charleston Medical Journal, vol. viii. p. 97.
  || Diet, des Science M6d., tome xvii.       If Histoire des Polypes du Larynx, 1830. 
262
PRINCIPLES AND  PRACTICE OF SURGERY.
mucous  membrane,  in  which he describes minutely a series of symptoms
that have, perhaps, beeu more frequently  seen than recognized, as  similar
symptoms have sometimes  been  noted without the  observer being able to
recognize the lesion which  occasioned them.   Although alluded to once in
the Fnited  States, by Cheeseman, of New York, in 1817,* few writers prior
to ls.">0 seemed to have investigated this complaint as thoroughly asEhrman,
and  the student will find  in  his work many practical details,  which  want
of space compels me to pass, with only this brief allusion.   As this account
must be mainly limited to operative details, I  shall  only furnish  a synopsis
of a case reported by Green, of New York.f  In this case, the polypus was
removed  by excision, though generally laryngotomy has been employed in
consequence of  the difficulty of obtaining access to the polypus through the
glottis.
   Operation of Green, of  New York.—A young girl, ten years of age,
after severe suffering, in connection with her trachea was found  to have  a
white fibrous-looking polypus, the pedicle of which appeared to  be attached
to the left ventricle or left vocal  ligament, as it  could  be  seen when the
tongue was  firmly depressed and the patient coughed and  gagged.   This
polypus being indubitably recognized,  Green proceeded to excise it by  seat-
ing the girl in a good light, with the head  firmly held back  by an assistant,
while he depressed the tongue  until the epiglottis was in  view.  Then,
gliding  a slender double hook down to the tumor, when raised by the pa-
tient's effort to  cough, he fished it  up, and after one or two attempts suc-
ceeded in slicing it off from its pedicle by cutting it from behind  forward  by
means of a probe-pointed knife with a strong handle and a delicate  slender
blade.   Some coughing followed, and a few drops  of blood, but this soon
passed away, and the young lady has for  several years enjoyed excellent
health.
   Remarks.—In  a paper by Gurdon  Buck, Jr., of New York, read before
the American Medical Association in  1853, and published  in volume six of
their Transactions, it is shown that the cases  of  pediculated polypi of the
larynx similar to  the above are very rare;  but Buck, whose experience in
this  disease  has  probably been  the most  extended  of any surgeon in the
United States, regards the operation of Green  as  especially well calculated
for their relief, and as highly creditable to the operator.  In the majority of
the cases the morbid growths are, however, more extended in their base, and
seated lower in  the larynx, requiring  the  performance of laryngotomy for
their relief.   The method of treating them will  therefore be found in the
account of  this latter operation.
   The prognosis of the disease when left to nature  is almost always a fatal
one, and the chances of an operation,  except as a means of  prolonging life,
are also very slight, only two, that  of Ehrman and  that of Green,  having
recovered out of six who were subjected to an  operation.


                          \ 4.—Tracheotomy.

   The perforation of any portion of the trachea by means of a cuttiug in-
strument, with the view of  affording a new passage  for the entrance of air
into the lungs, has  long been designated  as Bronchotomy, though, as the
opeuing  is limited to  those  portions of the trachea which are above the
sternum, the term Tracheotomy is  now more generally employed.  Either
* Transact. Physico-Med. Society, New York, vol. i. p. 413.
f On the Surgical Treatment of Polypi of the Larynx und Edema of the Glottis. 
TRACHEOTOMY.                         263
may, however, be used to designate the operations practiced on the larynx
or trachea proper, the incision of  the larynx being most frequently spoken
of as Laryngotomy.   As the operation of opening the windpipe varies a
little, according to the point operated on, the steps of each operation may
be best described separately.
   I.—Tracheotomy for Croup.—The operation of tracheotomy dates back
to a  very early period, Antyllus,  a.d. 340, having recommended and  per-
formed it in several instances.  It has also been performed at various times,
and in different manners, solely in  order to meet the  peculiar views of the
operator.  To specify all these  methods would, however, be  a useless task,
and I shall, therefore, limit myself to such a general plan of proceeding as
may be advantageously resorted to under most of the  circumstances which
demand this operation.
   Preliminary Measures.—When the operation  has been decided on, pre-
pare  a sharp scalpel; two curved spatula or blunt hooks; a director; one
straight,  sharp, and one probe-pointed bistoury;  dissecting forceps, and
dressing forceps, if it is intended to remove a foreign body; a tenaculum or
a pair of torsion forceps; sharp-pointed straight scissors; threaded needles;
ligatures, and several small pieces  of sponge attached to sticks or quills as
handles,  as well as one or two pieces of sponge, cold water, and towels, to-
gether with such other articles as may be demanded in the dressing.
   Ordinary Operation.—Place the patient upon his back, with the head
thrown sufficiently backward over  a  pillow, yet  not so  as to stretch it too
much, or compress the trachea by contracting the muscles in front of it.
   Then, while standing on the  right side of the patient, let one assistant
steady the head, Plate XXXI. Fig. 4, another confine the arms and steady
the shoulders, a third attend to the lower limbs, and a fourth  hand sponges,
etc.,  as needed; or if the patient is a child, bind its arms to the body by in-
closing them in a folded sheet or towel, so that one person  may be able to
hold  it.
   In commencing the operation, place the fingers of the left hand upon the
skin near the median line, so  as to  steady it, and make  an incision from the
inferior part of the larynx down to near the top of the sternum,  so as to cut
only through the skin, or puncture  a transverse fold of the skin  when raised
by the assistants, and cut from within  outward ; then,  raising  the fascia
superficialis on the forceps, puncture and slit it upon a director to the full
extent of the external wound.  After  finding  the  line  of junction of the
sterno-thyroid muscles, separate them with the handle or back of the knife,
by tearing the connective tissue  between them,  and have them held back by
curved spatula? so as to expose the parts beneath, when the isthmus of the
thyroid gland, if found to come so low  down as to be in  the  way of the in-
cision, should be tied by means of two ligatures passed beneath it by needles,
after  which it may be divided between the ligatures.  A t this time the venous
hemorrhage from several points of the  wound will often demand attention,
and such  vessels as can be seen should therefore be ligated.    Then, pushing
aside  the two inferior thyroid veins, or ligating  any anastomosing branches,
or the middle thyroid artery  if it exists, divide  freely the condensed areolar
tissue, which has been called  by Porter* the Tracheal  Fascia, aud dissect a
small portion of it from around the contemplated opening of  the trachea, in
order to  prevent the parts  from subsequently becoming emphysematous and
closing the orifice.   The trachea being now freely exposed, and  the bleed-
ing checked, a tenaculum may be  inserted in the median line of the rings,
Plate XXXI. Fig. 4, and  the part thus raised  excised by  sharp-pointed
* Surg. Anat. of Larynx and Trachea. 
264
PRINCIPLES AND PRACTICE  OF SURGERY.
scissors;  or a bistoury may be at once passed in, and the trachea slit open
from below upward, to the extent of three or four rings, not higher however
than the  second; after which, the wound may either be kept open  by means
of a dilator, as proposed by  Trousseau, or by bending a  piece of lead or
pewter, so  as to enable it to pass round  the  neck, and be  attached to the
sides of the wound, but not to the divided rings of the trachea, or by resort-
ing to  what I  have found to be  a neater  instrument, viz., an elastic ring
of broad  watch-spring, which  may be  readily adapted to any neck simply by
turning the pivot that holds the two  halves together, Plate XXX. Fig. 12.
The introduction of the old-fashioned canula into the trachea is, I think, so
objectionable, that it may suffice at present simply to mention it, though, for
the instruction  of such as desire to  employ  it, I  have  added a  figure to
show how it is  to be retained in the wound, Plate XXXI.  Fig. 6.  But
whether the cartilages are trimmed so as to leave an opening, as advised by
Lawrence and Porter, of England, or  simply incised, the  use of the blunt
hooks or the watch-spring will always prove serviceable by keeping the soft
parts from  contracting and  closing the  orifice in the trachea, as  is very apt
to be the case when the rings are merely divided without excising any por-
tion of them;  but as soon as the parts  are sufficiently  retracted, which hap-
pens sometimes in thirty-six hours, the  hooks  or springs should be removed.
  Aftar-Treatment.—The operation having  been  promptly performed, the
next most important point is the after treatment, as on this depends the suc-
cess of the  operation.   To one familiar with the pathology of croup, this will
of course be simple, and may be summed up in the employment of such meas-
ures as would generally be useful in relieving inflammation of the throat.  As
it is, however, of importance that there should be no error on the part of the
operator, I will briefly state the means that are most likely to contribute to
the success of the operation.   The wound  should  be lightly and carefully
covered by a piece of  moist gauze, so as to exclude dust from the tracheal
mucous membrane.   The temperature of the chamber should  always  be
closely watched, and  seldom  permitted to  sink below 80°  Fahreuheit, as
the air will now enter the lungs through the orifice in the trachea, without
having been previously warmed  in the mouth and nose.   The atmosphere
should also be kept moderately moist by a vessel of boiling water  or vinegar
and water so placed as to favor  the  evaporation of its contents.  Then, if
the trachea continues  to be filled with the false membrane  usually seen in
membranous croup, it may be lightly  touched  once, with a camel-hair pencil
wet with a solution  of the nitrate of  silver,  9j to 3j, introduced into the
trachea through the wound.  The frequent resort to this solution after the
operation, though once practiced, is now seldom employed,  as  Trousseau has
lately discountenanced it. When the edges of the wound  and the trachea
become dry aud disposed to crusts, it will be  found useful aud agreeable to
the patient to paint both surfaces with  glycerin and water, the constitutional
treatment being as carefully pursued as  it would have been before  the opera-
tion was  performed.  After the disordered action within the trachea has been
arrested, the wound may be  gradually  approximated and  union favored by
the use of  the warm water-dressing.    The  tracheal fistula sometimes seen
may often be induced to  heal  by touching it daily  with the solid  nitrate of
silver, or a resort to a plastic  operation may be required.   The object of the
direct or surgical treatment of croup, it should be remembered, is merely to
gain time for the efforts  of nature to effect the cure, the life  of the patient
and the  success of the operation being almost entirely dependent upon the
remedial measures otherwise employed.
   II.  Tracheotomy for  the Removal of a Foreign Body.—The perform-
ance of tracheotomy, for the removal  of a foreign body, differs in no way from 
TRACHEOTOMY.                         265
the operation just referred to in connection with croup;  but the following
plan, being presented as applicable to a case of this kind, and showing the
results of a prompt incision into the trachea with the view of checking venous
hemorrhage, is related in order to enable an  operator to make a selection.
The chief difference between this and the preceding operation will be found
in the fact that it is not proper to delay opening the trachea until the hemor-
rhage is arrested, as was previously advised.
   Operation of Liston.—In a patient, five years old, who had swallowed a
small glass seal, the operation  of tracheotomy was performed by Liston as
follows:—
   The patient, being securely fastened by a large sheet, wrapped several times
round the body and arms, and closely pinned, was held by an assistant hori-
zontally with his face upward, and his head between the operator's knees.  The
preliminary incisions being made  as usual, the blood gushed out freely from
the veins, which were greatly distended by the efforts of the child and the
difficulty of breathing, but none of these were tied.   After waiting a few sec-
onds  till the first rush of blood had somewhat abated, the trachea, which was
never still for a moment, rising and falling rapidly with the hurried move-
ments of respiration, was seized by means of  a small hook, and drawn for-
ward toward the mouth  of the wound, Plate XXXI. Fig. 4.   The scalpel
being then entered at the lower extremity of the incision, with its point directed
upward aud its back toward the vertebral column, with the handle kept  low,
and with a light hold of  the instrument, so as to avoid injuring the oesopha-
gus by any sudden movement of the patient, two or three of the rings were
divided, and the assistant immediately directed to turn the child over with his
face downward.  For an instant, the little patient seemed on the point of suffo-
cation, as the first inspiration drew in a certain quantity of blood, which could
not be prevented from flowing; but the next moment, by the change of posi-
tion, the blood trickled on the floor, a deeper inspiration was taken, the for-
eign body was expelled with force, and, as if by magic, the breathing became
quiet, and  the venous hemorrhage ceased spontaneously.   In a patient on
whom I operated some few years  since for the removal of  a grain of corn,
and in another for the removal of a watermelon seed, the same  course was
pursued successfully.  The hemorrhage was quite free in each case, and drawn
by the inspiration into the trachea, but turning the patient's face downward,
the freer respiration sufficed to  prevent its further flow into the trachea.
   Remarks___In this mode of operating, the great object seems to be to open
the trachea promptly ; but, unless in cases of threatening suffocation, as from
the introduction of a piece of meat into the windpipe, there is no occasion for
such haste.   In removing other foreign  bodies, it sometimes happens  that
the opening of the trachea produces such violent coughing as ejects the  arti-
cle solely from the efforts of the patient;  but  in others its escape is by no
means so easy or certain as in  the case just detailed. Not  unfrequently it
becomes  necessary to remove it by means of narrow forceps, Plate XXXI.
Fig. 5, though sometimes, and in  my opinion most  frequently, it remains for
days and  weeks, being subsequently thrown up in a spasmodic attack  of
coughing.   In some of these cases, the performance of tracheotomy has  been
beneficial; but in others  the patient has not derived such relief as would jus-
tify the operation.  Cautiou in diagnosis and prognosis is, therefore, a  mat-
ter of  much importance  with patients who are  thus situated, and the opera-
tion should not be performed until the evidence of the  presence of the foreign
body and its injurious effects are quite apparent.
   III. Tracheotomy for Epilepsy.—The suggestion of Marshall Hall, to
relieve one of  the forms of Epilepsy (Laryngismus) by opening the trachea,
seemed at one time likely to lead to the frequent performance of the opera- 
266
PRINCIPLES AND  PRACTICE OF  SURGERY.
tion of tracheotomy.  Notwithstanding the able arguments adduced  in sup-
port of  this theory by its accomplished author, the profession have not gen-
erally coincided in its propriety, and many have even regarded  it as  unjusti-
fiable.   In several of the patients on whom the operation has been performed,
the disease was only checked temporarily, as had often been previously noticed
after accidents or other events calculated to make an impression on the ner-
vous system  of the epileptic.  Some of those operated on, in accordance with
the suggestion of Hall, have either had a return of the disease  or died,  not-
withstanding the existence of an opening in the  trachea, through which air
was freely transmitted to  the lungs; and in  a paper read by Radclifle, of
London, before the London Medical Society, the opinion  is expressed "that
the convulsions have been almost uniformly as bad as ever" after the opera-
tion.  Many members of the Society doubted, therefore, whether tracheotomy
was beneficial in this complaint.*  In a case operated on in Philadelphia, by
John Neill, the patient died with the tube in the trachea.
  IV. Laryngotomy. — Laryngotomy may be demanded by very much the
same circumstances  as those which  indicate  the propriety of performing
Tracheotomy, but the former operation is less frequently employed than  the
latter, in consequence of the greater risk of hemorrhage in its  performance,
as well  as the subsequent effects  upon  the voice.   It may be performed
thus:—
  Operation of Desault.—After dividing the skin and fascia superficialis by
an incision which extended from the projecting  angle of the thyroid carti-
lage to  a  little below the cricoid, but not near so long as  that required in
tracheotomy, Desault separated the thyroid muscles, placed  his  forefinger on
the crico-thyroid ligament, and, feeling for the artery of the same name,  en-
deavored to depress  or raise it out of the line of the incision; and then, plung-
ing the  scalpel into the ligament, cut it either upward or downward,  accord-
ing to the position of the vessel.
  When the incision is continued down through the cricoid cartilage and first
rings of the trachea, it constitutes the operation which has been designated
as laryngo-tracheotomy.   In bad cases of Polpi in the Larynx, it may also
be necessary to prolong the incision upward to the os hyoides, as was done
by Buck, of New York, in the operation which is hereafter quoted.
  Y. Laryngotomy for the Removal of Polypi in the Larynx.—In  two
cases reported f by Gurdon Buck, Jr., of New York, the operation of Laryn-
gotomy, as recommended by Ehrman, of Strasburg, was performed, and with
considerable relief.
  Operation of Gurdon Buck, Jr., of New York.—The patient being seated
before a window, on  a low arm-chair, with the head thrown back and the front
legs of  the chair raised  about three inches, on blocks, an incision was made
for about four inches in the median line of the neck, dividing the skin and
subjacent tissues till the laryngeal cartilages and the three upper tracheal rings
were laid  bare, the latter being done partly by lacerating and  partly by de-
pressing the isthmus of the thyroid gland.  The hemorrhage having ceased, the
crico-thyroid membrane was incised, and the incision continued upward in
the median line, with the greatest precision, throughout the whole extent of
the thyroid cartilages, the division being made with the scissors in consequence
of the ossification of the cartilages.  The section being then continued  through
the cricoid cartilages and  the exposed rings of the trachea, the sides of the
larynx were stretched apart, with retractors, thus exposing the polypus growth
attached to its lateral walls.  On  snipping off the polypus the hemorrhage
* London Lancet, 1853.
f Transact. Amer. Med. Association, vol. vi. p. 509, 1853. 
TRACHEOTOMY.
267
(which was of short duration) was absorbed by pieces of sponge held in the
forceps, and  the blood thus prevented from flowing into the  trachea.   A
portion of the two upper rings of the trachea being now removed on either
side, the tracheal tube was introduced, fastened by a tape passed round the
neck, Plate XXXI.  Fig.  6,  and the respiration thus rendered easy and
comfortable.   The wound subsequently healed kindly around the tube, which
was changed once in twenty-four hours,  and the patient soon found that by
closing the outer orifice of the tube  she could breathe through the nostrils,
and also blow her nose.  The disease having reappeared after three or four
months, a second operation was  performed, the incision being carried along
the median line, from the upper margin of the  opening occupied by the tube,
to within one inch and a half of the chin, so as to expose the whole of the
larynx and os hyoides.   It was also  extended downward one inch below the
opening for  the tube, when it was removed and the larynx split open to its
whole extent.   After overcoming many difficulties in removing as much as
was possible  of  the tumor,  the wound was closed by three sutures above the
tube, when the  latter was  replaced.   The subsequent changing of the tube
often caused  considerable hemorrhage; and, the tumor again becoming de-
veloped, a third operation, of a similar character, was performed.  This wound
also healed kindly,, but the  difficulty in removing the tube was again experi-
enced and the disease again progressed, though the  patient did  not die un-
til  nearly fifteen months after the first operation, without which, Buck sup-
poses, she could have lived but a short time.  In employing the tracheal tube,
Buck advises that it should be made  with a large opening on the convex side
of its curve, in order to permit the use of the voice and the expulsion of mat-
ter from the trachea when  the outer  orifice is closed.
   Estimate of these Different Operations.—Tracheotomy presents  so few
dangers that are not  equaled by the operation of laryngotomy,  and has, in
several diseases, so many additional points of recommendation, that the latter
is but seldom resorted to.  In selecting a mode of operating, preference may,
it is thought, be justly given to that  described at the commencement of this
section.   The advantages which  I think it  possesses are: first,  less  risk of
hemorrhage in consequence of the surgeon lacerating the parts about the
median line of the muscles, instead of dissecting them, as well as from his
ligating the isthmus of the thyroid gland previous to  incising it;  second, the
preservation of the opening in the trachea without irritating its lining mem-
brane, by the application of the blunt hooks to the  sides of the  wound, the
tracheal wound remaining patulous,  if not closed by  the adjacent tissues, or
resorting to an instrument, like a  canula, that exposes the patient to the risk
of suffocation by its escape from the  wound, or clogging with the secretions
of the part; and, third, the power of looking into the windpipe, and judging
accurately of its condition,  or of applying remedies to correct it, if desirable.
Indeed, much of the success which has attended this operation in the hands
of Trousseau and  others seems to  have been due to their judicious  after-
treatment, especially keeping the wound covered by gauze, and moist  so as
to obviate the dryness of the trachea caused  by evaporation in breathing
through the wound.
  The excision of even a small portion of the rings of the trachea, in order
to aid in  preserving the opening, has been  objected to by some surgeons as
being likely to cause a subsequent contraction  of  the canal when the wound
cicatrizes.  But  in the patients who have recovered, this has not been the
result. In Bigelow's case,*  after employing  a tube two days, it was deemed
* Am. Journ. of Med. Sciences, vol. xxvi. N. S. p. 81. 
268
PRINCIPLES AND  PRACTICE OF  SURGERY.
better  to remove it, and excise a  portion of the tracheal rings, and subse-
quently a dilator of wire was kept at the orifice of the wound.
  The points especially worthy of notice in the performance of tracheotomy
may then be summed up as follows: 1st, to lacerate and stretch, rather than
dissect the parts about the trachea; 2d, to check  all hemorrhage by the liga-
ture before opening the canal;  3d, to clear away the  condensed connective
tissue (tracheal fascia) around the proposed opening;  4th, to keep the wound
covered with fine and constantly moist gauze ; and,  lastly, to keep the wound
and orifice in  the trachea distended by a spring or by hooks, Plate XXX.
Fig. 12.
  To those not familiar with the details  of this operation, it may also be use-
ful to state that the puncture of the trachea generally brings on a most vio-
lent and convulsive  cough, during which little or nothing can be done.  This,
however, usually passes off as soon  as the first stimulus of the cold air ceases
to be felt.   When, then, an incision is to be made into the trachea, it should
promptly follow the puncture of the knife, or if  a  tenaculum is  inserted, in
order to favor the removal of a portion of the rings, their excision should be
quickly effected after the hook is introduced, the  violence of the cough con-
sequent on the puncture being sometimes so marked as to alarm the by-stand-
ers for the life of the patient.
   It is now doubtless apparent, from reading the above estimate of trache-
otomy, that I regard it as an operation requiring some skill and preparation
on the part of the surgeon, and that it should not be attempted by any prac-
titioner, unless totally regardless of consequences.   No matter how simple
the operation may appear upon the dead subject, or upon the healthy adult,
it will often prove to be a difficult one when the  vessels are rendered turgid
by dyspnoea, or when it is to be performed  on the short, fat neck of a child,
or when it is  resorted to on a patient  apparently at the last  gasp, whose
larynx  and  trachea are  actively raised  and depressed at every respiration.
To the experienced  surgeon such facts are well known, but to those who have
judged of the  operation solely from its performance in the dissecting-room,
such statements should create caution and lead them to anticipate difficulties,
if they are induced  to operate.  In all cases, special  precautions should be
taken in regard to hemorrhage, as, in some instances, the flow of blood has
been of the  most alarming and intractable kind.  Desault,* whose skill no
one can doubt, was, it is said, compelled to give up an operation,  on  one
occasion, in consequence of hemorrhage; and Recamier has advised surgeons
to defer opening the trachea for several  hours, lest the patient should suffer
from a flow of  blood.   Roux,  also, is reported to have saved one of  his pa-
tients from the suffocation caused by the blood escaping into a trachea which
had been promptly  opened in hopes of arresting it, only by placing his own
mouth to the wound and sucking it out.    In a recent number of the Gazette
des Hopitaux, as translated by  Fraser, and published in the Transylvania
Medical Journal  for  June, 1853, is  also an account of a discussion on
Tracheotomy  in the French Academy  of Medicine, in which  the serious
character of the operation is admitted both by Guersant and Boyer.  When,
therefore, tracheotomy is spoken of " as an operation not much more difficult
than venesection," the opinion should be received with some hesitation, as it
may be the result of the want of experience on the part of those  who utter it.
   Supposing,  however, that the operator is aware of these dangers—and it is
admitted that they  are not universally encountered—the question which has
of late years occupied so much of the attention of surgeons yet remains to be
decided, to wit, Should tracheotomy be resorted to for the relief of all patients
* Diet, de M6d., tome vi. p. 58. 
TRACHEOTOMY.                         269
who are liable to die asphyxiated ?  That such a recommendation cannot be
universally admitted requires no argument, and the  proposition may, there-
fore, be more definitely settled by showing in what cases the performance of
this operation may be advisable.
  That an opening may be  made into a healthy trachea for the removal of
a foreign body, or in order to overcome a spasm of the glottis caused by in-
haling a noxious vapor, or in cases of edema of the glottis, is a point which
I cannot but regard as settled by statistics.   From an examination of various
cases as reported, as well as from a review of many  of  the works upon Sur-
gery, from a very early period, I am inclined to think that tracheotomy, in such
cases, is not only a justifiable operation, but also one which furnishes the  pa-
tient  with a ready  means of escape from the dangers likely to ensue.  And
although instances  are recorded in which nails and coins have  remained in
the windpipe for years,  and even in the lungs, without destroying life, there are
others, well authenticated, where the presence of a small bean, or of a grain
of  coft'ee  or of corn, has induced laryngeal phthisis, ulceration, and death.
In  edema of the glottis, though  the  operation of tracheotomy may be  re-
quired, I would not resort to it until scarification of the parts had been fairly
tried  ; but this being  done, I  should  anticipate from  tracheotomy prompt
and permanent relief.    In  hydrophobia, I  should certainly be disposed to
try it rather than see the patient die without the operation.
  As  to  the  propriety  of advising  tracheotomy in cases of membranous
croup, there is apparently so much of the result that might be charged to
the peculiarity of  the  mode of operating heretofore employed, and to  the
delay that has generally preceded its  performance, that the decision of  the
question must be considered as "sub judice."  By referring to the statistics
hereafter  quoted, an opinion of the success of the operation, as usually per-
formed, may be readily obtained, and  it is one which  has  gone far toward
diminishing professional confidence in this operation as a means of treating
croup.  Yery many of the best surgeons at different periods have, in their
day, doubted its propriety or only advocated its performance at the last mo-
ment.  In the United  States, the experience of Physick was adverse to it;
and in Boston, the opinion of some of the profession is at present opposed
to its performance, as I noticed no reply was given* to the question proposed
by  Storer, of Boston, to the members of the Society for Medical Improve-
ment, whether " Tracheotomy had ever been successfully performed in that
city in membranous croup?"  More extended statistics, as collected for this
volume, also show that  the prognosis of the operation, as heretofore per-
formed, should be  very guarded.
  In  most of the cases as yet reported, tracheotomy has, however, been de-
ferred until the complaint had existed some time, aud the inflammation pro-
gressed from the larynx into the trachea, or induced congestion  of the lungs,
or  augmented the  dangers from the incisions, by causing engorgement of the
vessels of the neck; while in others there was an unhealthy condition  of the
lining membrane  of the trachea at  the point operated on, or sometimes
sloughing  of the wound, and constant irritation from the changing of the
tube employed to preserve the opening in the trachea.   Until, then, we  can
acquire such statistics  as will show that in the cases operated on at an early
period after a positive diagnosis of membranous croup has been made, and
operated on so as  to leave an opening  which by the use of glycerin would
not be liable to clog with mucus, while it is also kept free from the continued
irritation of a tube, by the use of the hooks or spring—Plate  XXX. Fig. 12__
the number of deaths correspond with  the mortality under the former mode of
* Amer. Journ. Med. Sciences, vol. xxvi. N. S. p. 81, 1853. 
270
PRINCIPLES  AND  PRACTICE OF  SURGERY.
 operating, this question cannot be regarded as settled.  Cauterization of the
 pharynx and trachea through the mouth, together with  early depletion, calo-
 mel and emetics, have saved many cases  of true membranous croup,  and
 will, consequently, be strong arguments against the performance of an early
 operation.  But when croup occurs  in those  who are hereditarily  predis-
 posed to it, or when other members of a family have died from it, I would
 advise an early operation, and anticipate more success  from it than I should
 from medical means  alone, provided the operation  was resorted to  before
 the  inflammation  had reached  the portion of the  trachea which was to
 be  opened,  and the wound was kept dilated by hooks introduced upon its
 sides.   The chief  difficulty  here is  to designate any signs which  would
 indicate that inflammation of the tracheal membraue had not gone too far,
 since auscultation furnishes no evidence that can be relied on, De La Berge
 and Moneret* citing one case, in which, though the vesicular  murmur  was
 extremely pure and heard everywhere, yet during the operation  a false mem-
 brane was drawn  out which represented the trachea and  division of the
 bronchia; and Pepper, of Philadelphia, having also reportedf one similar
 case, and another  in which, though the respiratory  murmur could  not be
 heard, yet the exudation  was  strictly  confined to the larynx.   The only
 test that I know of is  the  one suggested^  by my friend, J.  Forsyth  Meigs,
 of  Philadelphia,  in which he states  that in some patients the pulse  was
 much  less rapid when the disease  was limited to the larynx  and trachea
 than it was  when it had  invaded the  bronchia.   In two cases involving the
 bronchia, the pulse  counted 140 to 150 for several days  prior to death, while
 in two others in which only the larynx and trachea were diseased, as shown
 post mortem, it counted  only 120 or 130.   In the case reported by Pepper,
 in which the disease was found after death to be confined to the larynx, the
 pulse was also only 120 the day preceding its termination.  Meigs also sug-
 gests that the signs of asphyxia will have existed longer and come on more
 slowly and gradually when the bronchia are diseased than they  will in those
 in which these tubes are not involved.   He therefore advocates the operation
 in hopes of saving some  who would otherwise certainly perish.   Although I
 am not so sanguine in regard to the frequent success that might ensue if the
 operation of tracheotomy, in croup, was performed at  an early period, I think
 that it is justifiable in many cases, and especially in those with a pulse not
 above 120, especially if the parents  are anxious for the operation, the moral
 comfort  often afforded them by the thought that everything possible had
 been done to save the life of an  object of deep affection  being  sufficient to
justify the performance even where  death ensued.  Like the operation for
 strangulated hernia, tracheotomy, to be moderately successful, must be per-
 formed before the changes  in the part caused by disease are likely to render
 it useless.
  Statistics of the  Operation of Tracheotomy.—In  order to show the data
 upon which  the opinion just expressed has been  based, I have collected from
 various sources the reports of the operation, as performed for  the relief of
 croup as well as for other purposes, and present  them in the tabular form,
 as being that which most readily exhibits the result.
  Tracheotomy for Croup. — The  following table shows the  success  ob-
 tained from  the operation of Tracheotomy,  as usually  performed for  the
 relief of  membranous croup, the  wound being mostly  kept open  by means of
  * Practical Treatise on Diseases of Children, by J. F. Meigs, M.D., lid edit  n 111
Philad. 1853.                                                      "  r
  f Summary Trans. College of Physicians of Phila., vol. iii. p. 106.
  X Am.  Journ. Med. Sciences, vol. xvii. N. S. p. 33L', 1849. 
TRACHEOTOMY.
271
 a canula in the windpipe.  This table contains all such cases as were accessible
 to me, and  may be relied  on, in the formation of an  opinion, as far as  any
 mere enumeration of the result of any operation can be, unless more details
 of the cases were furnished than is compatible with the limits of this volume.
 As the Bibliographical Index at the end of this part presents a full refer-
 ence to such of the cases in the following table as were reported by Amer-
 ican surgeons,  those desirous of further details will find them in the journals
 there quoted.
       OPERATOR.                              OPERATIONS.   CURED.      DIED.
       Amussat.................................................    6         0        6
       Baudelocque.............................................   15         0        15
       Blandin ..................................................    5         0        5
       Bretonneau.............................................   18         4        14
       Gerdy.....................................................    6         4        2
       Guersent..................................................    9         0        9
       Uuersent,  Hopital des Enf'ans Malades, in 1850  20         6         14
                                         1851   31        12        18
                                         lH.->2   59        11         48
     This success was owing to greater attention to the treatment of the wound.
       Maslieurat...............................................    2         11
       Petit......................................................    6         3        3
       Roux......................................................    4         0        4
       Velpeau..................................................    6         0        6
       Trousseau................................................  153        41       112
       Pancoast.................................................    9         4        5
       Page.....................................................    10        1
       Smith.....................................................    10        1
       Thompson................................................    10         1
       E. Atlee..................................................    1         0        1
       Townsend................................................    10         1
       V.in Buren...............................................    10         1
       Buck, Jr  ................................................    2         2         0
       Johnson.................................................    10         1
       Go.ldard..................................................    1         0         1
       Burgess...................................................    2         11
       Mcllvain........................................................    10         1
      Carter Johnson....................................................    10         1
      Pitney......................................................................    110
       Ayres...................................................................    110
      Bigelow................................................................    1         0         1

                                             366        91       274

   From this it is seen  that of 366 cases of tracheotomy performed for the
relief of croup, in which  the operation was not resorted to  until  nearly every
other means  had been tried, only 91 were cured, while 274 died, that is, in
the 366 cases operated  on, only two more than one-fourth of the  patients
recovered.
   Since  the  publication of the preceding statement in the second edition of
my "Operative Surgery," the  statistics of tracheotomy in croup have ac-
cumulated, but without augmenting the ratio of cures.  Trousseau's recent
experience has only confirmed  his former opinion as to the propriety of the
operation, regarding it now "as a duty as imperative as that of ligating the
carotid artery after a wound of that vessel."
   In  the  Gazette des Hopitaux, as republished  in the Southern  Medical
and SurgicalJournal of November, 1858, there is published the statistics of
the Hopital des Enfans Malades of Paris, in tracheotomy, as performed
during the last ten years.   The years 1850-51-52 having been included in
the preceding table, I only add the account of the subsequent years. 
272
PRINCIPLES AND  PRACTICE OF  SURGERY.
1853........	OPERATIONS. ........... 61	CURED. 7 11 10 14 15 57	DIED. 54
1855 ..... 1856........	........... 45 ........... 48		34 38 41
1857 .......	........... 71 280		56 223
  From which it appears that since the year 1853 the mortality is as 1 in 4
to 1  in 5 of the whole number operated on yearly—though it must be remem-
bered that the majority of the cases operated on were in the last stage of
croup, and therefore in imminent danger of death.
  Guersent admits the mortality to be  greater in proportion to the age of
the child, those  under two  years  presenting peculiar difficulties in the per-
formance of the operation,  and in  several instances dying in convulsions
during its performance.  One decided  contraindication  to  the operation is
admitted even by Guersent, and that is  geueral diphtheritis, false membrane
being seen in the throat, etc., as well as on the vocal chords.
  George II. Gay, of  Boston, has however reported* two cases of recovery
after the operation, where false membrane was coughed up, and also seen in the
fauces of one case.  Of six cases operated on by Gay, four recovered, a  suc-
cess  which he ascribes to the comparatively early period  of  his operations.
  The house surgeons of  the  Hospital  for Infants reply  in  substance  as
follows to the three questions :—
   1.  On what symptom, at the different periods of croup, do the house sur-
geons of the Hospital  for Infants resolve upon performing tracheotomy?
  2. What symptoms  induce them to abstain?
  3. What symptoms  lead them to temporize ?
  First. They operate when, in  spite of  medical treatment, the difficulty of
breathing rapidly increases, the general symptoms  are aggravated,  and the
paroxysms of suffocation occur frequently and at short intervals.   The As-
phyxia is accompanied with Cyanosis in some cases, with paleness in others;
in both the operation is proper.
   Second. They are deterred from operating on children under two years of
age, and operate reluctantly on those under two years and a half.  They do
not operate when manifest general infection of the system exists, as indicated
by the simultaneous existence of livid paleness, swelling of the submaxillary,
cervical, and sometimes Parotid glands, with general tumefaction of the neck,
and  edema unconnected with the glandular swelling.f the breath being fetid,
and  the pulse small and feeble.   Also  they do hot operate  in general Diph-
theritis, as indicated by the  symptoms just mentioned with serous coryza, and
secretion of false membranes behind the ears, at the vulva, or on blistered
surfaces.
   Third. They hesitate in the presence of thoracic complications.  In Pneu-
monia, they operate if the inflammation is limited to one lung and the con-
dition of the patient is otherwise  favorable, but they  do not operate in cases
complicated with double Pneumonia.
   In cases of Pseudo-membranous bronchitis, indicated  by the ejection of
cylindrical and evidently bronchial false membranes,  they are guided by the
general state and age  of the patient.
   The next table shows a very different result, the operation of tracheotomy
being performed at a period when the trachea was  not diseased.
* Boston Med. and Surg. Journal, 1858.
f The Virginia Medical Journal, Nov. and Dec. 1859, from Champonniere's Journal. 
TRACHEOTOMY.                          273
  Tracheotomy for the Removal of Foreign Bodies, etc.—This table con-
tains cases collected by myself, and reported up to January, 1860.
John Newman, N. C.........
Amassa Trowbridge, N. Y.
H. G. Jameston, Md.........
Samuel Cartwright, Miss..
H. T. Waterhouse, N. Y...,
Joseph Palmer................
Richard Hurgess.............
Peter P. Woodbury,  N. H.
Calvin Jewett, Vt...........
Enos Barnes, N. Y..................
Abner Hopton,  N. C................
Zadok Howe, Mass...................
J. F. Hardy, N. C...................
Charles Hall, Vi......................
J. Mason Warren, Mass...........,
Twitchell, N H.....................
William Davidson, Ind.............
W. H. Van Buren, N. Y...........
J. H. Kearny Rodgers, N. Y......
Evans, Ky.............................
N. R. Smith...........................
Liston..................................
Pancoast................................. 3
Henry II. Smith........................ 3
Brainard.................................  1
Gilbert.....................................  3
Moorehouse....
May..............
Neill.............
Hoyt.............
Trabue..........
W. H. Mussey.
Cured 44 Died 5
        SUBSTANCE.
 Bullet.
 Bean.
 Watermelon seed.
 Pebble.
 Watermelon seed.
 Watermelon seed.
 Bean.

 Bean.
 Bean.
 Iron nail near two inches long.

 Grain of corn.
 Bean.
 Watermelon seed.
 Pipe stem.
 Bean, pin, carpet-tack, nail.
 Bean.
 Grain of corn.
 Plum stem and watermelon seed.
 Cherry stone.
 Vapor of hot water.
 (Laryngotomy.)  Cockle bur.
 Glass seal.
 Result not stated.
 Grain of corn  1, cured;  watermelon
   Beed  1, cured;  grain  of coffee 1,
   cured.
 Abscess at root of tongue.
 Coffee grain, raw potato,  corn.
 Almond shell.
 Coffee and corn grains.
 Epilepsy.
 Bean.
 Corn grain.
 Soup bone (chip.)

Total 49.
   From this it appears that, in 49 cases of tracheotomy performed for the
removal of foreign substances from the trachea, 44 were cured, and only 5
died—the  trachea being allowed  to close and heal as soon  as possible after
the operation.
   In  comparing the results of these  two tables, it is very evident that the
dangers which ensue upon  incising a healthy  trachea are comparatively
slight, and that the great mortality which has attended the  operation, when
performed for the relief of croup, must be due to some  other cause than the
mere  incision of the windpipe.  But whether this cause  is to be found in the
changes produced by the disease, or whether it is the result of an incision in
an inflamed instead of  a healthy structure, or  whether it is not owing to the
delay usually attending the performance of  the  operation,  is a point which
can only be settled by each operator hereafter specifying the peculiarities of
his cases.
     VOL. II.—18 
CHAPTER  IV.
DISORDERS  OF  THE  THROAT AND NECK.
                             SECTION I.

                      ANATOMY OF THE THROAT.

   TnE term Pharynx is applied to all the upper portion of the oesophagus,
or the oriflce of the gullet, and is formed by a series of muscles which are
designated as the superior, middle, and  inferior  constrictors ;  the object  of
these being to seize upon the bolus of food, and, by their successive contraction,
carry it dowu into the oesophagus, the muscular coat of which, by like contrac-
tions, carries it down  into the  stomach.  The pharynx is attached  poste-
riorly to the bodies of the vertebras by a certain amount of loose connective
tissue, which, like all  connective tissue,  may become the seat of inflam-
mation and  abscess.   The entrance  from the mouth into the pharynx  is
guarded on each side by the two half arches of  the soft palate, which have
between them the tonsil gland.   Just below this point, and  anterior to the
pharynx, or  at the root of the tongue, is the epiglottis cartilage, which
closes the orifice through which the air passes into the larynx  and trachea
when the patient swallows.   As  the  thyroid cartilages, which compose the
upper part of the larynx, are open  posteriorly, or rather united only by
fibrous tissue, they do not  afford that  protection to the surface of the
larynx which is next to  the  pharynx that they do on  its front, while the
rings of the  trachea being also imperfect on the posterior side, any force
that distends the  pharynx and oesophagus acts with  great readiness upon
the air-passages, so as to produce compression and all the consequent symp-
toms of difficulty of respiration, and strangulation. It should also be noticed
that the  situation of the  great vessels of the neck, in regard to the oesoph-
agus and pharynx,  is such that any forcible distention of the  oesophagus or
pharynx is liable to interfere with the freedom of the circulation, by inducing
spasm of  the  muscles of the neck, aud  thus  compressing the  veins  which
bring the blood from the brain.
                            SECTION  II.

                      DISORDERS OP  THE THROAT.

                  \ 1.—Foreign Bodies in the Pharynx.

  The foreign bodies which are most likely to get into the pharynx are such
as are ordinarily taken into the mouth for the purposes of nutrition, although
bodies of various characters may, through  a variety of accidents, obtain the
same position.  Of the first variety of foreign bodies, the most common are
      (274) 
FOREIGN  BODIES  IN THE PHARYNX.              275
 such as fish-bones, especially the smaller bones of such varieties as the her-
 ring or shad, the smallness of which causes them to pass unnoticed to the
 fauces, when, getting transversely, their length is sufficiently great to cause
 them to lodge across the pharynx ; or the offending substance may be a piece
 of tough meat or gristle taken into the mouth during a meal.  Of the second
 kind are foreign bodies taken into the mouth for any purpose and accidentally
 swallowed, such as pins, which are often held in the mouth by housemaids
 and others, bits of glass, beads, coins, etc.
   Seat.—When  any  of these substances  are swallowed, the first  place at
 which their progress is likely to be arrested is  at the half arches, where the
 body, if sharp, such as a pin, needle, or fish-bone, will often  be  found stick-
 ing  directly into the structure of the tonsil, it being sometimes imbedded by
 means of the spasmodic contractions of the isthmus of the fauces, the mus-
 cular contractions of which have  occasionally such power that cases are  on
 record in which pins and similar poiuted articles have been driven completely
 through the fauces, so as to  wound the great vessels of the neck.
   Diagnosis.—In these cases, the surgeon will generally be able to recognize
 the  foreign body by the sight, simply by directing the patient  to open his
 mouth widely ; but if, from the minuteness of the  substance or its position, he
 fails to do so, and the symptoms clearly indicate its presence, he should have
 no hesitation  in introducing his finger into the throat, by means of which the
 substance, if present, can always be felt.
   Very frequently, however, it passes the isthmus of the fauces, and becomes
 fast  in the pharynx, where it may generally be looked for about the bottom
 of the middle constrictor muscle, though sometimes it is held in the embrace
 of the superior constrictor.   Here, also, its presence can be recognized  by
 means of the finger, which, under these circumstances, should  be passed down
 a  little below  the orifice of the larynx.
   Symptoms.—When a foreign body is arrested in the pharynx, it is very
 apt  to produce such  pressure  upon the larynx or trachea  as  will be fol-
 lowed by violent  spasm in  the  muscles  of respiration,  with  evidence of
 strangulation.  As a general rule, foreign  bodies which pass fairly into the
 pharynx, yet are of such a size or shape as prevents their passage into the
 stomach, hitch upon a point that corresponds with the posterior face of the
 larynx, and,  irritating the thyroid  muscles, induce  spasms which are  very
 violent in their character, owing to the irritation of the nerves of respiration.
 The  patient therefore  soon gasps and struggles  for breath; while, by the
 contraction of the respiratory muscles thus  thrown into a state of spasm, the
 larynx is pressed forcibly back upon  the  foreign body, and the danger is
 increased.
   Treatment.-1—The treatment in these cases must always be prompt, par-
 ticularly if the foreign  body is large, as the spasm will soon result in closure
 of the glottis, when the patient will be suffocated in a few minutes.
   A person when seen making these violent spasmodic efforts, under circum-
stances which would lead to the suspicion of a foreign body being the cause,
should, therefore, at once be  compelled to lean forward and drop his head
upon the chest in such a manner as  to  relax the  muscles of his  throat, and
thus   prevent  as  much as possible  the occurrence  of  contraction in such
muscles as will» by forcing the larynx against the pharynx, only increase the
 evil.   Then, having widely separated the jaws by ineaus of a fork-handle or a
cork, thrust a finger into the  throat and  hook out the foreign body if possi-
ble, when the  relief will be prompt.
   If, however, this manipulation  should fail, the patient's head  should be
retained  by  assistants  in  the same position, while the surgeon resorts to
more efficient  means hereafter mentioned. 
276           PRINCIPLES AND PRACTICE OF  SURGERY.
                             SECTION  III.

                        DISORDERS OP THE  NECK.

               \ 1.—Disorders of the Muscles  of the Neck.

   Torticollis,  or Wry-Neck,  is an affection connected with  the  muscular
structure of the neck, which  is generally due  to a spasmodic contraction,
often a permanent one, of the sterno-cleido-mastoid muscle.
   Treatment.—In its milder form this  disorder is only a rheumatic affection
of the muscle,  and may be  readily relieved  by  means  of warm stimulating
frictions, a very good article for  the  purpose  being found in the tinctura
saponis camphorata, combined with a due  proportion of the tincture of the
root  of  aconite; or  it may be necessary  to  abstract blood by cups.   The
popular plan of covering the neck with a damp cloth, and ironing it with  a
warm flat-iron  so long as  the patient  can bear it, is also  not  a  bad stimu-
lating mode of treatment.
   A  more permanent contraction of the  muscle requires, however, a more
decided course of action; and it should be borne in mind that  here, as in
                                strabismus,  while there is a preternatural
                                contraction  of the muscle of one side, there
                                is a marked relaxation in its antagonistic
                                muscle, so that if the condition has existed
                                for some weeks or months, and promises to
                                remain, it may be necessary to resort to an
                                operation, this being conducted upon pre-
                                cisely similar principles to that alluded to in
                                connection with strabismus;  bnt  here  the
                                operation must be  followed by the proper
                                application  of mechanical means  to  over-
                                come  the contraction.   The  operation of
                                myotomy, as  generally  practiced  for the
                                relief  of these  deformities, is a very simple
                                one, and  only dangerous in the hands of  a
                                surgeon grossly ignorant of the anatomy of
                                the part.   The mode of performing it will
                                be described hereafter.
                                  As the new tissue formed by the organi-
                                zation of the  lymph which is thrown out
                                between the edges of the divided muscle
                                is very extensible, it should subsequently be
                                brought to such a  length  as  will insure  a
                                removal of the deformity  by means of vari-
                                ous  mechanical contrivances, such as are to
                                be found either in the   handkerchief of
                                Mayor, specially designed for  this purpose,
or in  an instrument which regulates the position of the head by means of  a
pad and screw, or in a sort of helmet, with shoulder-bands so contrived as to
hold the head in the proper position, Fig. 425.
Fig. 425.
 HELMET, ETC. TOR THE TREATMENT OF TOR-
TICOLLIS AFTER THE OPERATION OF MYOTOMY.—
1, 2. Straps to pass under the chin and around
the head.  3. A movable rod to adjust the hel-
met to necks of different lengths.  4,4. Straps
to surround the shoulders.  5, 5. Straps to
fasten the t»houlder-brace around the chest, and
thus furnish a point of support for the appa-
ratus. (After Nature.) 
SURGICAL ANATOMY  OF THE PHARYNX AND  OESOPHAGUS.   277
                      2 2.—Hydrocele of the Neck.

  Hydrocele of the Neck is the name given to a disease which  consists
essentially in the accumulation of fluid in the proper structure or in the cap-
sule of the thyroid gland.   This fluid is generally serous in its character, the
conditions favoring its development, and the pathological changes which are
its proximate cause being very imperfectly understood.   Its treatment is
that of hydrocele of the tunica  vaginalis testis.   Thus, its contents should
be evacuated by means of a trocar and canula, and the tendency to its repro-
duction  overcome  by means  of injections of some stimulating substance,
that most frequently used being a solution of the tincture of iodine in water,
gradually increased  in strength  until sufficient adhesive inflammation is
established to obliterate the cavity of the sac.
  A fistulous orifice is sometimes  left which requires stimulation by caustic,
or the removal of the sac by dissection, before it can be healed.
                          CHAPTER  V.

       OPERATIONS  UPON  THE  PHARYNX AND OESOPHAGUS.

  The Oesophagus  is liable to various affections, the relief of which often
demands more or less interference on the part of the surgeon.  Among the
more important of these complaints may be mentioned those resulting from
the  passage of foreign substances, of a hard  and irritating nature, which
being inadvertently introduced into the mouth, are thence carried down the
oesophagus toward the stomach, and liable to be arrested at various points;
as well as the disorders consequent on inflammation in or around the proper
structure of the canal  itself.  From the importance of this tube, and the dif-
ficulties of reaching it from the outside of the neck, its relations to surround-
ing parts should  be  thoroughly studied by the surgeon before attempting
any of the cutting operations sometimes required for its relief.
                            SECTION I.

         SURGICAL ANATOMY OP THE PHARYNX  AND OESOPHAGUS.

  Although  to  an ordinary observer the  Oesophagus is  one continuous
canal, which reaches from the mouth to the stomach, anatomists have usually
divided it  into the Pharynx, or that funnel-shaped cavity which extends
from the base of the cranium to the lower part of the cricoid cartilage, be-
tween  the  cervical vertebrae and the  posterior part  of  the nose and mouth,
and into the oesophagus  proper, or the tube  which  extends from the same
cartilage, or lower part of the fifth cervical vertebra,  to the cardiac orifice of
the stomach. 
278
PRINCIPLES AND PRACTICE  OF SURGERY.
                         \ 1.—Of the Pharynx.

  The Pharynx is composed of two coats, a mucous one, which is continuous
with the same membrane in the mouth, and a muscular coat, composed of three
constrictor muscles, placed one above the other, the contractions of which con-
vey the food from the mouth into the oesophagus.  In the mucous membrane
of the pharynx may be noticed a large  number of muciparous follicles, which
occasionally enlarge and create irritation or inflammation about this region.
Beneath or behind the mucous membrane is a sparse layer of connective tissue,
in which are found the  blood-vessels and nerves of the part, the arteries being
branches  of  the carotid ; the veins emptying directly into the internal jugu-
lar,  and the  nerves being branches of the glosso-pharyngeal, pneumogastric,
and fifth  pair.
  The muscles of the pharynx mainly arise from the surrounding bony prom-
inences on each side, and, being joined  to their fellows, are enabled to dimin-
ish the transverse diameter of the opening, and force  the  bolus of food or
other substance downward,  till it  reaches the proper portion of the oesophagus.
                       \ 2.—Of the Oesophagus.

   The Oesophagus extends from the inferior extremity of the pharnx to the
stomach, is from ten to twelve lines in diameter, about ten inches in length,
and, when quiescent, flattened from  before backward.  In its descent to the
stomach, this canal is between  the  great vessels of the neck, directly upon
the muscles in front of the vertebrae, but inclined toward the left side of the
middle line.   At the lower part of the neck it is yet more to the left side of
the trachea than behind it, and is united to adjacent parts by a loose cellular
tissue.
   The (Esophagus presents three  coats, which are designated as the muscu-
lar, areolar, and mucous.
   The Muscular coat has its fibres arranged circularly, internally; and lon-
gitudinally, externally.  The  areolar coat is well developed, adhering more
closely to the mucous membrane than to the muscular fibres, presents a fila-
mentous character, and contains numerous lymphatic glands.
   The Mucous coat, in the undistended condition,  presents itself chiefly in
longitudinal folds, thus favoring the passage of substances  to the stomach;
and is covered by a delicate epidermis, which, under certain circumstances,
becomes thickened and very distinct.
                            SECTION II.

                   OPERATIONS UPON THE  PHARYNX.

  Among the diseases of the pharynx  requiring surgical treatment are the
formation of polypi, as has been already referred to in connection with the
nose; inflammation of  the upper portion resulting in  stoppage of  the Eus-
tachian tubes, as mentioned in the diseases of the ear; and the formation of
abscesses, the treatment of which is  to be accomplished by a simple punc-
ture of the swelling at  its most prominent point, as is hereafter shown.
  The other disorders demanding surgical interference are a hypertrophied
condition of the muciparous  follicles,  and  the  removal of foreign bodies
arrested by its walls. 
TUMORS IN THE PHARYNX.                  279
            \ 1.—Hypertrophy of the Follicles of the Pharynx.

  Hypertrophy, or an enlarged condition of the follicles of the mucous mem-
brane of the pharynx, is an affection which has  lately  received a degree of
attention that it does not deserve, and were it not that  the accounts given of
it are liable to lead the  inexperienced to regard it in too serious a light, this
disorder might justly be passed by without notice.  In many instances, and
especially in those who  smoke tobacco freely, it will  be found that these en-
larged follicles  have existed a long time without  attention  being  directly
called to them,  until they have been knowingly spied out as the seat of symp-
toms with which they are by no means certainly connected.  But when, after
a skillful investigation of the case, the surgeon believes  that they really cause
the  patient any inconvenience, he may do  much toward removing it, simply
by stimulating the surface of the membrane by the application of the nitrate
of silver, dilute  nitric acid, strong tincture of iodine, sulphate of  copper, or
some similar substance,  applied either with a camel-hair  pencil, sponge, or
swab.

                     \ 2.—Tumors in  the Pharynx.

  The Pharynx being lined with  a mucous membrane, and attached to the
fibrous structure—periosteum and ligaments—which covers the front of the
cervical vertebra?, as well as the basilar process and sphenoid bone, is occa-
sionally the seat of tumors, either of a polypoid or fibrous character, which,
encroaching upon this region, interfere so much with deglutition, respiration,
and  speech, as  to require their removal.  When they  attain  any size, their
removal will nearly always necessitate the division of the soft palate, or even
the cheeks,  in order to  expose them with sufficient freedom to  permit their
extirpation; but when  they are of smaller size, they may be strangulated,
by means of the ligature and canula, passed either through the mouth or
nostril, the latter being preferable.   The following  operation, as  performed
by  Dugas, of Georgia,  fully illustrates  the proceeding which may be  de-
manded under similar circumstances:—
  Operation of Dugas.—A man  laboring under a  tumor of the size of a
large egg, which filled  the pharynx, and extended  downward as far as the
larynx, and  laterally from one tonsil to the other, forcing down the right one,
while it carried the soft palate downward, so as to constitute  a prominence
of the size just  stated, causing difficult deglutition, etc., was operated on in
the following manner:   A ligature  being passed beneath  the  right carotid
artery, and left there to be tied when necessary, the patient was seated in  a
chair, and a free incision made through the cheek from the right angle of the
mouth to the edges of the masseter muscle, the divided facial artery being tied
in the wound.  A longitudinal incision being then made in the soft palate from
the side of the uvula to  the roof of the mouth, the palate was detached from
the tumor, in the form of flaps, exposing a bright glistening tumor which was
adherent posteriorly and laterally to the adjacent parts by strong cellular
tissue.   The access to the parts being now free, the cutting instruments were
laid aside, while the mass was seized with strong tumor forceps and drawn
forward, the attachments  of the lower portion of the tumor being torn
asunder by the fingers.    The left, upper, and  part  of  the right  portion of
the  mass being  theu torn  in  like manner by the fingers, this  part  of the
tumor was removed,  when  another  similar structure was  seen  on the right
side, in intimate connection with the right tonsil, which it  had passed down-
ward, being covered by a  thin stratum of muscular fibres, which were de- 
280
PRINCIPLES AND  PRACTICE OF  SURGERY.
rived from the pharyngeal muscles.  On dividing this stratum with the knife,
and pressing it aside, this portion of the tumor was also removed with  the
forceps and fingers, though not without  great difficulty, as it was found to
be attached to the ramus of the  lower jaw, near the sigmoid notch, to the
pterygoid process of the sphenoid bone, and to the posterior aperture of the
right nostril.   The hemorrhage was smaller  than might have  been antici-
pated, but required to be  checked  occasionally by cold water, thrown into
the pharynx with a syringe, after which the cheek was united by sutures and
adhesive straps, the ligature around the carotid artery being allowed to re-
main until next morning as a precautionary measure.  This  patient soon
recovered, and the microscope showed that the tumors were purely fibrous,
and without any evidence of a cancerous degeneration.
                    \ 3.—Retro-Pharyngeal Abscess.

  The formation of an abscess in the connective tissue situated between the
posterior wall of the pharynx and the fronts of the bodies of the cervical ver-
tebrae is an affection which, from its frequent fatal result, by extension of in-
flammatory action to the glottis, and its effects upon the trachea, should be
promptly treated. Although long noticed by surgical writers, the dangers of
this affection and the necessity of prompt treatment have not been generally
insisted on.   In a paper published* by Allin, of New York, the fatal char-
acter  of the complaint is justly noted, as well as the liability of the surgeon
to overlook its existence.  Of the fifty-eight cases referred to by Allin, only
twenty-eight were relieved or cured, or about one-half died.   Owing to the
distance of the  abscess from the mouth, and the liability of the matter to
escape suddenly into the larynx, various means have been advised  for its
evacuation, as the trocar  and canula, etc.   A simple  and  safe  method will
be found in the plan  pursued  by  Allin.
  Operation.—The patient's  head being firmly supported by an assistant,
pass the forefinger of the left hand  into the mouth, depress the tongue, raise
the velum palati, aud press the point of the finger against the tumor.   Then
pass a sharp-pointed bistoury, the  blade of which is covered with adhesive
plaster, to within  half an inch of  its point, along the left forefinger  as a
director, and make a free incision through the walls of the pharynx,  on the
median line of the throat, so as to  open the cavity of the abscess.   By this
free incision,  fistulous tracks will be  avoided, and simple  detergent  washes
will complete the cure.

                            SECTION III.

                  OPERATIONS  UPON THE  OESOPHAGUS.

  The (Esophagus, being the principal channel by which substances enter
the system, is liable to various complaints in consequence of the improper
character of the articles introduced into the mouth.   Particles of food taken
at a high temperature, or imperfectly masticated; or foreign bodies intended
to be  held temporarily in the mouth, but which are suddenly swallowed; or
a diminution of the calibre of the  passage, owing to  various causes, are all
instances of the evils to which a patient may be exposed in the daily use of
this part.  Two  specifications  will, however, embrace all  the operations
required by this structure, independent of wounds,  to which it is liable in
* New York Journ. Med., vol. vii. p. 325. 
    REMOVAL OF FOREIGN SUBSTANCES FROM  THE  OESOPHAGUS.  281

connection with other parts of the neck, to wit—the removal of foreign sub-
stances  from it, or from the  stomach, and the restoration  of its natural
calibre, in cases of stricture.
       \ 1.—Removal of Foreign Substances from the Oesophagus.

   Various means have been suggested for the removal of foreign substances
 from this canal, such as forceps, hooks, and sponges.  Without entering into
 the details of these inventions, it may be sufficient merely to direct attention
 to such as will  be found in Plate XXX., among which can be  seen  the for-
 ceps of Bond,  and  a hook brought to the notice of the profession in the
 United States, by  Nathan  Smith,  of New Haven.*  An instrument,.very
 similar to this,  is also represented as copied from the European  plates, the
 invention of which  is assigned to Dupuytren ; but as no date is given to it,
 I have  found it difficult to establish the priority of either, the difference in
 the character of the two being very slight.  Dupuytren has claimed the hook
 as his; but whether he followed Smith, or preceded him, the  latter states
 explicitly that  " his hook is unlike anything which he has known to be em-
 ployed  for a similar purpose ;" and  he therefore furnishes a drawing  of it in
 the paper referred to,f deeming it especially suited to the removal of coins.
 Both hooks, though adapted to a  certain class  of foreign  bodies,  are not
 applicable to all;  and, as compared with the gullet  forceps of Bond, are
 thought to be inferior.  The latter is capable of taking  hold firmly  and ex-
 tracting safely any foreign substance, no matter how fine or small, which is
 within  the grasp of the instrument, that is, two  or three inches below the
 top of  the sternum, measuring from the mouth, and yet not liable to pinch
 the internal coat of the  canal, while the  hooks are only adapted to larger
 objects.
   Operation with  Bond's Forceps.—Place  the  patient in a strong  light,
 with  the  head thrown back, if the foreign substance is  small, but, if large,
 with  the chin approximated to the  sternum,  so as to relax the sterno-hyoid
 and thyroid  muscles, lest, by compressing the trachea against the bodies of
 the vertebrae, the foreign article be caused to impinge  on the larynx, and
 such a spell of  coughing be induced as will materially interfere with the oper-
 ation.  Then, placing a plug between the molar  teeth,  depress the  tongue
 with the forefinger  of the left hand,  and pass the forceps  into the oesophagus
 with the right hand, when the substance, if high  enough to be seen,  may be
 readily extracted;  but if lower down, the tongue should be depressed by
 an  assistant by means of the instrument, Plate  XXX. Fig. 11, while the
 surgeon, opening and shutting  the  blades of the forceps, should carry the
 handles from left to right, or the reverse, so as to sweep the oesophagus with
 the points of the instrument.   Should it be a coin, or a similar  article, the
 dilatation of the walls of the oesophagus will render the passage of the blades
 on each side easy;  but if it is a smaller body, as a pin or  fish-bone, the  oper-
 ator need not fear an injury to the walls of the canal, as  the instrument is so
constructed  as  to render  such  an event almost impossible.
  Weever, of Michigan, has also published^ the description of a pair of for-
ceps,  consisting of a two-bladed whalebone stylet, which, being inserted in a
flexible catheter, is  passed down to the substance, pushed out of the catheter
so as  to expand on  each  side of the article to be removed, and then made to
* New York Med. and Phys. Journ., vol. iv. p. 576, 1825.
f See Plate XXX. Fig. 4.
X Amer. Journ. Med. Sciences, vol. xiv. p. Ill, 1834. 
PLATE   XXXII.
     OPERATIONS  PRACTICED ON  THE  CESOPHAGUS AND LARYNX.

  Fig. 1. A front view of the application of the (Esophageal Hook of Dupuytren
as represented upon  the subject, by a section of the mouth.   1. A longitudinal
section,  showing the left half of the tongue.  2. A vertical section of the lower
jaw.  3. Top of the epiglottis cartilage as applied over the  glottis in the effort
of swallowing.   4. The upper end of the (Esophageal Hook.  5. Its lower ex-
tremity, with  the basket attached to it.  6, 6.  Dotted lines  showing the  course
of the (Esophagus.                              After Bourgery and  Jacob.

   Fig. 2. A front view of a section of the Mouth and Throat, showing the ap-
plication of the sponge to the Larynx, as advised by Trousseau and Green.  1.
Longitudinal  section of  the tongue.  2. Inferior maxilla.  3. Os hyoides.  4.
Section of  the epiglottis cartilage.  5, 5. Sections of the thyroid cartilage.  6.
Point to which the sponge may be introduced.  7. Upper end of the instrument.
8. Its lower end, with the sponge in position.      After Bourgery and  Jacob.

   Fig. 3. A  view of the relative position of the Surgeon and  Patient  in the
operation of  washing out the stomach by means  of the Stomach Pump  and
(Esophageal Catheter, as suggested by Physick, of Philadelphia.  The  patient
is represented as reclining with the head thrown back, and the jaws distended by
a plug of wood introduced between the molar teeth.  The (Esophageal Catheter
of Physick has been introduced into the  stomach, and then attached  to the
nozzle of the pump, which is placed in a basin  close alongside of the patient.
The surgeon  is represented in the act of drawing the liquid into the pump from
the  bowl.  1.  Physick's (Esophageal  Catheter.  2. The  Stomach  Pump  of
Goddard.                                                   After Nature.
(282) 
Plate  32 .
Fig.l
 
 
POISONS IN THE STOMACH.                  283
seize  it by pressing the catheter upon its blades.   This instrument, which
acts on a principle similar to that of the litholabe of Civiale, may prove use-
ful where the foreign substance is very far down, and yet of such a nature as
should forbid its being pushed into the stomach by a probang.   If the article
to be  removed is barbed and sharp-pointed, like a fish-hook and line, no ex-
pedient will probably answer better than that suggested, under similar cir-
cumstances, by Brite, of Kentucky, to wit, the slipping of a sufficiently large
and perforated bullet over the line and point of the hook, by directing the
patient to swallow the bullet.
  Removal by  the Expansion of a  Sponge  carried  below the Foreign
Body.—David Rice has succeeded*  in removing a piece of bone of the size
of a  twenty-five cent piece, cut into a triangle, which had lodged in the
oesophagus of an old lady, about two inches below the top of the sternum, by
the following ingenious plan.   A piece of dry sponge, about one inch long,
and large enough, when dry, to fill  one-half of the oesophagus, was tied to the
extremity of a whalebone sound, and passed down  the oesophagus in a dry
slate,  until it went below the foreign body.  A little fluid being then swal-
lowed, the dry sponge absorbed it, and, enlarging to twice its  natural size,
entirely filled the oesophagus; when, being withdrawn, it brought the bone
with  it.
  When the daugers that may result  from the perforation of  the aorta or
trachea, as the result of the continued presence of  irritating articles in the
oesophagus, are recollected, it may be well for the surgeon to be  as unceasing
as is  prudent in  his efforts to carry the article either upward or downward.
  Where the foreign body is so placed in the oesophagus that its position
can be  distinguished by the touch  externally, the  propriety of performing
oesophagotomy is a question worthy of consideration.  Many substances of a
durable nature have, however, been known to remain for years in the oesoph-
agus  without creating intolerable inconvenience, one  of which is reported
by Dorsey, of Philadelphia, and the possibility of  such a condition  should
always, therefore, be recollected.   In this case a copper coin remained thir-
teen years  in  this tube without destroying life; and on one occasion I re-
moved an old-fashioned copper cent from  the gullet of a little girl, where it
had remained three weeks without its presence being positively recognized.
On  the other hand,  very small substances, especially when presenting sharp
edges, have ulcerated through into  the trachea, or penetrated the vessels, or
injured the important nerves about this region, though they have also occa-
sionally created abscesses, and thus been discharged externally.
                     § 2.—Poisons in  the Stomach.

   As the stomach is mainly evacuated through the oesophagus, we may now
study the effects of poisons found in this viscus, whether introduced accident-
ally or with murderous or suicidal design.
   Varieties.—These  poisons may  be  divided  into three great classes :  1,
those from the mineral; 2, those from the vegetable;  and 3, those derived
from the animal kingdom.
   1. The mineral poisons most frequently taken are arsenic, corrosive sub-
limate, salts of copper aud lead, aud the mineral acids, such as the sulphuric,
nitric or muriatic acids, and the like.
   2. The vegetable poisons  are  generally narcotic articles, such as opium,
cicuta, stramonium, belladouna, laurel, etc., as well as mushrooms, truffles,
* Boston Med. and Surg. Journ., Dec. 3, 1857. 
284
PRINCIPLES AND  PRACTICE OP SURGERY.
and other similar articles of diet in particular constitutions and under certain
circumstances; there are also some vegetable poisons which are not narcotics,
yet are highly poisonous, as strychnia.
  3. The poisons derived from the animal kingdom are very various, those
perfectly innoxious in some seasons being sometimes poisonous under diverse
conditions; thus fresh pork, so generally  used as an article of diet, will act
upon certain constitutions, in hot weather, as a positive poison ; and this,
perhaps, not merely from its nature, but also from the manner in  which it is
often eaten, being bolted in masses that are unmasticated.  In some cases of
poisoning thus induced,  a brisk emetic has occasionally brought away large
lumps of undigested pork several days after they were swallowed, the debility,
delirium, and cutaneous  eruption disappearing soon after the pork was vom-
ited.  Poisoning from this cause has  been  sometimes  noticed  among the
laboring classes  in the summer season.   So also certain shell-fish, though
often  used as articles  of diet, will occasionally produce in some individuals
symptoms of poisoning, one being well known to me, upon whom stewed
oysters  will act as a positive poison, creating violent retching, evidences of
gastritis, prostration, and a marked form of erythema nodosum.
  Besides these ordinary articles there are certain animal substances which
invariably act as poisons if given even in a comparatively moderate quantity;
such as  cantharides, etc.
  Symptoms.—The symptoms produced by these different classes of poisons
will vary greatly, and must be  separately  alluded to.
   1. Mineral  Poisons.—The  symptoms  produced by  the  ingestion of a
mineral  poison are usually the  symptoms of violent irritation and inflamma-
tion of  the mucous membrane  of the alimentary canal.   The tongue, there-
fore, presents more or less evidences of deficient secretion, and is dry,  while
the throat is sore,  and the pharynx inflamed, there being at the same time
all the ordinary evidences  of violent gastritis.   There is also vomiting with
frequent and violent retching, besides which, if the inflammation of the stomach
progresses, it may result in perforation and all the usual symptoms of peri-
tonitis.   As these symptoms gradually increase, cold  sweats come on, and in
a variable period the patient dies.
   2. Vegetable Poisons.—The  symptoms of vegetable poisoning are gen-
erally excessive narcotism, and all the symptoms of congestion of the braiu, as
loss of  sensation,  vertigo, dizziness,  loss of vision aud hearing, headache,
snoring  or stertorous respiration, loss of consciousness, coma, and all  the
symptoms of compression  of the  brain.
   3. Animal Poisons.—The symptoms  of the various animal  poisons will
depend very much, both in their violence and character, upon the nature of
the articles taken.  As a general rule, however, it may be stated that there
is in these cases a disposition to vomit, accompanied by all the other symp-
toms of gastric and intestinal irritation or inflammation, while it is not unu-
sual for these animal poisons, when not sufficiently active to destroy life, to
be followed in certain constitutions by the development of skin disease, etc. etc.
   Treatment of Poisons in the  Stomach.—The  indications for the  treat-
ment of poisons in the  stomach  are—1. To  evacuate the organ.  2. Where
this cannot be  accomplished, or after it has been accomplished, if there is
any reason to suspect that a portion of the poisonous matter has remained be-
hind in  the stomach or bowels, to employ proper antidotes.   3.  To get rid
of any  portion which may thus have passed into the bowels, even after the
administration of the antidote, by means of  brisk and active purgation.  4.
To combat any effects of the poison which may occur notwithstanding these
measures, these  effects being generally found either  in inflammatory action
in the mucous coat of the stomach, as in  the case of the mineral  and animal 
POISONS IN THE STOMACH.                   285
poisons, or in narcotism of the  brain, as in  the  case  of  certain vegetable
poisons.
  The means to be employed in carrying out these various indications differ
materially in  accordance with circumstances.  Thus, the simplest manner in
which  the  first indication  may  be accomplished,  and  the contents  of  the
stomach evacuated, is by means  of emetics, and as these are  sometimes  de-
manded with  great promptness, it is as well to remember those that are most
likely to be found under ordinary  circumstances, the simplest and most readily
and  speedily  obtainable of which is  dry mustard, salt, and  warm water, a
teaspoonful of the ordinary table mustard and a tablespoonful of  salt being
put into a tumblerful of lukewarm water, and drank off by the patient at a
draught, after which the throat may be  tickled with the finger or a feather
with  the view of exciting more  prompt emesis.  This substance generally
acts with great promptness and  efficiency.  Another article which is appli-
cable under these circumstances, particularly in the case of mineral poisons,
where it acts not only  as an emetic but as an antidote, is  one which  is also
readily obtainable, though not now found so generally in houses as formerly,
namely, common  lamp oil;  few  persons being able to drink a tumblerful of
it without having prompt emesis induced, while if it should not vomit it will
yet sheathe the coats  of the stomach from the action  of  acrid substances.
Powdered ipecacuanha or  powdered  alum, if either  can be obtained, is an
excellent emetic, and may be administered in the dose of a  teaspoonful every
ten minutes, warm drinks being freely given in the interval until the desired
effect is produced.  Sulphate of zinc may also be resorted  to in doses of
half a scruple;  or tartar emetic  in doses of  from two to five grains; san-
guinaria, or bloodroot, in doses of a scruple; or lobelia or tobacco, though
these articles should  be cautiously given  and carefully watched, lest the injury
ensuing from their  depressing and prostrating effect be  no  less  than that
resulting from the poison itself.   The effects of the tobacco can be obtained
either by giving it internally or simply (and this is preferable)by macerating
the leaf, and  binding it upon the skin at the pit of the stomach.
   But a more certain  mode of thoroughly evacuating the  stomach is by  the
use of the stomach-pump and oesophageal tube, which should be passed into
the stomach so as to remove its contents, as hereafter described.
  Having thus gotten  rid of as  much of the  poisonous matters as possible,
the next duty of the  surgeon is  to resort to  proper antidotes; these, of
course, varying according  to the nature of the poison, as  each one  has  its
appropriate and more or less efficient antidote. After thus neutralizing  the
effects of irritating poisons, the  gastritis, etc. should be treated on general
principles.
  Antidotes for Poisons in the Stomach.—1. Arsenic.—The antidote for
arsenic is albumen or gluten, which may be conveniently administered in the
form of the white of eggs, or of flour and water, or lightly  calcined mag-
nesia,  which  should be given very freely, the albumen  forming with  the
arsenic a comparatively insoluble and innoxious compound  which may be
subsequently  removed  from the  alimentary canal  by emetics and purgation.
The albumen, however, though it should always be resorted to if other means
are not at hand, is not nearly so  efficient an antidote for arsenic as it is for
corrosive sublimate,  and the surgeon should therefore, if it be in his  power,
resort at once, in the case of arsenic, to  the hydrated sesquioxide (peroxide)
of iron, which is usually kept by the  apothecaries ready prepared, and may
be promptly  made,* and which  is the most efficient antidote  for  arsenic
known.
* See U. S. Dispensatory. 
286
PRINCIPLES AND  PRACTICE OF SURGERY.
  2. Corrosive Sublimate.—The best  antidote for corrosive sublimate, as
already stated, is  albumen, though gluten, milk, or Peruvian bark may also
be resorted to if albumen  cannot be obtained.   Any of these articles, to be
thoroughly useful, should be given freely, and followed  by the use of emetics
and purgatives.
  3. Nitrate of Silver.—For nitrate of silver  the antidote is common table
salt.
  4. Salts of Lead.—For the salts of lead the proper antidote is diluted sul-
phuric acid, which forms with them, by a chemical  reaction, the sulphate of
lead, this being an insoluble compound.   If, however, the salt of lead taken
is  the  carbonate, the sulphuric acid should be cautiously given, and some
means  employed to prevent distention of the stomach from the carbonic acid
gas, which will be rapidly evolved.
  5. Salts of Copper.—In cases of poisoning from the salts of copper,  the
antidotes recommended are albumen, oil, etc.; but as  the compounds thus
formed are by no  means perfectly insoluble, resort  should afterward be had
to purgation and  emetics.
  Vegetable Poisons.—Among the substances derived from the vegetable
kingdom, the most common source of poisoning is the narcotics.  In case of
suspected poisoning from any of these substances, the first thing to be done
is to empty the  stomach, and this will be performed  most efficiently by means
of the stomach-pump;  but if that  is not  at hand, or while waiting for it,
prompt emetics may be given.   The stomach having thus been properly
evacuated, the  next indication  is to purge  with a view of removing  any of
the substance which  has passed into the bowels.   In  order to  obtain  full
benefit from this treatment, the  purge given should be an active one,  as ela-
terium, gamboge, large doses of calomel,  or  similar  prompt and efficient
drastic cathartics.  After having removed from the stomach all of the drug
that can  be  obtained, and  while waiting for the operation of the purgative,
the effect of any portion  of  it which may  have previously been absorbed
should be counteracted by keeping up the activity of the brain until the sed-
ative  influence  of the  poison shall have passed  off.   This object may  be
effected by  stimulating measures of various kinds, all  of  which should  be
steadily persevered in,  as it is an established fact, that if the activity of  the
brain can be kept up for six or eight hours,  in a case of narcotic poisoning
from an article like opium, the patient will  generally recover.   A very good
mode of carrying out this indication is by stimulating the nerves of the skin,
aud the  simplest manner  in which this can be effected  is  by switching  the
patient well by stripping him and striking him  round the legs with a switch.
The same end may be effected by the application of cold;  either by leading
him up and down  a cold room, or giving him every fifteen or twenty minutes
a shower-bath, or throwing a bucket of cold water over him ; but this treat-
ment should be  cautiously practiced, for if the cold is carried so far as to pro-
duce its sedative effects, it will only add to  the power of the drug.  If, how-
ever, all these means seem to fail, the surgeon  should not despair, as he  has
yet a resource which, in skillful  hauds, has saved life, and that is, to attempt
to keep up the  action of the brain by the galvanic battery, the most conve-
nient form of which is  to be found in the electro-magnetic machine, already
alluded to.
  Mineral Acids.—In the case of poisoning by the mineral acids, the anti-
dote is to be found in the free use of the alkalies, avoiding, however, the car-
bonated alkalies on account of the distention  which would result from  the
consequent evolution of carbonic acid gas.
  In the case of oxalic acid, a vegetable acid which is sometimes a source of
poisoning, the  most  serviceable antidote is lime, which may be obtained 
    EXTRACTION  OF NOXIOUS  SUESTANCES FROM THE STOMACH.   287

from a piece of chalk, or by scraping the ceiling of a room, and which forms
with the oxalic acid an  exceedingly insoluble compound.
   In all cases of poisoning in which the substance used is acrid or corrosive
in its nature, the indication  to follow the use of the antidote by free muci-
laginous drinks is  a clear one, as they sheathe the  mucous coat of the ali-
mentary canal, and facilitate the  action of the cathartic which is to be sub-
sequently employed.


 ? 3.—Extraction of Noxious Substanres from the Stomach, through  the
                              Oesophagus.

   The introduction of the oesophageal catheter, and the  extraction of any
substance capable of passing through its channel, is so simple an operation as
to require but a few words.
   Operation—After placing a plug between the back teeth, so as to  pro-
tect the  fingers or the tube from  being bitten by the patient, pass the fore-
finger of the left hand  to the root of the tongue, and  gently depress  this
organ.   Then pass the  catheter  rapidly backward till it reaches the  back of
the pharynx, when, if the  resistance that it meets with is not sufficient to
depress its point, turn it down by the forefinger previously introduced.   By
carrying the point of the catheter toward either half arch, there will be little
risk of introducing the  catheter  into the larynx, as the latter will be closed
in consequence of the gagging  induced by the presence of the finger in the
pharynx.   The introduction of the liquid, when it is necessary, to wash out
the stomach, may then be effected by the stomach-pump, Plate XXX. Fig. 1,
or by alarge rectum syringe.  In withdrawing the catheter, its free  end should
always  be closed by the finger, in order to prevent the  escape of any drops
of liquid into the trachea.
   Remarks—The performance of the operation of introducing the stomach-
tube is so simple an affair that the evacuation of the contents of the stomach
has more than once been done by a good hospital nurse.   Within about fifty
years, the extraction  of poisons  from the stomach, except  by emesis,  was,
however, an operation quite  unknown, until Physick, of  Philadelphia, em-
ployed the now well-known stomach-tube, or oesophageal catheter, the bene-
fits resulting from which have been so great that the profession in  the United
States may well be jealous of the credit of the invention and application of
such a simple contrivance.   In support of this assertion, I  would  mention
the following facts: In  the American Medical Recorder* Matthews pub-
lished a paper, in  which he  showed, very satisfactorily,  the  origin  of this
instrument,  Physick, in  1800, having recommended it in his annual lectures
in the University of Pennsylvania.  Dorsey,  who was in Paris in 1803, also
states that he had a gum-elastic  tube or catheter, made to Physick's order,
for the  purpose of evacuating the contents of  the stomach, the length of
which was so great as to excite  considerable curiosity  among the Parisian
manufacturers of catheters, who could not  divine for what  purpose it was
intended.  Iu 1809 this instrument was employed by Dorsey,f and by others
subsequently, an indefinite number of times.  From a claim afterward made
for the priority of this invention by Alexander  Monroe, Jr., of Edinburgh,
it seems that this gentleman  had also conceived  the same idea, and in an
inaugural thesis, published  in 1797, proposed similar means for extracting
poisons, though he does not  appear to have ever brought his  suggestions
* Am. Med. Recorder, vol. x. p. 322.  Philad., 1826.
f Eclect. Repertory, October, 1812. 
288            PRINCIPLES  AND  PRACTICE OF  SURGERY.
into practice.   Physick, though admitting at a later period the coincidence
of the suggestion, always  stated his ignorance of the thesis in which it was
published,  and,  being the first person  who had one constructed and em-
ployed, is certainly entitled to the credit of the operation, though willing to
share the originality of the suggestion with another.
  In the paper advocating the claims of Physick, will also be found a refer-
ence to the apparatus of Ewell, of Washington, as proposed in 1808, and of
Jukes, of London, who contrived similar means in 1822, as well as the  testi-
monials  of  the distinguished  practitioners of that period, who, by common
consent, seem to have  awarded  the  merit of the original manufacture and
application of the tube to Physick,  he having, in the paper referred to, also
furnished drawings of the  stomach-pump to which it was adapted.
                   \ 4.—Stricture of the Oesophagus.

  Pathology.—The  analogy existing between  strictures of the oesophagus
and those of the urethra has always attracted the attention of surgeons when
referring to this  complaint.   From the difference,  however, which  exists
between the surrounding tissues in these two structures, a special description
of the effects of the complaint, as developed in the oesophagus, is essential to
a correct appreciation of the value of the various  modes of treatment pro-
posed for its relief.
  The condition  of  the  oesophagus, under the various causes  producing
stricture, is very varied;  but, however excited, the constriction will generally
be found to exist either  near the upper or lower extremity of the  tube, and
to be due to certain deposits  around, or changes in the  mucous  coat  of the
canal.   Sometimes this coat is  simply thickened,  though  it has  also been
found to be decidedly hypertrophied.  When the  stricture has existed for
some time, or has commenced  in the areolar  coat  of the  oesophagus, the
induration  of the part is so marked  as to present  a  mass  closely analogous
to scirrhus, while  it has occasionally been found to  have changed or entirely
destroyed the ordinary characters of both the mucous and  muscular coats,
thereby rendering it difficult to decide in which tissue the disease  had com-
menced.*
  The extent of a stricture in the oesophagus is very variable; usually it is
not more than a  few lines, though  it may reach  to the length of several
inches.   At the seat of stricture there  is often found a  central contrac-
tion, or bandlike thickening, above and  below which the  indurated  part is
less constricted; while the  portion of the canal immediately around the seat
of the stricture has been known to be dilated into a pouch capable of hold-
ing a quart  of  liquid.  Below the stricture, the oesophagus is occasionally
more contracted than natural, and its parietes are also found to be thicker
than in the normal condition.  Frequently, on the  contrary, it has presented
no marked alteration.  Ulcerations  have also been found in the  strictured
portion of the canal, though they are believed to be  more common above it,
either in consequence of the particles of various substances remaining in the
dilated portion, or from the efforts of the muscular coat of the canal to eject
them, inducing increased inflammatory action.
  In many instances, the adjacent lymphatic glands are either engorged or
degenerated, and when the stricture  has been seated in the neighborhood of
the thyroid gland, the latter has been seen to be either hypertrophied, or
very materially changed in  its structure.  In some  instances, adhesions have
* Dictionnaire des Sciences M6dicales, tome xxi. p. 397.   Paris, 1840. 
DILATATION OF THE  STRICTURE.
289
formed between the posterior face of the trachea and the front of the oesoph-
agus, or between the latter and the carotid artery, or the aorta, under which
circumstances, a perforation of the oesophagus at  these points  is inevitably
fatal.
  From this statement of the changes in the structure of the part, every sur-
geon must see the dangers attending any attempt to overcome old strictures
of the oesophagus, and  he should, therefore, be especially cautious not only
in his prognosis, but also in the employment of the various means that have
been suggested for the relief of the complaint.
  The operations that have been  recommended for the cure  of oesophageal
contraction consist in dilatation of the stricture, in the absoption or destruc-
tion of the diseased substance, or in a direct incision through  the constricted
portion, so as to destroy the permeability of the canal.
                     I.—Dilatation of the Stricture.

  Instruments.—Without entering into a description of the various instru-
ments that have been suggested for the purpose of dilating the stricture, this
account will be limited to the operation as accomplished by means of bougies.
As originally suggested by Sir Everard Home, these bougies were made of
waxed linen in the manner that will be referred to under the head of opera-
tions on the urethra, and being passed into the oesophagus, by the manoeuvre
directed for the introduction of the stomach-tube,* were either held for a few
minutes against the seat of the disease, or gently pressed  through  the stric-
ture, so as to dilate the canal  as they advanced.   The ordinary condition of
these bougies, when made entirely  of  linen, does not, however, afford suffi-
cient firmness to prevent the pressure upon them causing a lateral deviation
of the  instrument, in consequence of which the surgeon cannot tell accurately
upon  what point of the oesophagus  his force is applied.  An instrument
which  I have found to answer better, is one that was employed by Horner,
of Philadelphia, and represented in Plate  XXX. Fig. 6.   It is formed by
rolling a piece of waxed linen, about three inches long, and cut bias so as to
give it a conical shape, around the end of a flexible piece  of whalebone, like
that employed for the probang.
  Operation.—After smearing  the instrument either with  molasses or oil,
pass it into the seat of the stricture, and make  gentle pressure at the obstruc-
tion until it yields, directing the point of the bougie to the  part that seems
most constricted.
  Remarks.—In all attempts at dilating strictures of the oesophagus,  it
should be remembered  that gentle and continuous pressure  answer  better
than violent efforts.   In fact,  the principles that would direct the dilatation
of a strictured urethra are also those which  should guide the operator in
relieving  the similar condition of parts in the oesophagus.   But very little
force  should therefore be employed in dilating oesophageal strictures, as the
oesophagus about the seat of the stricture is very liable to dilatation, as well
as to  softening or ulceration ; if then the bougie is made to bear too forcibly
on  such  a point,  perforation of  the canal might ensue, and the patient be
exposed  to all the risks of suffocation or infiltration of the surrounding parts
on the first attempt that is made to swallow liquids.  In the lighter forms of
permanent stricture, in which the tissues are not much changed, and in the
spasmodic variety, dilatation  presents many chances of success; but dilata-
tion of strictures in the oesophagus, like those in the urethra,  will  prove but
a temporary means of relief if the surrounding parts are much indurated.
VOL. II.—19
* See p. 287. 
290
PRINCIPLES  AND  PRACTICE OF SURGERY.
Under these circumstances, the application of caustic may be advantageous,
if judiciously and carefully directed.


                       II.—Application of Caustic.

  The caustic applied for  the  relief of strictures of the oesophagus may be
either the Kali purum or caustic potash, or the nitrate of silver.   From the
difficulty of regulating the action of the potash, and the peculiar advantages
resulting from the application of the lunar caustic to the mucous membranes
generally, the latter is decidedly preferable.   It may be employed in the fol-
lowing manner:—
  Operation.—Pass a simple or unarmed bougie down to the stricture, and
mark accurately the distance  of the disease from the mouth.  Then arm  an-
other bougie, by scooping a little hole in the  end of the waxed linen, and fit
in this a small  piece  of  the nitrate of silver,  being  careful to fasten it accu-
rately in its place, so that it may project a little beyond the level of the poiut
of the instrument.  Mark then upon this bougie the distance of the stricture
from the teeth, as shown upon the former instrument, and, passing it rapidly
to the seat of the  disease, retain it in contact with the part from one to  three
minutes.  On withdrawing it, examine the caustic, in  order to judge how
much has been dissolved, and if it is deemed to be too much, or such as might
act upon the surrounding parts, cause the patient to swallow some strong salt
and  water, in order to neutralize it and prevent its continued action.
  Remarks.—The application  of the nitrate of silver in this disease is  bene-
ficial in  two  ways : 1st, by repeatedly creating a superficial eschar on  the
surface of the stricture,  it gradually destroys  it; and 2d, by allaying the irri-
tability of the canal, by stimulating and modifying the action of its raucous
membraue, thus doing much toward the radical cure of the complaint.  After
a few applications of  the catheter, the simple bougie will often be found to
pass readily, while the relief will be more permanent than that which ensues
upon mere dilatation  of the part, except in the spasmodic form of the com-
plaint.   It need hardly  be said that the application of the caustic  should be
restricted to the diseased portion of  the canal, by placing it in such a posi-
tion in the bougie as will prevent its action elsewhere.
                         III.—Oesophagotomy.

  Under peculiar circumstances, as when it is necessary to remove a foreign
body from the canal, or when, in cases of impervious  stricture, there  is a
necessity for the introduction of food in order to sustain life, it has been ad-
vised  to  open the oesophagus from the outside of the neck.  Although a
rare operation, and one which offers but slight chances of permanent relief
in cases of stricture, this operation has been successfully resorted to, an ex-
ample of which has been reported by Taranget,* where the patient was  thus
nourished sixteen mouths.
  Nearly equal success has,  however, been obtained by a direct opening into
the intestines or stomach, while the injection of nutritive substances into the
rectum presents a very  good substitute for  such  hazardous means of treat-
ment.
  In a paper by Watson, of New York, may also be found the history  of a
case in which the patient's life was considerably prolonged by this operation
* Diet, des Sciences Me\I., tome xxi. p. 412. 
CES0PHAG0T0MY.
291
though he ultimately died from the extension of the disease to the bronchia.
(Esophagotomy is, however,  very rarely resorted  to, having onjy been  per-
formed five times, two of which were reported more than a century since.
   Three modes of operating have been suggested, to wit:  that of Guattam,
who incised the  left  side of the  neck, and  dissected to the oesophagus, be-
tween the trachea and the sterno-hyoid and thyroid muscles, Plate XXXVI.
Fig. 6; that of Eikholdt, who made his incision between the two origins of
the sterno-cleido-mastoid  muscle;  and that of Boyer, who cut between the
sterno-hyoid and sterno-mastoid muscles.  Boyer only opened the oesophagus
for the extraction of foreign  bodies, and was, therefore, guided by the pro-
jection of the substance.   Giraud and Vacca Bellingheri  first introduced a
silver  sound, so as to render the oesophagus  prominent; and Begin trusted
entirely to the  anatomical relations of the part*
   Without further reference to these various plans of treatment, it may suffice,
as illustrative of a successful method of operating, to state the  manner in
which it was accomplished by Watson, in February, 1844.
   Operation of Watson, of New York.—The patient being placed on a cot
near a window, with his back well supported by pillows, and his head thrown
gently backward, the  incision was commenced ou the left side of the neck,
midway between 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 articulation,
dividing the skin, superficial fascia, and platysma-myodes muscle.
   A second incision, about an inch in length, was now made, nearly parallel
with the upper edge of the thyroid cartilage, terminating posteriorly 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 fas-
cia.   It  proved to be  very hard, and contained a yellowish concrete pus in
the centre.   The dissection  being then continued through the deep fascia,
the omohyoid muscle was exposed and  divided ;  the superior thyroid artery
brought into view, secured by two ligatures,  and divided between them and
the loose connective tissue between the carotid and the trachea, separated by
the handle of the scalpel until the lower portion of the pharynx and part of
the oesophagus 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 spatulae, an attempt was made to seize and puncture
the wall of the  pharynx ; but owing to the difficulty of accomplishing it with-
out 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 attempt to
divide it from  within,  it was found necessary to  open it from  without.   In
order  to obtain room, the sterno-mastoid muscle was therefore divided trans-
versely, and the upper border of the thyroid gland turned down.
   The recurrent nerve being now brought into view, one of the branches of
the superior thyroid artery was divided as it entered the  gland, giving rise
to the only hemorrhage that required attention during the operation; 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
* Malgaigne, Philadelphia edit., p. 376. 
292           PRINCIPLES AND PRACTICE OF SURGERY.
or six lines wide.  A stomach-tube being then introduced through the wound,
wine and arrow-root were administered.   This tube was next secured to the
side of the head by its free extremity, the transverse portion  of the wound
closed  by a single suture, and the balance 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-
ter 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 reappeared, so as to require the reopening of
the wound in the neck, and the patient died about three months subsequently.
  Remarks.—That (Esophagotomy is an operation requiring much delibera-
tion on the part of an  operator, in connection with its results, is a point that
has long  been regarded  as  settled, and  that it  is a formidable operation,
must, it is thought, be apparent to all  who read the account furnished by
Watson.  The question therefore naturally presents itself, whether, in order
to prolong life, it may be right to advise  a patient to submit to it.   Deem-
ing the relief afforded by it  dearly purchased at  the risks of the operation,
except in  very skillful hands, I cannot but think that the danger of making
an opening directly into the stomach, as subsequently referred to by Dr.
Watson, in the paper before  quoted, is certainly not greater than that incur-
red in cesophagotomy.  The number of instances in which wounds and open-
ings  iuto this organ have not proved fatal will,  on examination, be found to
be much larger than might  at first sight appear probable.  In addition to
those which  I have mentioned, there is also one reported  by Watson,*
as having been seen by  Archer,  of  Maryland, in which the stomach was
opened more  than two  inches by a wound with a  knife, and the  wound
so well  sewed up  by an  old soldier with an awl, needle  and thread, (the
stitches being only through the skin,) that the patient recovered, though an
abscess of some size formed in the groin on the  ninth day, as the result of
the wound in  the stomach, and was afterward  evacuated.   The well-known
case  of St. Martin, and  the case  reported by Etmiiller,  where a fistula in
the stomach  remained open ten years, together  with numerous other facts
collected  by Watson's extended research and stated in  his paper, also war-
rant his assertion that an opening  into the stomach is  an  operation  that is
justifiable in urgent cases of stricture of the oesophagus, and probably quite
as favorable  to the recovery of the patient as that of  cesophagotomy.  In
support of his suggestion, Watson quotesj" several cases in which fistula com-
municating with the stomach have continued for years, food being discharged
at the opening after each meal; while on three different occasions surgeons
have incised the stomach for the removal of foreign bodies,  and the patients
recovered.  The removal of a teaspoon  by opening the  intestines, as was
successfully done by Samuel  White, of Hudson, New York; the excision of
a part of the spleen by Powell, of  Kentucky ; the wound in the stomach re-
ported by Ashby,! of  Alexandria,  and the cases  of Dugas, of Georgia, and
Hart, of Mississippi, as well as the free incisions  made  in the  peritoneum in
ovariotomy, are all instances of the tolerance of  patients  under wounds of
this  region, and may certainly be  deemed sufficient to justify a surgeon in
opening  the  stomach  in the extreme cases of impassable stricture in  the
oesophagus.  But  though these cases hold out the  prospect of success in
* Am. Journ. Med. Sciences, vol. viii. N. S. p. 327, 1844.
f Ibid., p. 309, 1844.
X Virginia Stethoscope, vol. i. p. 660. 
DEFORMITIES FROM  BURNS.                  293
the execution of similar incisions, no one, it is presumed, would attempt gas-
trotomy with the view of nourishing a patient, unless specially urged thereto
by the peculiar circumstances of the case.
  In the event of the distribution  of property, or to accomplish some great
moral  good, or in order to fulfill  an important duty to another, a patient
might desire to prolong life, if possible, even for a few weeks, and under such
circumstances, it may become imperative on a surgeon to resort to such means
as will enable him to obtain the desired time.
                          CHAPTER VI.

 OPERATIONS DEMANDED FOR  THE RELIEF OF DEFORMITIES IN THE
                                 NECK.

   The affections of the neck which lead to such deformities as demand direct
 surgical interference in the way of au operation, being due usually to contrac-
 tions either of the skin, fascia, or muscles, it is generally necessary to employ
 some mechanical means either to extend the contracted tissue, or to prevent
 the reappearance of the deformity after the operation.   In  most instances,
 therefore, the assistance to be derived from proper dressings and mechanical
 contrivances should be remembered, and proper preparations made for their
 application before any incision is commenced.
   The deformities of this region may be subdivided into those affecting the
 skin and fascia,  which are usually the result of burns, and those confined to
 the  sterno-cleido-mastoid muscle, the latter  being  consequent  on various
 causes.

                             SECTION I.

                       DEFORMITIES FROM BURNS.

   The destruction of the skin  and areolar tissue, consequent on burns of this
 region, occasionally produces such a contraction of the features as results in
 hideous deformity, or in an inability on the part of the patient to perform
 many of the motions of the neck, thus interfering with the action of the head,
 and preventing the proper  execution of such movements as  are  required in
 various daily occupations.   Among the most serious of these injuries is such
 an adhesion of the skin of the neck to that of the chest as results in  an ina-
 bility to elevate  the head, or such  a contraction of the integuments about the
 chin as renders it impossible  to  close the mouth,  or draw up the lower  lip.
 Under these circumstances, operative  surgery is capable of adding much to
 the comfort and  happiness of the sufferer, and, even in very marked cases, has
 produced results that have  been  of the most gratifying kind.
  In order to appreciate the value of the operations that have been, at dif-
 ferent periods, suggested for the relief of deformities from burns, whether on
 the neck or elsewhere, it is important that attention should  be given to the
changes produced in the tissues affected—page 421, vol. i.—as well as to the
 almost  unvarying tendency of the structure  involved to reproduce  similar
contractile  tissue, unless the diseased portion is removed, and the space filled 
PLATE  XXXIII
                OPERATIONS PRACTICED ON  THE NECK.

  Fig. 1.  A view of the Lymphatics, together with  the  Blood-vessels and
Nerves found on the side of the Neck.  1. Carotid artery.  2. Par vagum nerve.
3. Internal jugular vein.  4. Subclavian artery.  5. Subclavian vein.  6. Brachial
plexus of nerves.  7. Lymphatic vessels and glands.  8. Phrenic nerve.   9, 9.
Sterno-hyoid  and  eterno-thyroid  muscles.  10. Thyroid gland.  11. Superior
thyroid artery.  12. Lymphatic gland, situated on the temporal vein.  13.  Lym-
phatic, at the angle of jaw, imbedded in the parotid gland, and liable, when
diseased, to be mistaken for  an  enlarged  parotid.  14.  Three superficial  lym-
phatic glands on the course of  the sterno-cleido-mastoid  muscle.   15. Deep-
seated lymphatic at the lower part of jaw. 16. Facial artery and vein. 17. Lym-
phatic gland in advance of the submaxillary. 18. Submaxillary gland. 19.  Three
superficial lymphatics behind the sterno-mastoid muscle.  20. A large lymphatic
gland situated outside, but adjacent to the sheath of the blood-vessels.  21.  A
chain of lymphatic glands which extend from the side of the neck to beneath the
clavicle between the trapezius and sterno-mastoid muscles.  All the lymphatic
glands above referred to are the occasional seat of tumors in the neck.
                                               After Bonnamy and Beau.

  Fig. 2. Effects of a Cicatrix from a Burn of the Neck.        After Nature.

  Fig. 3. Myotomy as practiced for the relief of Torticollis.  1.  Right hand of
the surgeon  in the act  of inserting the tenotome beneath the skin.  2. His left
hand raising the muscle.                        After Bourgery and Jacob.

  Fig. 4.  A view of the position aud development of a  Carotid  Aneurism.
1.  Common carotid artery.  2. Aneurismal sac.  3.  Par vagum nerve displaced
by the tumor.  4.  Hypo-glossal  nerve forced downward and forward by the
growth of the tumor.  5. Internal jugular vein. 6.  Sterno-cleido-mastoid muscle
and skin drawn to  one side by 7,  a curved spatula.
                                             After Nature, and John Bell.

  Fig. 5. Ligature of the Arteries about the Neck.   L. Ligature of the lingual
artery.  1, 1. Ligature passed  beneath  the  artery.  2.  Stylo-hyoid  muscle.
3. Hypo-glossal  nerve.  4. Digastric muscle.  5. Incision through the skin and
fascia.  6. Platysma-myodes muscle.               After Bourgery and Jacob.

  C. Relative position of the parts concerned in the Ligature of  the Primitive
Carotid.   1. The upper end of the incision.  2.  The skin and  fascia.  3. An
abnormal  arterial branch from  the arch  of the aorta to the pharynx, running
parallel to the  carotid artery.  4. The common  carotid.   5. Descendens noni
nerve.  6. Par vagum.  7. Internal jugular vein drawn aside.  8. Sterno-cleido-
mastoid muscle held back.  9. A  blunt hook.                   After Auvert.

  A. Ligature of the Axillary Artery.  1, 1. Line  and extent of the incision.
2.  Pectoralis major as divided.   3. The axillary artery.  4. A ligature placed
beneath it.  5. Axillary vein. 6. Brachial plexus.  7. Pectoralis minor muscle.
                                               After Bourgery and Jacob.
       (294) 
Plate  ?■>?>
Fig.l
Fiy. 2
 
 
TORTICOLLIS, OR WRY-NECK.
295
by healthy structure, the latter being usually obtained by some means similar
to those before referred to in connection with the class of plastic operations
upon the face.
  The following operation may serve as a type of those usually performed:—•
  Operation of Mutter,  of Philadelphia.—The  patient, a young  woman
aged twenty-eight years,  had been burned  twenty-three years previously,
upon the face, throat, and upper part of the thorax, from her dress taking
fire.   She  had been unable  to throw her head to the left side, or backward,
or to close her mouth for  more than a few seconds during the whole time.
The  right  eye was also drawn down some distance below the other, and
when an effort was  made to turn the head, the  eye  became closed.  The
chin  was drawn to within one inch and a half of the top of the sternum, and
this  place was so filled up  by the cicatrix, that no depression existed  in front
of her neck.
  Operation.—The patient  being placed  in a strong  light, on a low chair,
with her head thrown back as far  as possible and sustained by an  assistant,
an incision was commenced on the outside  of the cicatrix,  in the sound skin,
and  carried across  the throat into  the sound skin on the opposite side.  This
incision penetrated through  the integuments as near the  centre of the cica-
trix  as possible, and was about three-fourths of an inch above the top of the
sternum,  the object being  to get at the origin of the sterno-cleido-mastoid
muscle, which, inconsequence of the long-continued flexion of the head,
was  not more than three inches long.
  After exposing the muscles, a director was passed under that of the right
side, and both its origins divided.   The sternal origin  of the left muscle was
next divided in a similar manner,  when it  was  found that the head could be
placed in a proper  position.   The elevation of the chin now left a wound
six inches long by five and a half wide, to fill which a flap was formed from
the shoulder by an incision which, commencing at the left end of the wound
in the neck, extended downward and outward over the deltoid muscle, so as
to furnish  an oval piece  of integument  six inches and  a half long by six
wide, which was  left attached  by its base at  the  upper part of the neck.
On dissecting this flap free from the shoulder,  it was twisted  by a half turn
on its pedicle, brought round into the wound on the front of  the neck, and
retained there by numerous twisted sutures and adhesive strips ; after which
the wound  on the shoulder was closed as far as possible by sutures and strips.
The  head being now carried  backward, and maintained in this position, the
patient was put to bed, and  union by the first intention took place through-
out the entire wound, with the exception of one small point which healed by
granulation*
  Some  additional steps relieved the eye and mouth ; and twelve  months
subsequently the cure of the patient was complete.


                            SECTION  II.

                      TORTICOLLIS,  OR WRY-NECK.

  By the term Torticollis, or Wry-Neck, is  usually designated such distor-
tion  of the head, from  muscular  contraction, as brings the back part of it
forward, downward, and sideways, so as sometimes to turn the chin upward
and  over the  opposite shoulder, the  former being raised in proportion as
the occipital bone is drawn down.  Although disease of the vertebrae, inju-

               * Am. Journ. Med.  Sciences, vol. iv. N. S. p. 69. 
296            PRINCIPLES AND  PRACTICE OF SURGERY.
ries of the skin, or other causes may create this deformity, the present
account will  be limited to the consideration of such cases  as  are  mainly
dependent on an unnatural and permanent contraction of the sterno-cleido-
mastoid muscle.
   Among the various causes that excite this deformity, there is sometimes
seen an unnatural  contraction of one muscle, in consequence  of  the  partial
paralysis of that of the opposite side, the contracted muscle being generally
felt like a tense prominent  cord, or,  if not distinct, readily made so  by any
effort to turn the head toward the sound side.   To relieve this condition of
things, and bring the chin again to its natural line, the operation of myotomy,
or the subcutaneous division  of the  muscle or its tendon,  and the applica-
tion of a suitable apparatus for making moderate extension of the  muscle
and preventing the future contraction of the new tissue formed in the line
of the incision, is especially calculated.
   When,  after an examination of the origin of the complaint, its existence
is found to be mainly due  to  a contraction of the muscle, stimulating fric-
tions, electricity, galvanism, and  manual efforts to restore the head  to its
proper position may be first  resorted to ;  but when,  after a  trial  of these
and similar measures, little progress  is made toward a cure, the division of
the muscle or its tendon will materially expedite the result.
   Various modes of operating have  been  suggested  by different surgeons,
in order to accomplish  the accurate  yet safe division of a muscle which is
known to  be  so closely connected with important  blood-vessels  and nerves
throughout most of its course, as the sterno-cleido-mastoideus.   These sug-
gestions differ, however, mainly in the shape of the knife or in the point at
which  the muscle  may be most advantageously incised; bnt as the subcu-
taneous division  is  preferable  to  the old  plan of dissecting down  to the
muscle, the description of the operation  will be limited  to this  mode of
operating.
   Operation of J. C. Warren, of Boston.—A little girl, nine years of age,
much distorted, was operated on as follows:—
   The head being supported and the  muscles rendered  tense, a narrow sharp-
pointed bistoury was passed flatwise  between the skin  and the sternal origin
of the muscle, from without inward,  Plate  XXXIII.  Fig. 3, and the  edge
of the knife being then directed  upon the muscle, its division was accom-
plished.   The knife  being  now withdrawn and again entered at the same
orifice, was carried in front of the clavicular origin of the muscle, which was
divided in a similar manner.   Bandages, similar to those employed  in the
preceding case, were then applied ; and two months after the operation her
head was  so nearly straight that the  deformity was not perceptible to  ordi-
nary observers.*
   John W. Brown, of the Boston Orthopedic Infirmary.f after dividing the
muscle, employs a simple yoke to which bands from a  cap are attached, and
has published, in a paper on the subject, an expressive drawing of the appa-
ratus, of which my present limits forbid a  description.  In Plate  XXXV.
Fig. 14 may, however, be  seen a contrivance  which I  have found to be well
adapted to the object in view, and  which I employed successfully in  two
cases on which  I operated, by dividing the  muscle from before backward.
  Remarks.—Having  formerly followed closely the practice of Guerin in
Paris, and also noted the results of such patients  as I have operated on, I
am induced to think that more or less benefit will  be derived from the sec-
tion of this muscle in most of the cases which are unaccompanied by defor-
* Roston Medical and Surgical Journal, vol. xxv. p. 124.
f Idem. vol. xxvi. p.  58. 
THE ORDINARY POSITION  OF TUMORS.             297
mities in the bones, while in those solely dependent on a contracted condi-
tion  of the muscle a  perfect cure  may  be  anticipated.   Of the various
modifications suggested in the performance of the operation, there are none
of great consequence ;  though the section of the muscle from before back-
ward is, I think, the safest.  In operating  in  this manner, attention should
be given to the position of the external jugular vein as it  approaches the
subclavian vein ; and  when the knife is upon the muscle, the division of the
latter will be most  safely accomplished by holding the knife  firmly against
the muscle, and causing the latter to press  against the knife, by carrying the
head in such  a position  as will make the  muscle prominent.  A narrow
straight bistoury, or a  knife like  that in Plate XXXV. Fig. 13, makes so
small a wound that, if care is taken to  exclude the air, but slight inflamma-
tion  will ensue upon the operation.
   Much of the success  of this operation will, however, depend on  the proper
employment of  mechanical  means  subsequently.   The apparatus — Plate
XXXV. Fig.  14—before referred to is simple and efficient;  but  a nightcap
and  bandage, a  tin frame, or any other contrivance  which will enable the
surgeon to draw the head into the  proper position, will often be found to
answer quite as well.   The division of  the muscle, it  should  be recollected,
only facilitates the cure; the mechanical treatment accomplishes the most
important part of it, and also prevents that  reproduction of the deformity
which is likely to ensue, when means are not taken to obviate it.
                          CHAPTER  VII.

    OPERATIONS  FOR  THE  REMOVAL  OF  TUMORS  OF  THE  NECK.


                             SECTION I.

                  THE ORDINARY POSITION OF  TUMORS.

   The large number of lymphatic glands found  in the  neck, and the knowl-
edge of their ordinary position, render a diagnosis of  many of the  adenoid
tumors of this part more easy than might at first  sight be supposed.   Ac-
cording to the views of Allan Burns, nearly all the glandular tumors of the
neck may be referred to two classes, and arranged solely in accordance with
their position—as  1st, those which are without, and 2d, those which are within
the fascia, the existence of either being recognized by  their mobility, or the
ease with which they can be drawn from  their ordinary position.
   On examining the structures mainly concerned  in this class of tumors, it
will  be found that the great chain  both of the  superficial and deep-seated
lymphatics of the  neck follow the  course of the  superficial and deep-seated
veins, Plate XXXIII. Fig.  1.   In the healthy condition, these  glands are
for the most part flattened and oval, varying from two to nine or ten lines in
length.  Of the superficial glands  there are, between the skin and the  inser-
tion  of the sterno-mastoid muscle, from four to six; in the interstice between
the clavicular origin of the  sterno-cleido-mastoid  and  the  anterior edge of
the trapezius, just  above the clavicle, and bordering on the external jugular
vein, are half a dozen ;  between the skin and the parotid gland there are two,
one above or near the zygoma, and the  other below near the angle of the 
 298           PRINCIPLES  AND PRACTICE OF SURGERY.

jaw.  Disease and enlargement of the latter are very apt to be mistaken for
 an affection of the parotid itself.  In the early stages of this tumor, its mova-
 ble character  will, however, prevent such an error in connection with the
 parotid.   Around the submaxillary gland, especially at its anterior and pos-
 terior extremities, there are eight or nine, and in it as well as in the parotid,
 are lymphatic vessels and smaller glands which are the primary points from
 which the disorder of these structures originates.  The deep lymphatic glands
 of the neck are also very abundant; they are placed along the sheath of the
 carotid artery and jugular vein, and between them and the anterior  edge of
 the trapezius  are about  twenty.   When enlarged,  these glands project be-
 yond the sterno-cleido-mastoid  muscle  at  its  posterior edge, and in the
 removal  of some  of them a section of the muscle may be required.   Between
 the inferior  edge of the  thyroid  gland and the sternum, on the trachea, are
 four, and a chain  of them extends  from these around  the oesophagus, trachea,
 and blood-vessels toward the  heart,* Plate XXXIII.  Fig.  1.
   Adenoid tumors, formed at the expense of the deep lymphatic glands of
 the neck, are exceedingly liable to contract adhesions, especially to the sheath
 of the vessels, so  that their extirpation will involve these parts so  directly as
 to lead to danger unless  caution is  exercised.   Asa class,  these tumors are
 more fixed, and the finger cannot  be passed around them in the same  manner
 as is often the case in the superficial glands.   When a tumor in the neck of a
 solid, or  apparently semi-solid consistence, is seated  nearly on a line with the
 upper portion of  the laryux or toward the angle of the jaw, or close to the
 posterior edge of the sterno-mastoid muscle, and seems to elevate the  muscle,
 or is rendered more movable by relaxing the latter, it will often prove to be
 directly over the  course of the  great vessels if not attached to their sheath.
 When a tumor in the neck is  large, pediculated, or shows a tendency to ex-
 tend and elongate the  skin, so  as to become pendulous, its attachments will
 generally be superficial.  But if  the size of  the tumor is not large—say not
 larger than  a  lemon—if it is round or flat, hard, bosselated, and not easily
 moved, or excites doubts  as to its  mobility, especially if its attachment is near
 to and in the line of the sterno-cleido-mastoid,  it may be taken for granted
 that it is deep seated.  A small tumor not larger than a walnut, and appar-
 ently upon  the edge of the sterno-mastoid muscle, and whose removal seemed
 to be a very simple affair, was undertaken by a well-known surgeon.   Having
 noticed the liability to error  of diagnosis in  such cases, I was prepared for
 hemorrhage, and, in a very few minutes, was compelled to tie the  internal
 jugular vein with two ligatures, the vein and sheath of the vessels being so
 adherent to the base of the tumor as to mislead the operator as to its actual
 position.   So deceptive are the attachments of all tumors of the neck, that
 it has been justly said "that no one can tell how far he may be compelled to
 go in order to remove them, until he has completed  the operation."
                            SECTION  II.

        OPERATIONS  FOR THE  REMOVAL OF  TUMORS  OF THE  NECK.

  In the treatment of the morbid condition  of structures as varied as those
connected with tumors in the neck, it must evidently be  impossible to lay
down any general mode of operating that would be applicable even to a ma-
jority of the cases that may be met with.   Surgical  writers have, therefore,
generally been  satisfied with furnishing directions in regard to the form of
* U. S. Dissector. 
     OPERATIONS  FOR  THE  REMOVAL OF  TUMORS  OF THE NECK.   299

 the external incision, or in recommending that in all operations for the re-
 moval of tumors, the skin should be cut so as to create as little deformity as
 possible, while, at the same time, the deep-seated attachments of the struc-
 ture to be  removed are freely exposed.   In the neck, the latter recommenda-
 tion is especially serviceable, as too much stress may be laid on the deformity
 likely  to arise from the cicatrix.   When compared with the increased diffi-
 culty liable to be caused by a limited  incision, the inconvenience created by
 the  deformity from a cicatrix does  not deserve  a  moment's consideration.
 Wounds of the skin, it is well known, generally unite with great facility,
 while  a free incision, by enabling the operator to see distinctly the structures
 upon which he is acting, will greatly accelerate the accomplishment  of his
 object, and save the patient much unnecessary risk and suffering.  From the
 importance of the  parts connected with tumors in the neck, the first  object
 of the operator should certainly be to accomplish the  removal of the disease
 with safety and certainty, and  nothing will aid this purpose so much as a free
 external incision; the subsequent dissection being, if necessary, more limited
 in its extent.   The choice of the  shape of an  incision will also  often exert
 considerable influence upon the success of the operation;  and  a brief refer-
 ence to the adaptation of each of them to special cases may, therefore, prove
 serviceable.
   The straight incision  is especially applicable to the removal of small and
 superficial tumors,  or those situated  directly beneath the skin.   The ellipti-
 cal incision exposes a part more  freely, and is chiefly resorted to when it is
 desired to  remove an excess of integument, as in the case of a  large or pen-
 dulous tumor.   The  V incision is more free,  and adapted to tumors of mod-
 erate size,  so situated as to render it necessary to insure the safety of particu-
 lar parts;  while the crucial or the T, and especially  the former, will be found
 the best in all cases where  the tumor is large, and  likely to require a free dis-
 section.   But no matter what line of incision is selected, it is  essential  that
 the external or primary cut should extend at least to the very circumference
 of the base of the tumor, as seen  through the skin,  and in many instances it
 will  be found advantageous to carry it a few lines beyond this point.   After
 incising  the skin, there are certain rules which are applicable to the removal
 of the  majority of tumors, and the observance of which will prove highly use-
 ful to those who  have yet  to  gain their experience.   Thus Stevens, of New
 York,  directs the operator  first to cut down to the tumor before commencing
 its dissection; and, second, to remove the whole of the tumor, and  nothing
 more.
   It is also advisable that  the dissection should be  made by extensive cuts,
 by which is meant the  sweeping  motion of a good dissector, and  not the
 hacking  and  pricking of tissue occasionally seen, the edge of the scalpel
 being directed as much as possible from those parts  which it is important to
 leave untouched, whether they be in the tumor or in  the healthy structure.
 In connection with the dissection conducted  in the neighborhood of import-
 ant organs, whether nerves,  vessels, or muscles,  he also  directs that they
 should be drawn or put  to one side by means of blunt books, the fingers, or
 forceps.  When the principal portion of the tumor  is  removed, especially if
 it  is of a suspicious character, the surgeon should endeavor to satisfy him-
 self that uo particle is left behind, lest it serve to reproduce the disease;  aud
 when any of the remnants are  thus found, they should be removed either with
the knife or scissors, the wound  being left undressed until all the vessels are
tied  and the  flow of blood arrested, when an effort may be made to heal it
by the  first intention.*   On this latter  point surgeons have always differed.
* Malgaigne, Op. Surg.  Philad. edit. p. 104. 
PLATE  XXXIV.
  APPEARANCE AND POSITION OF SOME OF THE TUMORS SEEN ABOUT
                               THE NECK.

   Fig. 1. A large Cystoma of the right parotid region, caused by the develop-
 ment of a sebaceous follicle  in consequence  of a blow upon the part.  Com-
 mencing as a lump the size of a nut, this tumor gradually increased to nearly
 the size of the head; gave exit at one time to sebaceous matter; had a broad
 base;  was nearly immovable;  had the veins enlarged upon its surface,  and
 showed a small ulceration  in front, from which fetid, acrid, and  bloody sanies
 had escaped.   As  the  tumor  enlarged, the  jaw became closed ;  sensation
 of the face diminished, and there were all the other symptoms due to pressure
 on the vessels and nerves of the part.  The tumor differs in  appearance from
 scirrhus of the parotid gland in its  size and  period of development.  It was
 readily removed, and is represented as an example of one of the class of tumors
 of the parotid region not involving the parotid gland.           After Auvert.

  Fig. 2.  Large Adenoid Tumor of the Neck dependent on degeneration of the
 lymphatic glands of the neck.  Arising as a small swelling caused by an enlarged
 gland below the angle of the jaw, it gradually increased until it occupied the entire
 side of the neck, involving many glands, and reaching from above and behind the
 ear to below the clavicle, so as to turn the head to the opposite side.   Its appear-
 ance was that  of an irregularly lobulated  mass: it  was unaccompanied by pain,
 was perfectly  firm and hard, and gave  no sense  of fluctuation at any point.
 Under the use of chloroform, it was successfully removed by Mott.   After Mott.

  Fig. 3. Appearance of  an immense Adipose or Lipomatous Tumor  of  the
 Neck.   This tumor was not painful; had no pulsation ; was formed of numer-
 ous large lobes, with the superficial veins distended over them, and was attached
 to the neck by a large pedicle which extended from the angle of the lower jaw
 on the right side, down to the sterno-clavicular articulation, its weight being so
 great  that the patient could hardly retain the  erect  position.   The tumor was
 found to be covered by a strong capsule formed of the surrounding cellular tis-
 sue, and to have originated in  a  hypertrophy of the surrounding adipose tissue.
                                                           After Auvert.

  Fig. 4.  A large Cystoma of the left Parotid and Submaxillary Regions, which
was to the touch semi-elastic, unequally lobulated, and due to a chronic  irri-
tation of one of the sebaceous follicles, the duct of which had  become closed,
and thus caused a retention  aud degeneration of its secretion.    After Auvert.
       (300) 
Plate 3 4.
 
* 
          REMOVAL OF  LARGE ADENOMA  LYMPHATIC GLANDS.      301

In tumors of any size above that of a walnut, union by the first intention
will not usually  be  possible, especially if ligatures have been required;  and
individual experience has rather led  me to the  observance of the practice
of Physick, in the  introduction of a little slip of linen at the inferior angle
of the wound, so as to insure a  vent for any pus that may be secreted.   The
surface  of an incised wound  generally  unites without difficulty;  but the
deeper-seated parts are more obstinate, and in the neck it is especially im-
portant that pus should be prevented from burrowing, and that a free  vent
should be guaranteed it by other means than those furnished by bringing the
ligatures out at  the lower angle of the incision.
  In the extirpation of tumors about the neck, Langenbeck proceeds as fol-
lows :  He first makes a free division of the integuments, dissects the muscles
from over the tumor, but avoids cutting through or injuring them if possible,
thus making the tumor sufficiently movable, while, by preserving the muscles,
he is enabled to know accurately the place of the chief blood-vessels.  Then
when the surface of the tumor has been cleared, its separation is to be com-
menced on that  side which presents the least risk, or  where the least  con-
siderable vessels are, and the dissection carried from thence toward the  more
hazardous portions. This distinguished surgeon has also recommended  that
the knife should not be introduced deeply where there are any large blood-ves-
sels, but that the tumor should be strongly pulled outward, so as to separate it
from the vessels, and  put the connective tissue on the  stretch.   The latter
recommendation will be found especially serviceable, and the operator will be
well able to carry it out if he takes the preliminary step of passing a strong
ligature deeply into any solid tumor immediately  after incising the skin.
  Directions like those of Langenbeck, though of a general kind, should be
firmly impressed on the  mind of the  surgeon, when operating on tumors  of
this portion of the body, or indeed elsewhere. In every operation upon tumors
in the neck, the operator should always be on the watch to prevent the entrance
of air into  the  veins, and, when it occurs, immediately resort to stimulants
to the nostrils,  frictions, and artificial respiration, in order to  restore the
heart's action.   But,  though sufficiently useful as  far as they go,  these direc-
tions do not give such an accurate account of the best mode of  overcoming
the difficulties likely to be met with in the removal of tumors from the course
of the  great vessels of the neck as is desirable, and I have, therefore, made
a selection of a t'aw difficult cases, with a view of furnishing the best possible
substitute for the individual observation of any young operator, viz., the ex-
perience  of  those whose skill and life-long practice have  enabled them to
contend with difficulties in every shape.   As  these cases contain important
practical precepts,  they are furnished in full,  in  order that  nothing of the
details of the extirpation of tumors in this region may be overlooked.
     g 1.—Removal of Large Adenoma Lymphatic Glands of the Neck.

  Operation of Mott, of New York.*—A little boy, five years old, had a
tumor on  the neck, which had resisted every plan of treatment.  It occupied
the entire side of the  neck, reaching from above and  behind the ear to below
the clavicle, going underneath and also lapping this bone. In front, it passed
beyond the central  line of the larynx and trachea, crowding  these  parts  to
the opposite side; and behind, it passed under the trapezius muscle, so as  to
turn the head also toward the opposite side. In appearance, the tumor was
* Transact. New York Acad, of Med., vol. i. part i. p. 90.  New York, 1851. 
 302           PRINCIPLES AND PRACTICE OF SURGERY.

 irregular and lobulated, while to the touch it  was firm and without fluctua-
 tion at any point, Plate XXXIV. Fig. 2.
   The patient being placed entirely under the influence of chloroform, the
 operation was commenced.
   Operation.—In order to command the whole tumor, a crucial incision was
 made in  the integuments, the first cut extending from behind the ear to the
 clavicle,  and  the  second a little  obliquely to this, from the anterior to the
 posterior edges of the tumor, so as to traverse the longest axis of the whole
 mass.  These incisions being carefully conducted through the skin, platysma-
 myodes  and  under layer of the  superficial fascia, so as fairly to denude the
 tumor, the dissection of the lower flap was first commenced, the  veins and
 arteries  being  tied as they were divided.   In dissecting off this flap, the
 mastoid  muscle was found  to be so incorporated  with the tumor as to make
 it necessary to divide the muscle about two  inches from the sternum  and
 clavicle.   This division exposed the lower  portion of the tumor, and showed
 the internal jugular vein running through its substance.  On the inner side
 of the mass,  the common carotid artery could  be  dissected  bare  for  several
 inches;  but  the vein was  so imbedded in the tumor that it was totally im-
 practicable to save it.  Being therefore seized with a pair of forceps, it was
 divided,  and  a ligature instantly placed beneath the forceps, the upper end
 being held by the fingers of an assistant, while  the dissection wras continued.
 The tumor, being thus separated from the  vein, was found to have destroyed
 by its pressure the sterno-hyoid and sterno-thyroid  muscles, and was now
 detached from the upper and inner edge of the clavicle as far as the anterior
 edge of the trapezius muscle.  Getting under the mass in this way, the tumor
 could  be more readily and safely detached  from  the  parts below, and, on
 dissecting it from over the scalenus anticus, careful attention was given to
 the phrenic nerve.  The posterior and upper part being then dissected from
 over the  mastoid  process and  turned down, a portion of the diseased struc-
 ture was seen to pass beneath  the muscle,  and  to  be so  incorporated with it
 as to require the division of the  muscle at this point, the middle third of  it
 being left attached to the  tumor.
   The anterior and  upper part  being now separated  from the  side of the
 pharynx  and larynx, it was found, after dissecting the tumor from the com-
 mon carotid  artery opposite the thyroid and cricoid cartilages, that the deep
jugular vein could not be safely detached.   A second  ligature was therefore
 applied to this  vein, about an inch below the angle of the lower jaw, and the
 vessel divided below  it, leaving several inches of the vein in the tumor, after
 which the whole mass readily came away.  More than twenty ligatures were
 applied to different arteries and veins, and  the effects of the chloroform being
 allowed  to pass off,  the wound was closed by  stitches, adhesive  strips, lint,
 and a bandage.  When the parts had  sufficiently healed, care was also taken,
 by resorting  to bandages and position, to  prevent the head  becoming awry,
 and  the  patient recovered without inconvenience, notwithstanding the loss
 of the middle third of the mastoid muscle.
       \ 2.—Extirpation of a Large  Malignant Tumor of the Neck.

  Operation of John C. Warren, of Boston.*—In this case the tumor had
existed over a year;  occupied the whole of the left side of the neck  from
the ear to the clavicle, and from the trachea to the spine;  the  mastoid
* Warren on Tumors, p. 175. 
   EXTIRPATION OF A  LARGE MALIGNANT TUMOR OF THE NECK.   303

muscle, and all the arteries, veins, and nerves of the neck being presumed
to be included  in its substance, while a process extended under the jaw into
the pharynx, and filled  the left half of this cavity with a red tumor which
greatly impeded deglutition, the whole structure being very hard, knotted,
uncolored, and insensible.
   Operation—In commencing the operation, the  patient being of course
fully etherized, an incision was made from behind the ear to the anterior
third of the clavicle, the surface of the tumor uncovered, and the mastoid
muscle sought for, but found to be partly absorbed and partly buried in the
tumor.   After clearing  the latter from the ear,  the jaw, larynx, and dorsal
muscles, an attempt was made to get under the tumor just above the clavicle,
and then the difficulties of the operation appeared, the carotid artery, inter-
nal jugular vein, and par vagum nerve being covered by it and connected
with  processes of the mass in such a manner as  to render it difficult to dis-
tinguish them.   This being at last accomplished by breaking down the lower
part of the tumor, the vein was found  to  be  obliterated, and the artery di-
minished in size, but pervious.  A  ligature being then applied on the latter,
the par vagum nerve  was  separated  as  carefully  as possible,  though not
wholly cleared of the tumor, and the separation of the latter from the nerves
at the upper part of the neck attempted and successfully accomplished, with
the exception  of the sublingual nerve, which so barred  the access to the
pharyngeal  part of the tumor that it was determined to divide it.  This
being done, the  operation was finished  by breaking down such parts of the
tumor as could not be separated from the other nerves, when the parts were
brought together, and the patient put to bed, there  being  but little hemor-
rhage, a fact stated by Warren as common in large  and hard tumors.   The
patient at first  did well after the operation, but died about a year subse-
quently, of an  ulceration  of the throat, which created a difficulty in  swal-
lowing.
   A yet more complicated and severe operation was performed in another
case by Warren.*  In  this patient, the tumor extended from  the spinous
processes of the cervical vertebrae to  the  lower jaw, pharynx,  oesophagus,
and larynx, running upward  behind  the  ear, and  downward to  near the
clavicle.  This tumor, which had  existed for thirty years, had  turned the
face to the opposite side, impeded  the  motions of the head and neck, and
caused dizziness, headache, and dyspnoea.  After examining and considering
the case, Warren was induced to think that the tumor had originated in the
lymphatic glands  behind the posterior edge of the  sterno-cleido-mastoid
muscle;  had extended  backward under the trapezius to the spine, and for-
ward  under the mastoid muscle to the pharynx; that it adhered to the sple-
nius,  complexus, and trachelo-mastoideus muscles, and  also iuvolved the
digastricus,  as  well as  all the styloid muscles; that the external carotid
artery, with all  its branches,  excepting possibly the superior thyroid, were
involved; and  that the  jugular and smaller veins, together with  the three or
four superior cervical nerves, the par vagum, sublingual and  its descending
branch, the  glosso-pharyngeal, laryngeal, and great sympathetic were also
connected with it.
   After a full consultation and statement  to the patient of the dangers of
the operation, and the impracticability of disengaging the whole tumor, the
propriety of submitting to it was left to the  patient's  decision, and he
deciding to do  so,  the operation was performed at Lincoln, near Boston.
   Operation.—" The patient being seated in a chair with his head supported,
* Warren on Tumors, p. 177. 
304
PRINCIPLES AND  PRACTICE OF SURGERY.
an incision was made from the spine to the angle of the jaw, to meet another
incision which was carried from this point downward to near the clavicle, in
the direction  of the anterior edge of the sterno-cleido-mastoid muscle.  This
flap of integuments being turned down after a laborious dissection, in con-
sequence of its close adhesion to the tumor, the posterior half of the  latter
was exposed from the spine to near the trachea, showing the mastoid muscle
firmly imbedded in the scirrhous mass.  Having dissected  the muscle from
its inferior adhesions, the carotid artery was exposed and tied.  The superior
flap of the integuments being then  raised, an attempt was made to disengage
the mastoid muscle from  the furrow it occupied in  the upper portion of  the
tumor, in order to pursue the dissection  beneath it; but  this being  found
impossible, it remained either to divide the muscle and the accessory  nerve,
or to divide the tumor through its middle behind the muscle.   The  latter
course being  chosen, the mass was cloven in two, the posterior half dissected
out, and the anterior then diseugaged by great care from  the posterior face
of the sterno-mastoid  and digastric  muscles, as well  as  from  the nerves,
bones, parotid, and  submaxillary glands; but some portions remained ad-
herent to the fore part of the bodies of the vertebrae and to their transverse
processes, and could not be wholly dissected without exhausting the  pa-
tient's strength.   The  actual cautery  was therefore applied to them without
causing much complaint.
   " In the latter part  of the  operation, the patient was occasionally  seized
with a spasmodic cough produced apparently by the division of some  of the
branches of the accessory nerve.  The internal jugular vein, being buried in
the tumor, was compressed between it and the clavicle and then divided  and
tied, a few bubbles of air which entered the open mouth of the vessel being
arrested and forced back again by  a finger applied below the opening.    The
principal branches of the first and  second  cervical nerves were now seen  aud
divided, and  others in  the substance of the tumor were also divided, as indi-
cated  by the patient's  sensations, although they were not seeu.
   "The integuments being then  laid down  on  the  face of the wound,  and
moderately secured so  as to protect it, without too much confining the parts
destroyed by the cautery,"* the operation was completed,  and the patient is
believed to have recovered.
   Operations of a similar character by Rodgers and  Stevens, of New  York;
 Hay ward, of Boston ;  Gibson, of Philadelphia ; Spencer, of Virginia ;  and
 Smith, of Baltimore, will be found referred to in the Bibliographical Index
 at the end of this part.
   Remarks.—From the details furnished in  the preceding accounts  of the
 removal of a most dangerous class of  tumors  of the neck, a good idea  can be
 obtained of the anatomical as well as operative  skill requisite for their  exe-
 cution.   In  fact, no surgical operations require  a nicer discrimination  of
 structure than those connected with  the removal  of tumors in this region,
 muscles, nerves, arteries,  and veins  being all liable  to  be displaced  and
 changed in character to a greater or  less extent, yet all requiring to be accu-
 rately recognized at each step of the dissection.  But though an operation
 for the removal of large tumors is important and highly  dangerous,  it  does
 not really deserve as much consideration and caution as  those in which the
 disease is less developed.  In a case  of the magnitude of those above cited,
 danger  is so evident  that prudence  and forethought  are ready to contend
 with it,  the presence  of skillful assistants, together with all the adjuvauts
 likely to prove serviceable, being  naturally prepared by the operator.
* Warren on Tumors, p. 182. 
BRONCHOCELE, OR  GOITRE.
305
  The truly dangerous cases, in my estimation, are the small and apparently
inconsiderable tumors of the neck, the removal of which seems to be so
simple and easy that  they might almost be designated as traps to catch the
inexperienced and fool-hardy, or those in whom  boldness takes the place of
discretion.   The  young  surgeon  cannot, therefore, be too much upon his
guard when consulted in reference  to small tumors of the  neck.  In these
cases, when he has decided to attempt  their removal, let him always think
that, before his operation  is  completed, he may be compelled to open the
sheath of the vessels and ligate the carotid artery, and, with such a prospect
before him,  his operations  will  not  only  be well performed, but  acquire
a simplicity of character that will be mainly due to his thorough preparation
for all the contingencies that may arise, in consequence  of the difficulty of
settling a  question that can  only be decided by his  operation, to wit, the
attachments of a tumor in the neck.
                            SECTION  III.

                       BRONCHOCELE, OR GOITRE.

   In the preceding section, the account of the operative proceedings requi-
site for extirpating tumors of the neck has been limited to such as are sanc-
tioned by the highest authorities, aud therefore presumed to be fit cases for
such operations.   There remain, however, a class, yet  to be described, the
propriety of removing which is extremely doubtful, and seldom now thought
of, except in cases where  the patient's sufferings  from suffocation are most
urgent.

                     § 1.—Bronchocele, or Goitre.

  Pathology.—Bronchocele—#"">/<>?, trachea, and xrtX-q, a tumor—is a well-
known disease, which consists in the enlargement  of either one or both lobes
of the thyroid gland, though the same name has been occasionally applied to
a degeneration of the surrounding cellular structure and lymphatic glands.
According to Warren,* "the  thyroid  gland  is subject to two  kinds of
enlargement:  one  of a temporary nature, known as  goitre;  the  other,  a
permanent scirrhus."
  True goitre exists at all periods of life, especially in the  female sex, and
consists in a chronic inflammation of the thyroid  gland itself, which, begin-
ning at some one point, is apt to extend until, as in  a case related by Ali-
bert, it reaches to the thighs of the patient.   The changes within a goitre
vary with its development; presenting sometimes a soft gelatinous matter,
or a more hardened structure interspersed with  cysts containing  a serous,
glairy, or melicerous substance, and occasionally pus,  fibrin,  calcareous con-
cretion, or pure blood, f  Vascular derangement being here  very evident,
the thyroid arteries are commonly found  to be  much enlarged.   In some
cases the swelling seems to consist almost entirely of a congeries of varicose
veins, and, under these  circumstances, there may be considerable  sanguine-
ous effusions, the blood being poured into the enlarged vesicles, or into the
connecting cellular substance  of the gland. J   Besides the  hypertrophy of
the parts, consequent on chronic  inflammation  of this gland, the thyroid
* Warren on Tumors, p. 302.
f Pathological  Anatomy, by Samuel D. Gross, p. 407.         J Opus citat.
 VOL. II.—20 
306            PRINCIPLES AND PRACTICE OF SURGERY.
body is also sometimes  the  subject of scrofulous, lymphatic, or schirrous
degeneration.
  In the Scrofulous Goitre,  the areolar tissue  enveloping the gland and
prolonged throughout  its structure is thick, compact, and resisting, so that
each portion is transformed, as it were,  into a cyst which is filled with a mat-
ter of varied color and  consistence, though all the elements of the gland may
vet be recognized.
  In the Lymphatic Goitre, certain fluctuating points are readily recognized,
the cysts being found to contain serous, albuminous, lactescent, or puriform
matter; or the points, which appear to fluctuate, consist of a spongy structure
analogous to that of the placenta.*
  The Scirrhous Goitre presents a tumor covered  by a firm fibrous capsule,
and consists of a spongy texture, in which appears  a considerable number of
cells, some of  which are of large size, and contain a bloody fluid.   Its con-
sistence is  often  firm,  but  not  scirrhous, except at the  upper part,  which
sometimes has the texture,  consistence,  and white color of true scirrhus.f
  Diagnosis.—The Goitrous Tumor  has a smooth surface, a  somewhat
elastic feel, follows all the motions of the larynx, especially in swallowing, and
gives no sensation of crepitation, fluctuation, or  pulsation.
  Cysts of the thyroid region, unless enormously distended or multilocular,
give the sensation of fluctuation.  Tumors similar to these have been de-
scribed by Maunoir as  "Hydrocele of the Neck."
  Scrofulous enlargement about the  thyroid gland  tends to  suppuration, and
the patient shows the marks of a scrofulous diathesis.
  In Scirrhus, the tumor grows very slowly, and is small, its surface is hard,
lobulated, or tuberculate;  it  is accompanied by pain, and is liable to ulcer-
ation.   In Fungoid degeneration, there  is the ordinary constitutional disturb-
ance of the  complaint  as seen elsewhere.
  Owing to the position  of the  thyroid gland, it has occasionally happened
that its proximity to the carotid artery has led the observer to regard it as
an aneurism, a case of which has  been published  by Griffiths, of Philadel-
phia.!  In  this  case, dissection alone  revealed  the disease.  As a general
rule, however, the pulsations of an  aneurism give a motion to  the  whole
tumor; and Boyer has facilitated the  diagnosis of one from the other, by
directing the relaxation of  the muscles by inclining the head to one side, by
which means the impulse will be checked, if it is a  goitrous tumor. §
   The  propriety of operating on  these  tumors is a point on which most
surgeons  are  very decided,  the opinion being almost universal that any
attempt to  extirpate  them is most  hazardous.  It is presumed, therefore,
that any surgeon who may be called on to treat a case, will first resort to
every remedial measure, and especially to the  use of iodine internally and
externally, for many mouths, before entertaining for a moment such an idea.
To those who desire more  detailed information of  the pathology of this dis-
ease than  is to  be found in  most of the general works which  treat of this
tumor, I would recommend the articles in the volumes hereafter  quoted, an
extended article  by Gibson,|| of Philadelphia, and  the memoir of Benjamin
 Smith Barton, of Philadelphia,  published in 1800.
   Although the extirpation of a goitre cannot be regarded as a justifiable
operation in most instances,  the distress of breathing and swallowing which
it sometimes  causes may  render  it  imperative  on the  surgeon to attempt
some means of affording relief; but even then local depletion, iodine, and
* Diet, de Med., tome xiv. p. 172.         f Warren on Tumors, p. 807.
X Eclectic Repertory, vol. ix. p. 120.       \ Diet, de Med., tome xiv. p. 177.
|| Phila. Journal Medical and Physical Sciences, vol. i. p. 44,  1820. 
BRONCHOCELE, OR  GOITRE.
307
similar means should be first fully tried before resorting to so dangerous an
operation.
  Treatment of Goitre.—In a tumor which  has presented such varied
pathological changes  as those seen in this gland, and in which many points
have not beeu described with the accuracy that  might  be desired, it is not
surprising that various plans of  treatment should have been recommended,
in addition to the general  remedial measures just spoken of, surgeons having
at different  periods advised the  use of a seton,  or of caustic,  as well as the
ligation of the whole tumor, or the placing of a ligature upon the thyroid
arteries, or compression or extirpation.  That some of these means are better
adapted  to the mere cystic tumors of this region than to the cure of a true
goitre, cannot be doubted, and such suggestions can therefore be regarded
only as indicating the different views, in  relation to the condition of the dis-
eased part, held by those  who have suggested them.  Any operation upon a
true goitre being usually deemed inadmissible, except as a last resort, I shall
only refer to such means as have been  employed in the United States, and
of these  the  operation of  compression will be first mentioned, as  being that
which may be most readily and safely tried.
   Treatment of Goitre by Compression—Operation of Dwight, of New
York*—After  preparing "three  strips of  good  glazed  brown cambric,
spread with  emp. ol. lini  cum plumb, sem. vit. oxid.—diachylon—each of
half the width of the tumor, and of a length sufficient to  reach from the
lower edge of the scapula of one side obliquely up the opposite side of the
neck and across the lower  part of the tumor,  and passing thence around
the neck and across the shoulder, down  to the lower edge of the opposite
scapula, he warms and  applies  them to the  part  in the line mentioned, so
that each strap may cross behind the  neck like  suspenders.    The first
strap being  drawn quite  tightly produces very considerable turgescence of
the blood-vessels of the face, and causes the  patient to shrug his shoulders
for a few minutes,  until the thyroid vessels become sufficiently compressed
to enable him to  breathe more comfortably, when the countenance usually
resumes its natural appearance, as is often the case in less than five minutes.
The second strap being then  passed in  the same manner across the upper
part of the tumor, or from half  an inch to an inch from the first, according
to the size  of the tumor  or length of the neck; this strap  should also be
drawn as tightly as the first, and the  same  time allowed for  the change in
the countenance, when, the third strap being applied over the intermediate
space, the operation is completed.
  " Ordinarily, these plasters adhere to the part for ten days or a fortnight,
if the weather is cool, and, on becoming loose, ought to be removed, when, if
the pressure has been well applied, the tumor will be found to have become
slightly less,  and the  skin somewhat reddened  and tender.   When this is
seen,  it will be better to wait  till the  integuments  assume their natural
appearance, when the application may be renewed.
  " The first application of these straps has  in  one case been sufficient to
effect the cure, but the average repetition of  them has been as high as four
times in each case.   When the bronchocele becomes diminished  to half its
size at the time of the first application, the tumor will continue to disappear
without further care ;  there having been no failure in twenty cases from this
mode of treatment.   The  iodine  had not  succeeded in several  instances.  In
two patients, the disease returned at the end of  two years, but disappeared
on a new application of the straps, "f
* Transact. Am. Med. Association, vol. iv.  p. 248, 1851.
f Buffalo Medical Journal, Jan., 1851. 
308
PRINCIPLES AND  PRACTICE  OF SURGERY.
  Ligation  of one of the Thyroid Arteries.—Operation of Jameson, of
Baltimore.—An incision, about an inch long, being made  parallel with the
trachea, and about midway  between it and the inner edge of the sterno-
mastoid muscle, and, having reached the thyroid artery by a very cautious
dissection, so as to avoid dividing any considerable branch of the nerves, an
animal ligature was applied to the vessel, and the wound allowed to heal
over the ligature.  Several months subsequently, the tumor, by actual  meas-
urement, was considerably less.
  The ligature of all the thyroid arteries would only be  a repetition of this
operation, but would certainly increase the patient's danger, and require a
perfect anatomical knowledge of the structures concerned   Four cases of
cure from the use of the ligature have been recorded by European surgeons.
  Subcutaneous  Ligation of Goitre.— Operation  of Ballard and  Rigal
de Gaillac*—"The goitre, being very large, was  tied in three portions,
each being strangled  by a separate  thread, as follows : Two long  waxed
ligatures,  each armed  with  three needles, viz., one, straight and  cutting,
being applied  at one end of  the thread; the second, round and pointed, in
the middle of  the  thread, to be drawn double across the  tumor; and the
third, armed at the other end of the thread with a curved needle, were each
properly arranged.  Then a  vertical fold of the skin, being raised opposite
the superior part of the tumor, was traversed by the straight needle at one
end of the thread,  and, the  fold being  let go, the ligature was made  to de-
scribe a curve  round the upper part of  the tumor,  so that an end hung out
on each side of the goitre.   Through the same punctures, but beneath the
tumor, the round and pointed needle was then passed and directed from one
side to the other, so as to draw with it the middle of the ligature, which,
when passed, was removed by cutting across the loop, so that there was now
a complete loop surrounding the superior third of the tumor at its base, with
its two ends hanging out of  one  puncture, while  the  other  thread or that
passed across and beneath the upper third, was destined for  its middle por-
tion.  The second and  third ligatures  being then passed in  like manner, it
was only requisite to form round the middle  third a complete and subcuta-
neous loop, which was effected by using the remaining curved needle, when
all were tightened by a serre nceud."
  Febrile  reaction followed, and on the fifth day  a puncture with a  lancet
was necessary to give exit to a little pus  and gas which  had accumulated
under the skin;  but the patient was  subsequently cured, with only a slight
trace of the affection.
  Dissection  of the  Skin and  Ligation  of the Tumor.—Operation of
Mayor.—The tumor being  exposed by a double elliptical  incision,  which
turned back the skin  to the right and left, the  base of the tumor  was
traversed  by two ligatures, the two ends of the same ligature being tied so
as to strangulate separately each half of the tumor.
  A somewhat similar operation has been successfully performed by Liston,
of London, and is represented in Plate  XXXVII. Fig. 1.
  Extirpation of a Scirrhous Thyroid  Gland, by J.  C. Warren, of Boston.|
—The patient being in the  upright position, an incision nearly four  inches
long was carried along the anterior edge of the sterno-mastoid muscle, so as
to expose  the  platysma-myodes, which  was incised so as to present the edge
of the sterno-mastoid.   On turning this aside, the sterno-hyoid and thyroid
muscles were perceived to cover the tumor in such  a way that it was  neces-
sary to separate them and dissect between them.   The surface of the tumor,
being then brought into view, was  fully exposed by  dissection, and sepa-

    * Malgaigne, Philadelphia edit., p. 378.       f Warren on Tumors, p. 305. 
HYDROCELE OF  THE  NECK.
309
 rated from the sheath of the carotid artery by the handle of the knife.  This
 apparently loosened its attachments, but a solid adhesion being found to the
 trachea for one or two inches, and also to the oesophagus for a small extent,
 which required the use  of the knife, the dissection was pursued upward and
 backward, in order to extract the superior corner of the  gland.   The supe-
 rior thyroid artery being divided in so deep a position as to prevent its liga-
 tion between  the muscles, the common carotid was therefore tied.   The in-
 ferior thyroid did not bleed, or  was supposed not to exist, and the patient,
 after serious symptoms, recovered in about  one month.
   Remarks.—Of the different operations just detailed, compression is cer-
 tainly the safest, and, judging  from the accounts  furnished,  the most  suc-
 cessful.   Ligation  of the thyroid arteries, although successful in a few cases,
 is so hazardous and difficult an operation that few will probably be disposed
 to attempt it; in addition to which, there would certainly be good reason to
 fear a return of the circulation through the numerous anastomosing branches.
 As the ligatures must also be placed near the origin of the thyroid  arteries,
 there has not always been a sufficient amount of  the vessel left  to  prevent
 secondary hemorrhage, a case being on record, where, from the proximity of
 the carotids, the loss of blood has been most alarming, nothing but compres-
 sion by the fingers of assistants, during eight consecutive days, having res-
 cued the patient.
   Although I have placed among the preceding operations  an account of the
 extirpation of the thyroid gland as performed by Warren,  it has  been done
 rather to complete the record than from a wish to  lead  any one to its repe-
 tition, even when sanctioned by  such excellent authority.  Though occasion-
 ally performed, an attempt to extirpate a goitrous tumor is so liable to cause
 immediate death from hemorrhage, that few, as before stated, deem the opera-
 tion justifiable, more than one patient having died  on the table.  The liga-
 ture, both by the subcutaneous method and also after the exposure of the tu-
 mor, has succeeded ;  yet the obstruction of the circulation  through  the part
 by this method has also been followed  by alarming  symptoms of suffocation
 and  congestion of the brain.  Every surgeon, therefore, should avoid opera-
 ting on any case of true goitre, unless  fully prepared to encounter great dif-
 ficulties, or with the view of relieving certain suffocation.   In the operative
 treatment of this tumor, it  may well be said that  "discretion is  the better
 part of valor."

                            SECTION IV.

                       HYDROCELE OF THE NECK.

   Pathology.—The term Hydrocele—udwfi, water, and x-nhn, tumor—though
 generally limited to collections of fluid within the tunica vaginalis testis, has
 also  been applied by Maunoir, of Geneva, to those Encysted Tumors which
 are filled with liquid, and found  in  that portion of the neck which  is near the
 thyroid gland.   These tumors are met with, at various periods of life, in both
 sexes; their progress is slow, and they often arise,  without any appreciable
 cause,  from the cellular spaces of the thyroid gland, being occasionally con-
 genital.  Though seldom larger than a walnut, they may acquire  the size of
 an orange, and impede respiration and deglutition.   Their contents vary from
 a thin serum or oily liquid to a thicker consistence, the cyst itself  varying in
thickness from the fourth of  a line to a quarter of an inch or more.  The skin
covering the tumor seldom  undergoes any change  except  when  attenuated
by the size of the tumor, when the subcutaneous veins may become appareut.
 The  tumor is  free  from pain or tenderness on pressure, fluctuates  slightly, 
310
PRINCIPLES AND  PRACTICE OF SURGERY.
and, if seated over an artery, might be mistaken for an aneurism, or, if over
the thyroid gland, be supposed to be a goitre.*
  Operation.—These cysts may be treated on the same principles with  those
seen elsewhere, that is,  evacuated by a simple puncture, or with a trocar, or
cured by exciting inflammation within the cyst itself by means of a seton, or
by acupuncturation, or by injecting  iodine, or wine and water, or a solution
of sulphate of zinc, or by excising the cyst, or by incision and tents, as pro-
posed by Porta,  of Padua.
  The selection of any  of these plans of treatment will depend somewhat on
the patient's constitution and circumstances.   The use of the seton has led
to such irritation as to  induce death.  Erysipelas is apt to follow the injec-
tion of iodine or other  stimulating liquids, and the excision of the cyst, like
any operation upon an  enlarged thyroid gland, exposes the patient to the
risks of severe hemorrhage if the proper structure of the gland is  invaded.
All these plans of treatment have, however, sometimes succeeded, and,  when
the surgeon is aware of the risk attending them, under certain circumstances,
the selection of either plan may justly be left to the decision of the moment.
  From the resemblance of these tumors to those seen  in other regions, they
are generally regarded as belonging to the encysted class ; and the  applica-
tion to them of the  term " Hydrocele of the Neck " is, therefore, liable to
lead to error.  In the opinion of Percy, those found over the thyroid gland
were simply "softened bronchocele." .1 have seen these tumors twice in this
position, and  once over the parotid gland, in  both of which they were nearly
of the size of an orange.   The fluctuation being evident, puucture and the
introduction of a seton  accomplished the cure.
               CHAPTER  VIII.

THE LIGATION OF  THE ARTERIES OF  THE NECK.
                            SECTION  I.

            ANATOMY  OP THE  BLOOD-VESSELS OP  THE NECK.

  The great points of reference in ligating the  arteries  of any portion of
the body are the course of the muscles of the part,  after which  the operator
may seek for the adjacent bony  prominences, or be guided  by  the  position
of the nerves of the  region.  In  the  arteries of the neck, such points may
be readily found, and a brief reference to the normal anatomical relations of
each of  them will, therefore, prove sufficient as the  general guides for these
vessels.
  The Common Carotid  Artery, arising from the  innominata on the right
side about the level of the top of the sternum, and  from the  arch  of  the
aorta on the left about one inch and a quarter below the top of this bone,
ascends  the neck on the outer side of the trachea and larynx, as far as  the
inferior  cornu of the os  hyoides  in the male, though  a  little lower in  the
* Liston's Surgery, by S. D. Gross, M.D., Louisville, p. 386. 
           ANATOMY OF  THE  BLOOD-VESSELS OF THE  NECK.       311

female.   In the lower part of the neck, the right artery inclines more out-
wardly than the left, the latter ascending almost vertically.
  In  this course, each  artery, together with the internal jugular vein  and
par vagum nerve of each side, is inclosed in  a  firm sheath, which is con-
nected with the fascia of the neck, the vein being on the external side of the
artery, and swelling in front and above it, while the nerve is situated between
the two vessels or a little  behind  them.
  Directly above the sternum and clavicle, the vessels and nerve, arranged
as just described, are covered  by the sterno-hyoid  and thyroid muscles, as
well as by the sternal origin of the  sterno-cleido-mastoid.   On a line with
the lower part of the thyroid cartilage, the artery is crossed  obliquely by a
ribbon-like muscle, the  omo-hyoid.  Behind the vessels and Outside of their
sheath may be felt the transverse  processes of the cervical vertebrae, covered
by the longus colli muscles, and  upon  these  muscles, but exteriorly to the
course of the vessels, as well as behind them,  is the great sympathetic nerve.
Alongside of the larynx, the carotid artery is very superficial, being covered
only by the skin, superficial fascia, and  platysma-myodes, though it is here
also crossed by the omo-hyoid muscle.   Having reached the  space between
the os hyoides and the larynx, the common carotid divides into the internal
and  external  carotids,  the latter being  generally the  smallest in children.
No branches come off from the common carotid  in the normal condition of
the parts, though occasionally the inferior thyroid or the inferior pharyngeal
arteries may be in  the  way of any  incisions upon the main trunk, at the
upper part of the neck.
   The Internal Carotid in the adult is smaller than  the external, and extends
from  the level of the larynx to the brain, being between the external carotid
and the vertebras of  the neck, in  front of the internal jugular vein, and hav-
ing the par vagum nerve at its external margin.  Near the base of the lower
jaw, it is crossed externally by the digastric and stylo-hyoid  muscles, and is
immediately afterward concealed  by  the ramus  of the jaw.*
   The  External Carotid extends from  the  termination of the  primitive
carotid to the neck of the lower jaw.   In the early part of  its course,  it is
in front of the internal carotid and between the pharynx and  sterno-mastoid
muscle, where  it is only covered by the skin,  superficial fascia, platysma-
myodes, and its own sheath.  Just above this, it is  crossed internally by the
hypoglossal nerve, which  sends off  the descendens noni  branch, the latter
nerve being found upon the sheath as  far  as below the  omo-hyoid muscle.
Somewhat above this nerve, the artery is crossed by the digastric and stylo-
hyoid muscles, and lies on the superior constrictor muscle of  the pharynx
near  the tousil gland.  About  its  middle, it is crossed internally by the
stylo-glossus and stylo-pharyngeus  muscle, and  then  ascends  through the
substance of the parotid gland to the neck of the jaw, where  it  gives off the
internal maxillary and temporal arteries.
  The Superior  Thyroid Artery arises from  the external carotid, about a
line from its root, and the Lingual comes off about six to twelve lines above
this.f  The anastomosis  between the arteries of the two sides, through all
their branches, is also exceedingly free.
  The course of the artery, from its origin to the level of the os hyoides,
may be designated by a line drawn froip the mastoid  process  to  the inner
edge of the clavicle, or  by the course of the sterno-mastoid muscle,  when it
can be recognized.
* Horner's Anatomy.
f Ibid., vol. ii. p. 207. 
312
PRINCIPLES AND  PRACTICE OF  SURGERY.
                            SECTION II.

      RULES TO BE  OBSERVED IN THE LIGATION OF ALL ARTERIES.

  The accumulated experience of the profession in the application of the
ligature to an artery having established certain general rules as essential to
the proper performance of the operation—although some few surgeons have
modified them, or substituted others to meet  particular difficulties—it will
be found  useful to follow them  in the application of every ligature,   As
the object to be attained  in  ligating a vessel is  a direct change in the
course of  the normal circulation, these rules  may  be condensed  into  two
general ones, and on these all  surgeons, it is  believed, agree, to  wit:  1st,
always to expose the vessel without opening it; and 2d,  to ligate  it with as
little disturbance as possible to the surrounding parts.  These general princi-
ples have  been carried out in various ways; but as the views of Lisfranc, in
relation to the details, are not only the soundest, but have also been tested by
personal experience, I shall adopt them as those most likely to prove useful
to the young operator.
   In  ligating any artery, Lisfranc advises the  surgeon—
   1st. To expose the vessel without opening it; and in order that he may
do so, suggests the following method of proceeding :—
   a.  To make sure of the position of the vessel.
   Special anatomy, as usually taught, presents every medical man with ac-
curate information in regard to the  ordinary  position of the arteries ;  but
as these vessels are liable to various  anomalies and to irregular distribution
as well as to the changes consequent  upon  disease, special attention should
be given to the position of the vessel upon each patient at the time of the
operation.
   b.  To find the artery.
   In  seeking the vessel, notice should be first taken  of the position of such
muscles asusually indicate the course of the artery, or of those which have
been  termed "muscles of reference,"  so that by causing these muscles to con-
tract  and  become prominent, the  surgeon may readily recognize any devia-
tion of the artery from its natural relations  with these parts ; or he may feel
for the pulsation of the artery ; or, if the tissues are too much thickened, or
the vessel lies too deep to  admit  of this, lines may be drawn from such  fixed
points of the skeleton as normal  anatomy teaches us will cross or follow the
usual course of the artery.
   2d. To  ligate the artery with as little disturbance  as  possible to the
surrounding tissues.
   After recognizing the position of the vessel, its exposure becomes the next
point for consideration, and, in order to prevent any variation from the pro-
per line of incision, as well as to steady the skin, Lisfranc advises the operator
to bring the four fingers of his  left hand to the same level, and then, placing
them  perpendicularly on the skin, to be careful  not to draw the latter to one
side,  while he incises the integuments by  drawing the scalpel close along
the edges  of the nails.  Malgaigne, hpwever, objects to this direction as being
likely to displace the integuments over the vessel,  though my own  experi-
ence  is favorable to it.
   When the artery is superficial, the incision through the integumeuts should
be parallel to its course;  but when it is deep seated, an oblique incision, by
affording  a greater line for any variation, will add much  to the facility with
which the vessel may be  found.  WThen the aponeurosis of the part is directly 
RULES FOR THE LIGATION  OF ALL ARTERIES.         313
in contact with the sheath of the  vessels, it  is generally safer to open the
sheath on one side and then  slit it up  upon a director.   On reaching the
sheath of an artery, or the artery itself, the vessel may generally be  told by
its yellow or dull-white  color,  by  its pulsation, and by its  becoming  flat-
tened and collapsed when the circulation  is interrupted between it  and the
heart.
   In order to isolate the  artery with as little  disturbance as possible of sur-
rounding parts, the relative position of the adjacent veins and nerves should
be recollected, and the adhesions of the sheath and other tissues only loosened
sufficiently to permit the passage of the ligature.   To  do  this, it is  import-
ant that a good aneurismal needle be selected, that is, one which is neither
so sharp as to  expose the  vessels to perforation, nor so thick and dull as to
render  it difficult  to pass its point through the cellular tissue of the part.
When,  in passing the needle around the vessel, the point  appears  beneath
any dense cellular structure, the latter should be supported by the pressure
of a finger iu order to facilitate  its  perforation by the instrument.
   Another rule, which is  an excellent one, and which  Malgaigne*  has de-
signated as " the rule of the guiding points," is the following :—
   " Do not, at  the  commencement of the operation,  occupy yourself  with
looking for the artery, but seek  the first marked point of reference, then the
second, then the third, if there be one, and so on to the vessel."
   Mott, of New York, whose experience in ligating the large  arteries has
probably been  greater than that of any other  surgeon  in the United States,
advisesf that in every operation upon these vessels but little use should be
made of the scalpel after the edge of the muscle  of reference is laid bare,
the fingers, director, or handle of the knife being capable of separating these
parts quite as readily  as its edge,  without  at  the  same time exposing the
surgeon to the troublesome oozing which is apt to  ensue on the  division of
the minute vessels.  By  pursuing this plan, the main artery can  also be
more distinctly seen.
   Parrish, of Philadelphia, in connection with Joseph Hartshorne and Tho-
mas Hewson, also of Philadelphia, was accustomed to employ a knife which
was rounded at the end, Plate XXXV. Fig. 1, for the purpose of dissecting
about the sheath of the vessel. J
   In order to hold the parts asunder, Mott employs curved  spatulas, Plate
II. Fig. 10, and divides the sheath  of the vessels perpendicularly, and  only
upon the front  of the artery, never dissecting or using the blade on the sides
of the vessel, but introducing the knife-handle, and  separating the structure
on each side, so as to denude  the artery only to such an extent  as will  per-
mit the aneurismal needle to pass.   He has generally  employed the Phila-
delphia needle,—Parrish, Hewson, and Hartshorne, Plate XXXV. Fig.  2,—
and always introduces it so that its point will pass from  the vein,  and not
to it.
   This  needle  having been  employed by Mott, has been very  incorrectly
credited to him—it being, as is well known, by the  publication of Parrish in
the Eclectic Repertory, in 1813, the "Philadelphia needle."
   In attempting the cure  of aneurisms by the  application of the ligature,
surgeons now generally resort to the  method of Hunter, in which the liga-
ture is applied  to the sound coats of the vessel at some little  distance above
or on the cardiac side  of the tumor, that of Brasdor, in which it was ligated
on the distal side of the tumor, being seldom employed.  The latter opera-
*Operat. Surg., Philad. edit. p. 140.
| Mott's Velpeau, vol. i. p. 301.
X Eclectic Repertory, vol. iii. p. 229,1813. 
PLATE  XXXV.
INSTRUMENTS EMPLOYED IN THE LIGATION OF ARTERIES: WRY-NECK;
                (EDEMA OF THE  GLOTTIS, AND  HERNIA.

  Fig. 1. Parrish's knife for dissecting about the sheath of arteries.
                 *                                         Rorer's pattern.
  Fig. 2. The  Philadelphia  Aneurism needle, employed by  Parrish,  Hewson,
and Hartshorne.                                            Rorer's pattern.
  Fig. 3. Another form of this needle.  Each needle has two eyes, and the liga-
ture is passed through the one nearest the handle.            Rorer's pattern.
  Fig. 4. Another needle, very much curved.
  Fig. 5. Blunt points, adapted to a common shaft, and intended to  be detached
in order to pass the  ligature around the artery.               Rorer's pattern.
  Fig. 6. Sharp points, intended to be similarly attached and detached.
                                                          Rorer's pattern.
  Figs. 7, 8. Needles of other curves and lengths, adapted to deep arteries in
confined points.                                            Rorer's pattern.
  Fig. 9. A hook to be inserted into the eyes near the points of Figs. 5 and 6,
when unscrewed from the shaft, in order to  draw them around the vessel.
                                                          Rorer's pattern.
  Figs. 10, 10. Knot-tiers, to tighten deep-seated ligatures.      "      "
  Notk—The above set comprises the instruments included in the operating case
of the late Jos. Parrish, now in my possession, and is the same as that often desig-
nated as " Mott's American  needle."  Its value as an instrument renders it pro-
per that the invention should be correctly credited.   The full  account of  the
investigations of Parrish, Hewson,  and Hartshorne may be seen in  the Eclectic
Repertory,  vol. iii. p. 229, 1813.
  Fig. 11. Horner's aneurism needle.                         Kolbe's pattern.
  Fig. 12. Gibson's  aneurism needle.   A watch-spring is passed beneath  the
vessel, and the ligature being attached is thus drawn round it.
                                                           Kolbe's pattern.
  Fig. 13. Tenotome or knife adapted to the section of the sterno-cleido-mastoid
muscle.                                                    Kolbe's pattern.
  Fig. 14. Apparatus to bring the head  into position in cases of wry-neck, es-
pecially after the division of the muscle.                      Kolbe's pattern.
  Fig. 15. Gurdon Buck's knife for  scarifying the glottis in cases of oedema.
                                                              After Buck.
  Fig. 16. Curved scissors for the same object.                      "     "
  Fig. 17. Enterotome of Dupuytren.                     Charriere's pattern.
  Fig. 18. Blandin's Enterotome.                            "         "
  Fig. 19. Cooper's  Hernia bistoury.                        Kolbe's pattern.
  Fig. 20. Small  blunt-pointed Hernia bistoury.                  "       "
  Fig. 21. Straight-pointed Hernia bistoury.                    "
        (314) 
 
 
LIGATION OF THE CAROTID ARTERIES.            315
tion is also applicable only to cases in which no branch  comes off  from the
artery between the ligature and the sac, as is often the case, or in th<>se where
there is no branch communicating with  the  sac itself, which  is also  often
met with.  It is, however, especially applicable to aneurisms  so  seated as
not to leave sufficient space between the tumor and the main  trunk of the
artery for the application of the Hunterian  plan, as  in an  aneurism  at or
near the innominata,  or at the root of the right subclavian; in these cases,
Brasdor's operation is very useful.  In other cases, and they are by far the
most numerous,  the application of the ligature can be most  advantageously
made by the plan proposed by Hunter, that is,  its application  on the sound
artery between the tumor and the heart.   This operation is, therefore, that
which will be hereafter followed in the description given of the treatment of
aneurisms by the ligature, except in the cases above mentioned of  their de-
velopment at the root of the subclavian, or in the  innominata arteries.
                            SECTION  III.

                  LIGATION OF THE  CAROTID ARTERIES.

   The ordinary position of  an aneurismal tumor of the arteries in the neck,
rendering it a difficult matter to  keep up a steady pressure upon the main
trunk, without also exposing the  patient to the dangers of congestion of the
brain from the proximity of the jugular vein to the artery, has prevented
any attempts to cure these aneurisms  by compression from being  generally
resorted  to.   The  ligature  has therefore been employed, whenever direct
surgical interference was demanded.
   The object of  the  applications of  ligatures  to  the  carotid artery being
to cut off the circulation through the main  trunk  of the vessel,  it is unne-
cessary now to mention  the complaints which, in addition to aneurisms, may
call for this operation, further than to say that wounds and erectile or other
tumors constitute the greater  number.   Some  of  the  various instruments
employed for passing the ligature around arteries may be seen by referring
to Plate  XXXV., and are of course applicable to the carotid as well as else-
where.   But, to a dextrous  operator,  the selection of an aneurismal needle
will prove a matter of but little moment, and any of them may therefore  be
taken, the choice being  guided mainly by individual predilection.
   History of the Ligation of the Carotid Artery.—In the various accounts
furnished by  surgical writers of the history of the  ligation  of the  primitive
carotid artery, it is generally stated  that the first application of it, as  an
operation, was made by  Sir Astley Cooper, in November, 1805,* the ligating
of the vessel by Heberstreit and Abernethy having  been consequent  on
wounds  of the throat.   It  is, however, well known in the United States
that,  two years prior  to the operation of  Sir Astley Cooper, this important
vessel had been effectually ligated by Mason  F.  Cogswell, of Hartford, Con-
necticut, who, in  November, 1803, tied the  carotid  during  the  removal of
a scirrhous tumor of the neck.f   In this case, " the ligature separated from
the artery on the 14th, and the patient did well until the 20th, when he sunk
in consequence of a slight hemorrhage from  a small vessel near the angle of
the jaw,  acting on a system  enfeebled by a long-standing disease."  It may
interest the American student to know that  this distinguished  surgeon  gra-
duated at Yale College  in 1780, and served in the United States army during
* Velpeau, Op. Surg , Am. edit. vol. ii. p. 236.
f Williams's Am.  Med. Biog., p. 103. 
316
PRINCIPLES AND  PRACTICE OF  SURGERY.
part of the Revolution, with his brother, James Cogswell;  commencing the
civil practice of his  profession in  Hartford, in 1789.  He died in 1830. in
the 70th year  of his age.*   Since the  first four cases of ligation  of this
vessel—by  Abernethy, for a wound from the  horn of a cow, in 1799; by
Heberstreit, 1800, for the extirpation of a scirrhous tumor ; by Cogswell, of
Connecticut, for a tumor,  in November, 1803,  and by Fleming, in the  same
year, in a case of suicide—it has also  been  tied  successfully  by Travers, in
1804, for an aneurism in  the  orbit of  the eye; by Sir A. Cooper, in 1805,
for aneurism, the woman  dying on  the  19th day;  and since then by very
many surgeons  in all sections of the globe.  In the United States, the liga-
tion of this artery was successfully performed for aneurism, by Wright Post,
of New York,  in  1817 ;  by Mussey, of  New Hampshire, successfully, in
1822 ; and by Sykes, of Delaware, successfully, in 1823.  The ligature has
also been placed upon both carotids by McGrill, of Maryland, in 1825, suc-
cessfully; by Mussey, of  New  Hampshire, at  two  days' interval, in 1829;
by  Mott,  of New York,  unsuccessfully, in 1834,  both vessels being  tied
simultaneously; and by J^ Mason Warren, on both vessels successfully—at
an interval of five weeks—in 1846.  Reference to  the Bibliographical  Index
at the end  of this part will also show that the single ligature has oeen very
frequently practiced  by other American surgeons, whose names are  there
given.  Of these, few have  been so frequently called on to  perform  it as
Mott, of New York, he having, as I am informed, ligated the carotid artery
for the thirty-second time.
             \ 1.—Ligation of the Primitive Carotid Artery.

  Operation of Mott, of New York.f—The  skin,  superficial fascia,  and
platysma-myodes muscle being cautiously divided on the  inner edge of the
sterno-cleido-mastoid muscle, on a level with the larynx, separate the edges
of the wound with the fingers, and push the omo-hyoid muscle downward.
Then, carefully picking up the deep fascia in the forceps, nick it, and, open-
ing it on a director, seek for the descendens noni nerve, where it  lies upon
the sheath of the  vessel, and, pushing it to one side, cautiously open  the
sheath of  the artery, and pass the ligature around it by means of the Phila-
delphia needle—Plate XXXV.  Fig. 2—which Mott prefers to all  others.
Any small vessels  that may bleed during the  incisions  should  be promptly
tied in order to prevent the blood from obscuring the parts around the main
artery.
  Operation of Velpeau.—The  plan  recommended by Velpeau,\ and by
him designated as the ordinary operation, from its being pursued by nearly
every surgeon, when circumstances admit it, is substantially as follows :—
  Operation.—The patient  being placed  upon the back, with the chest
slightly raised, the neck a little stretched, and  the face  inclined to the  side
which is opposite to the tumor, the surgeon  should stand on the side of the
aneurism,  and feel  for the anterior edge of the sterno-m&stoid muscle, or for
the depression which shows its border.   Then  placing  upon it—as directed
by  Lisfranc—the four fingers of his left hand,  all brought to the same level,
let  him make in  this direction an incision about three inches in length, com-
mencing on  a line with the cricoid cartilage and terminating near the sternum,
if he desire to tie the artery in the omo-tracheal  triangle, that is, below the
omo-hyoid muscle.  But if  the  disease permits the  artery to be tied in the
* Williams's Am. Med. Biog., p. 109.
f New York Register of Med. and Pharmacy, vol. i. p. 93.
X Med. Op6ratoire, tome i. p. 240. 
       EFFECTS  RESULTING  FROM LIGATION  OF THE CAROTID.    317

omo-hyoid triangle—above the  muscle—the incision  should be carried a
little higher up and not so low down.   A second cut of the scalpel should
then divide the platysma-myodes muscle and superficial fascia, and lay bare
the fibres of the  sterno-mastoid muscle, when  an assistant may draw the
inner edge of the wound toward the trachea, and the operator push its exter-
nal edge outward by means of the first and  second fingers of his  left hand.
The patient's head being then turned  so  as to relieve the extension  and
inclination of the neck, and relax the parts,  the fibrous layer, which extends
from the sterno-hyoid  and thyroid muscles  to the posterior surface of the
sterno-mastoid—layer of  deep cervical fascia—should  be divided by raising
and nicking in it a little opening, through which a director may be  passed.
   The omo-hyoid muscle, being now seen as a reddish ribbon, may be divi-
ded upon the director, if it should  be in the way of the operator, though
generally this may be avoided by drawing it to one side.   Above and below
the line of the muscle will then be  seen the yellow-looking sheath  of the
vessels,  on  the anterior  surface of which  is the  descendens noni  nerve.
The sheath being picked up in the forceps over the  artery—not  over the
vein—and slightly nicked, the director should be introduced and the  sheath
opened upon it to the extent of an inch.   If  the jugular vein swells up in ex-
piration, so  as  to embarrass the operator, it should be compressed, as advised
by Hodgson, near the  superior angle, of the  wound, when it  will soon empty
itself and shrink.
   When the sheath is  opened, the artery, par vagum, and vein, in the order
mentioned—counting from the trachea—will be exposed, when the aneurismal
needle should be introduced between the vein and artery, so as to keep its
point close to the artery, in order to avoid the par vagum nerve, and being
by a slight rocking motion made to pass round  the vessel, its  point should
be made to  perforate any  areolar tissue that  opposes its exit, by the pressure
of a finger of the left hand.
   After  the ligature is withdrawn, the artery may then be very slightly raised
upon it,  and tied by a  double knot, both ends being left attached in order to
favor the escape of any suppuration that may subsequently supervene. The
wound should next be lightly dressed, and the patient placed in bed in such
a  position as will relax the parts, until the ligature separates, this happening
sometimes in ten days, though often not till  much later.
   Remarks.—To avoid error in the first incisions, it has been advised to cut
directly upon the belly of the sterno-mastoid muscle,  and then to draw the
wound toward the trachea, instead  of cutting upon the inner edge  of the
muscle, as this, in the lower part of the neck, is liable to throw the  operator
upon the tracheal muscles instead of the sterno-cleido-mastoid.  Chassaignac*
has also  advised the surgeon, in case of difficulty, to feel for the tubercle or
projection made by the anterior branch  of the transverse process of the sixth
cervical vertebra—carotid tubercle—which is in front and a little inside the
artery, if, in operating at  the inferior third of the vessel, he finds the parts so
infiltrated as to prevent their being recognized.  I have tried this rule re-
peatedly  upon the subject, and seldom failed to find the artery simply by the
touch.

           \ 2.—Effects resulting from Ligation of the Carotid.

   When  the circulation is cut off from one side  of the head by the applica-
tion of a  ligature to the carotid artery, it is useful to know by what means
nature remedies this obstruction to the natural course of the supply of blood
* Malgaigne, p. 155. 
318
PRINCIPLES  AND  PRACTICE OF SURGERY.
intended for the head, and especially for the brain, as well as its effects upon
this organ. From the free anastomosis found between the vessels supplying the
head and upper part of the neck, it might readily be surmised that their en-
largement would be the chief means employed by  nature to compensate for
the temporary loss occasioned by the operation, and such has been accurately
found to be the result,   From a dissection made by Mott,* of New York, of
a subject whose arteries were injected after a death consequent on a pulmo-
nary affection, three months and nineteen days subsequent to the operation,
it appeared that the carotid, which had beeen tied, (right side,) had been en-
tirely obliterated from  the innominata to the angle of the jaw, leaving a firm
ligamentous cord divided into two parts at the point where the ligature had
been applied.   The vein and nerve were found to be perfectly natural;  the
right subclavian artery enlarged to a size equal to that of the innominata;
left carotid increased to twice its natural size, and its branches augmented
in the same ratio.  The branches arising from  the right subclavian artery
were also enlarged.  The inferior thyroid was dilated  in  the  ramus thyroi-
dea, and the thyroideae ascendens were twice their natural size ; but the trans-
versalis cervicis and transversalis humeri, though arising from the same trunk,
retained their  natural  dimensions.   The  thyroidea ascendens was fouud
mounting up the neck in a  zigzag direction, forming many communications
with the vertebral  artery, and with the mastoid branch of the occipital.  The
left carotid artery was  also equal in size to the innominata, and furnished
the greater part of the  blood to the right side, the superior thyroid, lingual,
pharyngeal, and internal maxillary arteries inosculating with  those  of  the
opposite side, so as to have the appearance of continuous trunks.  The men-
tal, inferior labial, coronary, and facial were also found to anastomose freely
with the same arteries  from the right side.   Although no direct  mention is
made of the condition of the right vertebral artery, there can  be  no doubt
that  it  also participated in the enlargement seen in its parent subclavian,
and thus materially aided the supply of blood to the brain by means of  the
circle of Willis.
  Notwithstanding the numerous facts cited to show that, in most instances,
no serious disturbance of the  function of the  brain ensues upon  ligation of
the carotid,| yet the reverse  has been noted, the failures having been  as-
cribed to some disorder or anomalous arrangement of the arteries chiefly
concerned in equalizing the circulation after the operation.  In a  patient
operated on by Key, who died almost immediately, the left carotid was found
to be nearly obliterated at  its origin from the aorta.   In a case treated by
Langenbeck,  the patient suddenly presented alarming symptoms, and died
thirty-four hours after the operation, in consequence, as is supposed, of some
abnormal condition of the arteria communicans.  Three patients in the hands
of Molina, of Mayo, and of Sisco, suffered more or less  in the sight and hear-
ing of the side operated on.   A patient of Magendie, one of Baroven, one of
Macauley, of Cooper, of Vincent and others, suffered from hemiplegia of the
opposite side to that on which the artery was tied, thus indicating a lesion in
the side of the brain  corresponding with the artery. J  It is better, therefore,
in all cases, to watch the effect upon the patient after tying the first knot be-
fore forming  the second, so that, if requisite,  the  ligature may be removed
from the vessel.
  Though the ligation of one carotid has occasionally created these serious
results, it has been successfully practiced on both arteries, at intervals varying
* Amer. Journ. Med. Sciences, vol. viii. p. 45, 1831.
f Chelius, by South and Norris, vol. ii. p. 607.
X Diet, de Mgdecine, tome vi. article Carotide. 
          LIGATION  OF THE  LINGUAL  AND FACIAL ARTERIES.      319

from two to six weeks, by McGill, Mussey, Mason Warren, Ellis, and Black-
man in the United States, and by several surgeons in Europe, and in these
cases it is to be presumed that the vertebral arteries were in good condition.
In a case in which both carotids  were ligated simultaneously by Mott for
extensive disease of the parotid gland, the patient died in twenty-four hours.*
  Death also ensued  upon ligation of the primitive carotid by A. C.  Post,
of New York,  one month after the operation, in consequence of phlebitis of
the corresponding vein, pus being also found between the meninges of the
brain.

     \ 3.—Statistics of the Operation of Ligating the Carotid Artery.

  The attention of surgeons having  been closely bestowed upon  the results
of the application of a ligature to the carotid artery, we are now able to form
a tolerably correct estimate of the conseqnences of this operation, and, with-
out specifying  the diseases which  required it, the following table will show
the data from which an opinion may be formed :—

                                TABLE.
                                                 CURED
  Of 137 cases reported by Velpeauf...........................  82
  Of 1-8 cases reported by Norris, of Philadelphia, J (in
    reference to  the cure of the disease).......................  69
  Of 21 cases reported by E. Crisp$.............................  10
  Of 7 cases reported by Lente, of New Vork||..............    5
  Of 30 cases collected by myself,  from the operations of
    surgeons in  the United States..............................   22
  Of Scases of the ligature  of both carotids..................   6

          Total of cases, 330.................................... 194   113      22     2

  From  this table it appears that in 330 cases, more than one-half of those
operated on were cured.
  Of the cases reported by Velpeau,  32 were by surgeons in the  United
States, of which 27 were cured.
  Of those  reported by Norris, 38 were performed in  the United States, of
which 28 were  cured ; and Lente and myself report only those performed by
American surgeons, being 45  in all, (including those  of  both  carotids,) of
which  33 were  cured.
  Total of cases in the United States,  115; of which there were cured, 88.
  Total of those in Europe, 216; of which there were cured, 106 ; showing
a decided result in favor of the surgeons of the United States, either in con-
sequence of their subsequent treatment of the case, or, what is more proba-
ble, the better  constitution and habits of the  patients operated  on.
            \ 4.—Ligation of the Lingual and Facial Arteries.

  The ligation of the Lingual or Facial artery, though seldom required, may
occasionally be demanded for the relief of tumors of the tongue or face, and
may be accomplished as hereafter directed.  Although rarely demanded dur-
* Am. Journ. Med. Sciences, vol. xiv. p. 530, 1834.
f Me"d. Ope"ratoire, tome ii. p. 232.
X Am. Journ. Med. Sciences, vol. xiv. N. S. p. 13.
| Lond. Med. Examiner, vol. ii. No. 3.
|| Transact. Amer. Med. Assoc, vol. iv. p. 326.
      UNSUC-  DOUBT-
      CESSFUL.  FUL.
40      13    2

50      9
11
 2

 8
 2 (simultaneous
     ligature.) 
PLATE   XXXVI.
                     OPERATIONS UPON  THE NECK.

  Fig. 1. Ligation of the Carotid, Lingual, and Facial Arteries.  C. Ligation of
the primitive carotid.  1. Lowest point of incision. 2. Fascia profunda.  3. Inter-
nal jugular vein.   4.  Carotid artery raised  on the  aneurismal needle.  5. Par
vagum nerve.  L. Ligation of the Lingual Artery.  1. External incision.  2.
Fascia. 3. Lingual artery.  F. Ligature of Facial Artery.   1. External incision.
2.  Fascia.  3. Facial artery.                     After Bernard and Huette.

  Fig. 2. Surgical Anatomy of  the Subclavian and  Axillary Arteries.  1. Sub-
clavian artery; as it  passes from beneath the clavicle,  it becomes axillary.  2.
Axillary vein.  3 Brachial plexus of nerves.  4. Supra-scapular artery passing
across the neck.   5. Omo-hyoid  muscle.  6. Phrenic nerve.  7. External jugular
vein.   8. Clavicular portion of sterno-cleido-mastoid.  9. Its sternal origin.  10.
Clavicle  sawed across.  11. Deltoid muscle.  12. Cephalic  vein.  13. Pectoralis
minor muscle. 14. Section of pectoralis major muscle.
                                                After Bernard and Huette.

  Fig. 3. Origin of the Carotid and Subclavian Arteries and Branches of  the
Subclavian.   1,1. Aorta.  2. Innominata.  3. Primitive  carotids.  4. Right sub-
clavian.  5. Left subclavian.  6. Scalenus  anticus muscle.   7, 7. Vertebral arte-
ries.   8, 8.  Thyroid axis.  9, 9. Posterior scapular  arteries.  10,  10.  Internal
mammary.                                      After Bernard and Huette.

  Fig. 4. Ligation of the Subclavian and Axillary Arteries. A. Ligation of the
subclavian.   1. Incision  in  skin.  2. Deep fascia.   3.  Omo-hyoid  muscle.   4.
Brachial plexus.  5. Subclavian artery raised on the needle.  6. Scalenus anti-
cus muscle.   7. Subclavian vein. B. Ligation of the axillary below the  Clavicle.
1.  Incision in skin.  2. Deep  fascia. 3. Fibres of pectoralis  major cut across.  4.
Axillary artery raised on  the needle. 5. Axillary vein.
                                                After Bernard and Huette.

  Fig. 5. Relative Position  of  the Subclavian Vessels. 1. Subclavian artery.
2.  Subclavian vein.  3. First rib.  4. Scalenus anticus muscle.
                                                After Bernard and Huette.

  Fig. 6. A view of the operation  of CEsophagotomy. 1, 1. Incision in the skin.
2. Deep fascia.  3. Blunt hook drawing the  trachea inward. 4. The oesophagus. 5.
Fingers of the surgeon drawing the blood-vessels outward,  so as to protect them
during the incision in the oesophagus.  6.  Bistoury incising the oesophagus.  7.
Sterno-cleido-mastoid muscle drawn aside.  8. Internal jugular vein.  9. Primi-
tive carotid artery.                               After Bernard and Huette.
        (320) 
Plate 36.
Fig. 6.
 
 
         LIGATION  OF THE LINGUAL AND  FACIAL  ARTERIES.      321

ing life, the ligation of these arteries upon the subject, and especially the lin-
gual, will be found to be a good operative exercise, and worthy of repetition
by the  student.

                  I.—Ligation of the Lingual Artery.

  Anatomical Relations.—The Lingual artery, after arising from the ex-
ternal  carotid, will be found in the supra-hyoid region of the neck.   In the
early part of its course, it is concealed by the digastric and stylo-hyoid mus-
cles; after which it penetrates the hyo-glossus muscle, just above the cornu
of the  os hyoides—which  is the first point of reference—or between it and the
middle constrictor of the pharynx.  It then ascends between the hyo-glossus
and the genio-hyo-glossus muscles, and, running forward, lies between the
latter muscle and the sublingual gland, which is the second point of reference.
It may be ligated most readily at its nearest point to  the os hyoides, Plate
XXXVI.  Fig.  1.
   Operation of Malgaigne.*—Feel for the greater cornu of the os hyoides,
and make an incision, one inch and a  half long, and parallel to the greater
cornu,  through the skin,  fascia  superficialis, and  platysma-myodes muscle,
taking special care not to divide the facial vein,  which runs obliquely  across
the incision.   After  exposing the submaxillary gland, which is readily re-
cognized, push it upward, and the bright tendon of the digastric muscle will
be seen showing through the cellular tissue, half a line above which will be
found the hypo-glossal nerve, which is to be drawn aside.   Then, at one line
below it, raise the hyo-glossus muscle carefully, and, dividing it transversely,
the artery will be found  directly beneath, unaccompanied by any vein or
nerve.   The first incision  must not be extended too much toward the sterno-
mastoid muscle, lest  it involve the carotid region.
                   II —Ligation of the Facial Artery.

  Anatomical Relations.—-The Facial artery arises from the external caro-
tid, a few lines above the lingual, and goes forward within the angle of the jaw
and  above the submaxillary gland, with which it  is closely connected, until
it mounts over the base of the inferior maxilla just in advance of the anterior
edge of the masseter muscle.  When compression of the artery upon  the jaw
will not arrest the circulation on the side of the face, or when tumors about
the submaxillary gland demand it, the ligation  of this artery may be accom-
plished as follows, Plate XXXVI.  Fig.  1 :—
  Operation.—Make an incision through the skin and fascia, an  inch and a
quarter long, obliquely across the jaw-bone, from the masseter muscle toward
the angle of the mouth.  Then, lacerating the connective tissue with the di-
rector, and pushing the accompanying veins to each side, apply the ligature
carefully around the artery, so as not to include any nervous filaments.
* Op.  Surgery, Philad. edit. p. 155.
VOL. II.—21 
CHAPTER  IX.
   LIGATION  OF  THE  INNOMINATA  AND SUBCLAVIAN ARTERIES.

  As a remedy for the relief of aneurismal tumors of the carotid, or of the
subclavian  artery close to the clavicle, the ligation of the innominata or of
the subclavian within the scaleni muscles has been  practiced.   Before show-
ing the plans that have been resorted to for the accomplishment of this object,
a brief reference must be made to the relative position of the parts concerned.
                             SECTION I.

  SURGICAL  ANATOMY OF  THE INNOMINATA  AND SUBCLAVIAN ARTERIES.

  The Aorta, in forming the arch which permits it to pass from the heart
downward into the thorax, rises to within eight or twelve lines of the supe-
rior edge of the sternum, and at this point gives off the Innominata and the
Left Carotid and Left Subclavian Arteries.
            \ 1.—Anatomical Relations of the Innominata.

  The trunk of the Innominata artery, which is from an inch to an inch and
a half long, or rarely two inches, arises from the  arch  of the aorta as just
stated, aud extends to near the level  of the sterno-clavicular articulation,
where  it gives off the right subclavian and  right carotid arteries.  In this
short course  it passes obliquely from  below upward, from within outward,
and from before backward ;  is very nearly in contact on its outer side with
the top of the pleura; rests against the front and right side of the trachea;
is crossed on its anterior face by the left transverse vein, and lower down by
the vena cava descendens, which is parallel with it, but more and more distant
as it approaches the heart.*  It is covered by the skin, superficial and deep
cervical fascia?, by areolar tissue, by the origins of the sterno-hyoid and thy-
roid  muscles, and  by  a  portion of the sterno-clavicular  articulation, Plate
XXXVII. Fig. 3.
          § 2.—Anatomical Relations of the Subclavian  Artery.

  The Subclavian artery of the  right side  arises from the innominata, and
that of the left from the  arch of the  aorta.  Each crosses the first  rib of
its respective  side in the interval between the scalenus anticus and medius
muscles, and,  passing between the subclavius muscle and the  rib, escapes
from under the clavicle, and is thence known as the Axillary artery.   The
right subclavian is much shorter  and more superficial than the left from its
origin to the  scaleni  muscles.  Near  these muscles, both arteries are covered
                 * Diet, de M6d., tome xxviii.
(322) 
LIGATION  OF THE INNOMINATA ARTERY.            328
 in front  by the sternal end of the clavicle; by the sterno-hyoid and thyroid
 muscles, and by the subclavian vein of the corresponding side.  Behind them
 is the longus colli muscle;  below them, the pleura, the  left  artery being in
 contact with it for its whole length in the thorax, and on their internal side
 is the primitive carotid artery.   Near the scalenus anticus, the right subcla-
 vian artery is  crossed  by the par  vagum nerve, while  the phrenic  nerve is
 found in front of it, but on the internal edge of the scalenus muscle.
   The Left Subclavian artery runs  nearly vertically from its origin to the
 interval  in  the scaleni muscles; is  nearly parallel  to  but  behind  the  left
 primitive carotid ;  has  the phrenic  nerve in the same relative position as the
 artery on the right side, though the left par vagum goes parallel with and in
 front of the artery for some distance along its root.   At the  inner margin of
 the scaleni muscles, on  both sides, is found the thyroid axis or cluster of five
 branches.   The sympathetic nerve  is generally behind the root of the artery
 on the  right side, while  on the left, the  thoracic duct is very near its pos-
 terior face, and usually crosses it above before emptying into the left subcla-
 vian vein.                                                         *
   Having become  horizontal, the subclavian  arteries present the same rela-
 tions on both sides, and lie directly on  the first rib, the insertion of the scalenus
 anticus muscle  separating them from the subclavian vein.  All the nerves of
 the brachial plexus form  a net-work around the arteries,  resembling  the
 plaiting of a whip-cord.
   Outside the  scaleni  muscles,  the subclavian artery corresponds  to  the
 supra-clavicular fossa, and rests upon the first intercostal space.  The sub-
clavian vein, which covers the artery while descending toward the clavicle,
receives at this point the subscapular vein, external jugular, and sometimes
the acromial veins.  The brachial  plexus accompanies the artery thus far,
but soon  afterward passes behind it.  The artery is, therefore, generally
found in a triangular space formed  by the omo-hyoid muscle on the outside,
 the scalenus anticus on  the inside, and the clavicle below.*
                             SECTION II.

                 LIGATION OF THE INNOMINATA ARTERY.

   The difficulties attendant on  the application of a ligature to the Arteria
Innominata may be readily understood when reference is had to its anatomi-
cal relations, as well as to the changes likely to be created in the surround-
ing parts by the formation of such an aneurism as would lead to its execution.
This operation has been performed ten times.f and in every instance resulted
in death: to wit, first by Mott, of New York; secoud, by Grsefe,  of Berlin;
third, by Bland; fourth, by Hall, of Baltimore; fifth, by Kuhl, of Leipsic;
sixth, by Lizars, of England; seventh,  by Arendt, of Russia; eighth  and
ninth, by Bujalski,  of St.  Petersburg; and tenth, by Hutin, for a wound.
   In order to obviate the numerous difficulties attendant on this operation,
various plans of proceeding have been recommended;  but this account will
be limited to the method  of Mott,  as  it  is generally admitted to expose the
parts as freely as is safe, and is also  sanctioned by the experience of Mal-
gaigne and others,  who regard it as the  best  that can be employed, if the
operation should be again resorted to.
* Horner's Anatomy, vol. ii. p. 215.
f Diet, de M4d., tome xxviii. p. 448. 
 324           PRINCIPLES  AND PRACTICE OF  SURGERY.

   The appearance of the tumor, and the incisions required in the operation,
 ore shown in Plate XXXVII.  Fig. 2, for a special drawing of which I am
 indebted to the politeness of  Dr. Mott, it being believed by him to do justice
 to the appearance of the parts.
   Operation of Mott,  of  New York, May  11, 1818.—The patient  being
 placed in a recumbent position upon a table of the ordinary height, a little
 inclining to the left side, so that the light  might fall obliquely on  the upper
 part of the thorax and neck,  and the surgeon seated on a bench  of conve-
 nient height, an incision was commenced upon the tumor just above the cla-
 vicle, and carried close to this bone and the upper end of the sternum, so as
 to terminate immediately over the trachea, the whole cut being about three
 inches long.  Another  incision, about the same length, being then  made
 from  the  termination of this along the inner edge of the  sterno-mastoid
 muscle, the integuments were  dissected back  from  the platysma-myodes
 musele, beginning at the lower angle of the incision, when the flap was
 turned over upon the tumor and side of the neck.
   After cutting through the platysma-myodes, the sternal origin of the sterno-
 mastoid muscle was cautiously divided  in the direction of the first incision,
 and also reflected from over the tumor—Plate XXXVII. Figs. 2 and 3—
 when the sterno-hyoid muscle was divided,  and then the sterno-thyroid, both
 being turned up  on the opposite side of the  wound over the trachea, so as
 to expose the sheath of the  carotid artery.  This sheath  being  now cau-
 tiously opened a little above the sternum, the  nerve and vein were drawn to
 the outside, the artery drawn toward the trachea, and the subclavian laid
 bare about a half  inch from its origin, the handle of the scalpel being mostly
 employed in order to avoid injuring these parts.
   While separating  the connective tissue from the artery with the  smooth
 handle of the scalpel, a branch of an artery was lacerated, which yielded for
 a few minutes a smart hemorrhage.   It was about half an inch distant from
 the innominata, and about the size of a crowquill; but the bleeding ceased
 upon a little pressure.
  The bifurcation of the innominata being now in view, the dissection was
 mainly done with  Parrish's knife—Plate XXXV.  Fig.  1—care being taken
 to keep it directly over and along the upper  surface of the  artery.   After
 fairly denuding the vessel on its upper surface, the connective tissue was
 very cautiously separated from the sides of it by the handle of the scalpel,i
 so as to avoid injuring the pleura, and a round silk ligature being passed by
 means  of the Philadelphia needle—Plate  XXXV. Fig. 2—the artery was
tied  about half an  inch below  its bifurcation, the recurrent and phrenic
nerves being undisturbed.
  In introducing  one of the smallest blunt  needles—Plate XXXV. Fig. 5
—around  the  artery, the instrument was  passed from without inward, so
that the areolar substance and the pleura could be pressed down with a part
of the  instrument, while the  point was very carefully insinuated under the
artery  from below upward, so  as to appear on  the  opposite side of the
artery.  The hook—Plate XXXV. Fig. 9—being then introduced into the
eye of the needle, the shank was unscrewed and the needle drawn through
with the utmost facility, leaving the ligature in  situ, after which the knot
was gradually tightened.
  The integuments being then  closed  tightly, the patient was put  to bed,
with a pulse beating sixty-nine, ten minutes after the operation.
  This patient subsequently did so well that, on the fourteenth day, the liga-
ture separated.  On  the twentieth day he  walked  several times across the
yard; but on the twenty-third day was attacked with  hemorrhage from the 
LIGATION  OF THE SUBCLAVIAN  ARTERY.
325
 wound,  which returned at intervals, till on the twenty-sixth day after the
 operation, he died.*
   Remarks.—The want of success attending the performance of this opera-
 tion in so many able hands—it having resulted fatally in every instance—has
 generally proscribed the operation from the list of those that are justifiable
 in cases of aneurisjn.
   The dissection of Mott's patient showed that a firm clot had formed in the
 artery below the ligature, and that ulceration of the opposite side of the artery
 was the source of the hemorrhage.  Graefe's operation in 1822 apparently
 did well for sixty-eight days, but then hemorrhage ensued upon  the patient's
 exerting himself.   Blandin, in 1837, lost his patient by hemorrhage on the
 eighteenth day.   TIall lost his on  the sixth day, also by hemorrhage;  and
 the patient of Lizars died, in ten days, of hemorrhage, the chest containing
 twenty ounces of blood, the subclavian artery alone being diseased.  Judg-
 ing from these results, Velpeau has therefore expressed the decided opinion
 "that the operation ought not to be attempted, at least for  the cure of
 aneurism, "f
   The little success that has followed this operation renders  a  reference to
 the operations of Brasdor  and  Wardrop, or the application of a ligature on
 the distal side of the tumor, essential to a knowledge  of the best method of
 treating aneurisms of this  vessel, and it should be deliberately considered be-
 fore repeating the ligation  of the innominata. According to Wardrop's views,
 the cure of an aneurism of the innominata by the application of a ligature to
 either the subclavian or the common carotid artery, corresponds  with the
 course taken by nature in  effecting the cure, as is shown in several prepara-
 tions now in the  Museum of the Royal College of Surgeons.   In addition to
 which Wardrop  has collected eight cases of aneurism of  this  vessel  thus
 operated on, in five  of which there was consolidation and diminution of the
 tumor, and though in three others the operation failed, one lived  a month, the
 second died in a few hours,  and  the third was benefited for the time, only dying
 on the increase of the tumor.   This success, as compared with that conse-
 quent  on the ligation of the innominata itself, is certainly  very great, and his
 method of treatment should, therefore, receive  that consideration which so
 serious an operation must certainly obtain  in the mind of every judicious op-
 erator.  In selecting one of two vessels—either the subclavian  or the caro-
 tid—Wardrop prefers the  carotid;  as this vessel was  found in his  prepara-
 tion to be the one most  frequently obstructed by the natural formation  of a
 clot.

                            SECTION III.

                 LIGATION OF THE SUBCLAVIAN ARTERY.

   The ligation of the Subclavian artery  is an operation which dates back
 only to the commencement of the present century,  having been first success-
 fully performed by Keate, of England, in March, 1800; by Ramsden  unsuc-
 cessfully  in 1809;  after which it was successfully ligated in 1815 by Cham-
 berlaine,  and then by Wright Post, of New York, in September,  1817,J  this
being the first  time the operation was performed in the United States.  Since
this period, it  has been frequently attempted both in  Europe and the United
 States, being  performed  by Dudley, of Lexington, in  1826;  by Gibson, of
* Mott's Velpeau; also Eclect. Repertory, vol. ix.
f Diet, de M6d., tome xxviii. p. 474.
X Norris, Am. Journ. Med. Sciences, vol. x. N. S. p. 14. 
PLATE XXXVII.
   OPERATIONS  PRACTICED  ON  THE  LOWER PORTION OF THE NECK.

   Fig. 1. A view of the operation for the Strangulation of a large (roitre which
 was inducing suffocation, as performed  by Liston.  By a crucial incision the
 skin has been dissected from the tumor, which was then caused to slough off by
 straugulating it by means of ligatures carried through and around its base by
 needles.  This tumor sloughed  off in eight days.  1.  Sterno-hyoid and thyroid
 muscles divided and turned down.  2. Upper portion of the same. 3. Os hyoides.
 4,4. Enlarged veins on the surface of the tumor.                After Liston.
   Fig. 2. A view of Mott's operation for Ligation of the Innominata.   1. Aneu-
 rismal tumor  of the subclavian.  2. Skin and platysma-myodes turned back.
 3. Section  of sternal origin of sterno-cleido-mastoid muscle.   4. Arteria in-
 nominata.                                                      After Mott.
   Fig. 3. View of the relative position of the parts concerned in this  operation.
 1. Vertical incision.   2. Corresponding  edge  of skin.   3. Flap everted.  4.
 Steruo-mastoid muscle.   5.  Arteria  innominata.  6.  Internal jugular vein.  7.
 Origin of subclavian  artery. 8.  Vertebral artery drawn forward.   9. Inferior
 thyroid  artery.  10. Internal  mammary.   11.  Transversalis  cervicis  artery.
                                                After Bourgery and Jacob.
   Fig. 4. A view of the position and arrangement  of the Blood-vessels and
 Nerves of the Neck, as shown by turning off the Clavicle.   1. Trapezius muscle.
 2. Sterno-cleido-mastoid. 3. Sterno-thyroid muscle and thyroid gland.  4. Upper
 portion of  sternum.   5. Omo-hyoid muscle.  6.  One of the cervical ganglia of
 the sympathetic nerve.  7.  First  cervical plexus.  8. Right primitive carotid.
 9. Subclavian vein.  10. Ligature on the subclavian artery. 11. Hook  holding
 down the internal jugular vein.  12. Hook holding the par vagum nerve.  13.
 Branches of the spinal  accessory nerve.  14. Section of the second rib.  15.
 Phrenic  nerve.  16. Aneurismal tumor of the subclavian arterv.
                                                             After Auvert.
   Fig. 5. Surgical anatomy  of the vessels just above the  clavicle, as connected
with the  ligation of the Subclavian Artery.  1. Incision in the skin.  2. Scalenus
anticus muscle.  3. Omo-hyoid.   4.  Subclavian vein.   5. External jugular vein.
6. Transverse cervical.  7. Superficial artery.  8. Subclavian artery outside the
scalenus  muscle.  9.  Supra-clavicular nerves. 10. Roots of the brachial plexus.
11. Phrenic nerve.                                            After Auvert.
  Fig. G. Excision of the clavicle as performed by Warren.  The skin has been
turned back by a crucial incision, and the bone, being  sawed across near its
humeral end, is represented as raised by a ligature so as to favor its disarticula-
tion-                                                         After nature.
       (326) 
 
 
LIGATION  OF THE SUBCLAVIAN ARTERY.           327
Philadelphia, in 1828; by Wells,  of Carolina, in  1828; by Mott, of New
York, in 1831; by the same  surgeon  within  the scaleni, in 1833;  also by
him upon the left subclavian, outside  the  scaleni, in 1834 ; and by Kearny
Rodgers, of New  York, within the scaleni  muscles, in  1845, this being  the
first operation ever performed at this point.   By a reference to the Biblio-
graphical Inde  at the end of this part it will also be seen that many other
American surgeons have succeeded in ligating the artery at the usual place.
  The ligation of the subclavian artery may be performed in any portion of
its course, though  it is generally admitted to be accompanied by many diffi-
culties, and to require perfect anatomical as well as surgical skill, no matter
what portion of it may be chosen.
  Three different points have been selected for the application of this liga-
ture, the choice being usually directed by the necessities of the case.   These
points are usually designated as  the operation upon the first rib, that be-
tween  and that within  the  scaleni muscles, the difficulties  being greater
in most of them when it is necessary to  operate upon the artery of the  left
side.   As the clearest account of  the operative proceedings, I  have selected
those furnished by Malgaigne and Velpeau, adding to them a few of the steps
taken by the American  surgeons  whose cases are referred to in the Biblio-
graphical Index at the end of this part.
  To expose the artery on the first rib, it is  necessary to divide "the skin,
subcutaneous areolar tissue, superficial fascia, and platysma-myodes muscle ;
the fascia profunda colli, and a loose connective tissue full of venous branches
and lymphatic ganglia, in which run two important arteries, the transversalis
cervicis being placed some lines above the subclavian and the superior scapu-
lar, running along the posterior border of the clavicle.  Sometimes the sterno-
mastoid muscle, from its wide origin  along the clavicle,  requires division,
while the external jugular vein, from running more outward than usual, re-
quires to be avoided."*
  In the latter stages of the operation, the following test of the position of
the artery,  which I have never known to fail, and which was suggested orig-
inally by Parrish,  of Philadelphia,")" will prove valuable, and that is, to  no-
tice the position of the tubercle or prominence on the first rib into which the
scalenus anticus muscle  is inserted, as the artery is invariably found on its
outer side.
  In the directions usually given by the French surgeons for the ligation of
this artery, much stress is laid by them upon  the importance of recognizing
this prominence of the first rib as a point of reference, and on many occasions
in which I heard it referred to at Clamart, and the Ecole Pratique of Paris, in
1839, I supposed  that the suggestion  was due  either to Lisfranc, Velpeau,
or Malgaigne, especially as the latter also mentioned it in his Manual of  Op-
erative Surgery.   Subsequent reading has, however, induced me to think that
this valuable direction originated in the United States, with Parrish, of Phila-
delphia, though, as  I am unable to find any date in connection with the ac-
counts of the  French surgeons,  I cannot be positive  on the subject.   A
perusal of Parrish's  paperj will, however, show that he published the descrip-
tion  of this important land-mark to the position  of the artery in the year
1813, four years after Ramsden's operation, and this, I think,  is the earliest
notice taken of an infallible rule for finding the artery.
  The high estimate generally entertained of the accuracy of this point of
reference renders it desirable to credit correctly the author of the suggestion,
and in claiming it for Parrish, there is  every reason to think that nothing
* Malgaigne, Philadelphia edit. p. 148.
f Eclectic Repertory, vol. iii. p. 240.  Philadelphia, 1813.     J Ibid. 
328            PRINCIPLES AND  PRACTICE OF  SURGERY.
more than justice is done to the memory of a surgeon whose experience as an
operator is well  known throughout the United States.
          \ 1.—Ligation of the Subclavian Artery on the First Rib.

   Parrish's Rule for Finding the Subclavian Artery.—The depth at which
 the subclavian is placed rendering it very difficult to recognize the position
 of the  vessel  by the sight  alone, the suggestion of Parrish,  Hewson,  and
 Hartshorne, referred to in Parrish's paper, will prove highly serviceable.  It
 is as follows:  After dividing the external tissues, pass the finger down to the
 superior edge of the first rib, and,  sliding it along this  toward the sternum,
 feel  for the insertion of the scalenus anticus muscle.   The tubercle  at  this
 point is very perceptible to the touch, and the artery will be found close upon
 its outer side.
   Ordinary Operation.—The patient lying down with the head secured  anrl
 the shoulder drawn downward and slightly forward so as to depress the clavi-
 cle,  make an  incision immediately  above the bone  parallel  to its posterior
 border, commencing one  inch outside its sternal end, and extending to the
 insertion  of the  trapezius muscle,  and,  after cautiously dividing the skin,
 draw the external jugular vein, if it shows itself, inward, by means  of a blunt
 hook.   Then, cutting across the superficial fascia and platysma-myodes mus-
 cle, cautiously open the fascia profunda colli, and, laying aside the  knife, tear
 the connective tissue with the finger-nail or point of the director. On carrying
 the forefinger into the internal angle of the  wound, feel, as directed by Par-
 rish, for the scalenus tubercle of the first rib, and, reaching it, the artery will
 be felt pulsating  on its external side.   Then, while keeping the finger upon
 this tubercle as a guide, pass the  aneurismal needle  carefully under the ve
 sel from its inner side, and bring it out externally, holding the artery with  the
 finger to prevent its slipping; and, placing a finger between it and the first
 fasciculus of the brachial plexus of nerves, so  as to preserve them from iujury,
 facilitate the passage of the needle by depressing the shoulder and turning
 the patient's head to the opposite side.*
  Remarks.—As this method of operating  exposes  the  surgeon to the risk
 of wounding the external jugular vein, Roux  advises that the incision  should
 be made perpendicularly to  the clavicle, and I have fouud his mode of  opera-
 ting quite easy upon the subject.
  A somewhat similar, but more accurate method of operating,  is as fol-
 lows :—
  Method.—Make  an incision perpendicular to the clavicle by dropping a
 line from  the point where the anterior edge of the  trapezius and posterior
 margin  of the sterno-mastoid muscle meet, (supra clavicular fossa,) so as to
divide this triangular depression into two triangles, and then dissect or lace-
rate the tissues until the artery is distinctly felt.
  Remarks.—This  mode of reaching the subclavian was suggested since,
by Horner, of Philadelphia, and protects the surgeon not only  from the risk
of wounding the  vein, but also from injury of the  transvere vessels, so often
found near the subclavian  artery, should the  transverse incision fall'too near
the sternal end of the bone.
* Malgaigne. 
LIGATION OF  THE  SUECLAVIAN ARTERY.            329
        \ 2.—Ligation of the Artery between the Scaleni Muscles.

  Operation of Dupuytren.—Make at the base of the neck a transverse in-
cision extending from the anterior edge of the trapezius to the inner border,
or to a short distance upon the outer side of the sterno-mastoid muscle, cut-
ting through the different layers as before mentioned.   Having found the in-
sertion of the scalenus anticus, insinuate between its posterior surface and
the front of  the artery a grooved director, and divide the muscle upon it,
when the  retraction of the muscle  will lay bare the artery, and enable the
needle to pass under it from without inward.*
   Remarks.—In this operation, caution has always been given respecting
the position  of the phrenic nerve, which, it will be recollected, lies against
the internal side of the scalenus anticus and a little anterior to it.  But Mal-
gaignef also advises that attention should be given to the internal mammary
artery which runs outside of this nerve, and  is much exposed if the cut is
made too near the  rib.


    \ 3.—Ligation of the  Subclavian Aitery within the Scaleni Muscles.

   This operation, which was first performed by Colles, of Dublin, who lost
his patient on the eighth day, has since  been repeated several times in Eu-
rope and this country, Mott,  of  New York, performing the second  opera-
tion.
   Operation of Mott on the Right Subclavian Artery. |—The patient be-
ing placed upon the table, with the shoulders elevated, the head thrown back-
ward, and the face and body inclined to the left side, an incision was begun
at the lower  part of the outer edge of the sternal origin of the sterno-mastoid
muscle, and carried upward about two inches.   Another, commencing at the
same point, was then made along the  upper surface of the clavicle  for the
same extent.   When the triangular  flap of skin, with  the corresponding por-
tion of the platysma and its investments, was separately dissected and turned
aside, the clavicular portion of the  mastoid muscle was severed immediately
upon its insertion, and reflected upon the neck.  This laying bare the deep-
seated fascia, the latter was raised with the forceps,  and divided a little be-
low the course of the omo-hyoid muscle,  on the outside of the deep jugular
vein.   On  enlarging this opening an inch downward, the adipose and con-
nective tissues were readily pushed aside, and the scalenus anticus muscle ex-
posed to view.   The connective tissue being now separated with the fingers
and handle of the knife, the artery was exposed just within  the thyroid axis,
the branches of which could be plainly seen.   The sheath being then raised
from the  artery with the forceps and cautiously divided, the ligature was
passed under the vessel from below upward by  Parrish's needle, curved spa-
tula? being employed to draw  the  deep jugular vein toward the trachea as
well as to separate  the edges of the wound.  Three small arteries were tied;
no vein required the ligature; but on the eighteenth day the patient  died of
secondary hemorrhage.


  § 4.—Ligation of the Left Subclavian Artery within the Scaleni Muscles.

  Although the right subclavian  artery has been occasionally ligated on the
cardiac side of the  scaleni muscles, J. Kearny Rodgers, of New York, was,
* Velpeau.                   f Malgaigne, Philadelphia edit. p. 150.
J Amer. Journ. Med. Sciences, vol. xii. p. 354, 1833. 
330            PRINCIPLES AND PRACTICE  OF SURGERY.
I believe, the  first surgeon  who succeeded  in tying the Left Subclavian
within these muscles, such an operation being regarded as impracticable prior
to his case.  It was performed under the following circumstances :—
  A German,  forty-two years of age, was admitted September 13, 1845,
into the  New York Hospital, with an aneurismal tumor above the clavicle,
about the size  of a small hen-egg, extending externally  to the outer third of
the bone, and  covered internally by the outer edge of the  sterno-mastoid
muscle.   A' consultation  having left the decision of an operation  to Rod-
gers, this gentleman concluded, after mature reflection, that the operation
was possible, and therefore determined to try it.
  Operation of J. Kearny Rodgers.*—The patient being placed on a low
bed, with his head and shoulders raised, and his face  turned to the right side,
so that the light from the dome could shine directly on  the part to  be oper-
ated on, an  incision three  inches and a half long was  made on the inner
edge of the sterno-mastoid so as to terminate at the sternum, and divide  the
integuments and platysma-myodes.   This was then  met by another incision,
which extended along the sternal extremity of the clavicle, about two and a
half inches, and divided a plexus of varicose veins which were in the integu-
ments covering the clavicle, and communicated with the subclavian  vein.  To
check the free  bleeding which occurred from their cut  extremities, it there-
fore became necessary to tie them.
   The flap of integuments  and platysma-myodes  being now dissected  up,
and the  lower end of the sterno-cleido-mastoid laid  bare,  a director was
passed under  this muscle, and the sternal as well as  half of its clavicular
origin divided  by a bistoury.  This muscle being now turned up, the sterno-
hyoid and omo-hyoid muscles, as well as the deep-seated jugular vein, were
seen covered by the deep cervical fascia.
   On turning  up the sterno-mastoid,-a  portion of  the aneurismal sac was
seen strongly pulsating and overlapping about half the width  of the  scalenus,
so as to form the  outer half of the track, through which  it was necessary that
the operator should pass, showing fearfully one of the dangers of the opera-
tion, but one which Rodgers had anticipated.  The deep fascia being then
divided by the handle of the scalpel and the  fingers, the dissection was con-
tinued in contact  with the outer side of the deep jugular vein to the inner
edge of the scalenus anticus muscle, for the purpose of  reaching this muscle
fully half an inch above the rib, instead of at its insertion, in order  to guard
against  any injury to the  thoracic duct.  The phrenic nerve could now be
distinctly felt running down  on the anterior surface of the scalenus, and was
of course avoided, until,  by pressing the finger downward, the rib was dis-
covered,  when after some little search the position of the artery was recog-
nized.   By  pressing the vessel  against the  rib, all  pulsation in the tumor
ceased, while on removing  the finger the pulsation returned.  In order to
avoid any injury tc the pleura  and thoracic  duct in detaching the  artery,
Parrish's needle was employed after  that of Sir  Philip Crampton  had been
tried, the point of the former being introduced under the artery, and directed
upward so as  to  avoid the  pleura.   The needle being detached  from  the
shaft of the  instrument, the ligature was drawn upward  so as to surround the
artery, and then tightened with  the forefingers at the bottom of the wound,
all pulsation ceasing immediately in the tumor, and also  in the arteries of the
extremity.  Warmth was  subsequently applied to the  limb, and the  usual
treatment pursued.   On the thirteenth day, the patient, on changing his po-
sition from  the right side  to his back, was  attacked  with  hemorrhage, of
which he died  two days subsequently, or fifteen days after the application of

              * Am. Journ. of Med. Sciences, vol. xi. N. S.  p. 541. 
LIGATION OF THE SUBCLAVIAN ARTERY.
331
the ligature.   A post-mortem  examination, after detailing other points, es-
tablished the inaccuracy of one fact, which had been previously urged as an
argument against the operation, to  wit, the chances of hemorrhage from the
want of sufficient adhesions  in  the  artery.   In this case there was  a perfect
coagulum found in the vessels;  the hemorrhage had come from the distal end
of the artery in consequence of  the free communication of the internal carotid
at the base of the brain  with the vertebral, the latter vessel having been given
off from the subclavian just beyond  the point where Rodgers had applied his
ligature.  Decidedly the greatest danger in the operation was thought by
the operator to be the risk of wounding the pleura and the thoracic duct.
   § 5.—Statistics of the Operation of Ligation of the Subclavian Artery.

   Of sixty-nine cases reported by Norris, of Philadelphia,* thirty-six recov-
ered and thirty-three died, or a few more than one-half recovered.  Of fifty-
four cases, in which the  affected side is mentioned, thirty-one were  on  the
right and twenty-three on the left side.
   Of the fifty cases reported by Velpeauf—several of which have been also
counted  by Norris—twenty-three died and twenty-seven were cured.  Of
the twenty-three cases in which the left artery was tied, as reported by Nor-
ris, fifteen were cured and eight died;  but  there is no mention made of  any
of these  having been performed on the left side within the scaleni muscles.
   Of twenty-six cases of aneurism reported by Crisp, J ten were ligated suc-
cessfully, one was cured by pressure, and five died, after the application of the
ligature,  from hemorrhage.
   Of eighteen  cases of the ligation  of the subclavian collected by  myself,
fourteen  were cured and four died.   Of seventeen performed in the United
States, and reported by Norris, eleven were cured aud six died.   Of the
thirty cases, therefore,  in the  United  States, twenty-one were cured and nine
died.
   On summing up these one hundred and fifty-eight cases, eighty-three are
mentioned as cured, out of the whole  number reported in  the tables.  It ap-
pears, therefore, that the successful cases have been four more than one-half
of those operated on, but that the ligation within the scaleni muscles has been
by far the most fatal of all, the deaths ensuing chiefly from hemorrhage or
from inflammation of the pleura or pulmonary organs.
   The anatomical relations of the pleura to these  arteries sufficiently explain
this result.
    \ 6.—Anatomical Phenomena  Consequent on the Ligation of the
                           Subclavian Artery.

  After applying a ligature to a large artery, and thus for a time cutting off
the supply of blood from the extremity which it has previously nourished, it
becomes a  matter of some interest to learn in what manner nature can adapt
herself to  the change, and remedy the evil that it might be supposed would
ensue.   The following account, furnished in connection with  the dissection
of two of the operations practiced on the  subclavian,  will therefore, it  is
thought, prove instructive to the student by exhibiting the anatomical changes
* Am. Journ. Med. Sciences, vol. x. N. S. p. 18.
f Operat. Surgery, by Mott, vol. ii. p. 219.
J London Med. Examiner, No. 8, vol. ii. p. 209. 
332
PRINCIPLES  AND  PRACTICE OF SURGERY.
consequent on the obstruction caused by the ligation of the main channel of
this artery.
  In the account of the  autopsy—furnished by Ainsworth,* of Boston—of
a patient on whom  a ligature had been applied (four years previously) to the
left subclavian artery at the external border of the scalenus anticus muscle,
we  find "that the injecting matter which was thrown into  the  aorta of  the
subject passed readily into all the vessels of the left arm and hand ; that  the
arteries and veins of the neck, as well as the brachial plexus of nerves for the
space of three inches above the clavicle, were imbedded in a dense fibrocar-
tilaginous substance, and that the subclavian artery was completely oblite-
rated and reduced to a mere fibrous-looking cord at the point where the liga-
ture had been applied.  Three-fourths of an inch  from this spot the vessel,
however, nearly regained its usual size, and continued throughout its whole
course of the normal dimensions  and distribution, the collateral circulation
being maintained by the intercostal branches of the internal mammary through
the thoracic branches of the thoracico-acromialis, and by a large  inoscula-
tion between the supra-scapular  and a terminal branch of  the  sub-scapular
arteries.  A communication was  also traced between some small  muscular
branches of the transverse cervical and the thoracico-acromialis.   An irregu-
larity which is  not  uncommon  was also  noted in  the transversalis cervicis
artery, which was given off from the thyroid axis in a common trunk with the
posterior scapular, and formed  a large trunk, which, running parallel to  the
clavicle, so as to correspond at  first with the course of the subclavian, might
readily have been wounded or ligated in mistake for  the subclavian itself."
From  the information furnished by the  dissection of another anomalous
distribution  in  these vessels,  Ainsworth suggests that it may be well  here-
after to secure both  extremities of the  main artery so as to avoid the hem-
orrhage  that has  sometimes ensued in  the operation from the  collateral
circulation.
  In the report of the dissection of a patient operated on by J.  Mason War-
renf for the ligation of the left subclavian, one year previous, it was shown
that the subclavian was of its original size  as far as the  scalenus anticus,
where  it suddenly terminated,  while  the vessels forming  the  thyroid axis
were twice their natural  size,  the  internal mammary being enlarged and
given off from the thyroid.   It was through this vessel, by meaus of the inos-
culation of the intercostal arteries  with  the thoracic, and  of the  posterior
scapular with the sub-scapular,  that the  collateral circulation had been  ac-
complished.
* \m. Journ. Med. Sci., vol. xix. N. S. p. 84.
f Ibid., vol. xxi. N. S. p. 53. 
CHAPTER  X.
OPERATIONS  UPON  THE  CHEST.
                             SECTION I.

                   SURGICAL  ANATOMY OF THE CHEST.

   The extent of the Chest as a surgical region is usually regarded by anato-
mists as limited, above, by a circular boundary formed by the upper extremity
of the sternum, the first rib and first dorsal vertebra,  or, in other words, by
the bony constituents of the thorax; and  below, by the curved line formed
in the arrangement of the cartilages of the ribs, the chest being at this point
completely separated from the abdomen by the diaphragm.
   There is, however, a  portion of the body, of great  importance to the sur-
geon, which is  not included in these limits, and which  is yet not included in
those  assigned to the  upper  extremities,  to wit,  the structures  about the
clavicle ;  and it will, therefore, answer better for the purposes of description,
at present, to define the chest as that  portion  of  the body intermediate to
the neck and  abdomen, the upper portion being intimately connected with
the upper extremities, but the lower separated entirely from the abdomen by
the diaphragm.  As most of the constituents of this section of the body are
unimportant, consisting merely of skin and muscle, they do  not present any
points requiring either a precise regional description or a minute account of
their connections with subjacent parts.  The reader  may therefore be referred,
for their description, to  the anatomical account of this part which every one
gains in the course of a medical education. As its surgical details are also
limited, such a brief account as may readily be presented in connection with
the operations performed upon it  is all that is at present demanded.


   \ 1.—Surgical Anatomy of the Portion of the Chest  about the Clavicle.

   The Clavicle, being fixed by the articulations at its sternal and acromial
extremities, has for its  function the preservation of the pectoral  space, or
the steadying  of the shoulder, and the  prevention of its approach to the
sternum.  At each of its extremities is found a perfect  joint amply supported
by ligaments, in addition  to which may be noted two other ligaments, that
are upon its under surface, and teud to hold the bone in its proper  relations
to the ribs, to wit, the costo-clavicular or rhomboid ligament, which, arising
from the cartilage of the first rib, is inserted into the roughness on the under
surface of the clavicle near its sternal extremity, and  the coraco-clavicnlar
or conoid ligament, which, arising from the coracoid process of the scapula,
is  inserted into the tubercle near- the inferior and external surface of the
bone.  The ligamentum bicorne, or bifid  ligament, is so closely connected
with  the subclavius muscle,  that it may be regarded chiefly  as its fascia,
and a further account of it omitted.
                                                          (333) 
334
PRINCIPLES  AND PRACTICE  OF  SURGERY.
  The Muscles connected with the clavicle above are a portion of the sterno-
cleido-mastoid  at its sternal extremity, and a part of the trapezius at its
humeral end, while the pectoralis major and part of the deltoid are in front,
and the subclavius muscle below.  The latter muscle, arising from the carti-
lage of the first rib, is inserted into the inferior face of the  clavicle, from
near the sternum to the conoid  ligament, and therefore draws the clavicle
toward the rib.
  The Subclavian artery and vein are both placed between this muscle and
the first rib, the vein being close to the  artery, but in front of it.
  The Brachial Plexus of Nerves extends from the scaleni muscles to the
axilla, passing along with the artery between  the  subclavius muscle and the
rib.   It has the axillary vein in front of it, but the different nerves surround
the artery, as if plaited.
  The fascia superficialis of the chest and neck, together with the skin, com-
plete the coverings of this part.


                             SECTION  II.

                     RESECTIONS OF THE CLAVICLE.

  The Resections practiced upon the clavicle are such as are demanded for
the relief of caries,  necrosis, or osseous tumors, and may require  either a
partial or perfect division  or resection of the bone.  In describing the oper-
ation of resection of this bone, as well as in similar operations  on other
bones of the extremities, the reader should  bear  in mind that by  the term
"resection" is generally  understood the removal of  either  a part or the
entire structure of the bone, in such a manner as will yet permit the patient
to have more  or less use  of the  extremity to which it is  attached.  Any
operation, therefore, which destroys this use, or  removes the limb, is to be
regarded as an amputation and not as a resection.
  That this definition of  the operation  of resection is correct, is apparent
from the views expressed  by the  following excellent authorities.    Thus, J.
Cloquet and A. Berard,*  in speaking of the peculiar characters of a resec-
tion, state that " the preservation  of the soft parts constitutes the special
character of this operation, which should be practiced  so as to  avoid all
lesion of the arterial or venous trunks, and injure the muscles and tendons as
little as possible."  Again, they say : "  It is for this reason that resections of
the superior extremity, by preserving to a certain  extent the motions of the
limb, are superior to amputations."f
  Malgaigne, who is also good authority, remarks, when speaking of resec-
tions, that " we comprise under this title the removal of the articular extrem-
ities of bones, the resection of the long bones in their continuity, and the
extirpation of certain bones entire, without amputation of the soft  parts."^
All operations, therefore, which have not been performed with these restric-
tions, should be strictly excluded from  this class.   The rules adapted to the
performance of all resections will be given hereafter in the operations on the
extremities.

                 \ 1.—Resection  of the Entire Clavicle.

  The removal of the clavicle, either entire or in  part, is an operation that
has been  occasionally found  necessary or expedient, in consequence of the
* Dictionnaire de Med., tome xxvii. p. 402.            ■)• Ibid., p. 411.
X Op. Surg., Phil. edit. p. 188. 
RESECTION OF THE ENTIRE CLAVICLE.
335
development of osseous or enchondromatous growths upon it, and their en-
croachment upon adjacent parts, or for the relief of necrosis; the cases of caries
demanding rather the  healing of  the ulcer than the resection of the bone.
Although the function of the clavicle appears to be essential to the proper
action of the upper extremity, its removal  has been accomplished without
materially impairing the  utility of the limb.
  When in this resection it is found possible to retain a portion of the peri-
osteum, it should always be left,  as in the operation performed by the cele-
brated French surgeon Moreau for necrosis, where, although the entire clavicle
was removed, yet at the autopsy of the patient, made several months subse-
quently, the bone was found to have been entirely regenerated, so as to
preserve its relations  with  both the sternum and scapula.   There  is, how-
ever,  reason to think, from the account furnished of this operation, that  it
was rather the removal of a sequestrum resembling the former clavicle, than
a resection, and that the old bone, like  the sequestra of other bones in a
certain  stage of necrosis, had been incased  by  the new osseous deposit con-
sequent on the efforts of nature to remedy  the disease, and  hence  the for-
mation  of the  new clavicle.
  The only cases of entire resection of the bone, not consequent on  ampu-
tation, that I have  been able to  find recorded as performed in the United
States,  are one by Charles McCreary, of Kentucky,* who, in 1813, removed
the entire clavicle for a scrofulous affection of the bone, without impairing
the functions of the limb, the patient living for thirty-five years subsequently
without any return of the  disease;  one by Mott, of New York, in 1819;
one by Wedderburn, of New Orleans, in 1832; and one by Warren, of Boston,
in 1833.
  In  Europe,  Travers removed a large portion of the clavicle, leaving only
the sternal end, in a boy who twelve months subsequently had the free use
of his arm ; and Chaumet, of Bordeaux, also removed four-fifths of the bone,
on account of a tumor which originated in  it, while Meyer and Roux oper-
ated on it in consequence of caries.  The most perfect and difficult resections of
this bone in its continuity, unconnected with amputations, are therefore those
just referred to as performed by the four American surgeons above named.
  Extirpation of the Entire Clavicle, by Mott, of New York.—A  young
man,  nineteen years of age, had a conical tumor  to form on the left clavicle,
without his being able to assign for it any cause.   At the time of the oper-
ation it was about four inches in diameter at its base,  of an incompressible
hardness, firmly attached to the anterior portion of the bone, and with its
apex  covered with  luxuriant fungous  granulations, the  consequence  of
former means of treatment, from which profuse hemorrhage took place from
time to  time.
  Operation of Mott. — An  incision being commenced  over  the sterno-
clavicular articulation, was carried in a semilunar direction in  the sound
integuments, to near the junction of the clavicle with the acromion process
of the scapula, exposing the fibres  of the pectoralis major muscle.   These
fibres were then carefully divided, so as to  avoid injuring the cephalic vein,
a small  portion of the deltoid muscle beiu.g detached from  the clavicle, and
the vein drawn outward toward the shoulder.  It being now found impossi-
ble, from the size of the tumor and its proximity to the coracoid  process,  to
get under the clavicle  in this direction, another incision was made from the
outer edge of  the external jugular vein  over the tumor, to the top of the
shoulder, so as to divide the skin, platysma-myodes, and  a portion  of the
trapezius, by which means  a sound part of the bone was laid bare near the
* Gross, History of Kentucky Surgery, p. 180. 
336            PRINCIPLES  AND  PRACTICE OF  SURGERY.
acromion  process.   A  director,  very much curved, was  then cautiously
passed under the bone from above, great care being taken  to keep the  end
of the instrument in contact with  the under  surface, and an eyed  probe
being conveyed along the director, a chain-saw  was passed, and, after being
carefully moved a little to see that nothing intervened, made to cut the bone
entirely through at this  point.
  The dissection being now continued along the under surface of the  tumor
below the pectoralis  major, a number of very large arteries and veins were
cut and ligated; the first rib exposed under the sternal end of the clavicle ;
the costo-clavicular ligament divided  and the sterno-clavicular articulation
oj^ned  from below,  thus giving  considerable mobility to  the  mass.   The
sawed end  of the  clavicle  being then elevated  by means of strong curved
spatula?, the subclavius muscle was divided at its origin, the remainder of it
being obliterated in  the tumor.  The tumor was now separated  from  the
areolar  and fatty  structure  between  the  omo-hyoid and the subclavian
vessels, at  the upper and  outer  part of which a number  of large arteries
required the ligature, especially a large branch from the inferior thyroid
artery.  The auterior part  of  the upper incision being then made from  the
sternal  end of the clavicle over the tumor until it met  the other at the
external jugular vein, this vein was  tied with two ligatures,  and divided
betweeu them.   The clavicular origin of the sterno-cleido-mastoid was also
divided about three inches above the  clavicle, and, the deep  fascia  being
exposed, the mass was very cautiously dissected until the  scalenus anticus
was exposed ; the subclavian vein, which was firmly adherent to the tumor,
being most carefully detached, without injury, by the  handle  and  blade of
the scalpel.   The external jugular vein being so connected  with this part of
the tumor as to require the application of two ligatures near the subclavian,
and its division in the interspace, the whole mass was removed, the hemorrhage
throughout being so free as  to require more than forty ligatures, and  the
operation having occupied  nearly four hours for its execution.   The patient
recovered in about eight weeks,  and was subsequently enabled to use his
arm by means of a mechanical contrivance which kept the shoulder off from
the chest.*
  Operation of J.  C. Warren, of Boston, f—A man, aged twenty-four, after
violent muscular effort, felt a severe pain at the junction of the right clavicle
with  the  sternum.   A year  afterward, his clavicle  presented  a  tumor
measuring seven inches from  the sternal end, in a line with the bone,  to  its
scapular extremity ;  from the clavicle to the nipple it measured five inches;
the tumor being hard, with no evident fluctuation, though a slight  pulsation
could be perceived by the stethoscope.  There was no sensible difference in
the pulsation at the wrists ; the patient complained of its occasionally press-
ing on his windpipe, and the constitution presented signs of the scrofulous
diathesis.
   Operation.—The patient being  placed on the table, with the  shoulders
elevated, an incision was made from the acromial extremity of the clavicle
to the sternal end of the opposite bone.   This being crossed by another, at
right angles with it, beginning just below the middle of the sterno-mastoid
muscle, and extending to the face of the pectoral muscle, beneath the middle
of the clavicle, the four flaps were dissected from the surface of the tumor,
and the outer extremity of the bone laid bare by dissecting the deltoid from
its anterior, and the  trapezius from its posterior edge.   The coraco-clavicu-
lar ligament being then  divided, an  eyed-probe, armed with a ligature  was
* American Journ. Med. Sciences, vol. iii. p. 100, 1828.
f Ibid., vol xiii. p. 17, 1833. 
RESECTION  OF THE ENTIRE  CLAVICLE.
337
 passed under  the  clavicle, and a chain-saw attached to the ligature drawn
 after it under the  bone, so as to saw it entirely through.
   A strong band being  now passed around the outer extremity of the di-
 vided bone, the tumor was partlv moved by it so as to give tension to  the sur-
 rounding soft parts, Plate XXXVII. Fig. 6.
   The  pectoralis  major  muscle, being then divided  and dissected from the
 lower edge of the  tumor, was drawn so as to expose  the pectoralis minor and
 the  cephalic vein.   On continuing the dissection under the tumor, the sub-
 clavius muscle could be freed from the outer part, but  was lost in the tumor
 at its sternal  end, where  the dissection necessarily-proceeded over the  sur-
 face of the subclavian  vein.  An adhesion of the tumor to the second rib, in
 which it was imbedded,  prevented also its  perfect  separation at this part
 until the close of the operation.
   The  next step  being to divide  the attachments of the upper or  cervical
 edge of the tumor, the posterior external jugular vein  was divided and tied.
 Being filled with dense lymph, it discharged no  blood.
   The sterno-mastoid  muscle was next cut across, and the sheath of the cere-
 bral blood-vessels exposed, the internal jugular  vein, which passed into  the
 tumor,  being, after  much  care, separated from  it, and the carotid aud par
 vagum drawn  to  one  side.   The  anterior external  jugular vein was found
 imbedded in the internal  extremity of the tumor, and, though also filled with
 lymph, was tied, as a measure of safety, when the sternal  end of the tumor
 was, with great caution, separated from the corresponding parts of the jugu-
 lar and subclavian veins,  the whole extent of the latter vessel, as well as the
 lower part of the  internal  jugular aud par vagum nerve, being exposed and
 put in  motion by the pulsation of the subclavian, carotid, and innominata
 arteries,  when the extirpation was completed.   But little blood was lost;
 only one or two arteries, and the veins just stated, requiring the ligature. The
 flaps were then brought  over and retained  by  three  sutures and adhesive
 plaster, so as  to cover the wound perfectly.   On the thirteenth day after  the
 operation, the patient was attacked with chills, and in the fourth week he
 died—as far as could be judged from the post-mortem  examination—of con-
 stitutional irritation, being of a bad habit of body.
   Operation of A. J. Wedderburn, of New Orleans.—A man, aged  twenty-
 one  years, was admitted, January 21, 1852, into the  Charity Hospital at
 New Orleans,  with  caries of  the  clavicle, so  extensive  as to  require the
 entire removal of the bone by disarticulating it at its two extremities.
   Operation.—An incision being  made in the integuments over the entire
 length of the  clavicle, and sufficiently far beyond its extremities to permit
 the disarticulation, the soft parts over the superior  and anterior borders of
 the bone  were dissected off.   The clavicle being now disarticulated at its
 acromial  end,  the  dissection was continued on the under surface by keeping
 close to the bone, the adjacent structure being  kept tense by elevating the
 clavicle from its scapular toward  its sternal  articulation.  During this, the
 bone, owing to its being carious, broke in two at about one inch and a half
 from its sternal end, thus  rendering the disarticulation  at the sterno-clavicu-
 lar articulation more tedious than  it would have been if there had remained
 sufficient length of bone to have afforded a purchase.  It was, however, safely
 accomplished.
   After-Treatment.—After cleansing the wound, the  cavity left by  the re-
 moval of  the bone was filled with lint, saturated  with a solution of sulphate
 of quinia, in order to guard  against erysipelas,  which  was then in the hos-
pital, and the parts kept in this condition for twenty-four hours.  The next
day,  the lint being removed, the wound was united with adhesive plaster, over
which was placed a compress of lint, also wet with a solution of the  quinia,
     vol. n.—22 
338
PRINCIPLES  AND  PRACTICE OF  SURGERY.
five grains to the ounce of water. No other treatment was resorted to. The
shock from the operation was so slight that the patient sat up within twenty-
four hours after its performance, and  on  the  8th  of  April  he  was  dis-
charged, without any deformity, and with the perfect use of the arm.*
  Remarks.—In the details of  these operations, there  may be noted some
difference in the methods of operating, caused apparently by the peculiar cir-
cumstances of each disease, though in most of the important points they cor-
respond.  As such will doubtless be  the case hereafter, should the operation
be again repeated, any estimate of the advantages of one plan over the other
could only be  theoretical,  and not serve as a guide for future operators.  In
reviewing the accounts just given of these operations,  it must be apparent
that they create a great risk of life ; but this a competent surgeon will doubt-
less always be prepared to meet, and if the  patient's condition can be bene-
fited by a repetition of these rare resections, no experienced  operator should
for a moment  hesitate  about their performance.   A point  worthy of being
mentioned, in connection with these operations as well as others involving the
great veins of the neck, is the liability to the entrance of air into  the large
veins from even a very slight wound of the vessel; and when  the constant ac-
tion of the vessel, as affected by the expiration and inspiration of the patient,
is recalled, the rapid passage of a bubble of air  to the heart may be readily
understood.   But though this circumstance has caused most speedy  death,
yet it has not invariably done so, and  the use of anaesthetic agents, when judi-
ciously conducted, will, it  is thought, greatly diminish this  danger.   When
a patient is fully etherized, marked tranquillity is obtained in the respiratory
movement of the chest, and there is, therefore, less risk of a  wound being ac-
cidentally ic'Mcted ; while, in consequence of the diminished inflation  of the
lungs, absence of all efforts at crying, and  also  of  shock to the system in-
duced by this valuable agent, the risks of the operation, when thus performed,
must be less than they  were formerly.  With the heart beating about sixty in
the minute, and the respiration slow and comparatively feeble, as is usually the
case in etherization, it  may be doubted whether these large  veins would not
be as free from danger  as is possible  in any dissectiou in  the  neighborhood of
their parietes.
              § 2.—Resection of a Portion of the Clavicle.

  Resection of a portion of the clavicle is an operation that may be occasion-
ally demanded in cases of necrosis of this bone.  It may be performed either
at its sternal  or humeral third,  and is illustrated by the operations hereafter
described.
  Resection of the Humeral end of the Clavicle.—In a case of necrosis of
the clavicle, Velpeau operated in the following manuer :—
  Operation of Velpeau.—A crucial incision being made with each branch
four inches long, the flaps were dissected back, the acromio-elavicular liga-
ment and some portions of the deltoid and trapezius muscles divided, and the
necrosed bone raised  by means of a bit of wood which was  employed  as a
lever, until the sequestrum could be detached from the sound parts. \
  Resection of the Sternal end of the Clavicle.—The resection of this end
of the bone was performed by Davy, of Bungay,  England, in order to relieve
the pressure upon the oesophagus of a young lady, consequent on a disloca-
tion of this extremity of the clavicle by a disease of the vertebral column.
* New Orleans Monthly Medical Register, vol. ii. p. 1, 1852.
f Malgaigne, Philadelphia edit. p. 195. 
           RESECTION  OF THE ENTIRE BODY OF THE SCAPULA.     339

    Operation of Davy, of England.—An incision, two inches long, and fol-
  lowing the axis of the clavicle, being made on the extremity of the displaced
  bone, the articular ligaments were divided, and a piece of shoe-leather slipped
  under the end of the bone, so that it could be divided by  sawing upon the
  leather without involving the deeper-seated parts. The wound healed readily,
  deglutition was restored, and the patient perfectly  relieved by the opera-
  tion.*


                             SECTION  III.

                       RESECTION OF THE SCAPULA.

    Resection of the Scapula  has been performed, in several  instances, for the
  removal of large tumors, either so as to leave the neck and  glenoid cavity of
  the bone, with the  exception of its neck, or so as to retain all the portion above
  its spine.

             \ 1.—Resection of the Entire  Body of the Scapula.

    Operation of Gross, of  Louisville, (now of Philadelphia.)f—A tumor,
  fifteen inches in its vertical diameter, and fifteen and a  half inches  in the
  transverse, having  been developed on the scapula, so  as to impair the use of
  the arm and cause  great pain in the limb, it was removed with the scapula in
  the following manner:—
    A full dose of chloroform  having been  administered, an  incision, sixteen
  inches long, was made obliquely downward and inward from  the 'superior an-
  gle of the scapula to the  inferior portion of the tumor.  Another, which be-
 gan about five inches below the upper end  of the first, was then  carried in a
 curvilinear direction, so  as to terminate about the same distance from  its
 lower end, and, the dense integuments being dissected off,  first toward the
 spine, and then toward the axilla, the levator scapula? and trapezius muscles
 were divided.  The acromion process being then  sawed through just behind
 the clavicle, the latissimus dorsi and serratus anticus muscles  were divided, so
 that the fingers could be carried underneath ; the tumor was elevated so as to
 sever the connections which existed near the ribs, and the deltoid aud other
 muscles  of the arm being next incised, the neck of  the  scapula was sawn
 through, and the entire  mass removed with comparatively little difficulty.
 About twenty-four ounces of  blood were lost, several arteries near the neck
 of the bone requiring the ligature after the removal of the  morbid  growth.
 The immense wound being now united by sutures and adhesive strips,  the
 parts were supported by a compress and broad body bandage, and nearly the
 entire wound healed by the first intention.   At the end of  three weeks  the
 patient returned home, but, having taken cold on the  journey, was attacked
 by pleuro-pneumonia, which was followed by hectic fever, under which he
 sank in two months.
   Operation  of Hayman.J—A  large  tumor, which was attached to the
 scapula,  was laid bare by two  semicircular cuts through the skin and tendin-
 ous expansion,  and  cut away by rapid strokes of  the knife,  when the bone
 was sawn obliquely  through its spine, so as to leave only the glenoid cavity
and the parts immediately above  the  spine.  This patient  recovered, and
could  move the arm in most directions, except in elevation.
* Malgaigne, p. 196.
f West. Journ.  Med. and Surg., vol. xi. 3d series, p. 420.
X Chelius, Syst. Surgery, vol. ii. p. 762. 
340            PRINCIPLES AND PRACTICE  OF SURGERY.

  Operation  of Luke, of England.—An incision being made through the
skin, from the axilla along the axillary margin of the tumor and anterior
costa of the boue, and round the inferior angle to within a short distance of
the spine of the scapula, a second incision was carried along the lower mar-
gin of the spine, from the commencement of the first to its termination.  The
muscles in the supra and infra-spinata fossa being then incised in a direction
from a little behind the glenoid  cavity to a little above the superior angle,
the scapula was steadied and the bone sawed through near the  root of the
acromion process, when the whole structure was removed.  The hemorrhage
was very free, twenty or thirty arteries near the armpit requiring the liga-
ture, and about a  pint or a pint and a half of blood  was lost.  The edges of
the wound being then closed by adhesive strips, the arm was secured to the
side by a bandage, and the forearm  placed in a sling.  In two months the
wound had completely healed, and in eleven months  after the  operation the
motion  of the arm, forward and backward, was perfect, and, in fact, greater
than usual, the limb  moving with more  than the ordinary pliancy, and also
possessing considerable power.   Rotation outward and  inward was possi-
ble, and the  patient had  sufficient strength to lift with ease  moderate
weights, though elevation of the arm from the side could only be  accom-
plished by the aid of the opposite hand.
  Remarks.—The resections of considerable portions of the body  of the
scapula have also been performed by Liston, Janson, Syme, Wurtzer, Tex tor,
and Travers,  in Europe,* and are evidences of the progress of operative sur-
gery in a department which has for its  special object the  preservation, to a
certain extent, of the usefulness of the limb.   With the exception of some
variety in the external incisions required by the development of the tumors
which demanded the  resection, these operations have all  had  some general
points of resemblance, the preservation of the glenoid cavity being the great
object of all of them,  in order that the mobility of the limb might be retained.
Among American surgeons, the most marked case is that of Gross, though
excisions of the scapula, and even of the scapula and clavicle, have been per-
formed by other surgeons in the United  States, either in the act of amputa-
ting at the shoulder or in consequence of the development of disease in this
region after amputations.  As these latter operations are, however, properly
amputations  of the shoulder-bones, they will be  referred to  in connection
with amputations of the upper extremity, in a subsequent portion of this
volume.

        \ 2.—Resection of the Acromion Process of the  Scapula.

   The resection of the Acromion process of the scapula is an operation so
very similar to that of the acromial end of the clavicle, allowance being made
for the position of the muscles as well as for the greater facility of access to
the part, that it can be readily understood without further reference.
   The resection of the Inferior angle of the scapula would require the em-
ployment of  such incisions as would freely expose the part, after which its
removal  could be accomplished by bone nippers or strong scissors  passed
beneath the bone.
* Chelius, vol. iii. p. 763. 
LIGATION OF THE AXILLARY ARTERY  BENEATH  THE  CLAVICLE.   341
                            SECTION IV.

            OPERATIONS  ON THE PARTS ABOUT THE CLAVICLE.

  In the portion of the chest immediately about the clavicle only one oper-
ation  of  importance is ever requisite, to wit, the  ligation of the  Axillary
Artery, or,  as it is sometimes though incorrectly termed, the ligation of the
subclavian artery beneath the clavicle.
         \ 1.—Ligation of the Axillary Artery beneath the Clavicle.

   The Axillary artery in  this portion of its course maybe found in the tri-
angular space which is bounded above by the clavicle, below and on the out-
side by the pectoralis minor  muscle, and below and on  the  inside by the
sternal origin of the pectoralis major.
   Ordinary Operation.*—The  patient being laid upon the table,  with the
shoulders slightly raised, and the elbow carried a little off from the body, so
as to stretch the  skin, an incision  should be made  three inches long, and
about three-quarters of an inch below the clavicle, parallel with the  bone,
so as to terminate outside of the line of junction of the  pectoralis major and
deltoid muscles, dividing only the skin.   The superficial fascia of the chest
and  the fibres of the pectoralis muscle being then carefully cut, and attention
given to the position of the cephalic vein, a director should  be introduced
beneath the posterior portion of the sheath of the muscle  ; then, after bringing
the  arm to the  side, so as to relax the parts, tear the connective tissue about
the  vessels with the point of the director, and carry the index finger behind
the  upper border of the pectoralis minor muscle, and, pushing it downward
and  outward, the vessels will  be seen in  the following order:  1st. On the
inside, the axillary vein swollen at each expiration, and partially covering the
artery.   2d. Outside,  and  a little  behind the vein, the axillary artery.  3d.
More externally and  behind,  the  nerves of the brachial plexus.  The vein
being drawn inward by a blunt hook, the aneurismal needle should be passed
between the vein  and the artery from within outward, above the origin of
the  acromial and  mammary arteries, which  would otherwise  interfere with
the formation of the coagulum, Plate XXXVI. Fig. 4.
   Operation of Lisfranc.—Abducting the arm  forcibly from the  body, so
as to render distinct the clavicular  and  thoracic origins of the pectoralis
major muscle, Lisfranc incised the skin in an oblique direction  from  the clav-
icle  downward  and  outward.   The fascia superficialis being  then  carefully
divided, and the line of separation of these two parts of the muscle appar-
ent,  their adhesions were separated  by the finger or knife-handle, the arm
brought close to the side, and the artery sought for and tied,  as in the plan
just  described.  Malgaignef  gives  as a "rule" a direction  which I have
always found to be a good one, and  that is, after the laceration of the pos-
terior part of  the  sheath of the pectoralis  major muscle, to search on the
inside of the wound for the vein, which is the first vessel met with, and is an
infallible  landmark.   Carrying it inward, the artery will be found a little
outside and a little  behind.
   Remarks.—The  ligation of the  axillary artery by either  of  the above
plans will be found to be  a very troublesome  operation, and in the case of
* Malgaigne, Philad. edit. p. 147.
f Ibid., p. 148. 
342           PRINCIPLES  AND PRACTICE OF  SURGERY.
 an aneurism or wound lower down, which are the principal disorders  likely
 to require it, a most difficult one to perform in consequence of the  infiltra-
 tion of the  parts, or the  enlargement of the thoracic vessels.   The  after-
 treatment will  also  be troublesome, and  require special  attention  at each
 dressing, in order to prevent collections of pus within the wound, or  the
 traveling of matter into the axilla, or beneath the pectoral muscles, in con-
 sequence of the depth  of the wound.   The position of the brachial  nerves,
 or any anomalous distribution of the vessels, is also liable to  lead  the  op-
 erator into error, although the rule laid down by Malgaigne would  obviate
 this in the hands  of a  careful surgeon and good anatomist.   As the artery
 may be more readily tied  in the  axilla — as will be  shown  in  connection
 with  the operations upon the upper  extremity — and  is not so  difficult
 to ligate above the clavicle as it is below, the latter place is now seldom  se-
 lected for the application of the ligature.  The results attending the  ligation
 of the axillary artery by surgeons in the United States may  be  seen to a
 limited  extent in  the Bibliographical Index of  this part,  and  will be  again
 referred to in connection with the operations on the extremities.
  In  studying  all operations, but  especially the ligation of arteries,  the
 student will  find it much to his interest to practice them  upon the  subject in
 the  manner that has just been described.  The French surgeons are partic-
 ularly fond  of this kind of practical exercise, and it is  one reason  why their
 directions in relation to the ligation of the arteries are especially valuable.  In
 every operation upon the blood-vessels, those who are accustomed  merely to
 the  practice  of the dissecting-rooms should, however, recollect the additional
 difficulties that they may have to encounter from the changes in the  relative
 position of the parts in consequence of disease, as well  as the  increased
dangers always to be encountered  from  the thin  coats of veins  being dis-
tended with  blood in the respiratory efforts of the patient.
                           CHAPTER XI.

     OPERATIONS UPON THE MAMMARY GLAND  OF THE  FEMALE.

    The Mammary Gland of the female is peculiarly liable to the development
 of tumors of various  kinds which may require either to be separated from
 the gland aud removed by themselves, or may be of such a character as Will
 render the extirpation of the eutire breast the most advantageous operation.
 To decide on the extent of an operation of this kind, the  surgeon  must be
 governed by his knowledge of tumors; and as reference has already been made
 to those of this region, we shall  limit this account to the  operations appli-
, cable to any of them  when demanding the removal of the  entire gland.

                              SECTION I.

         EXTIRPATION OR  AMPUTATION OF THE MAMMARY GLAND.

    The Mammary Gland is covered by the integuments in front and adherent
 behind, by a loose connective tissue, to the fascia covering the pectoralis muscle
 being chiefly supplied with blood  from the branches of the external  mammary 
      EXTIRPATION OR AMPUTATION OF THE MAMMARY  GLAND.  343

artery, while its veins  run up  into the axillary vein.   Its removal may be
readily effected by incising the skin in such a form  as circumstances may de-
mand, but the subsequent dissection of the gland should be conducted in the
line of the fibres of the pectoralis muscle, that is, from  the sternum toward
the axilla.
  Operation.—The patient being etherized and placed upon a table, rather
than upon a chair, with  her head and shoulders slightly raised, the  arm of
the affected side, should be carried off from the body, and held by an assist-
ant, so as to keep the  skin and  pectoral muscle upon  the stretch.   Then,
standing on the side of the disease, or  by the shoulders of the patient, place
the four fingers of the  left  hand upon the  skin, so as to  make it tense, while
an assistant does the same  with the integuments of the,opposite side of the
tumor.   After thus steadying the skin, make a semi-elliptical incision, with
its concavity upward and  the nipple near its centre, either by cutting from
the axillary margin of  the  gland, or lower  portion of the anterior border of
the axilla toward the  sternum,  if  standing on the  diseased side,  or  by
beginning  on the  sternal  side  and extending the  cut toward the axilla if
standing at the shoulder of the affected side, holding the scalpel  in the first
position, Plate II. Fig. 1,* and bearing on it with tolerable  firmness, so as
to divide the integuments thoroughly by the first stroke of the knife.   Then,
while the breast and skin are drawn in  different directions, dissect the integ-
uments free from the gland on its lower portion, and make another elliptical
incision, with its concavity downward,  on  the upper side of the gland,  so as
to meet the first one at its  sternal  termination, but  not quite reach it at the
axilla, including between  these two incisions as  much  integument as will
remove  any  excess of  skin, Plate XXXVIII. Fig.  1.   Then, dissecting
the upper flap off from the  gland in the same manner as before, seize the
mass firmly, either with the tumor forceps, or by means of a ligature passed
through  it, or  by the  fingers, which are  usually the  best instruments,  and
dissect it from the sternum toward the  axilla, either by working from above
downward or the reverse, according  as it is found  most  convenient,  though
the dissection from below exposes the operator to the risk of getting beneath
the fold of the pectoral  muscle in approaching the axilla.   As  the  various
branches of the mammary  arteries (external thoracic) are divided, the hem-
orrhage, if profuse, or  if the patient is  feeble, should be  checked, by ligating
each vessel  as it is  cut.   But if this is not the case, the  bleeding  may be
overlooked  for the moment, or temporarily checked by compression of the
arteries by the fingers of an assistant, when they will often contract and give
no further trouble.
   In prosecuting this  dissection, the left forefinger and thumb should con-
stantly examine the  surrounding textures, in order to detect any hardened
portions, the dissection being always carried so far  into  the healthy tissue as
to leave a margin of the latter to be extirpated along with the breast.   On
approaching the axillary end of the ellipse, grasp the breast in the left hand,
Plate XXXVIII. Fig. 2, and draw  upon it so as to insure the  removal of
any of the condensed laminae or fibres of indurated connective tissue which are
connected with it.   If  the  axillary glands also show any signs of  hardening,
they may now be  readily removed, by slightly prolonging the incisions into
the axilla, and working from above downward ;  but this part of  the opera-
tion requires considerable  care, in some instances, in order to avoid injuring
the axillary vein.   To  prevent this, it will be found  advantageous  not to
elevate the patient's arm to any great extent, as this position rather puts the
axillary vessels on the  stretch, and  brings them near  to  the point of the
knife.   When any of the thoracic veins appear to be connected with the lym-
* Vol. i. p. 184. 
PLATE   XXXVIII.
                OPERATIONS PRACTICED ON  1 HE CHEST.

  Fig. 1. Extirpation of the mammary gland of the female.  The patient is seen
lying  down with the arm carried off from the body, and the lowest of the two
elliptical incisions  has  been made from the axilla toward the sternum.  The
parts  being intended to  heal by granulation, much  more of the integument is
about to be removed than is usual in the United States.   1, 2, 3. First or lowest
incision.   1, 4, 5. Line  of second incision.    *      After Bernard and Huette.

  Fig. 2. Represents the completion of the operation of extirpation of the breast
as usually practiced.  The left hand of the surgeon grasps the gland and draws
it toward the sternum, while the thickened connective tissue or lymphatics are
being dissected from the margin of the axilla.                 After Nature.

  Fig. 3. A view of the arrangement of the  adhesive straps after the operation
These straps should be  long, and pass obliquely around the  chest, so as to leave
intervals between the different pieces.  A mesh of linen  has been introduced be-
tween the edges of the skin  at the lowest angle of the wound, in order to secure
a vent for the matter.   1. Line of union of the wound left by the incisions.  2.
Mesh  to favor escape of the pus.   2, 3.  Posterior course of the adhesive straps.
                                               After Bernard and Huette.

  Fig. 4.  Operation of empyema upon the right side of a man.   The patient
is represented lying down, and slightly inclined to the left side, while the surgeon
makes an opening between the eighth and ninth ribs.
                                               After Bernard and Huette.

  Fig. 5. Resection of  two  of the ribs on the left side.  The patient lying down
and inclined toward the right, a crucial  incision has been made over the seat of
the disease, the flaps, 1,1, turned back, the  ribs,  2, 2, sawed across or broken,
and the  posterior extremities elevated by a bandage, previous to their removal.
The thickened surface of the pleura, 3,  is seen behind the seat of the  disease.
                                                           After Nature.
        (344) 
Hale  3tt.
H
t-3
•■3
Hg.4.

 
 
       EXTIRPATION  OR  AMPUTATION OF THE MAMMARY GLAND.   345

phatic glands or indurated tissues, or when the disease is thought to approach
near to the main vein, it will be safer, instead of dissecting it out, to surround
the axillary portion of the structure with a strong ligature, and  cut off the
part connected with the tumor on the mammary side of the thread, leaving
the remainder to slough or ulcerate  out.
   After being fully satisfied that every  diseased particle  is removed, the
wound should be cleansed, any arteries that continue to bleed ligated, and
the ligatures brought out at the sternal extremity of  the incisions.
   The arm being now brought to the side, the edges of the  skin may be ap-
proximated and held together at the central  point by a single suture, sup-
ported by long adhesive strips, or the whole may be closed by the interrupted
metallic suture without resorting to the use of the plaster.  In either case, it is
a good practice to introduce a little  mesh of linen into the lower orifice of the
incision, Plate XXXVIII. Fig. 3, in order to secure a vent for the  pus by pre-
venting the entire union of the skin  before the ligatures come away, or before
adhesions have  formed in the  deeper-seated parts.   When adhesive  strips
are employed, they should be applied from below upward, obliquely across
the line of the wound, so as to leave spaces between each strip for the escape
of  matter, Plate  XXXVIII.  Fig.  3.   After  this,  a compress should be
firmly retained against the part by a spiral reversed bandage of the chest, so
as to prevent the pus collecting within the lower  flap,  while the  arm of the
side operated on should be supported in a sling, or kept close to the side, so
as to preserve perfect rest of the  pectoral muscle until union has  occurred.
   If  the  disease has involved a part of  the  pectoral  muscle, this  portion
should also be removed, though, as a general rule, it is best to avoid incising
even  the anterior fascia of the muscle, lest it subsequently interfere with the
free motions of the arm.   Should the gland be  known to be adherent  to the
muscle before operating, the chances of the cure will  be so much  diminished
that the surgeon may well hesitate before  he advises his patient to submit to
the knife.
   In cases of open or ulcerated cancer, such  as are not deemed suitable for
an operation, or where  the disease returns  and  creates a painful  ulcer in or
near the cicatrix, it will prove advantageous to  dress it by covering the sore
from  time to time with the coating formed by the application of the solution
of gutta-percha in collodion,  as suggested by Dugas, and  spoken of  under
cancer  of  the  lip.  In the case reported by  Dugas,* there was a can-
cerous ulceration, of several months' standing, of the size of  the areola,
in the depressed centre of which were  seen the remains of the nipple.   The
axillary glands were also much enlarged, and the patient a prey to continual
pain, which  was  especially severe  at night.   Under the application of  a
coating of the  solution of gutta-percha, applied  over the  whole breast at
first every twenty-four hours, and then, as  the discharge diminished, once in
a week, the patient was gradually relieved of  all pain about the  breast, and
even in the  axilla, slept quietly at night, and enjoyed  her  meals, a change
which must have proved  highly serviceable in arresting the progress of the
disease.
  Remarks on Amputation  of the Breast.—The simplicity of the operation
of extirpating the  breast  is often such that the detailed account of it just
given may by many be deemed unnecessary, and to the man  of  experience
such will doubtless be the case in this as  in most other operations;  but to
others it will, it is thought, prove  useful.    The  frequency of the operation
demands also, that those whose experience  is  limited should, if possible, be
made aware of the difficulties which are occasionally met with ; while, in an
* New Orleans Medical Register, vol. ii. p. 7, 1852. 
346            PRINCIPLES  AND  PRACTICE OF  SURGERY.
operation for the removal of a growth which is so very liable to return, too
much care cannot be taken to excise every portion that is diseased, and this
can only be accomplished by following the details of a proceeding similar to  *
that just stated.
  In what seemed  to be a simple case of extirpation of the mammary gland,
as performed  by Warren,  of Boston,  everything  did well  until it became
necessary to remove some of the indurated  lymphatic glands of the axilla.
When the  separation  of these  was nearly  effected,  "a  vein was divided,
which gave exit to a small quantity of venous blood, when  almost instantly
the  patient struggled, her complexion changed to a livid color,  and a bub-
bling, gurgling noise was indistiuctly heard,  showing the  entrance of air into
the vein.   The axilla was, therefore, instantly  compressed, but  the patient
became insensible,  and breathed as if in apoplexy. The tumor was at once sep-
arated,  the patient laid down, brandy poured down her throat, and the vapor
of ammonia introduced into her nostrils, but the pulse became  less distinct
every instant," and although every other possible means  of  exciting anima-
tion were tried, even to opening the larynx and inflating the lungs by a pair
of bellows, and continued without  intermission  for twenty  minutes,  the
patient never breathed again.   In the history of this case, Warren* suggests
that the entrance of air into the axillary vein, in this operation,  may be pre-
vented  by keeping the arm toward the side, so  as  to  relax the  coats of the
vessel, instead of extending them, as is done when the arm is elevated during
the progress of the dissection toward the axilla.  But when the surgeon is
aware of the risk  of this accident, and is cautious, he will be better enabled
to see the parts that he is about to cut, when the axillary dissection is made
with the arm slightly elevated.   In all  such cases it is, however, the safest
plan to secure the chain of glands and cellular tissue with a  ligature, and
leave the pedicle  to  slough out,  instead of dissecting  into  the axilla, in
order to remove them.
   The  selection of the different external incisions, or their direction, is, it is
thought, a matter that must be settled at the  moment,  by the  peculiar cir-
cumstances of the case.  The elliptical incision in the line of the fibres of the
pectoral muscle is that  most frequently resorted  to, and answers perfectly
well in most  instances.   The propriety of arresting the  hemorrhage as the
arteries are  divided,  or simply twisting or compressing them  during the
operation,  is also  a point on which surgeons differ, and must  be left to the
decision of the operator, who should be guided in  his course by the strength
of the  patient, and by the number and size  of  the vessels that  are divided.
I have  seen many instances where only from  one to four ligatures  were
demanded, while,  on the other hand, I have been compelled to apply fifteen
or twenty before  the bleeding was checked.
   Statistics.—A  very important question connected with this  operation is
the  advantages likely to result to  the  patient from its performance.    To
decide  this point correctly, it is essential that  the subsequent history of the
cases operated on should be known, and this,  from  various causes, it seems
to be almost impossible  to obtain.  In  order  to  gain reliable  statistics of
the  results of surgical  operations for malignant diseases  generally, the
American  Medical Association recently referred this subject to a committee,
of which S. D. Gross was chairman.  This gentleman accordingly furnishedf
a very  elaborate aud full report, embracing  the opinions of surgeons in every
section of the globe, and containing a large amount of valuable details.   As
  * Warren on Tumors, p. 2d0; also, Am. Cyclopedia Pract. Med. and Surg., by Hays,
vol. i. p. 2(53, article Air, 1834.
  f Transactions American Medical Association, vol. vi. p. 155. 
       EXTIRPATION OR AMPUTATION  OF THE MAMMARY  GLAND.   347

 the extent of this paper requires that it should be consulted in its unity, I
 can  only express my opinion of its value, and add as illustrative  of  its
 results, the following brief synopsis of  some of the conclusions at which it
 arrived :—                                                           ,
   " 1st.  Cancerous  affections, particularly those of the  mammary gland,
 have  always,  with a few rare  exceptions, been  regarded by practitioners  as
 incurable by the knife and escharotics.
   " 2d.  That excision, however early and thoroughly executed, is nearly
 always, in genuine cancer, followed  by a relapse, at a period varying from a
 few weeks to  several months from the time of the operation.
   " 3d.  That the profession  have always  been, and still  are averse to any
 operation for the removal of  cancer after it has ulcerated, contracted  adhe-
 sions, etc., because  it then almost invariably returns and progresses  more
 rapidly than when allowed to  pursue its  own course.
   " 4th. That extirpation is improper in acute or rapidly developing cancer.
   "5th. That all operations  for encephaloid growths are  more rapidly fol-
 lowed by relapses than those  performed in hard cancer.

   " 14th. That life has occasionally been prolonged, and even saved,  by  an
 operation after  a relapse ; but that, as a general rule, the second operation
 is as  incompetent to effect a permanent cure as the first."
   The following points are considered by Gross as  uusettled, opinions  being
 divided in respect to them
   " 1st.  The  propriety of excision is doubtful in cases which are of heredit-
 ary origin.
   " 2d. It is doubtful whether a very young patient should be operated on,
 if the disease is of rapid growth, as the operation will  only expedite the
 fatal  issue.
   "3d.  It is doubtful if a case attended  by suppression or irregularity of
 the menses should be operated on.
   " 4th. A quickened state of the pulse, if occasioned by the local irritation,
 should forbid the operation.
       #              #              *              ^c              +
   " Cdh. It is supposed, but not proved, that the excision  of carcinomatous
 tumors only tends to hasten the patient's death.
   "7th.  It is doubtful whether an operation on a recent cancer is more suc-
 cessful than that on an older one, other things being equal."
   Gross, therefore, sums up his report, which is chiefly based on the  expe-
 rience of others, by expressing his individual practice to be to discourage a
 resort to the knife in all malignant diseases, except  those of the skin or the
 cancroid variety.
   Prior  to  the  appearance of this  report, the professional opinion of the
 result of surgical operations  was formed from  limited accounts, and  from
 the recollection of operators,  that, in the  majority of cases of  well-marked
 cancer, the operation did not cure the patient, though it was supposed  to
 prolong  her days;  and the latter assertion has always  been urged by  those
 who advocated  the operation  in  all cases   The prolongation  of life is, I
think, a doubtful matter, as I  have known advanced cases of ulcerated cancer
to live months—in one instance  three years—under a  local  antiphlogistic
and palliative treatment, combined with the free use of  chalybeates, accord-
ing to the plan directed by Justamond and others.
   The following seem  to be the opinions  of the other surgeons hereafter
quoted, so far as I have been able to collect them, and, as they furnish the
views of many eminent men,  might  have been  very much augmented if it 
348            PRINCIPLES AND  PRACTICE OF  SURGERY.
had  seemed desirable.  But with the conclusions stated in  the  paper  of
Gross, such  an enumeration without a digest would have tended to con-
fuse  rather  than  elucidate the subject, and I  therefore present them very
brieflv.
  Rliazes,*  a. d. 024, opposed  all operations for cancer, when the tumor
was not entirely free from the surrounding parts.
  Albucasis.y a.d.  1100, strongly  doubted the  propriety of operating in
cancerous tumors, declaring that  he  never cured or saw cured a single case.
  Monro, in England, and  Delpech, in France, are believed  to have been
opposed  to the operation.    Velpeau,%  on  the contrary,  regards  most of  the
cancerous, encephaloid, or colloid tumors  as a primary local coraplaiut,  the
rest  of the  system being  only involved secondarily.   He  thinks,  therefore,
that every case of cancer  should be operated on,  and operated on as early
as possible,  without delaying in order to try remedial measures.
  Joseph Parrish, of Philadelphia, admits that, after considerable observa-
tion  and experience, he was much discouraged by the  final success  of  the
operation, and never resorted to the  knife—unless  at the particular request
of the patient—where  the disease had penetrated  into the axilla, or fixed
upon the parts beneath the  breast.   When the breast alone was affected,  he
advised the  operation, though believing it to offer but  a doubtful  prospect
of escape.
   Warren,§ of Boston, is satisfied  that many cases may be cured  by the
operation, and, according to the best of his information, thinks  that  one in
three has been  cured without a relapse,  and  that when the tumor is  not
ulcerated, and there  are no signs of a constitutional disorder, it is best to
try the experiment.
   Dudley, ||  of Lexington,  reports to  the Committee  on Surgery,  of  the
American Medical Association, for 1850, "that he never removed a scirrhous
breast without a return of the disease at a subsequent period."
   Paul F. Eve^[ "never operated when the diagnosis was unequivocal, that
the affection did not return."
   J. Kearny Rodgers,** of New York, gives, as the  result of his experience,
that "no two cases survived the operation, in good health, two years;  the
majority being in their graves in less than twelve,  aud many in six months."
   Mussey,yy  of Cincinnati, who was the  chairman of the committee of the
American Medical Association, on these  statistics in  1S50, in  speaking of
his own  experience, says that he  "has operated for  cancer of the  breast, in
many instances,  without learning the sequel; but  of those ascertained there
were only two in which the disease did not return in some part of the sys-
tem within four years, and most of them within one  year."
   Twitchell,|| of New Hampshire, entertained the same views; so also did
Knight,  of Connecticut;  but the latter thought that in  some instances life
has been  prolonged by the operation.
   Flint§§ has seen one case of undoubted encephaloid disease of the breast,
in which  the patient was  well seven  years after the operation.
   The result  of Mussey's report is, therefore, "that soft as well as hard
cancer of the  mammary gland is, in  some  instances,  a local disease, and that
the operation may prolong life."||||
 * General History of Surgery, p. 35, vol. i. of this work.    f Ibid., p. 35.
 X Diet, de Med., tome xix, p. 97.
 | On Tumors, p. 278, 1839
 || North Am  Med. and Surg. Journ., vol. vi. p. 300, 1828.
 fl Transactions American Medical Association, vol. iii. p 332.     ** Ibid.
ft Chairman of committee, op. cit.
XX Trans. Am. Med. Association, vol. iii. p. 332.
H Opus cit., p. 334.                               IHI Opus cit., p.  337. 
      EXTIRPATION OR AMPUTATION  OF THE MAMMARY  GLAND.   349

  Gross in his  late report to  the  American Medical  Association,*  just
referred to, also expresses the opinion, as based upon the views of surgeons
in every section, that it is improper to operate in any case when the  disease
is hereditary, as such cases are peculiarly virulent and intractable, and tend
rapidly to  a fatal termination.
  Leroy D'Etiollesf gives, as the result of his statistics, that, in four hun-
dred and twelve cases,  the mean result of cancer in women—not limiting the
disease to the breast—was three years and six months life, without the oper-
ation, and  two years and six months after it.   " Extirpation of cancer does
not, therefore, prolong  life."   Of cancerous tumors in the breast alone,
Leroy gives  the following result: "Of  two  hundred  and four, twenty-two
died in the year after  the operation, and eighty-seven had  a return of the
complaint, making the whole number one hundred  and  nine, or more than
one-half."   He, therefore, discountenances the operation.
  Broca.J in a prize essay on  the  pathological  anatomy of  cancer, has
added other  melancholy illustrations of the subsequent position of patients
who have been operated on for cancer.   In this essay he shows, that of 39
really  cancerous  patients—the  tumors  having  been examined  microscopi-
cally—11  died from  the consequences  of the operation,  and 28 survived
these.   Of 19 of  the latter who were kept in view, every one relapsed ; 16
dying within the first twelve months after the  operation; 2 in the course  of
the second year;  and  1 at the end of the 25th month.
  " Sir Benjamin  Brodie§ also  states that the elder Cline and Sir  Everard
Home  would scarcely ever  consent to  the  operation  under any  circum-
stances."
  " Bransby Cooper gives, as his recollection of the sentiments of Sir Astley,
that he acknowledged  there were only nine or ten out of a hundred extirpa-
tions that he had  performed in which the disease did not return."
  The  same surgeon, however, reports  one  of  his own cases where it was
eleven and a half years before the disease showed itself; and Callaway, a
case where the patient did not die till twenty years  subsequent to the opera-
tion. ||
  My own observation, though  limited in comparison with  the experience
of the distinguished men just named, is decidedly adverse  to  the  cure  of
cancer of the breast by an operation, not one out of teu, to the best of my
knowledge, having escaped a return of the disease.
  In  analyzing the opinions last quoted, it seems  that  nearly four are
opposed to the operation for every one who favors it, though, even among
those quoted as favoring it, the recommendation is  only  either as an experi-
ment, or in the hope of prolonging life.
  Under the statement exhibited in the  present statistics, I think a surgeon
had, therefore, better state to his  patient the little danger that is to be ap-
prehended from the performance of the operation, but also state the  chances
of a return of the complaint, indicating the temporary relief obtainable by.an
operation.
  Paget, in  summing  up the evidence  in connection with  the question—
"Whether it is probable that the  operation will add  to  the  length  or com-
fort of life enough to justify the incurring this risk (loss of life) from  its  own
consequences, says:^[ "I cannot doubt that the  answer may  be often affirm-
  * Trans. Am. Med. Association, vol. vi. p. 174, 1853.
  f Clielius's Surgery, vol. iii. p. 510, note by J. F. South.
  X Brit, and Foreign Med.-Chirurg. Rev. and Charleston Med. and Surg. Journ., vol.
viii. p. 413. 18-33.
  | Clielius's Surgery, vol. iii. p. 639.
  || Ibid., p. 540, note by J. F. South.           1f Op. cit., p. 528.  Philad. edit. 
350           PRINCIPLES AND  PRACTICE OF SURGERY.

ative.   1. In cases of acute hard  cancer the operation  may be riirhtly per-
formed, its performance  being justified by the probability that it will in some
measure prolong life, and save the patient  from dreadful suffering.  2.  On
similar  grounds the operation  seems proper in all cases in which it is clear
that the local disease is  destroying life by pain, profuse discharge, or mental
anguish, and is not accompanied by such evidence of cachexia as would make
the operation extremely hazardous."
                             SECTION II.

                   REMOVAL OF  TUMORS OF THE  CHEST.

   In addition to the tumors just referred  to in connection with  the mam-
 mary gland of the female, the surgeon may be called upon  to extirpate de-
 generations of the same gland or its resemblance as found  in the male.
 This, as well  as  the  ordinary lipomatous,  fibrous, or other tumors found
 upon the side of the chest, may be readily excised by the  means described in
 connection with the treatment of  tumors in  the  neck, that is, by making an
 elliptical, crucial, or other suitable incision through the skin over the tumor,
 introducing the loop of a ligature into it, in  order to obtain a firm hold upon
 the growth, and then  dissecting it, with as little injury as possible, from the
 surrounding  parts.  The after-treatment should be the  same as  that de-
 scribed in connection  with the operation on  the female mamma.
   When the tumor is a cyst with  liquid contents, it may be cured by means
 of the seton, according to the usual plan.
   The following case may serve as an illustration of the character and means
 of treatment occasionally useful in these tumors.

    § 1.—Congenital Encysted Tumor on the Right Side of the Chest
                    successfully treated by a  Seton.

   An infant, three weeks old, of good development and health, had a tumor,
 at birth, of a globular shape, six inches in its vertical diameter by seven and
 a quarter in the  transverse.   Its circumference at the  base  was thirteen
 inches, aud it reached  from within an inch and a half of the sternum in front,
 to the spine behind, and from the axilla, as low as the tenth rib.   It was
 soft, elastic, fluctuating,  and transparent, like a hydrocele.   Its surface was
 somewhat lobulated, of a bluish color, and traversed by large veins, the skin
 being sound, and the part free from pain.
  Operation of Gross, of Kentucky.*—After ascertaining, by an exploratory
 puncture with a cataract needle, that the contents of the  tumor were liquid,
 a small  trocar was introduced, and seven ounces of serum, colored  like Ma-
 deira wine, were drawn  off, leaving about one-third of the  contents in the
 tumor.  The puncture was then  closed by  adhesive  plaster.  Three days
 subsequently, six ounces of liquid  were evacuated in the same manner, emp-
 tying the sac entirely; after which the collapsed walls were approximated by
 a compress and bandage.   Four days subsequently there was a partial reac-
cumulation, which  was drawn off, and  a few silk threads  introduced to act
as a seton, as in  the  treatment of  hydrocele.   At the end of forty-eight
hours, sufficient inflammatory  action being excited, the seton was withdrawn
and  the patient, after a  convulsion and serious constitutional disturbance'
recovered.
* Am. Journ. Med. Sciences, vol. xvii. N. S. p. 22, 1846. 
                         CHAPTER  XII.

    OPERATIONS PRACTICED ON  THE  WALLS OF  THE THORAX.

  Owing to the  existence of caries, necrosis, exostosis, or other diseases
of the bones of the thorax, or from the formation of matter within the cavity
of the chest, it has occasionally been found necessary to resort to such opera-
tive measures as will facilitate the  removal either of the affected ribs, or of
the  liquid that may have accumulated within the pleura, so as to interfere
seriously with the action  of the lung.
                             SECTION I.

                  SURGICAL  ANATOMY OF THE THORAX.

   The parietes of the Thorax have been subdivided into the anterior, poste-
rior, and lateral portions, to the latter of which the surgeon is chiefly limited
in the operations about to be described.  The greatest portion of the thorax
being formed  of the ribs, and parts immediately connected with them, that
part of the chest which is bounded by these bones has been named the Costal
Region.
   This  region  presents two  faces: the one which is concave, smooth, and
lined by the pleura, being designated as the pulmonary surface;  while the
other, which is external and convex, is only covered by the integuments and
muscles.
   The muscles of the Chest are found both between the ribs as well as ex-
terior to them, and  are mainly concerned either in respiration, or in the mo-
tion of the body.
   Of these muscles  the intercostal  fill up each intercostal space, and present
their fibres  in differeut directions, those of  the outside passing from above
downward and from behind forward, and those which are within, taking the
opposite line.
   On the outside of the lateral portion  of the  chest, we find the serratus
magnus muscle, which, arising from the nine upper ribs, is inserted into the
base of the scapula.  At the same part, there may also be noted some of the
digitations  of the external oblique muscle of  the abdomen ; which, arising
from the eight  inferior ribs, are interlocked  in its five upper heads with the
serratus magnus.  The diaphragm, after being attached  to the lower edge
of the thorax, rises  up within the  chest by a convex surface, which is on a
level with the fourth rib.
   The Intercostal Arteries pass from behind forward, and are found on the
lower margin of each rib between the two intercostal muscles from the third
rib down.
   The Veins and Nerves follow pretty much the course of the arteries, and
all of these parts, as well as the inner surface of the bones, are lined by the
serous membrane known as the Pleura Costalis.  The adhesions of this mem-
                                                         (351) 
352            PRINCIPLES AND  PRACTICE OF  SURGERY.

brane to the ribs is often exceedingly firm, especially when diseased, though
at other periods it has been found to be much thickened,  and yet quite dis-
tant from the ribs, in cousequence  of the formation of exterior abscesses de-
pressing it upon the pulmonary cavity.
                            SECTION II.

                      OPERATIONS ON THE  CHEST.

  Resection of one or more of the ribs, or perforation of the sternum, or the
extraction of liquid from within the cavity of the pleura or pericardium, are
the principal operations to which  attention may now be given.


                      \ I.—Resection of the  Ribs.

  Resection of the Ribs  has been demanded in cases of serious diseases of
these bones.
  In a  patient of George M'Clellan,* a spina  ventosa was developed upon
the sixth and seventh ribs of the right side, which extended from their car-
tilages nearly to the dorsal vertebra?, so as to form a tumor not less than ten
inches  in  its longest diameter.  This tumor projected  four inches on both
the internal and external surface of the ribs, so as to push back the pleura,
and nearly destroy the function of the lung.
  Operation of M'Clellan,  of Philadelphia. — By  two elliptical incisions,
which included a  portion of the skin,  the integuments over the tumor were
removed from around this point, and the sixth  and  seventh ribs found to be
so involved in the disease as to have caused the destruction of most of their
central portions, their extremities projecting at  either side into the substance
of the tumor.   On removing the mass, by means of the chain-saw and bone
nippers, the hand  could be readily passed within and behind the ribs, so  that
the soft pulpy contents of the tumor, mingled  with the expanded and bony
fragments, could  be  rapidly scooped out, the remainder being carefully de-
tached from the  pleura by the  fingers and handle  of the scalpel  until the
whole  mass was  removed.   The hemorrhage, which  was free, was then
checked by lint, slightly moistened with creosote.
  The cavity left  by  the disease was now seen to be quite large, being capa-
ble, without exaggeration, of admitting with ease a child's head of the ordi-
nary size at birth.
  The  patient, immediately after the operation, did well; the wound filled
rapidly with granulations, and the lung gradually recovered its function, the
patient being sufficiently recovered to  dress and walk about  his room, when
an attack  of bilious  remittent fever caused death ten weeks after the opera-
tion.
  A remarkable case of resection of the fifth and sixth ribs, performed by
Antony, of Georgia, may also be found  by reference to the Bibliographical
Index.
  In the systematic description of resection of these bones, usually presented
in the  various works  on  operative  surgery, the following directions are
given :—
  Operation. — Lay bare the diseased portions of the bone  either by a
straight, curved, or crucial incision, Plate XXXVIII. Fig. 5.  Divide the
* M'Clellans Princ. and Pract. of Surg., note by J. H. B. M'Clellan. 
             PARACENTESIS THORACIS, OR THORACENTESIS.         353

intercostal muscles above and below the rib, either from without inward, or
the reverse, on a director passed under them.   Then detach the pleura from
the rib with the handle of a scalpel, and  saw through the bone with a chain
or Hey's saw.  The pleura being usually thickened, there is but little danger
of wounding it, though occasionally this membrane is almost healthy.
   Remarks.—The comparative rarity of a  disease which could create such
effects as  would lead a surgeon to think of the resection of the ribs, as well
as the risk of injuring the pleura, has rendered this operation not only un-
common, but also one from which many surgeons would at first recoil, as not
being likely to benefit the patient.   But this is not by any means  a modern
operation, nor  are such cases uuique  as that  reported  by Antony,  as
may be  readily seen by a brief reference to  the  history of the operation.
In an article on the Resection of the Ribs, by J.  Cloquet and A. Berard,*
and in  one by Velpeau,y there may be found a reference  to  numerous in-
stances  in which this  operation has been performed, the  periods varying
from the time of Galen up to the present day.   Velpeau mentions a case re-
ported  in the ancient Journal Encyclopedique, in which Suif excised two
ribs, and  removed  a portion of the lung in such a manner  as to be able to
introduce his fist into the chest, and yet the  patient recovered.   In a case
reported  by Richerand, in 1818, the middle portions of four ribs were re-
moved to the extent of four inches, and the thickened pleura also excised, so
that the pulsations of the heart  in  the pericardium could be seen.   The
patient  lived several months, but ultimately died of  a return of  the cancer,
for the relief of which the operation was performed.   According to Velpeau,
Severin, J. L. Petit, Duverney, David, Lapeyronie,  and Dessault have all
done the same thing in cases of caries and necrosis.   He has also performed
the operation himself in three instances with success.
   Warren, of Boston, also reports having successfully excised the seventh,
and in another case the sixth and seventh ribs  successfully for caries; and
McDowall, of Virginia, Mott, of New York, and  M'Clellan, of Pennsylva-
nia, in three other instances, performed this resection with varying success.
As an operation, its execution may therefore  be  said to be comparatively
easy, the thickened condition of the pleura obviating most of the risk likely
to arise  from opening the  pulmonary cavity.  But  it should  be remembered
that caries and necrosis can both be cured by the mere efforts of nature, or
by slight  surgical  assistance, and nothing can, therefore justify a repetition
of any of these operations, unless the sufferings of the patient and the effects
upon  his  respiration should be most urgent.   Indeed, in  this, as in many
other cases, surgical skill and judgment are often best shown when the sur-
geon can cure the complaint without resorting to the knife.
   Caries or Necrosis of the Sternum may usually be relieved, when an opera-
tion is demanded, by trephining the  bone, this operation being the same in
principle as that described in connection with the injuries of the head.
             \ 2.—Paracentesis Thoracis, or Thoracentesis.

  The evacuation of liquid from  the cavity of  the chest is among the most
ancient of surgical  operations, being referred to by Hippocrates, b. c  460,
as well as by many  others at different periods subsequently.
  Pathology of Liquid Effusions into the Chest.—The word empyema—sv,
in, now, pus—though originally employed to designate a collection of pus in
              * Diet, de Me"decine, tome ix. p. 147.
              f Operat. Surg., by Mott, vol. ii. p. 738.
vol. n.—23 
354           PRINCIPLES AND PRACTICE OF SURGERY.
 any cavity, and especially in the chest, is now often incorrectly used to express
 the presence of any liquid, or even the operation that is required to evacuate
 it.  The operation of paracentesis thoracis being, however, intended espe-
 cially for the relief of collections of pus within the pleural cavity, or for the
 removal of  the fluid of  hydrothorax, a brief reference to the pathological
 condition of the  parts concerned may advantageously be made to precede
 the description of the operation.
   A collection of pus, either within or without the pleura, is usually the re-
 sult of such circumstances as induce an inflammatory action of the part, such
 as external  injuries, or pleuritic attacks, or it may be produced by the burst-
 ing of large vomica, or from the discharge  of abscesses in the liver.  When
 the complaint results from external violence, the purulent  collection will
 often  be found to be nothing more than  an abscess exterior to the pleura,
 though the effusion may  also ensue upon the development of caries or necro-
 sis of the adjoining ribs,  the tumor which indicates the  collection  being made
 by pus  which comes from within the pleural cavity.  In most instances, how-
 ever,  whether of  external or internal empyema, the pleura exhibits the ordi-
 nary signs of inflammation of the serous tissues, such as opacity,  thickening,
 false membrane or pus, and sometimes adheres to surrounding parts so closely
 as to  create cysts.  Occasionally, it  has also happened that the pleura has
 been thickened to the extent of three or  five superimposed layers of lymph,
 exhibiting  a honeycomb  like arrangement, or a genuine  fibrous, cartilagin-
 ous, or  osseous degeneration.  When the  effused liquid is in  great quantity,
 and within the pleural  cavity, the lung will  be found compressed to the top
 of the chest, though occasionally strong adhesions to the pleura costalis may
 retain it much lower, and expose it to be wounded in the operation of thora-
 centesis.
   An account of the diagnostic signs of such a condition as would justify the
 operation would carry these remarks  too  far, and it must, therefore, suffice
 merely to state that auscultation and percussion of the chest should be skill-
 fully employed in every instance, before the surgeon attempts the operation.
   The  operation of thoracentesis has been variously performed, but the
 object of all the plans is to evacuate the liquid contents of the part, without
 admitting air into the  pulmonary cavity.   To  accomplish this, it has been
 suggested to puncture the parietes of the  chest with  a  trocar and canula, or
 with a trocar and syringe, or to make a direct dissection, layer by layer, from
 the skin to the pleura.  In all the plans that have been  recommended for the
 accomplishment of this object, surgeons have differed mainly in regard to the
 best point for the puncture ; but  as the patient is usually compelled to sit up,
 and as the general anatomical relations of the region especially favor a certain
 point, it is sufficient to state that, when circumstances admit of it, the space
 between the fourth and fifth, or fifth and sixth ribs, and a little posterior to
 their  middle, should be selected
  In order to avoid wounding the diaphragm, which is presumed to be pushed
up  by the liver, it is generally advised to puncture the right pleura one rib
higher than  that advised  for the  left.   Such a position  is, however, far from
 being established as correct, the  idea being based rather on the descriptions
 of the normal condition of the part than on the diseased state, and it is most
 probable that the weight of the fluid collected within the right pleura will more
 than counteract any elevation of the  liver when  the patient is in the erect
 position.  In counting the ribs in a person of moderate flesh, but little diffi-
 culty will be found in tracing them from below upward ;  but in those who are
 fat, or in those who have the side edematous and swollen, it may be impos-
 sible to distinguish these spaces, and under such circumstances the rule has
 been given to select a spot which is about six finger-breadths below the infe- 
             PARACENTESIS THORACIS, OR THORACENTESIS.         355

rior angle of the scapula,*  when, by directing the patient to take as full an
inspiration as possible at the moment of puncturing the pleura, the diaphragm
will be secure from injury.
  Ordinary Operations of  Thoracentesis.—The patient being propped up
in bed, and a little inclined to the  sound side, so  as to separate the ribs  as
much as possible on the diseased side, divide the skin to the extent of one
and a half inches in a direction parallel with the superior edge  of the lowest
rib  on the intercostal  space that  is selected for the puncture.   Then, after
dividing the  superficial fascia, and any portion of a muscle of the chest that
may intervene, as well as the external and internal intercostal muscles, the
pleura will generally be found to bulge into the wound, and being distinctly
felt by the forefinger, so as to establish the fact that only a fluid is behind  it,
puncture the membrane with the point of a bistoury, and enlarge the open-
ing gradually as the liquid escapes, y Plate XXXVIII. Fig.4.   If the pleura
is very much thickened, care will be requisite to avoid the error  of pushing it
before the instrument, for such  a case has been seen.J   Velpeau entertains
the opinion  that in cases which require the  operation of paracentesis, the
effused liquid, or even an abscess, will remove the lung from the point of punc-
ture, and thus secure it from being wounded.   He, therefore, objects to the
details just given, and advises that the side of the chest be at once opened
by  a  deep puncture with the bistoury in the same  manner as an ordinary
abscess.
  Operation of Metcalfe, of New York.§—The patient  being  placed in the
horizontal position, an exploring needle was passed between the seventh and
eighth ribs immediately beneath the angle of the scapula, and the presence
of serum rendered positive.   A bandage being then passed around the chest,
a short incision was made in the skin with a lancet, and the trocar of Schuh
passed into the chest to the depth of one inch and a half.  The cock of the
canula  being now  turned and serum  escaping, a flexible catheter  was ad-
justed to the mouth of the canula, and its free end immersed in  a little  clean
water, the fluid being thus allowed to escape from the chest without the ad-
mission of any air into the pleural cavity.  In this manner, seventy-two ounces
of  serum were evacuated, the steady tension of the bandage preventing any
discomfort from the evacuation of the fluid.   The operation lasted half  an
hour, and the patient was then able to take a long, full inspiration,  and was
temporarily relieved, the object of the operation in the present case being only
palliative.   The instrument employed  was a modification of Schuh's instru-
ment, and consisted of a trocar three and a half inches long by about  one line
in diameter, resembling the ordinary instrument for tapping hydrocele, which
was fitted into a canula in which was  a cock at the distance  of two and a
quarter inches from the end which entered the chest.  A roughened handle
projected at  right angles  to the axis of the tube  at its  external extremity.
The canula was of  the same diameter throughout, and had no  cup as in the
ordinary canula, so that an elastic catheter could be readily attached  to  it.
Its  simplicity over  the trough of  Schuh is its  chief recommendation in the
opinion of Metcalfe.  In order to tell when the serum from the chest passed
out of the end of the catheter which was immersed in the water, a crumb of
bread, pressed  between the  fingers to render it heavy, was dropped  near the
end of the catheter, and by its  motion indicated the current caused by the
effused liquid.
  After-Treatment.—If circumstances render it desirable to keep the wound
* Malgaigne.           j Velpeau, Op. Surg., by Mott, p. 515, vol. iii.
X By Sweet, Amer. Jour, of Med. Sciences, vol. xiii. N. S. p. 518, 1847.
I New York Med. Times, vol. ii. p. 377, 1853. 
356            PRINCIPLES AND  PRACTICE OF SURGERY.
open, a tent may be introduced, and removed from day to day.  This tent
may be made of  fine silver wire threads twisted together so as to  form a T,
the vertical part of which is to enter the wound,* when the discharge is puru-
lent.   But if the whole of the liquid to be evacuated is serum, the opening may
be at once closed with adhesive strips, a compress, and bandage. If the subse-
quent discharge  continues copious, or becomes very fetid, advantage may be
derived from washing out the cavity with warm water, or warm barley water;
weak astringent washes, or those of an antiseptic character, as dilute solutions
of the chloride of soda, being subsequently employed.   Metcalfe,f of New
York, has reported eight cases operated on in the  Bellevue  Hospital, New
York, four of which died, and the result  of two appears  unknown.
   In order to evacuate the  liquid, and yet prevent the entrance of air, vari-
ous contrivances have been employed.  Pelletan employed a syringe for this
purpose, aud Reybard placed a  piece of gold-beaters' skin, or the intestine
of the cat,  over  a canula introduced into the pulmonary cavity, by means of
a perforation in  the rib, so that the matter might flow out and yet the air not
enter.
   Wyman, of Cambridge, United States, has also  invented  a brass suction
pump with an exploring canula, in order to permit the evacuation of the fluid
without allowing the air to enter the pleura, and  has reported^ numerous
instances of the success of this mode of operating, all  the  patients being
immediately more or less relieved, and two being perfectly successful, though
the patients were very ill at the time with hectic, etc.  This mode of opera-
ting  by the  canula  he  thinks is  preferable to the ordinary mode of incising
the soft parts.
   Estimate  of the  Operation___In  estimating the value of any  of these
modes of operating, the difficulties  or objections applicable to each should
not be overlooked.  When the intercostal spaces are  prominent, and the pres-
ence  of liquid certain, the direct puncture of Velpeau is the best; when there
is any doubt of the position of the liquid, then the ordinary operation by dissec-
tion of the layers would be preferable.  Where, however, the diagnosis is posi-
tive, and the chances of failure from the accident of pushing forward the thick-
ened membrane, instead of perforating it, is guarded against, the instrument
of Wyman, of Massachusetts, may prove advantageous.   In Boston, the ex-
perience of the  profession is said to be favorable to it.  Under all circum-
stances, the surgeon may anticipate an anxious and long-continued convales-
cence of the patient, and one which will exact all his skill as a practitioner
to conduct the case to a favorable result.
   The employment  of a trocar is the most objectionable of the various instru-
ments employed, as it is not so shaped as to obtain a keen edge, while the
point of the canula,  even wheu closely fitted to the shoulder of the instrument,
is very liable to tear or push the pleura before it, as is occasionally seen in
cases of hydrocele accompanied by thickening of the tunica vaginalis.  When
the surgeon recalls the constitutional effects liable to result from opening closed
cavities, and especially those containing pus, from a free fibrinous deposit like a
false membrane, he can readily foresee the consequences of opening the pleura
in cases of empyema.  The natural tendency of such collections is either to
be absorbed or discharged by the efforts of nature.  If discharged by nature,
the inflammation of the surrounding parts and the character of the opening
made by ulceration  are well known to be more favorable to a cure than is the
case  when the surgeon punctures it.  I would, therefore, express the opinion
* New Fork Journ. Med., Jan. 1858, p. 42.
fNew York Med. Times, vol. ii. p. 337,1853.
X Transact. Am. Med. Assoc, vol. iv. p. 245. 
EFFUSIONS  INTO THE PERICARDIUM.
357
that this operation should not be resorted to until the latest possible moment;
that, when done, air should be prevented from entering the cavity of the
chest; that the pus should be slowly and only partially discharged, the wound
closed, and the operation repeated if necessary.  If, however, the entrance of
air cannot be prevented, it will be better to evacuate the whole of the liquid,
and treat the case subsequently like  one of cold abscess.
   The value of this operation has been very differently estimated at various
periods, most of the surgeons, up to the time of the discovery of Laennec, hav-
ing regarded it as either doubtful or dangerous, and especially from the diffi-
culties attendant  on the diagnosis.  Since the more general resort to auscul-
tation, many of these difficulties have been  removed.   Disease of the  lungs
are now no longer confounded with those of the pleura, and a skillful auscul-
tator can, in most instances, render the knowledge  of the presence of a liquid
in the chest absolutely certain.
   But, though the  cases can now be better selected than they were formerly,
a successful result is not always  obtained.  The true value of the  operation
may, it is thought,  be correctly stated thus : Thoracentesis will always afford
temporary relief,  and about one-half of the cases  will recover; but whether
these patients would have died without  it, is difficult to tell.
   The idea is certainly erroneous that paracentesis thoracis  is an eminently
successful operation, and though its results have sometimes been such as to jus-
tify its performance, the prognosis should be guarded, as it is shown that the
mortality has been  considerable, and the objections that were raised against
the operation in  former days should, therefore, not be  slightly disregarded.
They are thus stated by  Velpeau :—
   If the lung has been forcibly compressed by the  liquid, and yet is permea-
ble, the evacuation of the liquid without the entrance of air into the pulmo-
nary cavity may  distend it so rapidly as to excite  violent inflammation.  If,
on the contrary, the lung has shrunk so much as  to yield but slowly to the
entrance of air, the void which is immediately left about the parts is very lia-
ble to derange the respiration and pectoral circulation, while the introduc-
tion of air into the cavity of the pleura, though obviating this, yet exposes
the patient to danger by exciting inflammation and creating unhealthy pus,
thus giving rise to  adynamic symptoms, under which many have died.
   Barlow also  states* that his faith  in the utility of this operation has very
much waned of late, and believes that the majority of  the cases operated on
would have done  equally well without it.

                   \ 3.—Effusions into the Pericardium.

   A collection of fluid within the cavity of the pericardium, when the result
of chronic disease, has occasionally been deemed  a  proper subject for an
operation, and  several surgeons have, from time to time, reported instances
in  which they have successfully opened the investing membrane of the heart,
and given exit to the fluid which had been the source of such great distress
to  the  patient.  As, however, this relief can only  be temporary,  and  as the
patient is exposed  to considerable  danger from various steps in the opera-
tion, surgeons have not been disposed to advocate it.  In fact, the rare occur-
rence of such condition  as would justify a resort  to  the  operation has not
offered a sufficient number of cases to test its value.  Velpeau, in analyzing the
few cases that have been reported, expresses the opinion that doubt may  be
attached to all except the one performed by John C. Warren, of Boston, and
reported hereafter.  His  operation has also been described to the author per-
* London Med. Times and Gazette, No. 7, 1857. 
358
PRINCIPLES AND  PRACTICE  OF SURGERY.
sonally as successful, and is, it is thought, the first positively successful case
on record.
  Operation of Jno. C. Warren, for  Effusion into the Pericardium.—A
respectable female, aged  about thirty-five years, having suffered considerably
from  palpitation and  dyspnoea, with the other signs of hydrops  pericardii,
Warren  operated as follows :  An incision being made  on the face of the
seventh rib, the integuments were drawn upward to the sixth intercostal space,
and the  tumor or prominence, which  was very marked, carefully  punctured
with a small trocar  aud canula, the  pericardium being easily reached.   Be-
tween  five and six ounces of  serum being  thus  evacuated, the wound was
carefully closed, the chest bandaged, and the patient recovered sufficiently in
a few weeks to leave the  Massachusetts General Hospital, but was not heard
of subsequently.
  Operation of Schuh.—Another successful case of tapping the pericardium
is related  by Walshe,* in which Schuh introduced the trocar and canula in
the fourth intercostal space, or between the fourth  and fifth ribs, and  drew
off upwards of a  pint of reddish serum, which flowed  in gushes that corre-
sponded with the  systole  of the  heart.   This patient was also very much re-
lieved, and in the course of the month bid fair to be cured, but six  months
subsequently died of  an  encephaloid growth  near  the trachea.   The post
mortem  showed that the  operation had been perfectly successful, and that the
pericardium was adherent to the heart by thick areolar tissue.
AMERICAN PAPERS ON THE DISORDERS OF, AND  OPERATIONS  ON, THE
                          NECK AND TRUNK.
ON EXTIRPATION  OF THE PAROTID
               GLAND.

A  Case  of successful Extirpation of the
  whole of the Parotid Gland for Scirrhus,
  by George M'Clellan, M.D. Philadelphia.
  —N. Y. Mid. and Phys. Journal, vol. v.
  p. 649, lJSl'6; also Am. Med. Review and
  Journ.                         1S2().
The operation of Warren, of Boston, in
  1798, was the first case; that of M'Clel-
  lan, of Franklin County, Pa., in 1805,
  the  second; that of White, of Hudson,
  in  1808, the third; that of Sweat, of
  Maine, in  1811, the  fourth;  and  the
  operation of Geo. M'Clellan, referred to
  in his paper, was the fifth  time it was
  repeated in the  United  States, though
  the first published.
Case of Extirpation of the Right Parotid
  for  Melanotic  Enlargement, by George
  M'Clellan,  M.D.   Philada.,  1829, being
  his second case—iv".  Y. Med. and Phi/s.
  Journ., vol. ii. N. S. p. 309.      1830.
An Account of the Extirpation of the Paro-
  tid Gland,  by George M'Clellan, M.D.
  Philada.— West. Journ. of Med. and Phys.
  Sciences, vol. iv. p  465.          1831.
A Case of Extirpation of the Parotid Gland,
  by Valentine Mott, M D.  New York.—
  Am.  Journ. Med. Sciences, vol. x. p. 17.
                                1831.
Three Cases in which  the Parotid  Gland
  was successfully removed, (Dec. 14,1^'J7,
  Sept. 16, 1830, and one not  dated,) by
  George Bushe, M.D.  N. York.—Medico-
  Chirurgical Bulletin, vol. ii. p. 133.
                                18312.
Extirpation of the Parotid Gland, with other
  Cases, by Nathan R. Smith, M.D.  Balti-
  more.—Am. Journal Medical Sciences, vol.
  xxiii. p. 59.                    1839.
A Case of Extirpation of the Parotid Gland,
  by J. Randolph, M.D.  Philadelphia.—
  Am. Journ. Med. Sciences, vol. xxiii. p. ">17.
                                1839.
A Case of Extirpation of the Parotid Gland
  in 18U">, by John M'Clellan, M.D.  Frank-
* Walshe on Cancer, p. 366, Loud. edit. 
PAPERS ON  DISORDERS OF THE  NECK  AND  TRUNK.
  lin County, Pa.—Amer.  Journal  Medical
  Sciences, vol. vii. N. S. p. 499.    1844.
Extirpation of a Scirrhous Parotid Gland,
  by II. H. Wheeler, M.D.  Pennsylvania.
  —Am. Journ. Med. Sciences, vol. ix. N. S.
  p. 520.                          1845.
Extirpation of the Parotid Gland, by Wm.
  E. Horner, M.D.  Philadelphia.— Phila.
  Med.  Ex.. vol. vii.  N.  S. p 30.    1851.
Successful Removal  of the Parotid Gland,
  by A. J. Wedderburn, M.D.  N. Orleans.
  —iv". Y. Journ. Med, vol. vii. N. S. p.
  411, from A". 0. Med. Register.    1851.
Cases  (three) of  Extirpation of  Parotid
  Glands, (one in 1811, one in 1814,  and one
  in 1841, cured.) by Moses Sweat, M.D.
   Maine.—New York Journal of Medicine,
  vol.  vii. N. S. p. 23.             1851.
Extirpation of the Parotid  Gland, (under
  chloroform,)  by A. B.  Shipman, M.D.
  N. Y.—Nelson's North.  Lancet, vol. vi.
  p. 143.                          1852.
Successful Extirpation of a Scirrhous Paroj
  tid Gland,  by J.  Mason Warren, M D.
  Boston.—Amer. Journ. Med. Sciences, vol.
  xxiv. N. S. p. 332.              1852.
Removal of the Parotid Gland, (cured,) by
  H. H. Toland, M.D.  Sin Francisco.—
   Charleston  Med. and  Surg. Journ.,  vol.
  viii. p. 78.                       1853.
Extirpation of the Parotid Gland, by John
   P. Mettauer, M.D.  Va.— N. 0. Medical
   and Surg  Journ., vol. xi. p. 234.  1854.
Extirpation of the Parotid Gland, by F. H.
   Hamilton,  M D.  Buffalo, N. Y.—Am.
   Journ.  Med.  Sciences, vol. xxxvi. p.  578.
                                  1858.
  ON DEFORMITIES OF THE  NECK.

A Case  of Division of the Sterno-Cleido-
  Mastoid  Muscle, for  Wry-Neck,  by J.
  Mason Warren,  M D.   Boston.—Boston
  Med. and Surg. Journ., vol. xxv. p. 121.
                                  1841.
A Case  of Defoi'mity from Burns (on the
  Face and Neck) relieved by an Operation,
  by T. D.  Mutter, M.D.  Philada.—Am.
  Journ. Med. Sciences, vol. iv. N. S. p. 66
                                  1842.
A Case  of Torticollis successfully treated
  by Myotomy and an Apparatus, by John
  B. Brown,  M.D.   Boston.—Boston Med.
  and Surg. Journ., vol.  xxvi. p. 58.  1842.
Cases of Wry-Neck cured without cutting,
  (gradual extension  by the hand applied
  to the head, the  patient, being in a state
  of anaesthesia,)  by Gurdon Buck,  Jr.,
  M.D.   New York.— N. Y. Med.  Times,
  vol. ii. p. 131.                   1852.
Auto-plastic Operation for the removal of
  the Deformity of a Burn,  (on Neck,) by
  A. Clarkson Smith, M.D.  Columbia, Pa.
  —Am. Journ. Med. Sciences, vol. xxviii.
  N. S.  p. 411.                    1854.
Plastic Operation, by T. Wood, M.D.  Cin-
  cinnati.— West. Lancet, vol. xvi. p. 579.
                                  1855.
Tumors in the Parotid Region, by J. Ma-
  son Warren, M.D. Boston.—Boston Med.
  and Surg. Journ., vol. lvi. p.  288.  1857.


 OPERATIONS ON THE OESOPHAGUS.

Case  in which  a  Copper  Coin remained
  thirteen  years  in the Oesophagus,  by
  John Syng Dorsey, M.D.   Philadelphia.
  -t-A". Y. Med.  and Philos. Journ., vol  iii.
  p. 173, 1811; also Phila.  Med. Museum,
  vol.  i. N. S. p. 125.               1811.
Two Cases  in which Poison was removed
  from the Stomach by a new mode, (the
  Stomach-Tube,) by  P. S. Physick, M D.
  Philad.—Eclectic Repert.  and Analytical
  Review, vol. iii. p. 111.           1813.
A Case of Stricture  of  the Oesophagus,
  cured by Caustic, by Charles T. Hildieth,
  M.D. Haverhill.—New Eng. Journ.  of
  Med. and Surg., vol. x. p. 235.    1821.
Extraction  of a Fish-Hook and Line from
  the Stomach, by slipping a Perforated
  Bullet over the Line and Point  of  the
  Hook, by Dr. Brite.   Communicated by
  S. Brown, M.D., of Lexington, Kentucky.
  —Am. Med. Record., vol. vi. p. 581.  1823.
A new Instrument for extracting Coins,etc.,
  from the Oesophagus, by Nathan Smith,
  M.D. Yale College.—N. Y.  Medical and
  Phys. Journ., vol. iv. p. 576.      1825.
Case of Stricture  of the Oesophagus, (with
  a new Instrument for its  Relief,)  by H.
  G.  Jameson,  M.D.  Baltimore.—Med.
  Record, vol. viii. p. 1.           1825.
Description of an improved Instrument for
  extracting Poisons from the Stomach,
  with Statements assigning the Credit of
  the  Invention  of the Stomach-Tube to
  P. S. Physick,  M.D., in 1800, (he being
  then ignorant  that  Monro,  of  Edin-
  burgh, had done the same thing.) by C.
  B. Matthews, M.D.  Philada.— Am. Med.
  Record, vol. x. p. 322.            1826.
On the Removal of Foreign Bodies from the
  Oesophagus, by means of Forceps, etc.,
  by Henry Bond, M.D.  Philada.—North
  Am. Med. and Surg. Journ., vol. vi.  p. 278.
                                   1828.
Description of a  new GEsophagus Forceps,
  by Constantine Weever, M.D. Michigan.
  —Am. Journ. Med. Sci., vol. xiv.  p. 111.
                                   1834.
Description of a  new form of Stomach-
   Pump, by P. B. Goddard, M.D.  Philada.
   —Am. Journ. Med. Sci., vol. xv.  p. 262.
                                   1834.
Practical Observations on Organic Obstruc-
   tions of the Oesophagus, preceded by a
   Case which  called for Gesophagotomy,
   and  subsequent Tracheotomy, with  ac-
   companying Illustrations, by John Wat- 
360             PRINCIPLES  AND PRACTICE OF SURGERY.
  Bon, M.D. New York.—Am. Journ. Med.
  Science.-; vol. viii. N. S.  p. 309.    1844.
Case  of Ulceration  and  Stricture  of  the
  Oesophagus, with Remarks on Nutritive
  Enemata, as a means of sustaining  life
  in such cases, by  D. J. C. Cain, M.D.
  Charleston.—Charleston Med. Journ., vol.
  iii.  p.  393.                     _ 1848.
Death from a Foreign Body (a piece of
  Bone) cutting from the Pharynx into  the
  Larynx, by Paul F. Eve, M.D.   Georgia.
  —Southern  Med.  and Surg.  Journ., vol.
  v. p. 73.                        1849.
Stricture of the  Oesophagus, (caused  by
  swallowing Potash Solution, temporary
  Relief by Dilatation,) (died,) by Robert
  H.  Cummins, M.D. Wheeling.—Amer.
  Journ. Med. Sci., vol. xxii. N. S. p. 409.
                                 1851.
Extirpation of Pharyngeal Tumors, by L.
  A. Dugas, M.D. Georgia.—Southern Med.
  and Surg. Journ., vol ix. p. 264.  1853.
Case of Stricture of the Oesophagus, (cured
  by  Dilatation,) by Wm. Johnson, M.D.
  New Jersey.—New Jersey Med.  Reporter,
  vol. vi. p. 173.                  1853.
Gesophagotomy at the Commercial Hospital
  of Cincinnati.   Reported by S. Sharp,
  M.D.  Cincinnati.— Western Lancet, vol.
  xviii. p. 269.                    1857.
 ON TRACHEOTOMY  AND  OeDEMA-
         TOUS LARYNGITIS.

Case of Hydrophobia, with the proposal of
  Tracheotomy, by  P.  S  Physick,  M.D.
  Philada., 1801.— N. Y. Med. Repository,
  vol. v. p. 1.                      1802.
Case of Tracheotomy (cured)  for removal
  of a Leaden Bullet in the  Trachea, by
  John Newman,  M D.  Salisbury, North
  Carolina.—N. Y. Med  Repository, vol. x.
  p. 250.                          1807.
Tracheotomy for  Croup, (died,)  by  Dr.
  Thompson.—New Eng. Journ. Med.  and
  Surg., vol. v. p. 318.              1816.
Case of successful Tracheotomy,  for  the
  Extraction of  a Foreign Substance, (a
  Bean,) by Amasa  Trowbridge, M.D., of
  Jefferson County.  New  York.—N.  Y.
  Med. Repository, vol. xx. p. 79.    1820.
Bronchotomy successfully performed  for
  the removal of  a  Watermelon Seed, by
  H. G. Jameson,  M.D.  Baltimore.—Am.
  Med. Recorder, vol. v. p. 673.      1822.
Memoir on Bronchotomy, by H. G. Jame-
  son,  M.D.  Baltimore.—Am. Med.  Re-
  corder, vol. vi. p. 151.             1823.
Case of a Pebble, successfully extracted by
  Bronchotomy, by H. G. Jameson, M.D.
  Baltimore.—Am. Med. Recorder,  vol.  vii
  p. 36.                           1824.
Three Cases of Bronchotomy, by S. Annan,
  M.D.  Emmetsburg.—Am. Med. Recorder,
  vol. vii. p. 42.                    1824.
Case of Tracheotomy (successful) for the
  removal of a Watermelon Seed, by Henry
  S. Waterhouse, M.D.  Franklin County,
  New York.—Philad. Journ. of Med. and
  Phys. Set., vol. viii. p. 391.       1824.
Case of a Bean extracted successfully by
  Bronchotomy,by Joseph Palmer, M.D.—
  Am.  Med Recorder,  vol. vii. p. 32. 1824.
Two Cases of Bronchotomy, (in which one
  was  cured, one died,) by Richard  Bur-
  gess, M.D.—Am. Med. Recorder, vol. vii.
  p. 111.                          1824.
Case of Tracheotomy for the removal of  a
  Bean, (cured,) by  Calviu Jewelt, M.D.
  Newberg, Vermont.—New Eng. Journ. of
  Med. and Surg., vol. xiii.  p. X'M.  1824.
Case of Laryngotomy for  a  Watermelon
  Seed, (cured.) by Samuel A. Cartwright,
  M.D. Natchez.—-New Eng. Journ. of Med.
  and Surg., vol. xiv. p. 135.        1825.
Case of Tracheotomy for the removal of  a
  Bean, (cured.)  by Peter P. Woodbury,
  M.D.  Bedford, New Hampshire.—New
  Eng. Journ.  of Med. and Surg.,  vol. xiv.
  p. 32.                           1825.
Two Cases of Foreign Bodies lodged in the
  Trachea, one of which was removed by
  Tracheotomy, and the other by introduc-
  ing the Forceps  into the  Trachea, by
  Enos Barnes, M.D , of Yates  County,
  New York.—A'. Y. Med. and Phys. Journ ,
  vol. vi. p. 78.                    1827.
Operation of Laryngotomy and Tracheoto-
  my (successfully performed at the same
  time on the same  patient)  for the re-
  moval of an Extraneous  Body (a Grain
  of Com) from  the Larynx, by Abner
  Hopton,  M.D.   North Carolina.—Am.
  Journ. Mtd. Sciences, vol. iv. p. 534. 1829.
Case of Tracheotomy for the removal of  a
  Bean, (cured,)  by  Zadok Howe, M D.
  Massachusetts.—Am. Journ. Med.  Sci.,
  vol. iii.  p. 347.                   1829.
Case of Laryngotomy for the removal of  a
  Watermelon Seed, (cured,) by Joseph F.
  E. Hardy. M.D.  North Carolina. — Tran-
  sylvania Journ. of Med., vol. iii.  p. 207.
                                  1830.
Operation of Tracheotomy (successfully)
  performed for the removal of  a Water-
  melon Seed, by Horatio G. Jameson, M.D.
  Baltimore.—Maryland Med. Recorder, vol.
  ii. p. 594.                       1831.
An  unsuccessful Case of Cynanche Trach-
  ealis, in which Tracheotomy was resort-
  ed to,  by E. Atlee, M.D.  Lancaster.—
  West. Journ. Med. and Phys. Science*, vol.
  iv. p. 23.                        1831.
Remarkable Instance of a  Brass  N:iil re-
  maining in  the Lungs for more than a
  year, by Amariah Bi igham, M.D.  Hart-
  ford, Conn.—Am. Journ. Med.  Sciences,
  vol. xviii. p. 46.                  1836.
Case of Bronchotomy for the removal of an
  Iron Nail (I inch and  $ths long, and
  weighing 55 grains) from a child three 
PAPERS  ON  DISORDERS  OF  THE NECK AND TRUNK.
361
  years of age, nine days after it was swal-
  lowed, by Calvin Jewett, M D.  St. Johns-
  bury, Vermont.—Boston Med. and Surg.
  Journ., vol. xvi. p.  91.            1837.
 Foreign  Bodies  (a Pipe-stem  1|  inches
  long) in the Trachea removed by Trache-
  otomy,  (cured,)  by Charles Hall, M.D.
  Vermont.—Am. Journ. Med. Sciences, vol.
  ix. N. S. p. 357.                  1845.
 Foreign  Bodies in the Air Passages, (four
  Cases, viz., Pin in Larynx. Carpet Tack,
  Horseshoe Nail, and Bean,) Tracheotomy
  used in one Case, by J. Mason Warren,
  M.D.   Boston.—Boston Med.  and Surg.
  Journ., vol. xxxvii.  p. 389;  also, Am.
  Journ. Med. Sciences, vol. xv. N. S. p. 315.
                                   1848.
 Tracheotomy,  succesfully  performed, for
  Membranous Croup, (by  J.  Pancoast,
  M.D.,)  reported  by C. D. Meigs, M.D.
  Philadelphia.—Am. Journ. Med. Sciences,
  vol. xvi. N. S. p.  529.             1848.
 Case of  Membrauous Croup  of a  severe
  character, and  attended with  all the
  symptoms of approaching death, cured
  without an operation for  Tracheotomy,
  by Isaac Parrish, M.D.  Philadelphia.—
  Am. Journ. Med.  Sciences,  vol.  xvi. N.  S.
  p. 530.                           1848.
 A Foreign  Body (Grain of Corn)  in the
  Trachea, cured by Tracheotomy, by Wm.
  Davidson,  M.D.  Madison County, In-
  diana.—Am. Journ. Med. Sciences, vol.
  xvi. N. S. p. 263,  1848;  also,  Western
  Lancet, vol. May,                  1848.
 Gedematous Laryngitis successfully treated
  by Scarification of  the Glottis and  Epi-
  glottis, by Gurdon Buck, Jr., M.D.  New
  York.—Transact.  Amer. Med. Association,
  vol. i. p. 135, 1848; also, Am. Journ. Med.
  Sciences, vol. xvii. N. S. p. 240.     1849.
 History of five Cases  of Pseudo-Membran-
  ous  Croup, in  which Tracheotomy was
  performed, (three cured, two died. Oper-
  ation by  J. Pancoast, M.D.,) with Re-
  marks on the Treatment and on the Oper-
  ation, by J. Forsyth Meigs, M  D.  Phila-
  delphia.—Am.  Journ. Med. Sciences, vol.
  xvii. N  S. p. 307.               1849.
Case of Tracheotomy for Laryngitis, (died,)
  by  Dr  Town send.  Boston.  (Reported
  by J. B. S  Jackson, M.D.)—Am.  Journ.
  Med. Sciences, vol. xvii. N.  S.  p. 28.
                                  1849.
Tracheotomy (successful) for Abscess at the
  Root of the Tongue, by Daniel  Brainard.
  M D.   Chicago. — Northwest  Med.  and
  Surg. Journ., vol.  iii. p. 316.      1850.
Tracheotomy  successfully  performed in
  three Cases for the removal of  a Foreign
  Body, hy D. Gilbert, M.D.  Philadelphia.
(In  the first  it was a grain of coffee; oper-
  ation 12 hours after its entrance;  child
  3£ years.   In the second, a piece of raw
  sweet potato.  In  the third, aged 6years,
  it was a grain of  corn; operation a few
   days subsequently.)—Am. Journ. Med.
   Sciences, vol. xxi. N. S. p. 74.     1851.
 Pseudo-Membranous Croup, Tracheotomy,
   (as List resort,) portion excised, no can-
   ula, death, by R. H. Mcllvaine. M.D.  N.
   Carolina.—Am. Journ. Med. Sciences, vol.
   xxi. N. S. p. 387.                1851.
 Gedematous Laryngitis successfully treated
   by Scarifications of the  Glottis and Epi-
   glottis, by R. A. Kinlock, M.D.  Charles-
   ton —Charleston Med. Journ., vol. vi. p.
   517.                            1851.
 Tracheotomy for  Croup,  (fatal  17 hours
   after Operation,) by Carter P. Johnson,
   M D.  Richmond.—Stethoscope, vol.  i. p.
   670.                            1851.
 Tracheotomy for Oedema  of Glottis, (died
   of  Pneumonia,) by S.  Parkman, M.D.
   Boston.—Am. Journ.  Med. Sciences,  vol.
   xxi. N. S. p. 40.                 1851.
 Oedema glottidis  successfully  treated  by
   Scarification, by Dr. Clarke.  New York.
   — Western  Lancet, vol. xii. p. 306, 1851,
   from N. Y. Register of Med. and Pharmacy.
 Tracheotomy  successfully performed for
   Croup, by Gurdon Buck, Jr., M D. New
   York.—iV Y. Journ. Med., vol. vii. N. S.
   p. 269.                          1851.
 Tracheotomy successfully performed  for
   Gedematous Laryngitis, by  W. D. Ste-
   phenson,  M.D.   Mount Pleasant, Ala-
   bama.— Western Journ. of Med. and Surg.,
   vol.  viii. p. 91.                  1851.
 Tracheotomy for Croup,  (cured,) by Joseph
   T. Pitney, M.D.  Morristown. N. Jersey.
   (Reported by L. Condict, M.D., N. J.)—
   N J. Med. Reporter, vol. v. p.  332.
                                  1852.
 Laryngotomy successfully performed in a
   Case of  Foreign Body  in the  Larynx,
   (piece of Almond Shell lodged in the Left
   Ventricle,) by G. R.  Morehouse, M.D.
   Philadelphia.—Philada. Med. Examiner,
   vol.  viii. N. S. p. 215.            1852.
Tracheotomy for the Relief of Croup, (Tra-
   cheal Mucous  Membrane  healthy when
   opened;  died  42 hours,) by Henry  H.
   Smith,  M.D.   Philadelphia.—Philada.
   Med. Examiner, vol. viii. N. S. p.  222.
                                  1852.
Two Cases  of Tracheotomy for  Foreign
   Bodies,  (Coffee  and Corn Grain,) both
   cured, by John Fred. May, M.D.  Wash-
   ington—Am. Journ. Med. Sci., vol. xxiii.
   N. S. p. 413.                    1852.
Tracheotomy in Oedema of Glottis, (cured;)
   death six months subsequently from  sol-
   dering becoming softened, and permit-
  ting the tube  to fall  into the Bronchia,
  by Dr. Wederstaul, of New Orleans. (Re-
  ported to Society for  Medical Improve-
   ment,  Boston,  by  Dr. Alley.) — Am.
  Journ. Med. Sci., vol. xxiv. N. S. p. 87.
                                  1852.
Laryngotomy in consequence of Suffocation
  from  Enlarged  Tonsils,  (died,)  by  J. 
362            PRINCIPLES AND PRACTICE OF SURGERY.
  Mason Warren,  M.D.   Boston. — Am.
  Journ. Med. Sci., vol. xxiv. N. S. p. 96.
                                  1852.
Tracheotomy successfully performed, (for
  Asphyxia from  Acute Laryngitis,) by
  Joseph Pancoast, M.D. (Communicated
  by Joseph Mauran, M.D. Providence.)—
  Boston Med. and  Surg. Journ., vol. xlvii.
  p. 17.                           1852.
Membranous Croup successfully treated by
  Tracheotomy,  by Daniel  Ayres,  M.D.
  New York.—N.  Y. Journ. Med., vol. ix.
  N. S. p. 69.                      1852.
Cases  of Polypus Laryngis, by  Willard
  Parker, M.D.  New York.  (Reported by
  Stephen Smith, M.D.,Ncw York.)—A". Y.
  Journ. Med., vol. viii. N. S.  p. 15.  1852.
Tracheotomy performed for the Relief of
  Epilepsy, (died  subsequently in  a  fit:
  operation performed  March 18;  died
  with tube in trachea. May 2,) by John
  Ncill,  M D.   Philadelphia.— Trans,  of
  Phil. College of Phys., June, 1852; also,
  Am. Journ. Med. Sciences, vol. xxv. N. S.
  p. 274.                         1853.
Bean in Trachea—Tracheotomy—cure, by
  Moses Hoyt, M.D.  Ohio.—Am. Journ.
  Med. Sciences, vol. xxv. N. S p. 207. 1853.
Membranous Croup — Tracheotomy — its
  advantages;  fatal  termination twelfth
  day, by Henry J. Bigelow, M.D.  Boston.
  —Am. Journ. Med. Sciences, vol. xxvi. N.
  S. p. 80.                        1853.
Tracheotomy for  a   Foreign Substance
  (Grain of Corn) in  the Trachea,  by B.
  F. Trabue, M.D.  Kentucky.—Am. Journ.
  Med. Sciences, vol. xxv. N. S. p. 556.
                                  1853.
Tracheotomy successfully performed,  (in
  extreme cases for acute Laryngitis ) Oy
  Dr. Foster.  New Orleans.—Boston Med.
  and Surg. Journ., vol. xlviii. p. 168, 1853,
  from N.  0. Med. and Surg.  Journ.
Cockle Bur in  Rima Glottidis removed af-
  ter several days, by curved polypus for-
  ceps, by L. A. Dugas, M.D.  Augusta,
  Ga.—Am. Journ. Med. Sciences, vol. xxvi.
  N. S. p. 556, 1853,  from Southern Med.
  and Surg.  Journ., August,         1853.
Tracheotomy for a Foreign  Body, (chip of
  Bone in Soup,) successful, by W.  H.
  Mussey, M D. Cincinnati.— Western Lan-
  cet, vol. xiv. p. 660.              1853.
Foreign Bodies in  the Air Passages, by L.
  A.  Dugas, M.D. Georgia.—South. Med.
  and Surg. Journ., vol. ix. new series, p.
  453.                            1853.
Eight Cases of Foreign Bodies in the Air
  Passages, by John M.  Watson, M.D.
  Nashville, Tennessee.—N.  Y. Journal of
  Medicine, vol. xv. N. S. p. 153.    1855.
Foreign Bodies in the Air Passages, by S.
  D. Gross, M.D. Kentucky.— West. Journ.
  of Med. and Surg., vol. iii.  N. S. p. 119.
                                  1855.
Catheterization of the Air Passages, by B.
  Fordyce Barker, M.D.   New York. —A'.
  Y. Journ. of Med., vol.  xv. N. S. p 294.
                                  1855.
Bullet  in the Bronchial  Tube,   expelled
  after remaining  there two weeks, by S.
  S Emison, M.D.   Lafayette, Missouri.—
  Am. Journ. Med. Sciences, vol.  xxxii. N.
  S. p. 576                        1*">6.
Tracheotomy for Croup and Foreign Body
  in the  Trachea, by G. A. Hunkler, M.D.
  Indiana.— Western Lancet, vol. xvii. p.
  465.                            1856.
Laryngotomy  for  Syphilitic  Disease,  by
  Geo. Amerman, M.D.  New York.—Am.
  Journ  Med. Sci., vol. xxxiii. N. S. p. 284.
                                  1857.
Piece of Tin in the Windpipe,  Lanngo-
  Tracheotomy, by Paul  F. Eve,  M.D.—
  Am.  Journ. Med. Sciences, vol. xxxvi. N.
  S. p. 290                        1s-"'*.
Rupture  of Trachea from  a Fall, by J. L.
  Atlee, Jr., M.D.   Lancaster, Pennsylva-
  nia.—Am.  Journ. Med.  Sci., vol. xxxv,
  N. S. p. 120.                     1*58.
Laryngotomy, by  Thomas J.  Goff.  M D.
  Mississippi.—New Orleans Medical and
  Surg. Journ., vol. xvi. p. 333.     1859.
Tracheotomy, with Remarks, by W. Stme,
  M.D.   New Orleans.—New Orleans Med.
  and  Surgical Journal,  vol. xvi. p. 737.
                                  1859.
Case of Hydrophobia from Bite of Pole Cat.
  Tracheotomy, by R. De Jarnett, M.D.
  Texas.—South. Med. and Surg.  Journ.,
  vol. xv. N. S. p. 3.               1859.
Suggestions of Improvements in Trache-
  otomy, by  Danl.  Brainard.  M.D.  Chi-
  cago. — Am.  Journ.  Med. Sciences,  vol.
  xxxviii. N.  S. p. 291.             1859.
OPERATIONS  FOR TUMORS ON  THE
                NECK.

On  Goitre, by Wm. Gibson.  M.D.  Phila-
  delphia.—Phila. Journ. Med.  and Phys.
  Sciences, vol i. p. 44.             1820.
Case of Bronchocele relieved by taking up
  one of the Superior Thyroid Arteries, by
  H. G. Jameson, M.D.  Baltimore.—Am.
  Med. Record., vol. v. p. 116.        1822.
Case of Encysted  Meliceris  Tumor of the
  Neck, (cured  by Puncture, and Injection
  of Wine,) by Andrew Park, M.D.  Eaton-
  ton.   Georgia.—Philada.  Journ. of Med.
  and Phys. Sciences, vol. vi. p. 130.  1823.
Case  of  (Adipose  Sarcomatous)  Tumor,
  (weighing eight pounds,) extirpated suc-
  cessfully, (from  the side of the neck,) by
  David   L.  Rogers,  M.D    New York.
  Communicated by P. Cadwallader, M.D.
  —Philada. Journ. Med. and Phys. Sciences,
  vol.  xiii. p. 161.                  1826.
Case of a large Encysted Tumor, on the
  Side of the Neck, successfully removed,
  by  Alexander II. Stevens,  M.D.  New 
PAPERS  ON  DISORDERS OF THE  NECK  AND  TRUNK.       363
   York.—New York Med. and Phys. Journ.,
   vol. v. p. 311.                   1826.
 Case of an Operation for the Removal of a
   formidable Turn or from the Neck, (cured,)
   by John C. Warren, M.D.  Boston.—Bos-
   ton Med. and Surg. Journ., vol. i.  p. 26.
                                   1828.
 Case  of the Removal of a Tumor  of the
   Neck, in  which the Posterior Jugular
   Vein was cut off,  (cured,) by John C.
   Warren, M.D.—Boston Med.  and Surg.
   Journ.,  vol.  i. p. 367.             1828.
 Case of a  Tumor in the Neck, with an Ac-
   count of the Operation for its Removal,
   by  G.  Hayward,  M.D.   Boston.—Am.
   Journ. Med. Sci., vol viii p. 352.   1831.
 Case of the Removal of a large Steatoma-
   tous Tumor  of  the Neck, by John C.
   Brent, M.D.   Kentucky.— Western Journ.
   of Med. and Phys. Sciences, vol. iv. p. 487.
                                   1831.
 Two Cases of the Accidents from the admis-
   sion of Air into the Veins during Surgical
   Operations,  by  John C.  Warren,  M.D.
   Boston.—Am. Journ. Med. Sciences, vol.
   x. p. 545.                        1832.
 Case of Extirpation  of  a  Tumor of  the
   Neck, in which  the Carotid Artery and
   Internal Jugular Vein were tied, (died,)
   by William Gibson, M.D.  Philadelphia.
   —Am. Journ. Med. Sciences, vol. xiii. p.
   305.                            1833.
 Case  of  Extirpation of  a  Tuberculated
   Sarcoma, from the Neck, by Valentine
   Mott, M.D.   New York.—Am. Journ.
   Med. Sciences, vol. xii. p. 121.      1833.
 On Extirpation of Tumors on the Neck, by
   N. R. Smith, M.D.  Baltimore. — Am.
   Journ. Med. Sciences,vol. xiv. p. 526.  1834.
 Also article Air,  by J. C. Warren,  M.D.
   Boston.—Amer. Cyclopedia of Prac. Med.
   and Surg., vol. i. p. 263.           1834.
 Extirpation of the Thyroid  Gland,  (died
   thirteenth  day.) by Nathan  R. Smith,
   M.D.  Baltimore.—North American Ar-
   chives Med. and Surg. Sciences, vol. ii  p.
   309.                             1835.
 Case of Attempt at Suicide, in which  the
   Internal Jugular Vein was partially di-
   vided, successfully  secured by Ligature,
   by John G. Morgan, M.D.   Geneva, New
   York. — Am.  Journ. Med. Sciences, vol.
   xviii. p. 330.                      1836.
Case of Excision of a large Tumor on  the
   Neck, by R.  D. Mussey, M.D.  Ohio.—
   Am. Journ. Med.  Sciences,  vol. iv.  N. S.
   p. 253,  1842  ; also, West.  Lancet,  May,
                                   1842.
Case of Tumor  of the Thyroid Gland suc-
   cessfully extirpated, by Otis Hoyt.  M.D.
   Boston.—Boston Med. and Surg. Journ.,
  vol. xxxv. p. 297.                 1846.
Remarks on Tumors of the  Neck,  with
  Cases, by L.  A. Dugas, M.D.  Georgia.
  —Southern Med. and Surg. Journ., vol. ii.
  N. S. p. 513.                      1846.
On Hydrocele of the Neck, by Thomas D.
   Mutter, M.D.  Philadelphia.—Med. Ex-
   aminer, vol. vi. N.  S. p.  257.      1850.
Tumor of the Neck of extraordinary size,
   (weighed  nearly  twelve  pounds,  and
   non-malignant,) successfully  removed,
   by P. C. Spencer, M.D.  Petersburg,
   Virginia. — Stethoscope,  vol.  i. p. 228.
                                  1851.
Statistical  Table  of  Cases of Retro-Pha-
   ryngeal  Abscess,  with  the  Means of
   Treatment, etc., by Charles  M.  Allin,
   M.D.   New York.—New  York Jour-
   nal of Medicine,  vol. vii. N. S. p. 307.
                                  1851.
Remarks on Tumors, with  Cases, by James
   Bryan, M.D. Philadelphia.—New York
   Journ.  Med., vol.  viii.  N.  S. p. 205.
                                  1852.
Extirpation (successful) of Enlargement of
   the Isthmus of the Thyroid  Gland, by
   George A.  Otis, M.D.  Richmond.— Vir-
  ginia  Med.  and  Surg. Journ.,  vol. ii. p.
   115.                            1853.
Cystic Goitre, (treatedby incision and tents,
  not cured at last account,) by Jos.  Pan-
   coast, M.D.  Philadelphia.—Philadelphia
  Medical Examiner,  vol. vii. N. S. p. 501.
                                  1853.
Case of Hydrocele of the Neck,  by D. Gil-
   bert,  M.D.   Philadelphia.—Medical Ex-
   aminer, vol. ix. N.  S. p.  220.      1853.
Extirpation of a  Cervical Tumor, (Lym-
  phatic Gland,) by  L. A.  Dugas, M.D.
  Georgia.—South. Med. and Surg. Journ.,
  vol. ix. N.  S. p. 42.              1853.
Two Cases of Tumors removed from the
  Neck, with Remarks, by H. H. Toland,
  M.D.   California.  — Charleston Medical
  Journal, vol. x.  p.  145.           1855.
Extirpation of Tumors from the Neck, by
  B. Brooks,  M.D.  Wheelock,  Texas.—
  New Orleans Med. and Surg. Journ., vol.
  xi. p.  457.                       1855.
LIGATION OF THE ARTERIA INNOM-
  INATA AND CAROTID ARTERIES.

Case of Carotid Aneurism, cured by an Op-i f
  eration, by Wright Post, M.D., (being the »
  first operation successfully performed on
  this artery in the United States.)  Com-
  municated  by V. Mott, M.D. New York.
  — Transae,  of the New  York Phys. Med.
  Soc, vol. i. p. 367.               1817.
Case of Ligation  of the Innominata, (the
  Ligature separated  on the  fourteenth
  day, and on the twenty-sixth day the pa-
  tient was  attacked  with  Hemorrhage,
  and  died,)  by  Valentine  Mott,  M.D.
  New York,  May 11th, 1818.— N. Y. Med.
  and  Surg. Register, p. 9, 1818; also Ec-
  lectic Repert. and Analyt. Review, vol. ix.
  P- 1-                            1819!
Surgical  Anatomy of the  Arteries,  with 
364
PRINCIPLES AND PRACTICE OF SURGERY.
Y
/
v°«
         Rules for the Ligation  of all of them,
         by  Gec-ge M'Clellan,  M.D.   Philadel-
         phia.—Am. Med. Recorder, vol. iii. p. 25.
                                         1820.
       Case  of  Ligation of the  Carotid Artery,
         (cured,)  by R. D. Mussey, M.D.  Han-
         over, N. H.—New England Journ. of Med.
         and Surg., vol. xi. p. 369.         1822.
        ase of Ligation of the Carotid Artery for
         Aneurism, (successful,) by James Sykes,
         M.D.  Dover, Del.—Phila. Journ. of Med
         and Phys. Sciences, vol. vi. p. 139. 1823.
       A new Instrument  for tying Deep-seated
         Arteries, by Alexander E Hosack, M D.
         New York.—New York  Med. and Phys.
         Journ.. vol. iii. p. 334.           1824.
       Case  of Fatal Hemorrhage, occurring six
    >*    weeks  after the Ligation of  the Carotid
         Artery, by J. W. Cusack, M.D.—Medical
         Recorder, vol. vii. p. 104.         1824.
v      A Case of Ligation of the Carotid, (died,)
\  .    by  Mason F.  Cogswell. M D.   Hartford,
  /     Conn.—New England Journ.  of Med. and
         Surg.,  vol. xiii. p. 357.           1824.
       Account  of a Case in which both Carotids
         were tied successfully at the interval of
         one month after  the first Ligature, by
         Dr. McGill,  Maryland.   Account fur-
         nished  by J.  Kearny  Rodgers, M.D.
         New York.—New  York Med. and Phys.
         Journ., vol. iv. p. 576.           1825.
    \j  Three Cases of Ligation of the Carotid Ar-
         tery, successfully performed  on Children
         of five, eleven, and sixteen years of age,
         by  George M'Clellan,  M.D.   Philadel-
         phia.—New York Med. and Phys. Journ.,
   v     vol v.  p. 523.                   1826.
    ^  Case of an Operation for Carotid Aneurism,
         (cured,) by John C. Warren, M.D. Bos-
         ton.—Boston Med. and Surg.  Journ., vol.
     v.  i. p. 42.                         1828.
       Case of an Operation for Carotid Aneurism,
         (cured,) by Winslow Lewis,  M.D.  Bos
         ton.—Boston Med. and Surg.  Journ., vol.
         ii. p. 371.                       1829.
     J Aneurism of the Arteria Innominata, in-
         volving the Subclavian and  the Root of
         the Carotid, successfully treated by tying
         the carotid,  by Valentine  Mott, M.D.
         New York.—Am. Journ. Medical Sciences,
         vol. v. p. 297, 1829; also Maryland Med.
         Recorder, vol. i. p. 455.           1829.
       ■ Case  of Ligation of the Carotid, in 1825,
         for  Fungus of the  Antrum,  (died,) by
         Michael A. Finley, M.D.  Williamsporf,
         Md.—Maryland Medical Recorder, vol. i.
         p. 97.                           1829.
       Case of Aneurism by Anastomosis, in which
         both Primitive Carotids were tied,  (at
         two days' interval, successfully, but did
         not arrest the Aneurism,) by R. D Mus-
         sey, M. D. New Hampshire.—Am. Journ.
         Med. Sciences, vol. v. p. 316, 1829;  also
         Maryland Medical Recorder, vol. i. p. 543.
                                         1829.
       Case  of  Ligation of the Carotid for Anas-
  tomosing  Aneurism  in a  Child  three
  months old, (cured,)  by Valentine  Mott,
  M.D.   New York.—Am. Journ. Medical
  Sciences, vol. vii. p. 271; also  vol. v.  p.
  255.                             1830.
Description of the Circulation of the Head
  and Neck, in a Case in which  one Caro-
  tid  had been  tied, by Valentine  Mott,
  M.D.   New York—Am. Journ. Medical
  Sciences, vol. viii. p. 45.           1831.
Case of  Telangiectasis  of Cheek, cured by
  Ligation of the  Common Carotid, by
  George Bushe, M D.   New York.—New
  York  Medico-Chirurgical Bulletin, vol. i.
  p. 53.                            1832.
Case of  Ligation of the Common  Carotid
  (in  a court-room) for attempted Suicide,
  by William L. Horner, M.D.   Philadel-
  phia.—Am  Journ. Med. Sciences, vol.  x.
  p. 403.                          1832.
Case of  Aneurism  of the Carotid, treated
  by  Puncture with a  Cataract  needle,
  heated to  a white heat,  (in  1826,) by
  George Bushe, M D. New York—Medico-
  Chirurgical Bulletin, vol. ii. p. 209  1832.
Case  of  Anastomosing Aneurism of the
  External Maxillary (Temporal)  Artery,
  successfully treated  by tying the Com-
  mon Carotid, by David L. Rogers, M.D.
  New York.—Am. Journ.  Med. Sciences,
  vol. xiii. p. 271.                  1833.
Case of Aneurism of the right Subclavian,
  in which a Ligature  was applied to the
  Innominata, (patient  died on the fifth
  day,)  by  Richard Wilmot Hall.  M.D.
  Baltimore.—Baltimore Med. and  Surgical
  Journal, vol. i. p. 125.            1833.
Ligation of both  Carotid Arteries simul-
  taneously, (died  in twenty-four hours,)
  by  Valentine  Mott,  M.D., New  York.
  Reported  by Dr.  Vache.—Am.  Journ.
  Med. Sciences, vol. xiv. p. 530.     1834.
Case  of  Ligation of both  Carotids, (suc-
  cessful,) by R. D. Mussey, M.D.—Fair-
  field,   N.  Y —Am. Journ.  Med.  Sciences,
  vol. xxi. p. 397.                  1837.
Case of Gunshot  Wound of the  Face and
  Neck,  Ligation of the Carotid,  (cured,)
  by  Dr. Twitchell.  New  Hampshire.—
  Am. Journ. Med.  Sciences, vol.  v. N.  S.
  p. 510, 1843;  also New  England  Quar-
  terly Journ. Med. and Surg., Oct.  1842.
Case of Subcutaneous Erecti e Tumor of the
  Cheek, Ligation of the Common Carotid
  Artery, (death from Phlebitis and Pus
  between the Meninges of the Brain,)  by
  A. C. Post, M.D. New York.—Am. Journ.
  Med. Sciences, vol. x. N. S. p. 539,  1845 ;
  alsoiVew York Journ. of Med., Sept. 1845.
Case of  Gunshot Wound, Secondary Hem-
  orrhage. Ligation of both Carotids at an
  interval of four and a half days,  (cured,)
  by  John  Ellis,  M.D.   Michigan.—Am.
  Journ. Med. Sciences, vol. x. N. S  p 534,
   1845; also New York Journ. of Medicine,
   Sept.                            184.-,!
/ 
PAPERS  ON  DISORDERS  OF THE NECK AND TRUNK.
365
/
Case of Ligation of the Carotid Artery for
   Fungous Tumor of the Neck,  (died,) by
   George C  Blackman, M.D.   New York.
   —Am. Journ. Med. Sci., vol. x. N. S  p.
   331.                             1845
Ligation (successful) of both  Carotids (at
   an interval of  near five weeks) for a re-
   markable Erectile Tumor of the Mouth,
   Face, and Neck,  by J. Mason Warren,
   M.D. Boston.—Am. Journ. Med. Sciences,
   vol. xi. N. S. p. 281.              1846.
Case  of  Ligation of Common Carotid for
   removal of the Parotid Gland, (success-
   ful,) by A. B.  Shipman, M.D.   Illinois.
   —Am.  Journ.  Med. Sciences, vol. xiv. N.
   S. p. 264.                        1847.
Case  of Ligation of the Primitive Carotid
   Artery, (cured,) by H. F. Campbell, M.D.
   Georgia.—Am. Journ. Med Sciences, vol.
   xiv. N.  S  p.  542, 1847: also Southern
   Med. and Surg. Journ., August,     1847.
Case  of Ligation of the Carotid Artery,
   followed by Hemorrhage,  and  Recovery,
   by G. Hay ward, M.D.   Boston.—Boston
   Med. and Surg. Journ., vol. xxxvi. p. 449.
                                   1847.
Statistics of the Mortality following the
   Operation  of tying the Carotid Arteries
   and Arteria Innominata,  by George W.
   Norris, M.D. Philadelphia.—Am. Journ.
   Med. Sci.,  vol. xiv. N. S. p. 13.    1847.
Ligation of both Primitive Carotids, (suc-
   cessful,) by George C. Blackman, M.D.
   New York.—Am. Journ.  Med. Sci, vol.
   xv.  N. S. p. 357.                 1848.
Statistics of  Large Surgical  Operations,
   (performed in private practice,) by Usher
   Parsons, M.D.  Rhode Island.—Ameri-
   can Journ. Med. Sci., vol. xv.  N. S. p. 359.
                                   1848.
Case of Ligation of the Common Carotid,
   (in  two  cases, both died,)  by John P.
   Mettauer,  M.D.  Virginia.—Am. Journ.
   Med. Sci.,  vol. xviii. N. S.  p. 348.
                                   1849.
Case of Wound of the External Carotid—
   Ligation of the Common Carotid,  (result
   unknown,) by E. Geddings, M. D. Charles-
   ton.—Am  Journ. Med. Sci., vol.  xviii.
   N. S p. 550.                     1849.
Case of Ligation of the Primitive Carotid
   Artery, below  the Omo-Hyoid Muscle,
   (cured,) by George Fox, M.D.   Phila-
   delphia.—Am.  Journ. Med. Sciences, vol.
   xviii. N. S. p. 381.               1849.
Case of Wound of the External Carotid, in
   which  a  Ligature was applied  to  the
   Common Carotid, by E. H. Deas, M.D.
   South Carolina.—Charleston Med. Journ.,
  vol.  iv. p. 585.                   1849.
Case of Ligation of the Principal Carotid,
   (successful,)  by  Paul F.  Eve,  M.D.
  Georgia.—Southern  Medical  and  Surg.
  Journ., vol. vi. p. 210.            1850.
Ligation of the Carotid Artery in Epilepsy,
  (three  years after operation, patient as
  bad as ever,) by C. Morrogh, M.D. New
  Brunswick, N. J.—N.  Y. Journ. Med.,
  vol. viii. N. S.  p. 419.            1852.
Aneurismal Tumors upon the Ear success-
  fully treated by Ligation of both the Ca-
  rotids, (at four weeks' interval, patient
  etherized,) by R. D. Mussey, M.D. Cin-
  cinnati.— Ohio Med. and  Surg.  Journ.,
  vol. vi p. 125.                  1853.
Ligation of the External Carotid  Artery,
  as a preparatory act to the excision of a
  Fungus Haematodes, performed by Prof.
  C.  W. Wutzer, of  Bonn.  Reported by
  John C. Jennings, M.D.—St. Louis Med.
  and Surg. Journ., vol.  xii. p. 66.  1854.
Wound  of the  External Carotid  Artery
  Cured by Compression and Styptics, by
  J.  W. Reynolds,  M.D.   New  Market,
  Mo.—St.  Louis Med. and Surg.  Journ.,
  vol. xii. p. 69.                   1854.
Ligation of the Commou Carotid  Artery,
  by Joseph B. Brown, M.D.  U. S. Army.
  —Am. Journ. Med. Sciences, vol.  xxviii.
  N. S.  p. 415.                    1854.
Gunshot Wound of the Neck, Ligation  of
  the Common Carotid,  Recovery, by C.
  E. Isaac, M.D.  New York.—New York
  Journal of Medicine, vol.  xv. N. S.  p.
  151.                            1855.
Ligation of  the Carotid Arteries, with
  Statistics, by G. C. Blackman, M.D. Cin-
  cinnati.— Western  Lancet, vol. xvi.  p.
  514.           .                 1855.
AVound of the Occipital Artery and Jugu-
  lar Vein, Ligation of the Carotid Artery,
  by  John  H. Packard, M.D.   Philadel-
  phia.—American Journal Med. Sciences,
  vol. xxxi. N. S. p. 396.          1856.
Statistics of Ligation of  the Arteria Inno-
  minata, by P. F. Eve, M.D.   Nashville,
  Tenn.—New York Journal of Medicine,
  vol. i. 3d series, p.  275.          1856.
Aneurism of the Carotid communicating
  with the  External Jugular Vein, unsuc-
  cessful operation, by John  G. T. Holston,
  M.D.   Ohio.— Western Lancet, vol. xvii.
  p. 199.                          1856.
Deep  Wound  of the Parotid  region,  in
  which a ligature was simultaneously ap-
  plied to the Common and Internal Caro-
  tid  Arteries, Recovery,  by  Gurdon Buck,
  M.D.   New York.—Am. Journ.  Medical
  Sciences, vol.  xxxi. N. S. p. 267.   1857.
Early History of the Ligation of the Com-
  mon Carotid, with a Report of the  Un-
  published Operations in the city of New
  York, by James  R.  Wood, M.D.  New
  York.—New  York Journal of Medicine,
  vol. iii. 3d series, p. 9.            1857.
Ligation of the Primitive Carotid Artery
  for  Malignant  Disease, by G. C.  Black-
  man, M.D.  Ohio.— Western Lancet, vol.
  xviii.  p. 627.                    1857.
Case of  Ligation of the  Common Carotid
  Artery in the lower half  of its  course,
  by C. E. Isaacs, M.D.   New York.—New
v
V 
366
PRINCIPLES AND PRACTICE OF SURGERY.
  York Journal  of Medicine, vol. v. 3d se-
  ries, p. 11.                      1858.
Aneurism of the Right Carotid and  Sub-
  clavian Arteries, Ligation of the Arteria
  Innominata, by E. S. Cooper, M.D.   San
  Francisco,  Cal.—Am.  Journal Medical
  Sci., vol. xxxviii. N. S. p. 395.    1859.
Ligation of the Common Carotid Artery for
  Aneurism by  Anastomosis, with  other
  Surgical cases, by  E.  D. Cheuy,  M.D.
  Columbus, Miss.—New Orleans Med. and
  Surg. Journal, vol. xvi. p. 672.    1859.
ON LIGATION  OF  THE SUBCLAVIAN
     AND AXILLARY  ARTERIES.

Observations relative to the Ligation of
  the  Subclavian Artery,  (recommend-
  ing a new Aneurismal  Needle, since de-
  signated as the Philadelphia  Needle,
  with a drawing.)  by  Joseph Parrish,
  M.D. Philadelphia.—Eclectic Reperl. aud
  Analyt. Revieu; vol. iii. p. 229.    1813.
Ligation  of  the  Axillary Artery/(cured.)
  by  Thomas Hubbard. M.D.   Pomfret,
  Connecticut. — New England Journ. of
  Med. and Surg., vol. iv. p.  211.    1815.
Case of Brachial Aneurism cured by tying
  the Subclavian Artery above the Clav-
  icle, by Wright Post, M.D.  New York.—
  Transact. Phys. Med. Soc. of New  York,
  vol. i.  p  387.       •            1817.
Remarkable Spontaneous Cure of Aneu-
  rism, with Observations on Obliteration
  of Arteries, by William Darrach, M.D.
  —Phila. Med. and Phys. Journ., vol. xiii.
  p. 115.                          1826.
Case of Axillary Aneurism,  (from the re-
  duction of an old luxation,) in which the
  Subclavian Artery was tied, (died,) by
  William Gibson, M.D.  Philadelphia.—
  Am. Journ. Med. Sciences, vol. ii. p. 136.
                                  1828.
Case of Axillary  Aneurism removed by the
  application of  a Ligature to the Subcla-
  vian Artery,  (cured,) by Edward W.
  Wells,  M.D.   Communicated  by  Felix
  Pascalis, M.D.  New York.—Am. Journ.
  Med. Sciences, vol. iii. p. 28.       1828.
Ligation  of the Subclavian Artery for Ax-
  illary Aneurism, (cured,) by Benjamin
  W. Dudley, M.D.  Lexington, Kentucky,
  1825.—Transyl. Journ. Med.,  vol. ii. p.
  363.           '                 1829.
Case of Axillary Aneurism, in which the
  Subclavian was successfully secured by
  a  Ligature, by Valentine Molt, M.D.
  New York.—Am.  Journ.  Med.  Sciences,
  vol. vii. p. 309.                  1830.
Case of Aneurism of  the Right Subclavian
  Artery, in which  that vessel  was tied
  within  the Scaleni Muscles, (died on the
  eighteenth day,)  by   Valentine  Mott,
  M.D.  New York.— Am. Journ. Med. Sci-
  ence*, vol. xii.  p. 354.             1833.
Case of Ligation of the Left  Subclavian,
  (successfully performed,) by Valentine
  Mott,  M.D.   New York. — Am. Journ.
  Med. Sciences, vol. xiv. p. 530.      1831.
Entrance of Air into the Vein  while ligat-
  ing the Subclavian Artery,  (recovery,)
  by R. D. Mussey,  M.D.  Fairfield, New
  York. — Am. Journ. Med. Sciences, vol.
  xxi.  p. 377.                      1837.
Case of successful Ligation of the Subcla-
  vian, by  G. H. White,  M D.   Hudson,
  N. Y. —Am. Journ.  Med. Sciences, vol.
  xxiii. p. 351.                     1839.
Case of Axillary Aneurism. Ligation of the
  Subclavian, (above the Clavicle,) death
  on the thirty-first day, by S. D. Gross,
  M.D.  Louisville.—Am Journ. Med. Sci-
  ences, vol. ii. N. S. p.  517.         1841.
Case of Wound of the Axillary Artery and
  Plexus of Nerves, Amputation below the
  Shoulder, Secondary Hemorrhage, Liga-
  tion of the Subclavian, (successful,) by
  Alfred C. Post, M.D.   New York.— Am.
  Journ. Med. Science^, vol. x. N. S. p. 263;
  also, New  York  Journ. Med. and Collat.
  Sciences, March,                  1845.
A Table, showing the Mortality following
  the Operations of tying the Subclavian
  Artery, by G. W. Norris, M.D.   Phila-
  delphia —Am. Journ. Med. Sciences, vol.
  x. N. S. p. 13.                    1*45.
Case of Ligation of the Subclavian Artery,
  between  the Scaleni  Muscles,  attend-
  ed with  some Peculiar  Circumstances,
  (cured.) by John C. Warren, M.D.  Bos-
  ton—Am. Journ. Med. Sciences, vol. xi.
  N. S. p.  539, 1846;  also,  Med. Times.
  Dec.  6,                           1845.
Case of Ligation of the Left Subclavian
  within the Scaleni Muscles, (died,) by
  J. Kearny Rodgers, M.D.  New York.—
  Am. Journ. Med. Sciences, vol. xi. N. S.
  p. 511, 1846; also N.  Y.  Journ. of Med.,
  March,                           1846.
Case of Ligation of the Left Subclavian Ar-
  tery, for Subclavian Aneurism, (cured,)
  Ligation remaining ninety-six days, with
  a  Remarkable  Deviation of the Vessel
  and Consequent Change of its Relations,
  by J. Mason Warren, M. D.   Boston.—
  Am.  Journ. Med. Sciences, vol.  xvii. N. S.
  p. 13.                            1849.
Notice of the Anatomical Phenomena, in a
  Case of Ligation  of the Subclavian Ar-
  tery, four years subsequent  to the Oper-
  ation,  (showing the  collateral Circula-
  tion, etc.,) by F. S. Ainsworth, M.D.  Bos-
  ton.—Am. Journ. Med. Sciences, vol. xix.
  N. S. p. 83.                      1850.
Ligation of Left Subclavian Artery, exter-
  nal to Scalenus Muscle, (cured,) by Val-
  entine Mott,  M.D.   New York.  Re-
  ported by John  O'Reilly, M.D.__N. Y.
  Journ. Med., vol. v. N. S. p. 16.   1851.
Subclavian Aneurism successfully treated
  by Ligation of the Left  Subclavian Ar- 
PAPERS  ON  DISORDERS OF THE  NECK AND  TRUNK.       367
/
  tery, with an Accountof the Appearances
  on  Dissection,  a  year  subsequently,
  (being the result of the case of ligation
  of this  artery reported in 1849,) by  J.
  Mason  Warren,  M.D.   Boston.—Am.
  Journ. Med. Sciences, vol. xxi. N. S.  p.
  53.                              1851.
Case of Ligation of the Subclavian Artery,
  with  Statistical Data, by Wm. II. Van
  Buren,  M.D.   New York.—Trans.  Med
  Society of New York, p. 27.        1853.
Ligation of the Right Subclavian Artery
  for Axillary Aneurism, by H. E. Dray-
  ton, M.D.   Philadelphia.—Am. Journ.
  Med. Sciences, vol. xxxviii. N. S. p. 402.
                                   1859.

  ON REMOVAL  OF  THE CLAVICLE.

An Account of a Case of Osteo-Sarcoma of
  the Left Clavicle, in which Resection of
  that Bone (entire) was successfully per-
  formed, by  Valentine Mott, M.D.   New
  York.  This was the first case published,
  though the second  performed.—Amer
  Journ  Med. Sci,, vol. iii. p. 100.    1828.
Case of Removal of the Clavicle in a State
  of Osteo-Sarcoma, (died  on  the fourth
  week,) by JohnC. Warren, M.D. Bosion.
  — Am. Journ. Med. Sciences, vol. xiii.  p.
  17.                              1833.
Case of Complete Removal of the Clavicle,
  (for Caries,) by A. J. Wedderburn, M.D.
  New Orleans.—N Orleans Monthly Med.
  Register, vol. ii. p. 1.              1852.
Csection of the entire Clavicle, in 1813, by
  diaries M'Creary, M.D.   Hartford, Ky.
   This was the first operation of the kind
   n the United States, though it was not
  published till 1850.)  The patient lived
  thirty-five  years subsequently, and had
  a useful limb. —History of Kentucky Surg.,
  p. 180.                           1853.
Exostosis of the Clavicle, and its Extirpa-
  tion, by E.  M. Bartlett, M.D.  Louisiaua,
  Missouri.—St Louis  Med. and Surgical
  Journ., vol. xii. p. 64.            1854.
Osteo-Sai coma of the Clavicle.  Operation
  by J. A. Owens, M.D.  Monticello, Ark.
  — New Orleans Med. and Surg. Journ.,
  vol. xi. p.  164.                  1854.
Removal of the Entire Clavicle, (recovery,)
  by G. C. Blackman, M.D.   Ohio.— Am.
  Journ. Med. Sciences, vol. xxxii. N. S.  p.
  573.                            1856.
Extirpation  of the  Entire Clavicle, by C.
  R. S. Curtis,  M.D.   Chicago.—Amer.
  Journ. Med. Sciences, vol. xxxiv. N.  S.
  p 350.                           1857.
 ON RESECTION OF THE  SCAPULA.

Case of Resection of  the  Entire  Scapula,
  (for  a large Tumor, the glenoid cavity
  being left—recovery—but died  subse-
  quently of Pleuro-Pneumonia, followed
  by hectic,) by S. D. Gross, M.D. Louis-
  ville.— Western Journ. of Med. and Surg.,
  vol. xi. 3d S. p. 419.             1853.
Removal of the  Scapula, by G. C. Black-
  man, M.D.  Ohio.—Am. Journ. Med. Sci.,
  vol. xxxvi. N. S. p. 578.          1858.
    OPERATIONS ON THE BREAST.

I On Cancer of the Breast, by Joseph Par-
    rish,  M.D  Philadelphia.—North Amer.
\    Med.  and Surg. Journ., vol.  vi.  p. 293.
I                                   1828.
j History of a Case of Sarcomatous Tumor of
    the Mamma, extirpated by N. Hitt, M.D.
    Vincennes, Indiana.—Transylvania Jour-
    nal of Med., vol. iv. p.  508.       1831.
 Case of Cancerous Breast, with partial Os-
    sification of that Organ, by John  Maclel-
    lan, M.D.   Greencastle —Am. Journal
    Medical  Sciences, vol. xiii. p.  277.  1833.
 Extirpation of the Mamma of a female, in
    the Mesmeric Sleep,  without, any evi-
    dence of sensibility during the operation,
    by L. A. Dugas, M.D.  Georgia.—South.
    Med. and Surg. Journ., vol. i. N.  S. pp.
    122, 508.                        1845.
 Extirpation of Scirrhus Tumors from the
    Mammary  Region and of the enlarged
    Axillary Glands, the patient being ren-
    dered insensible by Mesmerism, by L. A.
    Dugas, M.D.  Georgia.—South. Med. and
    Surg. Journ., vol. ii. N. S. p. 72.  1846.
 Amputation of the  Breast for Scirrhus,
    (during etherization—healed readily—
    disease  returned in nine months.)  by
    Henry H. Smith, M.D.   Philadelphia.—
    Philadelphia Medical Examiner,  vol.  vii.
    p.  33.                          1851.
 Amputation of Breast for Scirrhus, (during
    etherization — healed   readily — disease
    returned in thirteen months,) by  Henry
    H.  Smith,  M.D.  Philadelphia.—Phila.
   Medical  Examiner, vol.  vii. N. S. p. 236.
                                   1851.
 Removal of the Breast, (successful, but no
   subsequent history,) by Jos. Pancoast,
    M.D.   Philadelphia.—Philadelphia Med.
    Examiner, vol. vii.  N. S. p. 249.   1851.
 Medullary Sarcoma of the Right  Breast,
    (amputation—Tumor weighed four and
   a half pounds—died fifty-seven days sub-
   sequently,) by Carter P. Johnson, M.D.
    Richmond, Va.—Stethoscope, vol. i.  p.
   139.                            1851.
 Fibrous Tumors'of the Mamma, Extirpa-
   tion,  by L.  A. Dugas,  M.D.  Georgia.
    Southern Medical and Surg. Journ., vol.
   vii. N. S. p. 271.                 185L
 Cancer  of the Breast, by T.  M. Markoe,
    M  D.   New York.—N.  York Journal of
    Medicine, vol. xiii. N. S. p. 85.    1854.
 Scirrhus and  Fungoid Affections  of  the
    Female  Mamma, by John P. Mettauer, 
368
PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  M D.  Virginia.—New  Orleans  Medical
  and Surg. Journ., vol. xi. p. 23,8.  1854.
Disordered Nipple, Excision, by Juriah
  Harris,  M.D.    Augusta,  Georgia.—
  Southern Med. and Surg. Journal, vol. xi.
  N. S. p. 408.                     1855.
Fibro-plastic Tumor, (of the Breast,) Extir-
  pation, by Juriah Harris, M.D.  Augusta,
  Ga.—Southern Med.  and Surg.  Journal,
  vol. xi. N. S. p. 407.              1855.
Hypertrophy  of  the  Male  Mamma,  re-
  moval, by P. F. Eve,  M.D.  Nashville,
  Tenn.—New  York Journ.  of Med., vol.
  xiv. N. S. p. 156.                1855.
Observations on Inflammation and Abscess
  of the  Female Breast, by J. E.  Thomp-
  son, M.D.  Butler, Mo.—St. Louis Med.
  and Surg. Journ., vol xiv. p. 193.  1856.
Treatment of Abscesses of the Breast when
  open, by means of Compressed Sponge,
  etc., by S. Conant Foster,  M.D.  New
  York.—New York Journ. of Med.,  vol.
  iii. 3d series,  p. 179.            1857.
Report of Fourteen Cases of Mammary Ab-
  scesses treated with Compressed Sponge,
  (Foster's method,) by John G. Johnson,
  M.D , House  Surgeon to Bellevue Hos-
  pital.  New York.—N.York Journ Med.,
  vol. iii  3d S  p. 247.            1857.
Silver Ligatures and Sutures in a Case of
  Amputation of the Mammary Gland, by
  Thomas Addis Emmet, M.D. New York.
  —Am. Journ.  Med. Sciences, vol. xxxviii.
  N. S. p.  120.                    1859.
     ON  TUMORS OF THE CHEST.

Case of Enormous Steatoma, removed from
   the Side, by J. M. Foltz, M.D.   U.S.N.
   —Am. Journ. Med. Sciences, vol. xi. N. S.
   p. 358.                         1846.
A Case of Congenital Encysted Tumor of
   the Right Side of the Chest, successfully
   treated with the Seton, by  S. D. Gross,
   M.D.  Louisville.—Am. Journ. Med. Sci-
   ences, vol. xvii. N.  S. p. 22.        1849.
Statistics of Twelve Cases of Fungus Haem-
   atodes of the Trunk, Mamma, Face, and
   Extremities, in which seven were oper-
   ated upon, and five benefited probably,
   by Paul  F.  Eve,  M.D.    Georgia.—
   South. Med. and Surg. Journ., vol. vi. p.
  577.                             1850.
Axillary   Tumor,  (Enlarged   Lymphatic
  Gland,) by Juriah Harris, M.D. Augusta,
  Ga.—South. Med. and Surg.  Journ., vol.
  xi. N. S. p. 403.                  1855.
    OPERATIONS ON THE CHEST.

Case of Extensive Caries of the Fifth and
  Sixth  Ribs, and Disorganization  of the
  greater part (about two pounds) of the
  Right Lung, with  a  Description of the
   Operation for the same, (being its re-
   moval, the pitient living several months
   subsequently,) by Milton Antony, M.D.
   Augusta, Georgia.  (With  a  Certificate
   from  John  Pugsley,  M.D.   Jefferson
   County, Georgia.)—Phila.  Journ.  Med.
   and Phys. Sciences, vol. vi. p. 108. 1823.
 Escape of all the Intestines through a Hole
   in the  Diaphragm into the Right Side of
   the Thorax, by  Edward  Cornell, M.D.
   Coventry, Chenango County, N. Y.—Am.
   Med. Record., vol. viii. p.  236.     1825.
 On the Pathology of Bones,  with a Case of
   successful removal of Carious Ribs, by
   H. McDowell, M.D.  Fincastle, Va.—
   Am. Med. Recorder, vol. xiii. p. 98. 1828.
 Operation of the Trephine for the  removal
   of a portion of Carious Sternum,  by
   Abner  Hopton,  M.D.  North Carolina.
   —Am.  Journ. Med.  Sciences, vol. v. p.
   545.                            1829.
 Two Cases of Excision of the Ribs, (suc-
   cessful,) by John C.  Warren, M.D. Bos-
   ton.—Boston  Med. Journ.,  vol.  xvi. p.
   201.                            1837.
 An Account of a successful  Operation for
   the Excision of the  Ossified Cartilages,
   and Anterior Extremities of two  Carious
   Ribs, and the Lower Portion  of the
   Sternum, (the patient lived twenty years
   subsequently,) by  George  M'Clellan,
   M.D.  Philadelphia.— Western Journ. of
   Med.  and Phi/s. Sciences, vol. iv. p. 479,
   1831; also A Report, by J. H. B. M'Clellan,
   M.D., Medical Examiner, vol. vi. N. S. p.
   75.                             1850.
 Statistical Observations on Wounds of the
   Heart, and on their Relations to Forensic
   Medicine, with a Table of 42 recorded
   Cases, by S. S. Purple, M.D — New York
   Journal of Med.,  vol. xiv.  N. S. p. 411.
                                  1855.
 Gunshot Wound of the Lungs, by E.  P.
   Gaines, M.D. Mobile, Ala.—New Orleans
   Med.  and  Surg. Journ., vol.  xii.  p. 233.
                                  1855.
 Aneurisms of the  Aorta,  Wound  of  the
   Aorta,  by  J. Mercer  Green,  M.D.
   Macon,  Ga.—Southern Medical and Surg.
  Journ.,  vol. xi. N. S. p. 325.      1855.
Case of Impalement, by A. C. Garratt,
   M.D.  Boston.—Am. Journ. Med. Sciences,
  vol. xxxv. N. S. p. 568.           1858.
Remarkable  Recovery from a Wound of the
  Lung, complicated with numerous severe
  wounds of the Back and Face, in a Man
  sixty-one years of age, by Thomas Ken-
  nard, M.D.  St. Louis.  (St. Louis Medi-
  cal Society's Reports.)—St. Louis Med.
  and Surg. Journ., vol. xvii. p. 486. 1859.
            ON EMPYEMA.

Operation for Empyema, Excision  of  a
  Piece of the Lung as large as a Nutmeg, 
PAPERS  ON  DISORDERS OF THE NECK AND  TRUNK.       369
  (cured,) by Isaac Rand, Esq., Vice-Presi-
  dent of the Massachusetts Medical So-
  ciety, May, 1783.—Med.  Communications
  and Dissertations of Mass. Med. Soc , vol.
  i. p. 69.                          1790.
Case  of Paracentesis  Thoracis,  (cured.)
  by Charles Hall, M.D.  Swanton,  Vt.—
  New York Medical Repository, vol. xx. p.
  36.                               !«:>().
Case  of Paracentesis Thoracis, (life pro-
  longed,)  by Lemuel W.  Briggs,  M.D.
  Bristol, R. I—New  England Journal of
  Med. and Surg., vol.  ix. p. 223.    1820.
Case of Empyema  successfully treated by
  Paracentesis Thoracis,  by J. Craven,
  M.D. Harrisonburg, Va.—Am. Med. Re-
  cord., vol. vii. p. 363.             1824.
Case of Effusion into the Chest, in which
  Paracentesis Thoracis was  performed,
  (died.) by Samuel Jackson, M.D.  Phila-
  delphia.—Phila. Journ. Med. and  Phys.
  Sciences, vol. x. p.  119.            1825.
Case of Empyema, (cured by Paracentesis,)
  by A. S Sheldon, M.D. Broome County,
  N. Y.—Am. Med. Record., vol. ix. p. 273.
                                   1826.
History of a Case of Empyema  from pro-
  tracted  Measles  and  Pleurisy, in which
  the Operation of Paracentesis gave im-
  mediate Relief, by Samuel  Merriwether,
  M.D.  Indiana. — Western Journ. Med.
  and Phys.  Sciences, vol. iii. p. 65.  1830.
Paracentesis  successfully  performed  for
  Empyema, by T. Wolfley,  M.D.  Lancas-
  ter, Ohio.—Maryland Med. Record., vol.
  ii. p. 56.                         1832.
Case of Empyema cured by an Operation,
  by  J. Pancoast, M.D.  Philadelphia.—
  Am. Journ. Med. Sciences, vol. xiii.  p. 93.
                                   1833.
Case of Empyema successfully treated by
  an  Operation, (Paracentesis Thoracis,)
  by W. C. Sneed, M.D.  Kentucky.—Am.
  Journ. Med. Sciences, vol. x. N. S. p. 538.
                                   1845.
Case of Gunshot Wound of the Chest, the
  thick Linen Patch with  which the Ball
  was  enveloped  remaining in  the  Left
  Lung twenty years,  by M. H.  Houston,
  M.D.  Virginia.—Am. Journ. Med. Sci.,
  vol. ix. N.S. p. 342.              1845.
Case  of Empyema, in  which Paracentesis
  Thoracis  failed  from a cause not gener-
  ally noticed, (a  membrane, lining  the
  Pleura Costalis, being pushed before the
  instrument, and  not opened,) by John
  A. Sweet, M.D.  New York.— Am. Journ.
  Med. Sciences,  vol.  xiii.  p. 518,  1847;
  also, New  York Journal of Medicine, Jan-
  uary,                           1847.
Case of Paracentesis Thoracis for Abscess
  in the Lungs, (Vomica.) recovery, by S.
  Howard Dickson,  M.D.  Mecklenburg,
  Tenn. —Charleston Med. Journal, vol vi.
  p. 667.                          1851.
Case of Empyema, with Remarks especially
  in reference to Paracentesis,  (recom-
  mending  it,) by William Pepper, M.D.
  Philadelphia.—Am. Journ. Med. Sciences,
  vol.  xxiii. N. S. p. 38.            1852.
Three  Cases  of  Paracentesis  Thoracis,
  (performed  by  means  of the exploring
  trocar and suction apparatus,) by H. J.
  Bowditch, M.D.   Boston.—Am. Journ.
  Med. Sciences,  vol.  xxiii. N. S. p. 103.
                                  1852.
Paracentesis  Thoracis (successful)  in  a
  Case of Acute Pleurisy, by J. Williams,
  M.D. Boston.—Am.Journ.Med.Sciences,
  vol.  xxiii. N. S. p. 112.          1852.
On  the Necessity  of Paracentesis Thoracis
  in Pleuritic  Effusion, by Henry J. Bow-
  ditch, M.D.   Boston.—Am. Journ. Med.
  Sciences, vol. xxiii. N. S. p. 320.  1852.
Cases (four) of Paracentesis Thoracis, (by
  the trocar of Schuh,)  by John T. Met-
  calfe, M.D.   New  York.— N  Y. Med.
  Times, vol. ii. p. 337.             1853.
Paracentesis Thoracis performed on a Child
  seven years of age for Pleuritic Effusion,
  rapid recovery, by Wm. A.  Tracy, M.D.
  New Hampshire.—New York Journ. Med.,
  vol. xi. p.  353.                   1853.
Empyema, with Pneumothorax, from Punc-
  tured Wound, by L. D. Waterman, M.D.
  Cincinnati.— Western Lancet, vol. xv. p.
  76.                             1854.
Paracentesis Thoracis, by  Henry J. Bow-
  ditch, M.D.   Boston.—Am. Journ. Med.
  Sci., vol. xxxiv. N. S. p. 291.     1857.
Empyema treated by Injections  of Water
  into the Cavity of  the Pleura, by Sterns
  De Witt,  M  D.  Baker County,  Georgia.
  —Southern Med. and Surg. Journ., vol.
  xiv.  N. S. p. 175.                 1858.
Paracentesis Thoracis, by John  T. Met-
  calfe. M.D.  New York.—N Y. Journal
  of Medicine, vol. iv. 3d series, p. 25. 1858.
Empyema of the Left Pleural Cavity treat-
  ed  by Injection  of Iodine, by  Daniel
  Brainard, M.D.  Chicago.—Am.  Journ.
  Med. Sci., vol. xxxvi. N. S. p. 289.  1858.
vol.  ii.—24 
\ 
PART   XIV\
DISORDERS OF, AND  OPERATIONS ON, THE  ABDOMEN.
                          CHAPTER I.

  The Parietes of the Abdomen, like similar tissues elsewhere, are liable to
the development of tumors of various  kinds, the  fibrous  and lipomatous
being those most frequently met with.   As the removal of these  tumors is
to be accomplished on the same general principles as  those already desig-
nated in the account  of the neck, this slight  allusion to them may be suffi-
cient to preserve the continuous arrangement  of the subject adopted as the
order of the present work.
  Within the  walls of the abdomen there are, however, such  a  variety of
organs that their  surgical disorders  require a more detailed consideration ;
and while reserving  the  account of Hernia for another chapter, and the
operations upon the genito-urinary organs through the abdominal parietes
for another Part, there remains to be described the surgical treatment adapted
to the relief of certain disordered conditions of  the peritoneum, liver, stomach,
and intestines.
  As the surgical  anatomy of these organs does not offer any points worthy
of special consideration, when we exclude such details  as are generally pre-
sented in an account of their special  anatomy, the operations demanded for
the relief of affections  of the  peritoneum  may first claim attention; after
which, those required by some  of the disorders of the abdominal organs will
be referred to.
  In doing this I  shall, however, limit my descriptions to such as  are gener-
ally recognized as justifiable;  extirpation of  the spleen or scirrhus of the
pancreas not being included in  this class.


                            SECTION I.

                      PARACENTESIS ABDOMINIS.

  The accumulation of  such  an amount  of serum within the  peritoneal
cavity as seriously interferes with respiration,  has usually been deemed suffi-
cient cause to justify its  evacuation  by an operation,  although little more
than temporary relief can  be anticipated, unless the cause of the effusion is
of  a  comparatively slight character  and amenable to  a  constitutional
treatment.
  Ordinary Operation of Paracentesis Abdominis.—Having prepared  a
                                                        (3U) 
372            PRINCIPLES AND PRACTICE  OF SURGERY.
good flat trocar and canula,  surround  the patient's belly with a broad band-
age, the euds of  which should be cut  into tails, crossed upou the back, and
drawn  tight by assistants, in order to  keep up constant pressure upon  the
abdominal cavity as the liquid escapes; or the same pressure may be effected
merely by the  pressure of the assistants' hands; or, in debilitated patients,
the escape of the liquid may  be left entirely to the contraction of the abdom-
inal walls, which will thus regulate the flow of the liquid and the rapidity of its
escape.   The surgeon, being then perfectly  satisfied of the correctness of his
diagnosis, has  only to push the trocar through the abdominal parietes near
the median line of the abdomen,  about two  inches below the umbilicus, and,
withdrawing the  trocar, allow the fluid to escape through  the canula until
he is satisfied that sufficient has been evacuated, when, removing the instru-
ment, he should  close the wound by a piece of adhesive plaster, and cover
this with a compress and bandage.
  Remarks.—Simple as this operation evidently is, surgeons have differed
somewhat in regard to the details of its  performance.   Thus, some have
advised that the patient should  be seated, others  that  he  should be lying
down ;  some have recommended the  entire evacuation  of the fluid at  the
first operation, while others direct the removal of only a part of it; some
have selected the trocar and  canula, as meutioned iu the preceding account
of the operation, and others  preferred  the use of  a lancet and catheter.   As
these differences  are chiefly the result  of individual opinion, the surgeon, in
deciding upon the advantages of one method over another, must,  of course,
be guided by the peculiarities of the case.   Physick* always advised making
the puncture with a  lancet, and then  introducing  a flat canula or female
catheter; and  this will be found  to constitute a safe and easy mode of oper-
ating.   The use of  the  catheter has, however, been recently claimed for
Fleming, of the  Val  de  Grace,f though it had, as is  shown  above, been
employed many years before his suggestion was aunonnced.
   Physick's Operation.—The patient lying down near the edge of the bed,
with a  piece  of oil-cloth under him,  a lancet  was  inserted through  the
abdominal parietes in the line of the linea alba, about two inches below the
navel, the fluid being  allowed to escape through the puncture  as  soon  as it
was removed.  After the liquid had partially escaped, and the stream began
to diminish, a  female catheter was introduced into  the peritoneal cavity, in
order to favor the further evacuation of its contents.   The subsequent dress-
ing was the same as in the ordinary operation.
  Estimate.—The advantage  of the operation recommended by Physick
will be found in the slight pain caused by the puncture ;  iu the greater ten-
dency of the parts to heal;  in the impossibility of pushing the peritoneum,
especially in encysted dropsy, in advance of the  instrument; in  the patient
being less likely to faint when lying down than when sitting up ; and in  the
more gradual evacuation of  the fluid permitting  the abdominal  parietes to
accommodate  themselves to the vacuum otherwise  liable to be left in  the
abdomen, unless  the belly is  kept well bandaged.   As it is also well known
that incised wounds  are  less liable  to inflammation than punctured,  the
chances of peritonitis are hereby diminished.   Whether  the  proposal -to
excite inflammatory action in the sac of the peritoneum  by injecting  iodine,
or similar articles, will ever  be  generally adopted, is at present a matter of
doubt,  and sufficient data have not yet been obtained to authorize it as an
operative proceeding.
  The horizontal posture of the patient throughout the  operation has long
been regarded  with favor by many in the United  States; I always resort to
* Dorsey, Surgery, vol. ii. p. 365.
f Malgaigne, Philad. edit. p. 387. 
HEPATIC ABSCESSES.
373
it, and so has Storer, of Boston, during the last ten years.  In Europe, how-
ever, it appears to be regarded as a novelty, and has been lately advocated
by Simpson, of Edinburgh, as a new suggestion.


                             SECTION II.

                          HEPATIC  ABSCESSES.

   The production of inflammatory action in the liver, as the result of dis-
ease or injury, especially as alluded to in Wounds of the Head, has not un-
frequently terminated in the formation of pus, which, if allowed to accumu-
late, has a tendency to cause a disintegration of the secretory portion of the
gland.  This  purulent  collection, like  abscesses elsewhere,  will often be
evacuated solely  by the efforts of  nature, the matter sometimes escaping
through the diaphragm, lung, and bronchia, whence it is expectorated; or
flowing into the cavity  of the pleura, so as to constitute one source of em-
pyema ; or the abscess may open into the stomach,  bowels, or cavity of the
abdomen, or it may tend toward the abdominal  parietes, and be evacuated
externally like a superficial abscess.  As it is a matter of some consequence
to prevent any great increase in the amount of the  collection, which is apt
to be the case if  the complaint is  left too long to the powers of nature, the
surgeon may be required to aid  the progress of the pus to the surface by
means of an operation,  care being taken to insure the adhesion of the  liver
to the abdominal parietes, before attempting any puncture.
   Diagnosis.—When an abscess of the liver tends to point outwardly, it
creates a swelling or tumor, which is quite apparent through  the abdominal
parietes.  This may show itself at various  points ; sometimes it has  been
found  on the  back near the vertebral  column ; at others the  matter has
traveled nearly as low as the spinous process of  the ilium, though most fre-
quently it has been found under or near the false ribs.
   Other tumors may, however, occupy the same point, and it has been  found
so difficult to distinguish hydatids, encysted, or fatty tumors  of this region,
from the swelling caused by a hepatic abscess, that Recamier has proposed
to test the contents of such tumors by the exploring needle.  As such a test
exposes the patient to the risks  of peritonitis, from the escape of even a
small quantity of pus into the surrounding parts, this means of diagnosis is
generally discountenanced.   The best means of arriving at a correct contlu-
sion will be found  in studying the history of the  case, in watching for the
signs of fluctuation and  inflammation about the part. If the exploring needle
is employed, such  a portion of the contents as can be  obtained should  be
carefully examined under the microscope, as the microscopical and chemical
examination of the constituents of bile, with the well-known  characteristics
of pus, will render the diagnosis of supposed  hepatic abscesses much more
certain.
   When a diagnosis is established, it is  of much importance to evacuate the
collection promptly; and to do this, resort may be  had either to caustics  or
puncture, or to both, (Recamier;) or to a dissection and puncture, after adhe-
sions have formed between the peritoneum, covering the  liver and that lining
the abdominal walls, (Begin.)  To the latter  mode of operating I give the
preference.
   Operation  of Begin, of France.—Make an incision two or three inches
long upon the  most prominent part of the swelling, and divide with  great
caution the layers  of the abdomen—as  is done  in hernia—until the perito-
neum lining of the abdominal parietes is reached.   Raise this carefully with 
PLATE  XXXIX.
              OPERATIONS PRACTICED ON  THE  ABDOMEN.

  Fig. I. Evacuation  of a Hepatic Abscess.   An eschar has been formed near
the abscess, in order to favor the adhesion of the adjacent serous surfaces, after
which the puncture has been made by the bistoury.  1  The eschar produced
by caustic.  2. The bistoury puncturing the abscess.  3. Pus escaping through
the puncture.                                   After Bourgery and Jacob.

  Fig. 2.  Manner of enlarging  an  abdominal wound  in  order to favor the
restoration of the prolapsed intestines.   After the  fingers  of  one hand  have
gently separated the intestinal convolutions, and the forefinger  is insinuated at
the upper angle of the wound, the bistoury is to be passed along the finger with
its  back toward  the  finger-nail, and, being introduced, enlarge the  wound by
slightly incising the abdominal parietes upward.   After Bourgery and Jacob.

  Fig. 3. A longitudinal wound of the intestines, closed by Pellier's suture.
While the left hand of the surgeon holds the two ends of the thread, the  right
hand is occupied  in replacing the protruded bowel, commencing at that part
which last escaped from the abdomen, and retaining the ends of the suture to
attach the wounded intestine to the abdominal parietes.
                                               After Bourgery and Jacob.

  Fig. 4. Transverse wound of the intestines about to be treated by the method
of Eeybard. 1. The wound.  After introducing the plate through the intestinal
opening, and applying the suture, the parts are  to be restored.
                                               After Bourgery and Jacob.

  Fig. 5. Enteroraphy as performed in the method of Ledran. 1. The puckered
surface of the intestine. 2. Line of the wound.  3. The various sutures collected
together, and twisted into a cord.                 After Bourgery and Jacob.

  Fig. 6. Taxis, as practiced upon an ex ternal inguinal hernia  of the  left side,
the surgeon  standing on the right side of the patient, and manipulating the
tumor as directed in the text.                     After Bourgery and Jacob.

  Fig. 7. Taxis, as performed upon reducible crural hernia, on the right groin
of a man, the operator being placed on the patient's left side.  The palm of the
hand  inclosing the tumor pulls  it toward the saphenous opening, while the
fingers of the same and opposite hand press the  viscera vertically upward toward
the femoral ring.                                After Bourgery and Jacob.
(374; 
Plato  39.
Fio.l
Fi2.f1
Fig. 3
Fio..|
Fid
■

















    ■
    ■
 
 
HYDATIDS  OP THE LIVER.                   375
the forceps and nick it, dividing it subsequently upon the director.   If the
intestine presents itself, push it to one side; but it should be remembered
that when the patient  is well etherized, there  is but  little tendency in the
bowels to move toward the  wound, and that this direction will therefore be
seldom needed.  On reaching the surface of the tumor, the operation should
be temporarily arrested, the wound filled  with  lint, and the parts closed by
a compress and bandage ; and  after three   r  four days, or when adhesions
have taken  place  between  the swelling and  the  peritoneum, the  abscess
may be opened, the diet being always  strictly regulated, Plate XXXIX.
Fig. 1.
   Operation  of Savery, of New  Hampshire.—An intemperate man, aged
sixty, after laboring for some years under chronic hepatitis, presented a cir-
cumscribed swelling in the right hypochondrium, which became pointed and
painful, and gave  an obscure sense of fluctuation.  An incision was there-
fore made into the abscess, and nearly a gallon of sero-purulent fluid dis-
charged, the last portion evacuated  having all the properties  of bile.   A
broad bandage having been carried around the body some time previous to
the incision, was then gradually  tightened as the swelling diminished, so as to
keep the parts in apposition.  The discharge continued for a few days, and
then ceased;  but  considerable  constitutional  irritation existed  during the
first week, and required the free use of wine and  sulphate of  quinia, with
other appropriate  remedies.
   Remarks.—The opening of a  hepatic  abscess would be  a  very simple
measure, were it not for the doubts that are often excited as to the actual
existence of pus, and the difficulty of judging whether adhesions have formed
between the parietes of the liver and those of the abdomen.  Until the latter
exist, the evacuation of the pus must expose  the patient to the risk of the
peritonitis, consequent on its escape into the peritoneal cavity.   The appli-
cation of the bandage, as  employed  by Savery, may therefore be regarded
as a valuable  addition to the operative proceeding  recommended by Begin,
as it not only  tends to approximate the abdominal parietes and the liver, but
also diminishes the cavity of the abscess, by compressing its walls, and thus
favoring its adhesion.
   The necessity of an active constitutional treatment in connection with this
operation need only be mentioned,  as  every surgeon would doubtless resort
to it under such circumstances.
                            SECTION III.

                        HYDATIDS  OP THE LIVER.

   The occasional development of Hydatids of the Liver demands that a few
words should be said in relation to the operation which is sometimes required
for their removal.
   Although rarely met with, the existence of hydatids of the liver gives rise
to a train of symptoms which, when tested by "exclusion," has enabled the
surgeon to diagnosticate their presence, and operate for their relief.   In a
case reported by J. Edward Weber, of New York,* a tinsmith had suffered
for nine years from an enlargement of the right side, over the region of the
liver, which felt hard, and was more  apparent  when he had abstained from
food.  Being some time subsequently attacked  with severe pain,  he became
conscious, during each inspiration, of a sensation in the side, which gave to
his hand an impression similar to that caused by the purring of a cat.   The
* New York Med. Times, May, 1852. 
37G
PRINCIPLES AND  PRACTICE OF SURGERY.
diagnosis of hydatids of the liver having been satisfactorily established, it
was determined to evacuate the cyst so as to unite its walls, or cause them to
shrink, and he decided to do so by an operation, which he performed as fol-
lows :—
  Operation of  Weber.—The bowels having been freely moved, an explor-
ing trocar was thrust a few inches through the integuments into  the most
prominent part of the  swelling, the sensation caused by the passage of the
instrument being similar to that perceived  in paracentesis abdominis.   On
withdrawing it, a fluid  resembling whey dropped from its orifice, the micro-
scopical examination of which revealed nothing remarkable.  A longitudinal
incision, two inches long, being then made down to the liver, a direct punc-
ture  of the liver with the trocar gave  the same results.   As there was no
union of the peritoneal  surfaces, a well  oiled tent was  introduced  upon the
peritoneum, in order to  produce a limited inflammation, 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 space, of the  size of the hand.
Eighteen days subsequently, as it was  supposed that adhesions had taken
place, the second operation was commenced.  The first incision  having con-
tracted, 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 through the parietes of the liver into the cavity of
the cyst, which was thought to be of the size of the adult skull.   The con-
tents, which consisted of a fluid and small  cyst, being  now  very cautiously
evacuated, another oiled tent was  introduced as before, and  after a tedious
recovery,  and  the presence  of  a  hepatic fistula, the patient recovered  in
about twenty-two months after the first  operation.
                           SECTION IV.

                     GASTROTOMY OR ENTEROTOMY.

  Gastrotomy—yao-rinp,  the belly,  and ro>).rj, incision—is a term which has
been somewhat indefinitely applied to any incision upon the parietes of the
abdomen, by which  its contents could be exposed.  The word is, therefore,
sometimes employed to designate the opening of the uterus jn the Csesarean
section, or the incision practiced for the  removal of ovarian tumors, though
it should be limited to such operations as directly expose the stomach ; en-
terotomy designating the similar operations practiced on the intestines, ova-
riotomy the removal of  ovarian tumors, and herniotomy that employed for
the relief of protrusions  of the bowels.
  Either gastrotomy or  enterotomy must, however, continue to be very rare
operations, the risks of general peritonitis, as well as the possession of less
difficult plans of treatment, rendering  surgeons indisposed to resort to them.
These  operations have therefore been chiefly performed in order to remove
such foreign bodies  as were not likely to pass through the alimentary canal,
as in the three cases  quoted by Watson, of New York,* from  the  German
Epherides, in one of which a knife  which had been swallowed with the blade
open, and ten inches long, was extracted by a longitudinal incision two inches
long in the left hypochondriac region, and the patient recovered; in another,
in which a knife seven inches long  was also successfully removed by a similar
incision, the cure being  very prompt;  and, in a third, a knife of  nine inches
being successfully removed in  the same  manner.  Enterotomy has also been
performed iu order to overcome the intestinal obstruction in cases of volvulus.
* Am. Journ. Med Sciences, vol. viii. N. S. p. 330. 
GASTROTOMY.
377
                             § 1.—Gastrotomy.

    Gastrotomy, or the incision of the abdominal parietes, in order to open the
  cavity of the stomach, is  an operation that has been recently suggested in
  cases of impermeable stricture of the oesophagus, in order to permit the in-
  troduction of nutriment, and has, as just stated, also been resorted to for the
  removal of foreign bodies of such size as to preclude all reasonable hope that
  they could otherwise be evacuated,  as in the case reported by Marcet, where
  a sailor swallowed a  number of clasp  knives.  Although gastrotomy is  an
  operation that could  seldom be justitiable, yet under such circumstances as
  have been referred to in the account of Gesophagotomy, and with our knowl-
  edge of the wonderful recoveries of patients under extensive wounds of this
  viscus, of which several cases are cited,* it must be admitted that there are
  instances in which the surgeon  might be induced to advise its performance.
     Operation of Opening the Stomach.—As the mere operative proceedings
  connected with the exposure of the  stomach cannot require any extended de-
  tail for the instruction of one  who  is familiar with the anatomical relations
  of this organ, it seems to be only requisite to state that the  general course
  of proceeding would be  very similar to that just detailed for the treatment of
  hepatic abscess; or, in more definite terms, cut through the abdominal pari-
  etes  with caution, over the front of the stomach in  the line of the  linea alba,
  extending  from an inch below the  ensiform cartilage, to an inch and a half
  above the umbilicus, until the peritoneum is exposed ; carefully open the por-
  tion which lines the abdomen ; hook or seize the front surface of the stomach
  between its curvature ; stitch it fast to the  abdominal parietes, and then wait,
  if possible, for adhesiou to occur, before puncturing the viscus, lest its liquid
  contents should escape into the peritoneal cavity, when, if the patient is able
  to sustain the constitutional shock,  or peritonitis that may ensue, it frill sub-
  sequently be necessary to treat the wound so as to create a fistula, through
  which food might be introduced, as was done by Beaumont, in  his experi-
  ments on digestion, as practiced in the celebrated case of St. Martin.  Should
  gastrotomy, however, be attempted for the removal of a foreign  body, such
  as a knife, or other large substance, similar to those that have been accident-
  ally  swallowed, and referred to by Watson, of New York, Alarcet, and others,
  the wound should be made to unite  as soon as possible, by a treatment analo-
  gous to that reported hereafter, in the case which occurred in the  practice of
  Ashby, of Virginia, or in that now  quoted.
     In a case reported by Barnes, of  a young peasant, who, while endeavoring
  to produce vomiting with the handle of a knife, let it slip into his stomach;
  it was removed by a surgeon named Shoval, in the following manner :—
     Shoval's Operation in 1635 for the Removal of a Knife from the Stom-
  ach.—A straight incision being made in the left hypochondrium, two fingers'
  breadth below the false ribs, first through  the skin and connective tissue, aud
  then  through  the muscles and peritoneum, the stomach was exposed,  but
  slipped from the fingers whenever it was attempted to be seized.   Being at
.  length caught with a curved needle, aud drawn out of the wound,  a small in-
  cision was  made into it, through which the knife was easily extracted, when
  the stomach immediately collapsed.  After  thoroughly  cleansing the exter-
  nal wound, it  was united  by five  sutures, and tepid balsam poured into the
  interstices, and tents impregnated  with balsam completed the dressing by
  closing the wound  accurately.   Two sutures being removed next day, and
  two more on the following day, the  wound healed on the fourteenth day after
* See Bibliographical Index, end of this part. 
378
PRINCIPLES AND  PRACTICE OF  SURGERY.
the operation and the patient completely recovered.  The knife, as seen by
Oliver at Konisberg, in 1685,  was six and a half inches long.
   Extraction of a Bar of Lead from the Stomach.—John Bell, of Wapello,
Iowa, successfully removed a foreign-body from the stomach by the following
operation :—
   The patient, a  man aged thirty-two, while performing the feat of running
a bar of lead down his throat, accidentally let it slip,  so that it descended into
his stomach.   At  first, no evil consequences were observed, but three or four
days subsequently he  became unwell, and, when seen a week after the acci-
dent, was suffering with considerable gastralgia and abdominal soreness, with
retching and  vomiting of a dark,  watery fluid ; pulse small and tense, great
anxiety, restlessness, prostration, and apparent sinking of the vital powers.
   Operation of Bell.—Having administered chloroform,  Bell made an in-
cision from the point of the  second false rib to the umbilicus, and divided
skin, adipose  tissue, and muscles, down to the peritoneum, which he laid bare
the whole length of the incision.   The peritoneum was then raised on  a di-
rector, and divided the entire length of the incision.   A considerable quantity
of omentum and intestines were protruded through the wound at this moment;
they were replaced, however, as speedily as  possible, and  the operator then
grasped the stomach, in  which he immediately discovered the  bar of  lead
The bar of lead, having been grasped by the thumb and middle finger, with
the forefinger on the lower  end of it, was pushed upward  and backward, so
as to make the incision in the stomach as high as possible, and then the coats
of the  stomach were  divided over the  extremity of the bar,  by an incision
parallel with  the  muscular fibres, and  not  larger than to admit of the re
moval  of the  lead.  A long pair of forceps was then introduced, and the
lead seized  and withdrawn.
   The  external orifice was  closed with  the  ordinary interrupted suture  and
adhesive straps, a compress applied, and a roller put around the body.
   The  patient was dismissed,  cured, the fourteenth day after the operation.
   The  bar of lead was ten and three-fourth inches long, and its weight nine
aud a half ounces  avoirdupois.
   This case is widely known,  and is a  remarkable  instance  of the success
sometimes attendant on Gastrotomy.
                           § 2.—Enterotomy.

  Enterotomy, or the division of the abdominal muscles and their peritoneal
lining, so as to permit the opening of a portion of the  intestinal canal, has
also been resorted to for the removal of foreign bodies,  for the cure of vol-
vulus, and in some instances for the relief of obstinate constipation, or for ob-
struction of the rectum in the formatiou of an artificial anus.  Like the opera-
tion of gastrotomy, that of enterotomy can only be thought of in desperate
circumstances, although the success which has attended the instances in which
it has been employed has been sufficiently marked to have attracted atten-
tion.   In a paper published by Phillips, of England,* it is stated that of 27
patients operated on for the establishment of artificial  anus, 13 recovered.
Of 53 cases referred to  as operated on, for obstruction of the bowels, includ-
ing both infants  and adults, 17 were cured.   He, therefore, advocates the
operation in obstruction where three or four days have passed without relief
from other means.
  In cases of volvulus, the difficulty of the diagnosis must render the resort
* Brit, and Foreign Med. Review, April, 1849. 
ENTEROTOMY.
379
to an abdominal incision a most hazardous and uncertain operation ; yet such
operations have been  performed, and, when  the  patient is under the influ-
ence of an anaesthetic,  might be again employed with less risk and difficulty
than has heretofore been the case.  Although I  doubt very much the pro-
priety of these operations, as a general rule, and would urge the utmost cau-
tion in respect to diagnosis on the part of any surgeon who might be placed
iu such circumstances as apparently demanded them, I am convinced that they
present some chances  of success; and  as such a concatenation of circum-
stances may occur as will demand their repetition hereafter, there seems to
be  a good reason for exhibiting the few facts that have been presented in
connection with the subject.   By  referring  to  the  Bibliographical Index
of this part, several cases will be found in which the intestinal canal has been
most rudely treated without causing death.  In the case reported by Brigham,
of Utica,  a patient survived  the removal of seventeen inches of the intestinal
canal; in  one reported by Dugas, of Georgia, the intestines were cut iu two by
a bowie kuife and sewed  up, yet the  patient recovered; and in others there
referred to, they sustained the rudest handling, and were even severed, with-
out causing death.  But, though success followed  these cases,  it is presumed
that nn judicious  surgeon would take  any of them  as a precedent for  an
operation which is universally regarded  as a forlorn  hope, except under the
urgent circumstances in which an operator is fully satisfied that the patient's
chances of life are less before than they would  be after the performance of the
operation.
  Enterotomy successfully performed by J.  E. Manlove, of Tennessee.*—
A negro,  aged seventeen  years, who had had no evacuation of the bowels for
twelve or fifteen days, and was  laboring under fever, etc., was on the fourth
day found to be in the following condition : Abdomen enormously distended;
breathing difficult; extremities cold; pulse very feeble and quick,  and coun-
tenance anxious.   A consultation decided that, although the operation of
enterotomy promised but little benefit, yet the certainty of death without it
justified its performance.
  Manlove's Operation.—An incision being made in the median line of the
abdomen, commencing about two inches below the umbilicus,  and  extending
down toward the  pubis four or five inches, the peritoneum and bowels along
the lower half of the incision were found adherent.  An opening of about a
fourth  of an inch in length was therefore made  into the bowel nearest the
wound, from  which there escaped large quantities of flatus and liquid feces,
as well as some of the medicine which had  been taken a short time pre-
viously.   A further examination showing  that the intestines were united to
the peritoneum by extensive adhesions at various  points, within reach of the
finger and probe, and  that there was therefore  but little probability of the
escape of any liquid into the peritoneal  cavity, the wound was closed by su-
tures and  adhesive strips, except at the intestinal opening.  The amendment
in all the  symptoms was prompt, the extremities becoming warmer, and the
pulse fuller and slower within an  hour afterward.   On the next day the ap-
petite was good, and the  patient continued to improve, discharging the con-
tents of the bowel through the artificial anus thus  made until the seventeenth
day, when he had an evacuation per vias naturales, the wound having nearly
closed.   Nine months  after this, he was presented to the Tennessee State
Medical Society for  inspection, being perfectly well.   The adhesions were
supposed to have been the result of a contusion of the abdomen, received six
months previously.
  Remarks.—In  the paper  just quoted,  there m also mentioned  another
*• Boston Med. and Surg. Journ , vol. xxxii. p. 492. 
3S0
PRINCIPLES AND  PRACTICE OF  SURGERY.
marked instance of the success  of this operation, in which Wilson, of the
same county, performed enterotomy in a case of volvulus, drew out the in-
testines until he reached  the obstruction, dissected the adhesions tound at
the invaginated portion, overcame the obstruction, replaced the bowels, and
the patient rapidly recovered.
  Successful Enterotomy, and Removal of a Silver Teaspoon, by Samuel
White, of Hudson, New York.*—A man, aged twenty-six years, suffered,
in May 180fi from rheumatism, when, after a severe relapse, he became de-
lirious  and bent upon self-destruction.   On  the 7th of July, he procured a
full-sized teaspoon, with some fruit jelly, and forcing  the  spoon down his
throat  in the  absence of his nurse, was enabled to swallow it, by pressing his
finders against the handle.  He was then greatly agitated, talked much, and
declared that no attempt could save his life.  On the 9th, a spasmodic affec-
tion of the stomach, alternating every fifteen minutes with stupor, showed
itself, during which he would throw  himself violently about.  This lasted
during two hours, while the spoon probably passed the pylorus, when he sud-
denly fell asleep,  became  rational, and expressed  great anxiety for relief.
On the 25th of July, a cutting sensation, confirmed  by the pressure of the
hand when the abdomen was relaxed, led  to the discovery of the spoon in
one of  the convolutions of the ileum near the line dividing the right iliac and
hypogastric regions.   It remained  fixed in  this position, with increased heat
and irritation in the adjacent parts, till August  7th, when, fearing the con-
sequences of further delay, it was decided to attempt its removal.
   Operation of White.—An incision, three inches long, being made through
the abdominal  parietes, and  parallel with  the epigastric artery, extending
upward to the level  of the crest of the ileum, the peritoneum was opened
with a lancet;  the turn of the intestine, which contained the spoon-handle,
protruded; the intestine pierced with the lancet over the end of the handle,
and the spoon extracted  by forceps.  The divided edges of the intestine
were then secured by the glover's suture, and  the  external wound closed
with adhesive strips and lint.
   Under simple dressings, the wound healed  by the first intention, and the
patient recovered.

                             SECTION  V.

                   GASTRIC AND INTESTINAL FISTUL.E.

   The formation  of a fistula in the abdominal  parietes, and a communica-
tion of it with the viscera of the part, may be produced by various causes.
Like those resulting from strangulated hernia, (artificial anus,) these fistulae
nearly always present  certain common symptoms, and may be  relieved  by
very much the same general treatment.   Most frequently they will be found
to give rise to more or less excoriation and inflammation of the skin of the
abdomen, in  consequence  of the escape  of the discharges externally, while
they also affect the nutrition of the patient, and expose him to a protrusion
or even strangulation of the mucous coat of the bowels, in a manner analo-
gous to that  seen  in prolapsus of  the  rectum.   As  illustrative  of a simple
plan of relieving this  condition, the following case is cited :—
   Fistulous  Opening of  the  Stomach successfully treated by Pressure,
etc., by Cook.f—A widow lady, aged thirty-nine  years, had been attacked
  * New York Repository, vol. x. p. 367, 1807.
  f Am. Journ.  Med. Sciences, vol. xiv. p. 271, quoted from Western Journ. Med. and
Phys. Sciences,  Jan. 1834. 
GASTRIC AND INTESTINAL FISTULA.              381
with constipation and violent pain at the pit of the stomach, which resisted
every remedy until the nineteenth day, when a fistulous orifice showed itself.
Six months subsequently she presented a fistula immediately by the side of
the umbilicus, the external orifice of which was about the size of a buckshot,
and, on removing the dressing, a gill  of bile was suddenly discharged, after
which  a small  quantity of (gastric ?) fluid came  slowly away.   The acrid
character of these discharges had excoriated and inflamed the abdomen, and
rendered it intolerably painful.   On drinking a glass of water, the whole of
it was discharged through the fistula in twenty seconds, and an examination,
by a catheter  introduced into the opening, therefore led to the conclusion
that the opening was in the stomach near the pylorus.
   Treatment.—A beef-bladder, being cut open longitudinally, was spread
with adhesive  plaster and applied over  linen spread with cerate, so as  to
cover the  excoriated part, an  opening being made in  the dressing corre-
sponding to the fistulous orifice, after which a firm bandage and compress
were applied and the diet limited, nourishing enemata being resorted to in
order to sustain the patient.   The external irritation soon healed ; the band-
age  was gradually  tightened, and a cylindrical compress  employed, under
which  treatment the fistula was completely healed in thirty-days, and the
patient  subsequently regained her health.
  Remarks.—Should the orifice of such a fistula fail to heal under similar
measures, the surgeon might derive advantage from the  use of  escharotics,
or of the actual cautery carefully applied.   As the experiments connected
with digestion,  performed by  Beaumont upon St. Martin, who also  labored
under one  of these  fistula?, have long been before the profession, the refer-
ence to his paper before given will furnish sufficient evidence of the powers
of nature under such circumstances, as well as the means employed by sur-
geon Lovell, U. S. Army, to obviate  the  inconvenience resulting from the
creation of the opening.   The eversion  of the mucous membrane of the
stomach or bowels, and its tendency to become strangulated at the orifice of
the fistula, should always be guarded against by appropriate pressure during
the treatment of the case, and especially in its early stages. 
CHAPTER  II.
                     WOUNDS OF THE  ABDOMEN.

  As wounds of this region have  been already described, an allusion to the
treatment of such cases as present protrusion and wounds of the viscera now
require  attention.  As  the abdominal contents, when once protruded, are
often with  difficulty replaced, not only in consequence of the  contraction of
the muscular fibres around the wound creating strangulation, but also from
the peristaltic action of the bowels, causing the protruded intestines to be
filled  with solid or gaseous deposits, their treatment becomes the first point
for consideration.

                             SECTION I.

      WOUNDS WHICH CAUSE PROTRUSION  OR STRANGULATION  OF THE
                       INTESTINES OR OMENTUM.

  In  treating such abdominal wounds  as are followed by a protrusion of any
of the viscera, it is the universal rule  to endeavor to replace the protruding
portion  by manual means, aided  by such  a  position of the patient, use of
anaesthetics, and other constitutional measures, as will induce perfect relaxa-
tion of the tissues forming the anterior abdominal parietes, before enlarging
the wound.  Since the  discovery of ether, the  restoration of  the  stomach,
intestines, or  omentum,  when  protruding  through  an abdominal wound, is
much more easily accomplished than was formerly the case.   The following
plan of treatment will, therefore, often succeed :—
  Treatment.—Place the patient upon his back, with the shoulders elevated
and the knees drawn up in order  to favor the  relaxation of the abdominal
muscles, and then, by means of ether,  produce perfect anaesthesia.   As soon
as this  is accomplished, cleanse the  protruding parts thoroughly from all
foreign matter by squeezing water upon them from a sponge, and then gently
seizing, between the thumb and fingers, that portion of the viscus which had
last protruded, compress it lightly so as to force back its contents, endeavor-
ing to carry it into the  cavity of  the  abdomen by pressing upon it with the
forefingers. The peristaltic action of the digestive canal being entirely arrested
during anaesthesia, the muscles of the abdomen perfectly relaxed, and  the
diaphragm partly quiescent, success will often crown these efforts.
  When the protruded portion is  returned, it then remains to  unite the sides
of the wound by a few points of  the  twisted suture, and support them by
adhesive strips and a bandage.  But if it  should be found impossible to ac-
complish the restoration  in this manner, it  may become necessary to intro-
duce a director, and enlarge the upper angle of the wound a little by means
of the probe-pointed bistoury, Plate XXXIX. Fig. 2.
  When the protruded portion is omentum, the treatment will be very much
the same unless strangulation has  occurred, in  which case it may become
necessary to treat it as is recommended in a similar condition in hernia
       (382) 
WOUNDS OF  THE  INTESTINES.
383
  In cases in which the protruding viscus has been wounded, as frequently
happens, the opening in it should be  carefully approximated by one or two
points of the interrupted suture, so placed as not to include the mucous coat,
and then leaving the ends of  the threads attached to the viscus, its opening
may be made to correspond with that  in the abdominal parietes.
  Operation of C. W. Ashby, of Alexandria.—In a very marked case re-
ported by Ashby, a boy, six years of age, fell upon the points of a pair of sheep
shears,  which he had in his hand, and  drove the instrument into the stomach
obliquely  from above downward, so  as to graze the left side of the  sternum
and the edges of the ribs.  The external wound was flap-shaped, and through
this nearly the  entire stomach protruded, discharging its contents through
an aperture about three-fourths of an  inch long.  Having placed a single
suture  in  the  middle of the  wound  in the stomach, nausea and vomiting
ensued from the handling of  the viscus, and the boy became  so unruly as  to
prevent the restoration  of the stomach, although  the  abdominal  wound was
several times enlarged.  At this period, anaesthesia was induced by chloro-
form, and, after slightly enlarging the abdominal  wound, the  stomach was
readily replaced, although the  boy vomited freely, as  before, from handling
the organ.  The wound in the stomach being then brought directly opposite
that in  the abdominal parietes, it was  gently retained within the verge of the
external wound  by a single stitch, and lint wet with cold water was retained
upon  the part  by means  of  a  bandage.   A large dose of opium was then
administered; and on  the fifth the wound  discharged freely;  on the  sixth
day the ligature came away, after which the recovery was rapid.


                             SECTION II.

                      WOUNDS OF THE INTESTINES.

  When an Intestine is wounded in such a manner that the injured part can
be seen through the opening  in the abdominal parietes, it becomes necessary
to treat it by such means as may induce union, and prevent the escape of the
contents of the bowel into the cavity of the abdomen. These means vary some-
what,, according to the extent of the wound, and its  longitudinal or trans-
verse direction, sundry suggestions having been made by surgeons at different
periods, in order to accomplish this object, and  yet diminish the risk conse-
quent upon peritoneal inflammation.
  Two kinds of wounds of the intestine require  the application of  sutures,
the first being that in which  the wound  is  longitudinal, the second that in
which it is transverse, and the consideration  of these various sutures will,
therefore, be referred to separately, it  being premised that, in every instance,
it will  facilitate the operation, and add to the patient's chances of life, to
resort to the use of ansesthetic agents  before commencing the operation.
  When a wounded intestine presents itself, so that the injured point can be
readily reached, the extent of the wound is  the first point to  which attention
should be  directed, the means of treatment being necessarily varied according
to the nature of the injury.   In small  punctures, or those less than a third of
an inch in extent, or those openings through the  intestinal coats which  are
consequent on the  strangulation and ulceration that ensue upon certain con-
ditions of hernia, Sir Astley Cooper recommended that the sides of the open-
ing should be gently gathered together, or pinched up, and then the adjacent
portion constricted by tying  a fine  ligature around  it, in a firm knot, the
ends of the  ligature being cut off close to the  gut.   This  loop gradually
ulcerating through the coats of the viscus, while lymph is effused upon the 
384
PRINCIPLES AND PRACTICE OF SURGERY.
peritoneal surface, the ligature will be soon discharged by stool, without ex-
posing the patient to the risks consequent on the escape of its liquid con-
tents into  the abdominal cavity.
  But if the opening is more extensive, then resort must be had to some of
the various sutures that have been  recommended by surgeons at different
periods: Albucasis, a d.  1100, Guy de Chauliac, a.d. 1360, Ledran, Rams-
dohr,  Shipton, Travers,  Thomas Smith,  Gross, and others, having advised
peculiar methods of treatment.
  The different  sutures  that have been employed  by these surgeons are
usually designated as the glover's suture, which was suggested by  Guy, and
supported by the opinion of Heister;  the suture of the four masters, in
which a forefgn body (trachea of an  animal) was introduced  into the intes-
tine, in order to support the sides of the wound; the looped suture of Palfyn;
that of  Ledran; and  the continued  or interrupted suture, as recommended,
with various modifications, by Reybard, Jobert, Bertrand, aud others.


    § 1.—Sutures employed in Longitudinal Wounds of the Intestine^

  The Glover's Suture may be  formed by means of a straight round needle
and a waxed thread, by passing the needle obliquely through the sides of the
wound when held together by an assistant, the first point of the sutHre being
made at one line from the upper angle of the wound, aud  at an equal distance
from its edges.   The thread  being then drawn through to within a few inches
of its end, the needle  should be repassed through the edges of the wound,
from the same side as it  commenced on, and the  wound traversed obliquely
from side  to side, so as  to carry  the thread  over and  over, from  stitch to
stitch, as in "whipping a seam."  On reaching the lower end of the wound,
the needle should be removed, and three or four inches of the thread be left.
This and the first end being then held by the assistant, Plate XXXIX. Fig.
3, the surgeon should proceed  to reduce the  intestine,  and on drawiug the
ends of the thread toward the  abdominal  parietes, cause the outer coat of
the intestine to approximate the peritoneum lining the abdomiual  parietes,
so that it  may be made to adhere to the surface  of the  abdominal  wound.
Five or six days subsequently, one end of the thread  should be cut off  close
to the abdomen, when, by gently drawing on  the other, while  the  edges of
the wound are supported, the thread may be  withdrawn without deranging
the adhesions.
   The Loop Suture of Ledran.—Having prepared as many ordinary sewing
needles and threads as he wished to make stitches, the  edges of the wound
were approximated, and  each needle passed  transversely to the line of the
wound,  at a distance of about a quarter of an inch from each other.   The
threads on each side being then tied together,  the two bundles were collected
together and twisted into one, so  as  to pucker up the edges of the wound,
Plate XXXIX. Fig.  5.
  Loop Sutnre of  Palfyn.—A ligature being passed  through the middle of
the wound in the intestine, so as to leave a  loop on its inside, the ends were
left out of the external wound, so as to draw the  serous coat of the intestine
up  to the  peritoneum  lining the abdomen, after which the abdominal wound
was closed, and the threads fastened upon the skin by adhesive strips,  Plate
XL. Fig. 2.
   Suture of Heyward.—A small, thin, and  oiled piece of light wood, twelve
to fifteen  lines long, and four to six broad, being first  introduced into the
intestine at the wound with a piece of thread attached to it, each end of the
thread was armed with a needle.  After passing each needle from one side to 
SUTURE  OF TRANSVERSE WOUNDS.              385
the other, from the inside outward through the thickness of the intestine, and
also of the abdominal parietes, the wooden  plate was drawn upon so  as to
compress the peritoneal coat of the intestine against the serous lining of the
abdomen, and close the wound hermetically.  When the adhesions thus ex-
cited seemed  to be sufficiently strong, that is, in about three days, the thread
was withdrawn, and the little plate of wood left to be discharged by stool.
  Suture of Jobert.—After cleansing the edges of the wound, this surgeon
turned in the serous  surface on each side with the needle, and  passed the
threads transversely through them, at sufficient distances to keep the serous
membrane of each side in contact.  Then the ends, being knotted and tied
as in the interrupted suture, were left to come  away by stool, or they were
twisted and brought out of the wound, as in the suture of Ledran.
  Suture of Bertrand.—The lips of the wound being approximated, pierce
them both rather obliquely about  two lines from their edges,  and one from
their extremity.  Then repassing the needle in the same way on the opposite
side, two lines further on, continue them in  the same direction to the  other
end by a series of equal  stitches.   The intestine being reduced, fasten the
end upon the abdomen, and three days subsequently cut off one  end of the
thread near the wound, and draw out the other, Plate XL. Fig. 1.
                   \ 2.—Suture of Transverse Wounds.

   Suture of Ramsdohr,—Invagination of the two ends of the intestine being
 accomplished, this surgeon stitched them together by two or three points of
 the interrupted suture, reduced the intestine, and left the suture to the efforts
 of nature.   If the  mesentery interfered with the invagination, he excised it
 to a sufficient extent.
   Suture of Jobert.—With a piece of silk passed at each end into a needle,
 Jobert operated as follows: After traversing the anterior part of the upper
 end from without inward with one needle, he then passed both needles from
 within outward through the lower end  of the intestine, and after placing as
 many threads in  this manner as were sufficient to unite the wound, invagi-
 nated the intestine by gentle traction upon the threads, and either knotted
 them on  the outside of the inferior end, or brought them out of the wound in
 the abdomen, Plate XL. Fig. 3.
   Suture of Lembert.—After preparing as many threads, each armed with
 needles, as seemed requisite, one needle was pushed through the coats of the
 intestine as far as the mucous  membrane, from without  inward, and then re-
 passed from within outward, so as to  come out about one line from the edge
 of the wound.   Then passing it Across the fissure, he carried it from without
 inward, at a similar distance from the opposite side of the wound, and brought
 it out again  at a distance of about  three  lines from its point of entrance,
 Plate XL. Fig 4.  All the threads being passed in a similar way, the serous
 surfaces were brought in contact, so as to force the lips of the wound to double
 inward,  and form a  sort  of  valve, Plate XL. Fig. 5, after  which the knots
 were tied, the ends cut off, and the intestine reduced.
   Remarks.—In the account of the  different sutures just given, as adapted
 to the union of both longitudinal and transverse wounds of the intestine, a
 brief enumeration of such of the various plans as are deemed most available
 has been given.   The importance of the subject, and the numerous  experi-
 ments that have  been performed  upon  animals in order to test the result of
similar injuries in man, might perhaps have authorized the addition of much
to the above account, but as this would have transcended the limits of  this
    vol. n.—25 
PLATE   XL.
            SUTURES OF THE INTESTINES—ARTIFICIAL ANUS.

   Fig. 1.  Continued Suture for Longitudinal Wounds. 1, 1. Ends of the thread.
 2, 2. Points perforated by the first stitch, showing the distance from end wound.
 3, 4, 5, 6.  Subsequent  points, showing the distances to be observed between the
 several stitches, and their relations to the edges of the wound.
                                               After Bernard and Huette.
   Fig. 2.  Looped Suture of Palfyn, to unite the sides of a wound, and bring the
 peritoreal coat of the intestine in contact with the abdominal parietes.   1. Ab-
 dominal parietes.  2.  Intestine.  3. Longitudinal wound of intestine.   4. Loop
 of the suture as seen in the intestine.  5. Ends of the thread brought  out aud
 knotted on the abdomen.                        After Bernard and Huette.
   Fig. 3.  Suture of Jobert for Transverse Wounds.  1. First  thread passed
 through the intestine.  2. Second suture.  3. Edges  of transverse wound of
 intestine.  4. Mesentery.  5. Point at which  it has  been  incised in order to
 favor the union of the  two ends of intestine.       After Bernard and Huette.
   Fig. 4.  Suture of Lembert for uniting Transverse Wounds of the Intestine by
 approximating the adjacent serous surfaces.  1. The first insertion of the thread.
 2, 2. Its point of exit aud re-entrance, or the second suture.   3.  The third
 point.                        "                  After Bourgery and Jacob.
   Fig. 5.  Profile of this Suture.  A. The suture as first formed.   1.  End of the
 thread.  2. First loop.  3.  Portion of thread over the wound.  4. Second loop.
 5. Termination of thread.  B. Profile of this suture as finished.  1. Exterior
 knot.
   Fig. 6.  Artificial Anus, in which  the  ends  of the intestine  open upon  the
 groin by separate orifices.  1, 2. Ends of the intestine.   3.  Mesentery  between
 them.  4, 5. The two  anal orifices.                After Bourgery and Jacob.
   Fig.  7.  Artificial Anus where the two ends of the bowel open by a single
 orifice.  1, 2.  Upper  ends of  intestine.  3.  Septum formed by union of  the
 adjacent sides.   4. Lower orifice or point of the artificial anus.
                                               After Bourgery and Jacob.
  Fig.  8.  Artificial Anus, showing the funnel-shape of the cavity near the orifice.
 1. The cavity of the peritoneum.   2, 3.  Ends of the intestine.  4. Intervening
mesentery. 5. The septum.  6. Funnel-shaped orifice formed around the arti-
ficial anus by the peritoneum.   7. A probe passed into the orifice to show  the
course  of the fecal contents.         After Scarpa, from Bernard and Huette.
  Fig. 9. Another view of the same.  1,2. The intestines.   3. The septum.   4.
The course of the contents of the bowel.           After Bernard and Huette.
  Fig.  10. The septum partially removed.  1, 2. The intestines.  3.  The short
septum.  4.  The mesentery.                      After Bernard and Huette.
  Fig. 11. A view of the Enterotome of Dupuytren as applied.   1. Abdominal
parietes.  2. The instrument.                     After Bourgery and Jacob.
   Fig.  12. Enterotome of Liotard applied.  1. The septum.  2. The instrument.
                                               After Bourgery and Jacob.
       (386) 
Plato  40.
luM
 
 
SUTURE  OF TRANSVERSE WOUNDS.               387
 work, it must suffice merely to mention a few of the points generally admitted
 as settled in the treatment of these injuries.
   From the experiments of former surgeons, and especially  of Travers,* it
 appears that sutures of every description, when applied to an intestine and
 left unconfined at the external wound, ulcerate through into the bowel and
 are discharged by stool, the opening made by their escape through the intes-
 tine being closed by the effusion of  lymph,  and strengthened by adhesion of
 the edges of the ulcer to surrounding parts.
   If a  small portion of the  intestine is encircled by a ligature, as was done
 by Sir A. Cooper, lymph is rapidly effused around the constricted point, and
 while the thread ulcerates into the bowel, the external coverings are reunited
 by new adhesions.  But if the ligature surrounding a portion of the intestine
 is attached externally, it does not ulcerate  through, but comes away  in the
 same manner that the loop of the thread does  from an artery.
   As these facts have been established by the observations of Smith,  of Phil-
 adelphia, f Gross, of  Philadelphia,! as well as  by many surgeons in Europe,
 no one  can doubt the advantages of that mode of closing a  wounded  intes-
 tine which cuts off  the  ends  of the  thread  and leaves the suture to be dis-
 charged per anum.
   In the application of every suture, it is important that the stitch should
 not, if possible, pass through the mucous coat,  but rather between it  and the
 muscular coat; that the wound should be so accurately closed that fecal matter
 cannot  escape; that two peritoneal surfaces be brought in contact in order to
 promote adhesions; that, the bowels be kept  as  still as possible, and that
 every means  be employed to keep  down general peritoneal inflammation.
 Under proper treatment, and with the exhibition of sound judgment, moderate
 wounds of the intestine are by no means a hopeless class of injuries, various
 cases having been reported, in which patients recovered after most extensive
 injuries, and even the loss of seventeen inches of the intestinal canal.  Al-
 though such a case could not be taken as exemplifying the usual result, yet
 it may  be mentioned as a fact justifying the surgeon iu forming a prognosis
 of a more favorable kind than  might be the case if he trusted solely  to gen-
 eral ideas on the subject, and induce him to exert his skill toward the preser-
 vation of life in even the most desperate cases.
  Estimate  of  these Different Sutures.—For a small punctured  wound,
 there can be  no question that the application of the ligature, as advised by
 Sir A.  Cooper, is the most advantageous; that  the loop suture of Palfyn and
 Ledran comes next, according to the extent of the wound, and then the pro-
 cess of Jobert.   In the union of transverse wounds, the interrupted suture is
 probably equal to any other.  The plan of Ramsdohr is generally deemed ob-
jectionable from  the difficulty of invaginating the part; from  the necessity of
 incising the mesentery in order to permit it, and from the great tendency  of
 the intestinal contents to escape into the abdominal cavity, owing to the want
 of accurate adjustment.   The modifications  usually spoken of as the plans of
 Denans, Duverger, or Amussat, in which a  foreign substance is introduced
 to preserve the relative position of the two ends of the intestine, though more
 useful,  are yet not without serious  objections.   The union of a transverse
 wound  by the suture of Lembert is, therefore, thought to present the best
 prospect of an accurate agglutination of  surface.
  * Inquiry into the Process of Nature in repairing Injuries of the Intestines, by Ben-
jamin Travers.  London, 1812.
  f An Inaugural Essay on Wounds of the Intestines, for the degree of M.D. in the
University of Pennsylvania, by Thomas Smith, Member of the Philadelphia Medical
Society,  1805.
  J An Experimental and Critical Inquiry into the Nature and Treatment of Wounds of
the Intestines, by Samuel D. Gross, M.D.  Louisville, 1843. 
CHAPTER  III.
                             OF HERNLE.

  Hernia, or Rupture, is the name  given to a disorder which consists " in a
protrusion of any of the contents of the abdomen through natural or preter-
natural openings." As the  existence of hernial protrusions is very common,
about one in every eight of  mankind being believed to labor under them, and
as the complaint is  one which either rapidly destroys life  or  exposes the
patient to constant annoyance, it is not surprising that it has  claimed and
received so large a share of professional attention.   From  a very laudable
desire to investigate  the anatomical relations of a tumor  which involves
parts of such vital consequence, the examination of the structures through
which herniae  escape  has also been conducted with a degree of minuteness
that has hardly left any shred or portion of the  tissue concerned without a
name.   These details have  consequently thrown  a mist around  the descrip-
tion that has confused and  puzzled the brains of  many students, who, under
a less artificial account of the parts, would promptly have seized on all the
facts possessing a practical value.   The anxiety which has been shown to
individualize tissues  that in other  parts of the  body were  scarcely noted,
together with the habit of attaching  to areolar tissue the inappropriate name
of " fascia," has also tended not a little to add to the cloud which surrounds
this  disorder, as first presented to the mind of a young student;  and though
by subsequent study he may find that the various names given  by different
writers often designate the same part, it is  long before  the impression of
extraordinary difficulty, which has been associated with the very term of her-
nia,  wears away.  That the profession have materially benefited by the details
furnished by the distinguished anatomists whose  names are identified with
the subject of herniae, cannot be denied ; but that the student or inexperienced
surgeon has  been misled, when, knife in hand, he undertook to investigate
the structure for himself,  will, it is thought, be admitted by those who recall
the earlier moments of professional  experience.
   A very material defect in the usual account of herniae,  as adapted to the
wants of the surgeon,  may also be seen in the tendency of anatomical teachers
to present the relation of parts furnished by normal anatomy, instead of those
shown in the pathological  changes of the complaint; while, instead of de-
scribing the alterations of structure  produced by disease, they present a per-
fect  and minute detail of the disposition of tissues as found in subjects where
no hernia has existed.
   In an acccount like the following, which it is necessary to  make as con-
densed  as  is possible, it is thought to  be inexpedient to dwell long upon
minute anatomical description; and in the subsequent sections there will, there-
fore, be first presented such general pathological facts as are applicable to
Herniae wherever found ;  after which such descriptions of the surgical or topo-
graphical anatomy of each  region will be given as may be demanded for the
explanation of the peculiar condition of tissues found in the  three most com-
mon varieties of the  complaint,  to  wit, Inguinal, Femoral, and Umbilical
Herniae.
       (388) 
GENERAL PATHOLOGY OF HERNLE.               389
                             SECTION  I.

                    GENERAL PATHOLOGY  OF  HERNIA.

  Any  portion of the contents of the abdomen, as the bladder, uterus, or
other organ, which protrudes through a natural or preternatural opening,
constitutes a Hernia, though, iu the majority of instances, the protruding
part is composed of  the intestines or omentum.  As these viscera are so sit-
uated within the cavity of the abdomen as  to have the great sac of the peri-
toneum in front  and around them,  it follows that their protrusion at any
point will also involve a prolapse of this membrane, as well as of such other
tissues as may be so  situated as to be acted on by the protruding mass.
  Etiology of Herniae.—The causes of hernia?  may be  arranged under two
separate heads:  first, those  which are exciting, and second, those which are
predisposing.  The exciting causes are such as act violently upon the abdom-
inal parietes, as lifting heavy weights, blowing horns, jumping, and strains of
every character.  It is often excited in females by the tight lacing of corsets;
while crying violently  sometimes causes it in children.   Pregnancy is  also
a common cause;  and falls and blows, or  any similar violence, may at any
time induce the complaint in either sex.
  The predisposing causes are a preternatural relaxation of the abdominal
walls, or  an unusual size  of the various  normal openings in the abdom-
inal  parietes for the passage of vessels.   Thus, a very wide pelvis  in the
female is often a predisposing cause, because it creates a larger space beneath
the crural arch, while the congenital deficiencies of the  abdominal  parietes,
especially  at the groin and umbilicus, greatly  facilitate the production of
hernias  on the subsequent application of slight exciting causes.
  Envelopes of Herniae.—The coverings  of any hernia which  protrude in
front through the  abdominal walls, necessarily consist of a portion  of every
tissue which is to be found between the skin and the peritoneum, unless vio-
lence has destroyed  the continuity of the  layers, or nature  left in them a
deficiency or opening through which the tumor could pass ; or unless the dis-
tention  of the structure has been so  great  as to  lead to  its absorption, or to
its being so thinned as to  escape our observation.  Following the natural
course of the most frequent varieties  of hernia, and tracing it from the abdo-
men, we have, therefore, first to notice the  Sac.
  The portion of peritoneum pushed out in advance of  a hernial tumor, or
the "Sac," presents on  its  inside the smooth  shining surface of  a  serous
membrane, but, when irritated,  displays the  usual  characteristics of serous
tissues,  by giving rise to effusions of serum  which often fill the sac, or to effu-
sions of lymph which glue together its  sides and its contents, or very much
increase or diminish its density  from that  seen  in  the  normal  condition of
parts.   Outside of the sac, or process of peritoneum, is generally seen a layer
of areolar tissue of greater or less thickness, according to its position, which
varies  somewhat in  its attachments to  the  peculiar region  in which it  is
placed ; thus, at the sides of the pelvis and groins it is loose and movable,
while iu front its adhesions are firmer and  less easily overcome.   In  this
extra-peritoneal areolar substance, or  outer layer of the sac, are found the
more important of the blood-vessels directly connected with  the operations
of strangulated  hernia, and  in it are  also found the particles of fat which
have occasionally been mistaken for  omental hernia.
  The changes  made  by disease in this areolar tissue are varied.   When 
390            PRINCIPLES AND PRACTICE OF SURGERY.
 moderate  pressure is made upon  it, it becomes more developed, thickened,
 and laminated, acquiring  a density and fibrous appearance which qualify it
 for the name of "fascia,"  which it has received;  but when  the pressure is
 very great, it becomes thinner and atrophied.
   In  the  herniae which are found to escape at the groin,  this layer con-
 stitutes either the fascia  transversalis abdominis,  or the fascia propria,
 according to  the  views  of different  writers.  Outside of  this tissue are
 occasionally noted layers of muscular fibre, which are held  together by the
 connective tissue which is always more or less spread around them, or by the
 condensed areolar structure which fills up the spaces  left around the vessels.
 Outside of this again is found the fascia superficialis, or second grand teg-
 umentary covering of the body, and outside of this is the skin.
   When, however, long-continued  pressure or inflammatory action  has ex-
 isted for some time, all these layers, which in the normal condition are easily
 distinguishable, will be  found so blended and thickened as to have lost most
 of their ordinary characters and position, being fused, as it were, into one, or
 they may have their laminae  so increased that nearly twice  as  many layers
 can  be made over a hernia as might be looked for in  the natural  envelopes of
 the  part.   When muscular fibre forms one of the laminae  covering a hernia,
 there is less change observed in it  than is the case  with  some of  the  other
 tissues.  Its presence may, therefore, generally be told by its normal fibres,
 and  by these a distinction may be made of the different envelopes  of the tumor
 which  otherwise it  would  be very  difficult to recognize, the extra-peritoneal
 and  the subcutaneous fascia,  or the areolar tissue outside of the  peritoneum,
 and  that underneath the skin, being sometimes so blended as to appear  to
 the operator like a thickening of one and the  same structure.   The  special
 coverings of each variety  of  hernia will  be  again referred to in connection
 with the particular class to which  it belongs.
   Seat of Herniae.—The  abdomen being  a closed cavity, accurately filled
 by its contents, the different tissues which  enter into the composition of its
 parietes naturally sustain  an amount of  pressure which varies according to
 circumstances.  Above,  or  at the upper boundary of this region,  the pressure
 is resisted by the diaphragm;  but  this septum is seldom the seat of rupture,
 in consequence of its mobility, though  some of the intestines  have  occasion-
 ally  been  forced through  it  into  the cavity of the  chest, thus creating a
 Phrenic or  Diaphragmatic  hernia,  which, when  strangulated, is  beyond
 the relief of operative means.   Below,  the abdominal  contents are  sustained
 by the  bones of the pelvis and their connections, the resisting nature of which
 is so marked that herniae  are  also rare in this direction, though they have
 been seen at some of its weaker parts,  and especially  at the point of exit of
 its arteries, as at the obturator foramen,  or at the opening for  the thyroid
 artery, (Thyroidal Herniae,) at the sacro-sciatic notch, (Ischiatic Herniae,)
 where the gluteal artery passes out, and also alongside of  the vagina of the
female, (Vaginal Herniae,) or through a laceration of the perineum of the
male, (Perineal Herniae.)
  Posteriorly, the abdominal  walls are composed of the muscles  of the loins
and of the vertebrae, the  former of which can alone give exit to hernia?, a few
rare  cases having been reported by Petit and Cloquet, and named Lumbar
Herniae, where  the intestines protruded through  the muscles immediately
above the pelvis, after the  parts had been wounded or submitted to extreme
pressure.
  As the natural tendency of gravity is to cause the abdominal  contents to
press against  the anterior  parietes of  the abdomen  when  the patient is in
the erect position, and as many weak points  exist in the latter for the trans-
mission of the various organs of the male and female, this region is by far the 
GENERAL PATHOLOGY  OF HERNLE.
391
 most common seat  of herniae  in both sexes.  In that part of the anterior
 parietes which is immediately at the  line of the groin, there  is also found
 openings for  the escape of the spermatic cord, or of the round ligament of
 the uterus as well as of the femoral vessels, and it is at  this point the In-
 guinal and Femoral Herniae are seen.   When an inguinal  hernia passes
 into the scrotum it is called  Scrotal Hernia; into the labia majora, Puden-
 dal Hernia;  when it is  forced through the abdominal parietes at some
 usually strong point, it is known as Ventral Hernia; and if from this it slips
 into a part of the inguinal canal, it is  called Ventro-Inguinal.
   The hernial tumor has also been named according to its contents:  thus, if
 it contain intestine,  it is termed an enterocele ; if omentum, epiplocele; and if
 both, entero-epiplocele.
   Certain terms, moreover, are applied to the varieties of herniae in accord-
 ance with the condition in which their contents are found.  Thus, if they can
 be restored to the abdomen at pleasure, the  hernia is said to be reducible;
 if this is not possible, it is said to be irreducible; and when, from any cause,
 an irreducible hernia is so constricted  as  to  impede or prevent the passage
 of the feces and the circulation of the blood in the tumor, it is spoken of as
 strangulated.  When a hernia has existed from birth, it is designated as con-
 genital hernia.
   Another  class of herniae, usually designated as Umbilical, presents a va-
 riety which, though often  supposed  to be due to the passage of the  viscera
 through the opening left by the umbilical vessels of the foetus, seldom if ever
 is so.   This variety of hernia, from having been rather loosely described hy
 writers, is liable to mislead such as do  not carefully  attend to the normal re-
 lations of the part, the fact being that a hernia seldom escapes by the umbilicus
 proper.  In  the foetus, a perfect opening  exists in this portion of the abdom-
 inal parietes, which is correctly designated as the umbilicus, through which
 the vessels of the cord are transmitted; and  while the latter exist, or  shortly
 afterward, a hernia may pass  directly  along the course of these vessels, but
 in the adult it is otherwise.  At the latter period, the former aperture is so
-closely contracted,  and the vessels which  occupied  it so  perfectly solidified,
 that this point offers greater resistance than the linea alba itself, aud a hernia
 through the umbilicus  proper in  an adult is, therefore,  almost impossible.
 An  examination of the linea alba shows,  however, even  in  the  normal con-
 dition,  at many points,  but  especially in  the neighborhood of the  former
 umbilical opening, a weakness  of the structure around the course of the ves-
 sels, as well as a number  of minute orifices in the tendinous parietes, which
 give exit to small cutaneous blood-vessels and nerves.  When, therefore, one
 or  more  of  these openings  have yielded to the relaxation consequent on
 pregnancies, or to such other  causes as produce distention of the part, the
 tumor,  when formed, may  be designated as an umbilical  hernia, because oc-
 curring in the neighborhood  of the umbilicus.
   Pathological Changes  in  Herniae.—When the escape of a hernia from
 the abdominal cavity has caused a protrusion of the peritoneum, and formed
 what has been termed the sac,  the effects  of  the complaint will vary accord-
 ing to circumstances.  Thus, if the protrusion has  been  gradual, there will
 generally be seen an elongation of all  the tissues in  front of it;  while if the
 rupture has been the result of  a sudden effort, or of direct violence,  it may
 lacerate one or more of them, and pass directly through. The majority of cases
 of hernias being produced by the application of forces which are continued for
 a longer or  shorter  period,  most of the tissues connected with the  seat of
 the tumor are elongated rather than torn, and acquire a peculiar pouch-like
 form, especially the peritoneum, which is for this  reason called  the Sac.
 Iu order to distinguish the different points of this sac, it has  been divided 
PLATE  XLI.
    SURGICAL ANATOMY OF THE  PARTS CONCERNED IN HERNLE.

  Fig. 1.  A sketch of the Exterior of the Abdomen, showing the general out-
line of the muscles, as well as the general points of reference required in oper-
ations upon this region.   1. The umbilicus.  2.  Hypogastric region.   3. A line
drawn from the anterior-superior spinous process of the  ilium to the umbilicus,
and crossing the course of the epigastric artery.  At  one period, the  puncture
in ascites was advised to be made in this line, but it was given up, owing to the
risk of wounding the artery.                      After Bernard and Huette.

  Fig. 2.  The same parts, as shown after  the removal of the skin, fat, and
superficial fascia by a careful dissection.   1, 1. The linea alba.  2, 2. Rectus
abdominis muscle, and lineae transversae.  3. External oblique.   4.  Its tendon,
also  the position of the  internal abdominal ring.  5. Round ligament of the
uterus at  its  exit from the external abdominal ring.  6. Epigastric artery.  7.
Peritoneum  covering the intestines.  8. A  section of the fascia transversalis
everted.  9. Transversalis abdominis muscle.  10. Internal oblique muscle.  11.
External oblique.  12. Section of the  rectus.      After Bernard and Huette.

  Fig. 3. A view of the Superficial Fascia of the Abdomen and Thigh,  as shown
by a careful dissection of the skin.  1, 1. The fascia superficialis, arising on the
thigh and extending over the abdomen as one continuous layer.  2,2. Branches
of the arteria ad cutem abdominis.   3, 3. Branches of the corresponding super-
ficial veins.                                      After Bernard and Huette.

  Fig. 4.  Another view of the same, as seen after a closer dissection,  but espe-
cially in its relations to femoral herniae.  1. Fascia superficialis.  2. Perfora-
tions in the superficial fascia of the thigh, for the passage of the  superficial ves-
sels.  3, 3. Extension of the superficial fascia over the cord and testicles.  4, 4.
Superficial arteries.                             After Bernard and Huette.
        (392) 
Plate  4.1.
Kg. 3
Fig.l
l-'ig,. 2
FiR. 4.
 
 
GENERAL PATHOLOGY OF  HERNLE.
393
into different regions, so as to enable writers to define more accurately the
part to which reference is made: thus its Mouth is the portion which is  con-
tinuous with the abdomen; the Neck that which adjoins the opening in the
abdominal parietes, through which it protrudes; while its Body is the main
cavity, and the Fundus its interior portion, or that which is  most distant
from the abdomen.   But though these names generally indicate the regions
of the sac, and therefore to a certain extent its outline, they are not univer-
sally applicable.  Sometimes there are two distinct  sacs, or the body of one
sac is contracted in the middle, so as to  present a kind of hour-glass  con-
traction, and create two necks, or two bodies, as may be seen by reference
to the plates connected with  this subject.   Under  ordinary circumstances,
when a sac has been formed, it is possible, if the patient  is seen immediately
after its protrusion,  to replace both it and its contents in the abdominal
cavity.   A little later the contents may be  returned; but  the external  sur-
face of the sac, having contracted adhesions to the extra-peritoneal  fascia,
(Fascia Propria,) the sac remains, (Reducible Herniae).   Sometimes  both
the sac and its  contents contract adhesions and are permanently fixed,  (Ir-
reducible Herniae,)  or the contents  may be  so constricted as to arrest the
circulation, and lead to the development of a certain train of symptoms de-
signated as those of Strangulated Herniae.   It is for the relief of the latter
that the  operation of herniotomy, as it is sometimes termed, or the incision
of the parts around the protrusion,  is demanded; before proceeding to the
details of which, it will prove useful to refer to the general symptoms  con-
nected with herniae as most frequently noticed.
   Reducible Herniae.—All  herniae, whether reducible, irreducible, or stran-
gulated, are composed either  of intestine or of omentum, or  of both, and
give rise to tumors which vary in shape, size, and position.   When the tumor
can  be  restored simply by the taxis, it constitutes  the variety of the com-
plaint which is designated as a Reducible Hernia.
   Symptoms.—The symptoms of a reducible hernia are as follows: There is
a tumor in the  abdominal parietes or  on the  thigh, which is  well  marked
while the patient is standing up, but which disappears when he lies down, and
to which coughing generally communicates  a distinct impulse, as may be felt
by placing the  hand  upon the tumor  and  directing the patient to cough,
when the movement will be readily noted.
   The tumor caused by a  hernia is  also very apt  to be  larger after a full
meal than at any other time, and the patient experiences more or less of the
evils of flatulence, as  borborygmi or grumblings and roarings in the bowels,
particularly in the neighborhood  of the tumor, these being caused by the
difficulty experienced by the  flatus in passing through the protruded portion
of the intestines.
   The hernial tumor generally commences above and extends downward,  and,
if  it attains any size,  is more or less pendulous in its character; the size at-
tained finally being in some cases truly immense, reaching,  in cases of scrotal
or umbilical hernia, almost to the knees of the patient.   Herniae may, there-
fore, at any time be rendered irreducible from blows  upon the tumor, or pres-
sure upou the neck of the sac, by improper manipulation, such as the appli-
cation of a truss when the tumor is not properly reduced; or from too great
an amount of violence in making taxis.  Every irreducible hernia is usually
reducible in the first instance,  and those which are found irreducible  are,
therefore, generally of some weeks' or months' standing.
  When the  contents of a hernia are chiefly Intestine, the tumor will be
elastic and springy, especially when the  patient coughs.   Gurgling is  also
heard at the moment of reduction, and the rumbling of flatus may occasionally
be felt in the tumor. 
394           PRINCIPLES  AND PRACTICE OF SURGERY.
  When the contents are Omentum, the tumor  has a more  doughy feel,
gives a less distinct succussion to the finger when the patient coughs, cre-
ates no rumbling, and is less painful.
  Diagnosis.—The diagnosis of each variety will be given hereafter.
  Prognosis.—Reducible herniae may exist  for years and not  destroy life,
and, beyond the mere inconvenience of bulk, do  not seriously trouble  the
patient.  But so long as a hernia exists, and is not properly kept up within
the cavity of the abdomen, so long is the patient  exposed to strangulation
and sudden death,  living as if the sword  of Damocles  were  constantly sus-
pended over him, ready to fall  without a moment's warning.
  Treatment.—The general treatment consists in reducing  the hernia, and
keeping it within the abdominal  walls, as hereafter mentioned.
  In  reducible herniae, the tumors containing intestine are  generally much
more readily replaced than those containing omentum, as the constriction at
the neck of the sac, which is always more or less present, interferes so rapidly
with the circulation in the omentum, that effusions take  place, and it soon
becomes  very difficult to replace  it in the abdomen.
  Another change which takes place, commonly after a very short time, even
in the reducible herniae,  is the contraction of adhesions between the hernial
sac and the surrounding parts, so that although the intestine can readily be
passed up into the abdomen, the sac itself still remains outside.   In this ca>e,
after the surgeon has  reduced any intestine or omentum  which the sac may
contain,  further  manipulation  can be of no service, and may do  harm by
bruising  the sac and exciting an inflammation in it that may create sloughing.
After the hernia is reduced, however, it has been recommended, by many, to
keep up a steady though moderate pressure for some time upon the neck of
the sac, and it has  been asserted  that adhesive inflammation has  thus been
produced, and the  opposite edges of  the mouth of the sac so glued together
that a hernia could no longer come down, a radical cure being thus effected;
but surgeons differ in opinion in regard to  the  possibility of  such  cures
being radical; my  own personal  observation  being decidedly adverse to its
practicability in the great majority of instances, except in childrtn.
  Symptoms of Irreducible Herniae.—The  tumor caused  by this class of
herniae is more or less permanent, varying in size and symptoms according to
circumstances; thus constipation, flatulency, the erect posture, corpulency,
or pregnancy,  may increase it, by filling  the cavity of the bowels, or by ob-
stiucting the circulation and giving rise to infiltration of the omentum, these
conditions being shown at the time by the pain and other symptoms detailed
in connection  with the  reducible class.   But colic is more  common in the
irreducible herniae than it is in  the reducible class, ou account of the greater
tendency of feculent matter to lodge in the protruded  intestine.   The patient
is also more apt to suffer  from  attacks  of nausea and vomiting, in  conse-
quence of the fixed position of the omentum or intestine interfering with the
distention and upward  movements  of the stomach, especially after a full
meal.  Irreducible herniae may also  give rise to symptoms which are  the
result of injury to the contents  of the tumor by external causes, as well as to
those which  will be hereafter detailed as the result of strangulation. 
STRANGULATED HERNLE.
395
                             SECTION  II.

                        STRANGULATED HERNLE.

   When, from any circumstances, a reducible or irreducible hernia is con-
 stricted  by the surrounding  structures to such a degree  as to interfere with
 the passage of the contents of the bowels through it, or when the circulation
 becomes interrupted either in the bowel or in the omentum, a certain class of
 symptoms are induced which are regarded  as positive evidence of the exist-
 ence of strangulation or constriction.
   Etiology.—Strangulation  may be caused, in an irreducible hernia, either
 in consequence of a sudden protrusion of intestine through a small aperture,
 from  the distention of the part by accumulations  of flatus,  feces, or  blood,
 from  swelling of the narrow portion (neck) of  the  sac,  from spasm of the
 parts around it, or from the formation of bauds at its mouth as the result of
 inflammation.
   Symptoms of Strangulated Herniae—The  symptoms of strangulated
 herniae will be found  to vary with  the tightness  of the constriction  and the
 length of time that it has continued.   They will also vary when the strangu-
 lation  results from obstruction to  the passage of  matter through the pro-
 truded part, and when it is the result of inflammation.
   When the consequence  of simple obstruction, the patient experiences a
 sense of uneasiness, fullness,  or constriction in the part  or in the abdomen,
 as if a cord was drawn around  the latter,  accompanied  by  flatulence, more
 or less violent colicky pains,  a desire to go to stool or to strain, but without
 any or at least slight evacuations.   This is followed  by nausea and vomiting
 of the  contents of the stomach, then of mucus and bile, and subsequently by
 distressing retching, restlessness, moisture of the skin, irritation and excite-
 ment of the pulse, and the  other usual symptoms of a bad attack of colic.  If
 promptly relieved by a reduction of  the tumor, these symptoms will all dis-
 appear, the patient obtain immediate relief, and have a free  evacuation of
 the bowels; though there  may remain a certain amount of  soreness of the
 region, or even of the whole  abdomen.  But if the obstruction remains, and
 inflammation is induced, then the symptoms just detailed will be followed by
 others of a more  serious character.   In some cases of strangulation, these
 violent symptoms may be the first indications given of the existence of con-
 striction, patients  often suffering from some of those just detailed without
 deeming them more than the  ordinary inconvenience likely to result, or which
 has previously resulted, from their  complaint.
   The symptoms of strangulation, in very marked cases, consist in a greater
 tension and tenderness of the tumor; in  increased tenderness and swelling of
 the abdomen; in  increased vomiting, which  finally brings up stercoraceous
 matter, accompanied  or followed by hiccough, and in a change in  the color
 of the tumor, which becomes  dark red or livid, and gives  a doughy or crack-
ling sensation to the touch.  The  pulse becomes more frequent, small, and
 wiry;  the skin more wet, cold, and sodden; the countenance expressive of
distress and suffering; the mind desponding and  anxious, though presenting
occasionally intervals of apparent relief, till at last the suffering ceases; the
patient is apparently easy, though very feeble;  the  pulse fails; respiration
becomes short and labored, and  death closes the  scene.
  Diagnosis.—There are several conditions with which strangulated herniae
may be confounded, and from which it is important to distinguish it.   Of
these, that for which it is most likely to be mistaken is ilius or intussttscep- 
PLATE  XLII.
  A VIEW OF  SOME OF  THE PARTS CONCERNED  IX  INGUINAL  AND
                          FEMORAL HERNLE.

  Fig. 1. Surgical relations of the Blood-vessels in Inguinal and Femoral Her-
niae.   1. Skin, fascia, external oblique, internal oblique, and transversalis mus-
cles incised.  2. Fascia transversalis and  peritoneum covering the intestines.
3. Position of internal inguinal ring. 4. Epigastric vessels. 5. Section of rectus
abdominis.  G.  Tendon of external oblique, or Poupart's ligament.  7. Fascia
lata femoris.  8. Femoral artery.  9. Femoral vein.  10.  Sheath of vessels.  11.
Saphena vein.                                    After Bernard and Huette.

  Fig. 2. Envelopes of an oblique Inguinal Hernia.  1. Skin and  superficial
fascia.  2.  Tendon of external oblique distended by the hernia.  3.  Cremaster
and tunica vaginalis communis, or the fascia propria of the hernia.  4. Sac.   5.
Omentum.   6. Intestine.                          After Bernard and  Huette.

  Fig. 3. Yiew of a direct Inguinal or a Ventro-Inpruinal Hernia.   1.  Integu-
ments of abdomen.  2.  Tendon of external oblique.  3. Fascia transversalis
and peritoneum.  4.  Spermatic cord.   5.  Sac laid  open.  6. Position  of epi-
gastric artery in this variety of hernia.   7.  Intestine.  8. Position of the crural
ring.  9. Saphena vein.  10.  Saphenous opening of fascia lata.
                                                After Bernard and  Huette.

  Fig. 4. Plan to  show the relation of the  parts  of the Sac.  1.  Abdominal
parietes and ring. 2. Neck of sac.  3.  Its fundus. 4. Its mouth.  5.  Peritoneal
cavity.                                          After Bernard and  Huette.

  Fig. 5. Peculiar form of a Sac, as occasionally seen.   1. Abdominal parietes
and ring.   2. Fundus of sac.   3. Body of  the sac above an hour-glass contrac-
tion.  4. Cavity of the peritoneum.                After Bernard and  Huette.

  Fig. 6. Commencement of the changes  seen  in  the formation of a  Hernial
Sac.  1.  Abdominal parietes.  2,2.  Knuckle of intestine protruding at the ring,
and forcing the peritoneum before it so as to form the sac.  3. Fundus of sac.
                                                After Bernard and Huette.

  Fig. 7.  Next step of the formation, as seen in a recent Hernia.  2. Abdom-
inal ring.   2. Intestine as protruding and constricted by  the ring.
                                                After Bernard and  Huette.

  Fig. 8.  A view of the parts, as seen in a  more advanced Hernia.  1. Abdom-
inal parietes.  2, 2, 2. Intestine.   3, 3,  3.  Continuous line of peritoneum.
                                                After Bernard and Huette.
        (396) 
Fxg.l.
Plate 42
Fig. 2
Fi£.3.
»t....../
Fi£.6.

Fi£.7
 
 
STRANGULATED HERNLE.
397
tion, or the train of symptoms not unlike those of strangulated hernia, such
as pain, constipation, stercoraceous vomiting, etc., which ensue when a por-
tion of the intestine is invaginated within itself, so as to create a diminution
of its calibre, or a continued spasm of its  muscular walls, so  as to obstruct
the passage of the fecal matter toward the anus.
   But although the general symptoms in these cases are similar to those of
hernia, yet a diagnosis can often be  made with facility; because in hernia a
careful examination will  always  show a tumor,  while  even in  those cases
which, from the difficulty  of recognizing the tumor, have  been named con-
cealed herniae, the tumor may be found with more or less readiness by ether-
izing the  patient and examining him carefully, when he  is fully relaxed by
the influence of the anaesthetic.  The history of the case will also materially
aid the diagnosis; and if  the patient be  old enough  or intelligent enough to
give one,  will generally leave no doubt as to the true state of the bowels.
   Pathology of Strangulated Herniae.—When, as a consequence of strangu-
lated hernia, the patient dies, the post-mortem appearances are very marked,
the tumor itself usually exhibiting all the symptoms of mortification of a por-
tion of the intestine.  The latter, therefore, will be observed to be of a brown
or chocolate color, resembling in  this respect the color already described as
belonging to moist gangreue.  The hernial sac also usually presents a greater
or less quantity of serum, which is generally tinged of a deep chocolate color
by the altered haeraatin that has been effusid as the result of the congestion
that follows the constriction of delicate and vascular tissues.
   Prognosis.—The prognosis in strangulated herniae is always serious, and
should be  guarded, death being apt to ensue if the strangulation is not relieved
by an operation, while the operation itself if delayed is frequently unsuccessful.
Still, cases occur in which, as has been already stated, the patient  will sur-
vive the strangulation without an operation in consequence of the formation
of an artificial  anus.  As regards the  prognosis of the  different  forms of
strangulated herniae, it should be remembered that  small herniae are more
frequently the cause of death  than those of greater bulk, because,  perhaps,
they are more frequently  overlooked or trifled with,  and  also  because large
tumors dilate the  parts to such  an extent that  the strangulation  is not so
complete, and therefore by no means so serious as is the case in the small
protrusions.  The prognosis of intestinal herniae, when strangulated, is much
more unfavorable  than that of strangulated omentum, as might readily be
imagined, because in the  latter the calibre of the intestine is not  iuvolved
and the passage of the feces not interfered with,  the risk in omental  cases
being chiefly from the development of peritoneal inflammation.   The time
in which death may occur from strangulated hernia  is various; thus it may
happen in twenty-four hours, though, as  a general rule, it will not take place
until sufficient time has  elapsed to  permit  the  patient to  pass through  the
symptoms above detailed, while very frequently to these will  be  added  the
more tedious symptoms of general  peritonitis, this.being not uncommonly
the cause of death.   The duration of strangulated  herniae varies from one
to ten days.
  Treatment.—The treatment of this variety,  when not  demanding herni-
otomy, will be given under the section on the reduction of a hernia,  strangu-
lation ceasing as soon as the contents are properly replaced. 
398            PRINCIPLES AND  PRACTICE OF SURGERY.
                            SECTION III.

                        TREATMENT OF  HERNIJE.

  The symptoms of the varieties of herniae just detailed having shown that
the dangers, though imminent, depend to some extent upon the existence of
strangulation, or on the period during which the protruded part has remained
constricted, it is evident  that the whole  treatment of this  disorder must be
resolved into either a prevention or removal of this constriction.
  In  every case,  therefore,  it becomes the surgeon's  duty to attempt  the
restoration of the contents of the  tumor at as early a period  as possible,
bearing in  mind, in all efforts, the great liability of  the protruded parts to
be bruised  or injured by pressure, as well as the possibility of lacerating, in
certain cases of strangulation, such  portions as are in a state of softening or
mortification.

                       g 1.—Reduction of Herniae.

  The manual treatment requisite for the reduction  of herniae is designated
by the term Taxi.<—r'/,-w, to arrange—this word signifying the replacing of
the contents of the tumor in the abdominal cavity.
  General Plan employed in practicing Taxis.—The details of the taxis,
as required by each form of hernia, being hereafter  given, this  account will
be restricted to such means as are applicable as  adjuvants to the taxis in all
cases.   To perform the taxis with success, it is desirable that the parts con-
stricting the tumor,  as well as the muscular system generally,  should  be
placed in as perfect a condition  of  relaxation as possible, both by the posi-
tion of the patient and by constitutional measures, and that the  pressure of
the fingers  should be made in the axis of the tumor, unless  its peculiar posi-
tion requires some  slight modification of the rule, as will  be shown in con-
nection with  the  special cases.   At present, the  general  or constitutional
treatment  likely to facilitate the reduction of all hernias, where  difficulty is
experienced, can alone claim attention.
  The earliest causes of difficulty in the reduction of most herniae being the
accumulation of either fecal, gaseous, or vascular secretions within the pro-
truded portion, the first  point to be attended to is,  to empty the bowels by
enemata, and relieve the stomach by emetics, especially if a  full meal has pre-
ceded the  difficulty, in order that a freer circulation may  be established in
the protruding portion.  At the same time, the  bladder should be voided of
its contents, in order to give as much room as possible within  the cavity of
the abdomen.
  If, in any hernia, the-constriction is supposed  to be the result of muscular
contraction, perfect relaxation of the whole system should be produced, and
the patient placed  in such a condition as will tranquilize the action of the
diaphragm and respiratory muscles.  To accomplish this, nothing is com-
parable to  perfect etherization, especially in the hernia of children, as these
patients, when  etherized, always lie perfectly quiescent, and have a respira-
tory movement of so slight a kind—compared  with the efforts  which they
usually make to resist the taxis, either in consequence of pain or fear—that the
facility of the reduction is much  increased. Indeed, a resort to ether is often
sufficient, of itself, to accomplish the reduction of herniae in  the adult without
the use of nauseants, the warm bath, or any of the other means usually em-
ployed ; but the entire evacuation of the contents of the stomach should always 
REDUCTION OF HERNLE.
399
 precede the employment of the anaesthetic.  Should the want of ether prevent
 a.resort to this powerful adjuvant to the taxis, then the practitioner must em-
 ploy some of the other means of inducing the same degree of muscular relaxa-
 tion, such as the warm or hot bath, or the administration of tobacco or tartar
 emetic.  The employment of tobacco, in the form of infusion, in the propor-
 tion of a drachm to the pint of water, one-third or one-half of which is thrown
 into the rectum every hour, is a very powerful means of inducing general re-
 laxation, but is liable to the objection of exciting a longer and more thorough
 depression of the  system  than is desired, in consequence  of the continued
 absorption of the infusion if  the  rectum  does not expel it, as will sometimes
 happen in consequence of the relaxation of its muscular coat, even though
 the sphincter ani muscle offers no impediment to its escape.   A much safer
 and more controllable method of applying tobacco will be found in the fol-
 lowing plan :—
   Macerate a drachm of tobacco for a few minutes in  a sufficient quantity of
 hot water to soften it; then tie the mass up in a bag  made of a small piece
 of gauze (bobbinet) previously soaked in water, and  leave the end of the
 string that is tied around the mouth of the bag attached to it.  Push the bag
 into the rectum like a suppository, and when a sufficient constitutional effect
 is induced, draw it out by means  of the string which has been left pendulous
 at the anus.
   Various local means have also been recommended as adjuvants to the taxis,
 such  as warm applications to relax the cause  of the constriction, or cold
 articles to favor the contraction of  the protruded portion;  but as the three
 principal varieties  of hernia  escape most frequently  through aponeurotic
 openings, which are attached to  muscular fibres, little or no relaxation near
 the seat of stricture can be anticipated from the  application of heat, while by
 causing an afflux of blood to  the  part, it must tend to  increase the local con-
 gestion in the vessels of the tumor, especially if  omentum constitutes a part
 of it.   Cold, on the contrary, will diminish this congestion, and reduce the
 size of the protruding tissues, by exciting contraction of the fibres of the cre-
 master muscle, or peristaltic action in the muscular coat of  the bowel, so as
 to favor the reduction of the tumor,  while it cannot affect the condition of a
 tissue  so purely fibrous in its character as that found in the usual position of
 the hernial rings.   In applying cold as a means  of restoring hernial protru-
 sion, or as an adjuvant to the taxis, it  will  be  found most useful when its
 action is limited  to the contents of the tumor.   To effect this, apply it as
 follows: Take a cold cloth or small  lump of ice  and apply it directly to the
 lowest portion of the tumor, without  permitting it to touch the upper por-
 tion, or that near the neck of the sac, so that it  may induce a contraction of
 the contents of the sac from below upward, when, if the case is one of scrotal
 or inguinal hernia,  the effect will be promptly noticed,  the  scrotum  and
 fibres of the cremaster muscle contracting so rapidly as to render the change
 in the  position of the tumor very apparent.   If the hernia contains intestine,
 the cold thus applied, by hastening the peristaltic movement, will also tend
 to empty the bowel of its contents or of its blood, thus diminishing its size,
 and aiding very materially in its  restoration.  When  the cold is applied to
 the largest portion of the  tumor, or a lump of ice is so placed upon it that
 its weight may aid the effect of the cold, or when it is indiscriminately applied
 all over the tumor, it is liable to produce contraction of the muscular parietes
 of the  abdomen, and by thus constricting  the parts near the mouth of the sac,
 to do  more harm than good.
  When a hernia  has been reduced, a good truss  should be well adjusted
to the opening—in  the manner hereafter directed in the special forms of
hernia—in order to prevent future protrusions. 
400
PRINCIPLES AND  PRACTICE OF SURGERY.
   If,  in strangulated  herniae, the efforts at taxis do not succeed, then there
will be a necessity for resorting promptly to herniotomy for the purpose of
relieving the constricted bowel aud preventing mortification, as this operation
is not near so dangerous as the taxis, when rudely or improperly practiced or
continued for too long a time.  It is  important, therefore, in this form of her-
nia, that the taxis should be of the  gentlest kind, so as to diminish as much
as possible the danger from bruising  and inflaming the intestine, and that her-
niotomy should be early resorted to, in order that there  may be as little time
for the strangulated portion to become inflamed and mortified.
   So  frequently  has this  been noted, that Desault,  in the Hotel-Dieu of
Paris, would not permit the young residents of his hospital to  touch a case
of strangulated hernia until he saw it himself,  and then, if the hernia was not
reducible  on the gentlest taxis, he proceeded at once to the operation.  Sta-
tistics clearly show that by such a course fewer lives are lost than when more
violent efforts at taxis are  made before resorting to the operation.   A simi-
lar result coincides with the experience of most operators, and cannot be too
strongly impressed on  the mind of  every physician, the surgeon  not  being
sent for, in many instances, until the progress of mortification  has rendered
an operation necessarily unsuccessful.
             I 2.—Palliative Treatment of Reducible Herniae.

   The removal of the weight of the intestines from a hernial tumor having
enabled its contents to return  to the cavity of  the abdomen, as frequently
happens when the patient takes the  horizontal position, or when pressure is
made on its contents in order to replace them in the abdomen, as in the opera-
tion of taxis, their  future descent should be prevented by resorting to some
of the bandages capable of making constant pressure  at the point of exit.
   These bandages are very varied, and, under the name of Trusses, have  re-
ceived every possible modification in the means of attaching them to the part,
composition of the pad, or variety of adaptation to particular seats of hernia.
From a very early period, the form  of a truss best adapted to the treatment
of hernia has been governed by the peculiar  views of the surgeon at the
moment, or by other accidental circumstances. As the manufacture of these
bandages  has also  led many  unprofessional men  to  study  the complaint
superficially, great  ignorance,  and often a want of common honesty, have
been exhibited in the  formation and laudation of such instruments as it  is
apparent cannot possibly accomplish the object  that is desired, namely, the
perfect retention  of a hernia within the abdominal walls.  Iu  the  United
States, the variety  in the instruments  recommended for this retention  has
been fully equal to,  if it has not exceeded, that found in Europe, and it would
be a useless labor to attempt either an enumeration of the different kinds or
an examination of their merits and  defects.  Nearly all trusses are liable to
the serious professional objection of being patented, in consequence of which
an unnecessary cost is charged  upon those who  require them.   I am there-
fore unwilling, in a professional treatise,  to specify any one truss as being
a better or more scientific instrument than another, lest improper advantage
be taken of the  recommendation, and  shall now merely state the  general
character of a good truss.
  A good truss is an instrument formed of a spring of sufficient elasticity to
retain a pad at the seat of the hernial  protrusion, and  resist the action of
the diaphragm and  abdominal muscles.   To prevent its chafing the skin  it
should be  very smooth, as polished bone or wood.  Those  covered with soft
leather aosorb moisture and soon become  harsh and rough.   When  a truss 
           PALLIATIVE  TREATMENT  OF REDUCIBLE HERNLE.      401

is well fitted to the patient's pelvis, it will not require straps to prevent the
instrument from slipping upward when once placed in a proper position.
  In order to adapt a truss to a patient, the surgeon should  pass a piece  of
tape or soft  wire  directly around the pelvis  at the seat  of  the protrusion,
and, allowing one additional inch for the covering of the spring and thick-
ness of the pad, select an instrument of the length of the string or wire.
  The spring of a truss will be strong enough when it will  press firmly on
the orifice through which the hernia escapes, and yet does not cause the pad  to
indent the tissues after it has been worn  a few hours.   If  it does more than
this, the spring is too strong, and will do harm by  inducing  atrophy of the
structures ;  if the pad is incorrectly shaped, it will favor the recurrence  of
the hernia when the truss is omitted,  by  enlarging the rings.
   The pad of a truss, being the most important part, has  generally received
marked attention, and been made of every conceivable shape and  material;
some being round, oval,  oblong, pyriform, pyramidal, conical, truncated, and
square, and composed of  uncovered cork, wood, ivory,  metal, glass, or of wire
springs, or of horse-hair covered by kid,  buckskin, leather, caoutchouc, linen,
or  cloth.   A good  pad should have the  following characters:  A perfect
anatomical adaptation to the shape of the region that it is to cover; sufficient
firmness to maintain its proper surface without variation ;  and be either com-
posed of, or  covered with, some substance  that is capable of preventing irri-
tation of the skin or its excoriation from the constant absorption of the per-
spiration.
   When a patient desires  to bathe, a similar truss covered with oil silk may
be employed, or an oil silk sheath be slipped over the truss as usually worn.
The pad should generally be permanently attached to the end of the spring,
or be so fastened by screws that it can be shifted only by the use of a screw-
driver.   The much  lauded "movable,"  "self-adjusting," "self-regulating,"
" ball-and-socket" trusses I regard as among the follies of  the day, and worse
than useless.  Every  pad should have its surface  so beveled as to adapt it
to the natural inclination  of the abdominal  or  femoral parietes; or, if the
patient is very corpulent, the pad should be so inclined upon the end of the
spring as to enable it to  press gently from  below upward.   With the knowl-
edge possessed by every reputable cutler in the United States, any surgeon
can have  a  proper truss constructed for each case  as it is wanted, and  it is
to be hoped  that the profession, by pursuing this plan generally, and giving
their attention to the  subject, will be  able to  do away with  the practice  of
employing such instruments as are patented and sold  by "bandage makers."
The common hair stuffed pads, so often sold by druggists, etc., for the treat-
ment of hernia, have two serious objections: 1st, the hair yields to the press-
ure, and the  pad loses its proper shape; and  2d, the pad and its covering,
by absorbing perspiration, often become exceedingly foul  and irritating, de-
veloping eczema of the skin, and requiring the truss to be laid aside.
  Fitting of Trusses.—To apply a truss  accurately to the retention of an
inguinal hernia, the patient should be first placed in the position for the taxis,
and the entire contents of the tumor restored to the cavity of the abdomen ;
then, while a finger is applied at the internal ring in an "oblique inguinal
hernia," or at the  external ring in  a "direct  hernia," place  the pad at this
point by slipping the spring under the patient's back and  around the pelvis,
fasten the circular  strap,  and, letting the  patient rise, notice whether any por-
tion of  the hernia escapes by the side of the pad.  If it does not, direct the
patient  to move about a little and cough, so as to see if the pad retains its
place, or whether it is disposed to slide up, as is sometimes the case.  If it
does, then apply the perineal strap to hold it down; but otherwise it will not
be required.  Some caution is also necessary in applying a truss to the male,
     vol.  n.—26 
 402           PRINCIPLES AND PRACTICE  OF SURGERY.

 lest the pad be so shaped or so placed as to touch the pubis and compress the
 cord, thus exposing the patient to the danger of having one testicle atrophied.
 Except in a direct inguinal hernia, there  is no occasion for a pad to touch
 the pubis ; on the contrary, it should close the internal rather than the exter-
 nal ring.   In the direct variety, or the more rare form of inguinal hernia, as
 the external ring must be the point for the pressure, the pad should be always
 so  rounded or curved on its inferior  edge that, while it approaches the pubis,
 it shall not be able to compress the  cord against it.
   In  employing a truss for the retention of a hernia, surgeons have experi-
 enced the following evils, which may occasionally result from the use of this
 instrument: thus, if a portion  of the  hernia escapes and is compressed  by
 the truss, the patient will be exposed to the risks of strangulation ;  if it presses
 very firmly on the rings, it may lead to absorption of the adipose and areolar
 tissue  around  them ; if it produces excoriation of the skin, it  may necessitate
 the removal of the instrument, and  do away with the possibility of making
 any pressure,  while if it compresses  the spermatic cord against the pubis, it
 will induce the atrophy of the testicle just referred to.
   A truss that is well made and properly applied will, however, be free from
 these  objections.   It may be said to  be well applied if the patient feels com-
 fortable under all movements, and has the sensation  of increased  strength in
 the part, and  it will be  well made if its spring is strong enough to support
 the hernia, without making such pressure as would indicate  the  position of
 the pad by the indentation left on the skin  after the truss has been removed.
 Nor should a truss, as a general rule, be  applied with the idea of inducing
 adhesive inflammation in the subjacent structures.   Its object is mainly that
 of a supporter, which, by preventing the descent of the bowel into the ingui-
 nal canal, affords  an opportunity to  the  tissues  to contract toward their
 original condition.  A truss that possesses the characters that I have detailed,
 and which is  constantly worn night and day, will render a patient perfectly
 secure from strangulation, and though I believe it  will be  unable, in most
 adult  cases, to cure a hernia radically, it yet  presents  us with the following
 advantages: 1st.  The pad may  be readily and accurately shaped to meet the
 anatomical relations of the region.  2d. From its being formed of firm  mate-
 rials, its shape is never changed, as is the case in trusses with soft pads. 3d.
 Screws upon the neck, by fastening the pad of the instrument to  the spring,
 except when  shifted  by a  screw-driver, materially facilitate  its accurate
 adjustment to  the part, and insure the safety of  adjacent blood-vessels. But
 in choosing any instrument, the surgeon should be especially observant of the
 force of the spring; generally they are too stiff, the cutlers having no idea
 except that of sufficient force "to push up the bowel," whereas a good instru-
 ment should have only sufficient power in  the  spring to prevent the descent
 of the contents of hernia, after it has been replaced either by the fingers  of
the patient or of the  surgeon.   If a spring seems to be too stiff, its power
 may be diminished by gently bending it backward, or from its natural curve,
care being taken to apply the pressure near the neck of the instrument, aud
 not to carry it so far backward as to break the spring.
  The selection of a truss is a subject that deserves, and has received, care-
ful  attention from a large  number of surgeons,  and  whether we entertain a
high opinion of its  efficacy in effecting a radical cure, or  only believe in its
utility in the  palliative treatment of this complaint, it should be well made
 and accurately fitted, or it will  do neither.
  In treating  a hernia by a truss,  I  would advise, under any circumstances
that the instrument should be applied in every case except in  children under
eighteen months, as the  patient is  only safe from the dangers of  strangula- 
THE RADICAL CURE  OF HERNLE.
403
tion while wearing one.   When a truss is once applied, the patient should
also be directed to wear it constantly, and cautioned against taking it off at
night, lest he  suffer  from sudden strangulation, such as I once  saw in  a
patient who, having  removed his truss on going to bed, was attacked with
strangulated hernia during sexual intercourse.
                           CHAPTER  IV.

                ON  THE  RADICAL  CURE OF   HERNLE.

   Although after  the reduction of a hernia and the application of a good
 truss, the patient is for the time secure  from the dangers of strangulation,
 yet his  liability to  omit  the  use  of the instrument, as  well as the  incon-
 venience which sometimes ensues upon  its employment,  has frequently
 induced surgeons to search for some means  of closing the openings or rings,
 so as to secure him permanently  against the recurrence  of the complaint.
 These means have, of course, been very  varied, though generally predicated
 on  the  development of such  an inflammatory action in the part as would
 create adhesions of  the sides of the opening, or plug up the orifice, through
 which the hernia escaped, by such articles as would remain in  consequence
 of their fusion with the structures around the rings.  Reserving an opinion
 of the value of  these plans of treatment until they have been enumerated, I
 shall now present a  brief  account of a few of such American and European
 suggestions as seem plausible or have been attended  with some success.
   Operation of Gerdy,   of Paris,  practiced in  1837. — A curved  needle,
 pierced  with an eye near its point, and  fastened  to  a handle, several quills
 for the quilled suture, some strong aqua ammonia, together with  ligatures
 and a camel-hair pencil, being prepared,  the operation is thus performed :—
   " While the  patient is lying down, the surgeon places his left forefinger
 under the anterior  edge  of the scrotum, pushes  back the skin from below
 upward  into the ring, and as far as possible into  the inguinal canal, leaving
 the  spermatic cord  behind.   The  needle, armed with a  double thread, is
 then directed on the finger to the  bottom of this blind pouch, and its end
 brought out in front, so as to traverse, at the same time, the reflected por-
 tion of the skin, the  front  of the canal, and  the skin of the  abdomen.  As
 soon as the  eye, near the point of the needle, is seen  outside, one end of the
 ligature  is disengaged and kept outside, while  the other  end is withdrawn
 with the needle,  Plate XLIV. Fig.  1.   Being  then pushed  through the
 same tissues, it is brought out half  an inch from its first  point  of issue,
 Plate  XLIV.  Fig.  2, and  the  second end disengaged  in the same way.
 The pouch, formed of the  skin of the scrotum, being now retained by a loop
 of thread in the  canal where it was pushed by the  linger, the threads of one
 side  are tied  on  a quill half  an inch long, and the  other threads on another
 tube so as to form the first point of a quilled suture, Plate XLIV. Fig. 3.
 Two other points of suture being made in the same  way, one on the inside
the other on the outside, at half an inch distance from the first, a camel-hair
pencil  should be dipped in the ammonia,  and the  scrotal skin in the pouch
cauterized sufficiently to destroy its epidermis.  Inflammation attacking this
skin, the two surfaces which are in contact suppurate, and adhere about the
eighth day, when the threads are removed and the canal obliterated." 
404
PRINCIPLES AND PRACTICE  OF SURGERY.
   The other plans of treatment are very varied: thus,  Velpeau, at one
period, revived the old plan of scarifying the sac, but has since  abandoned
it; and Belmas introduced strips or bags of gelatin  into the cavity of the
sac, though it proved to be a very imperfect plan of proceeding.  Bonnet,
of Lyons, and Mayor, have also attempted the constriction of the canal by
pins and ligatures—as in cases of varicocele—but have obtained only occa-
sional and temporary success.
   The following operation is among the more recent of those proposed, aud
presents some points which are worthy of notice :—
   Operation of T. Wood, of Cincinnati.—Having prepared a needle, with
the eye in the middle and a spear-point at each end  so as  to enable it to
pass readily in any direction without  becoming entangled,  place the patient
on his back in bed, with the pelvis elevated, so as to relax  the tension of the
abdomiual  parietes.  The,hernial  sac with all  its contents being then re-
turned through the ring, pass the little finger  of the left hand into the ring
so as  to carry before  it the thin structure of the scrotum.   After  thus ascer-
taining the condition of the ring, and  being satisfied  that there is nothing
between  its columns  but the spermatic cord, carry the latter downward and
inward, and hold it by the pressure of the finger in the angle of the ring,
which is  next to the symphysis pubis, and, while it is thus  retained, thrust
the point of the needle  through the  integuments  so  as to strike the  inner
column of the ring about one-eighth of an inch from its margin, and as near
the pubes as is possible without endangering the cord,  either by wounding it
with the needle or  by constricting it, when  the sides of the ring are approx-
imated by the ligature.  The point of the needle being then  passed through
the tendon  in  many points,  so as to excite  more  action, and carefully
directed  upward, pass it through and across the canal—so as to avoid the
cord, and also prevent its becoming entangled in that portion of the scrotum
which caps the finger—until it reaches the opposite column of the ring at a
similar distance from  its margin, when, the side of the needle being pressed
strongly  against the  abdominal ring, the  finger should  be  gradually with-
drawn until the point of the needle can be made to reach a proper point for
puncturing the tendon, when it should be thrust through and made to appear
on the external surface  of the  integuments opposite its point of entrance.
The point of the needle  being now seized, and drawn carefully through until
the ligature has passed through both  the punctured  columns of the ring,
make  it retrace its  course as soon as its  eye escapes from  the tendon,  so as
to carry the end of the ligature through and out of the first opening made in
the skin, thus placing the first end of the ligature at the puncture first made,
aud the last end at the opening made by the exit of the needle ; after which
the two ends should be tied over a compress placed between them, so  as to
bring the opposite columns of the ring  in contact  and cause their union by
adhesive inflammation.  After the  ligature  is applied  and  the columns
approximated, the patient  should  be kept constantly on  his back, and the
ligature not removed for eight or ten days, the free suppuration usually seen
at this time facilitating the escape of the ligature when  gentle  traction  is
made on it.
   Operation of Bowman,  of Kentucky.—A puncture being made, a syringe
with a very fine nozzle was introduced, and inflammation developed  in the
parts  around the abdominal canal and ring, by the use of Lugol's solution or
other articles. This treatment has been employed in six or  eight cases, about
one-half  of which were  successful.  Jobert, of Paris, has  recently  reported
the cure  of a patient  by  this means.
   Operation of John Watson, of New York.—The  patient  lying on his
back, with the scrotum and left spermatic cord drawn slightly to the right 
TnE RADICAL  CURE  OF HERNLE.
405
 side, and with the integuments over the left external abdominal ring slightly
 on the stretch, the point of a delicate bistoury was introduced directly down
 to the crest of the  pubis, so as  to touch without dividing the insertion of
 Poupart's  ligament.  Being then made to work  freely in the loose  tissue
 immediately in front of the ring, but without wounding  the spermatic cord,
 the nozzle of a  small syringe, charged with  about a  drachm of tincture of
 cantharides, was introduced, and the  liquid injected to  the bottom of the cut,
 the hand of an assistant pressing in the mean  time  over the inguinal canal so
 as to prevent the fluid from entering it or passing through the sac  into the
 abdomen.  A compress  and  spica bandage being then applied and  an ano-
 dyne administered, the patient was kept on his back,  and in a few  minutes
 began to complain of pain, which was most severe  along the spermatic cord,
 but by the next morning had nearly subsided.   Eighteen days subsequently
 he was able to walk without his truss, no tendency to  the protrusion  being
 noticed ; but, as he left the hospital,  the future result was unknown.
   Operation of W. H. Roberts, of Alabama.—Roberts employed  a small
 silver  syringe, whose canula was  an  inch long and terminated in a trocar-
 shaped  steel point, near which were  two, small orifices  for the exit of the
 fluid from the syringe, which would  hold about fifty drops.  After purging
 the patient freely,  and administering an anodyne, the operation of invagina-
 tion, etc. was performed, oil of cloves being, however, the liquid employed
 to develop inflammation.  In six cases reported as thus treated, most of them
 were subsequently as  bad as before.
   Operation of  J. C. Nott, of Mobile.—A man,  aged  fifty, labored  under
 enlargement of the testicle and scrotal hernia.   After  the attending surgeon
 had  removed the testicle, the operation  proceeded  as follows:—
   Extending the incision a little above the external ring, the latter was fully
 cleared of connective  tissue.   The hernial sac having been already opened, a
 considerable portion was removed with the testicle  to which it was adherent,
 and a leaden wire  passed through the internal column  of the ring, two or
 three lines from its margin and about four above the  pubis.  This, being
 continued down under the neck of the sac, between the latter and the pubis,
 was brought out through the  external column of the ring, at a point oppo-
 site to the  perforation in the other column, the object being to draw together
 the two columns of the ring, and at the same time  compress the neck of the
 sac.   A  single knot being  made in the wire, the latter was twisted by a pair
 of forceps  as tightly as  so  weak a substance would permit, but the opening,
 being large enough to  admit three  fingers to pass into the abdomen, was
 only reduced by the operation to  about half its breadth.  The integuments
 were now united by suture, etc.
   The wound suppurated very profusely, and was about six weeks in closing,
 owing to peculiar  difficulties.  Two months after the  operation,  a hard,
 insensible lump occupied the seat  of the external  ring, where the wire had
 been placed, and four months  subsequently the patient,  though engaged  at
 hard labor, had had no return of his  hernia.
   Operation of Jameson, of Baltimore.—Having  operated for crural hernia
 on a lady, who subsequently had a return of  the protrusion, and begged to
be relieved at all hazard, Jameson operated as  follows: Having, by an
incision similar to that required for strangulated femoral  hernia, exposed the
crural ring, a flap of integuments,  two inches long and ten lines wide at its
base, was dissected from  the adjacent parts, reverted on itself, and introduced
into the ring so as to plug it  up, the wound  being closed by several points
of the interrupted suture.  This operation cured the patient in this instance,
but has not, so far as I know, ever been repeated.
  Remarks.—The three cases operated on by Wood were, apparently, cured 
406
PRINCIPLES AND  PRACTICE OF  SURGERY.
at the time of his report, though he desired a longer period to test the cure.
The first case had then been operated on eighteen months, the second eight,
and the third three  months, but each continued to wear his truss.  The dis-
cussion in the Medico-Chirurgical  Society of Cincinnati, on Wood's paper,
led to the expression of sentiments which all familiar with hernia will proba-
bly admit to  be reasonable, viz.:  that his operation, like that of Gerdy, only
closes the external ring, and  does  not act on  the  internal ring or on the
inguinal canal, and that though applicable to direct herniae, it is  not equally
so in  the  oblique variety.  The same objection holds  good as to Wutzer's
operation, a plan which mainly differed from that of Gerdy in the instruments
employed, though often alluded to  recently as a novel method.
                              SECTION  I.

   OBSERVATIONS  ON THE  RESULT OF  THE  OPERATIONS FOR THE  RADICAL
                       CURE  OF INGUINAL HERNLE.

   A strong desire to ameliorate the condition of those who labor under the
 evils of hernia, having led surgeons, as has just been shown, to investigate
 the possibility of effecting  a radical cure of this complaint,  their conclusions
 in respect to the results of one plan of treatment (trusses) have, in some in-
 stances, been  so favorably received  as to have induced a  great  number of
 patients to believe that radical cures of herniae can be accomplished solely by
 the use of these bandages. The report of a committee of the Philadelphia Med-
 ical Society, appointed with a special  view to the investigation of the truss
 of Chase,* has often been quoted as indorsing the opinion that his truss will
 accomplish a radical cure  ; but such has never seemed to me to be the true
 verdict of the committee.  Though believing in the advantage of employing
 Chase's truss in preference to  many  others, their report says : " That  the
 success, in cases of umbilical herniae  in  young children, is almost general
 .  .  .   that success in other varieties  of herniae, affecting subjects (children)
 of similar ages,  is  by no means rare under the operation of  trusses with soft
 pads ; that, in children over  ten years of age,  it (a radical care) becomes
 rather  uncommon ;  that in youths between the age of puberty and twenty
 years, it (the  radical cure) becomes rare, and  after the latter* period very
 rare."   This committee defined a radical cure  as follows :  "A cure is radi-
 cal when  the tendinous and fascial barriers  to  the egress of the bowels are
 brought or restored  to their normal or original firmness and power of resist-
 ance," to  which  I would add, and capable of permitting the  ordinary actions
 of life, during three years,  without the reappearance of the  hernia.  Under
 this definition, there are few cases of adults over twenty years  of age  that
 are showu to have  been cured  in the  many works which  I  have consulted,
 and I therefore respectfully reiterate the opinion that a radical cure of hernia
 (not congenital) in a patient over twenty years of age,  has  very rarely been
 accomplished by a truss.  Temporary relief has enabled some patients to go
 without the truss for a few  months, but in the majority of instances I think
 it will be found that the complaint has  or will reappear in  about three years.
 Nor is  this opinion solely  that founded on my  individual observation of a
 large number of Chase's patients, as well  as  those treated by myself with his
 truss.   T.  Wood, of Cincinnati,  who was a private pupil of  Chase, and spe-
cially instructed in his opinions  and  mode of treatmeut, and who also  saw
 numbers of patients treated by him, says, in  an extended article on the radi-

      *  Report of Committee of Philadelphia  Medical Society.  Philad.  1837. 
THE RADICAL  CURE OF  HERNLE.               407
cal cure of herniae :* " I have seldom met with a patient who had not a her-
nia at the end of two years' treatment.   I have much more rarely met with
one that remained cured at the end of three years; and I have never known
one to be radically cured of a hernia at the end of four years' treatment by
any means whatever.   The conviction is  therefore indelibly stamped  on my
own mind  that  no truss will effect a radical  cure of hernia, any more than
indigo will cure epilepsy, or the thousand and one corn salves will radically
cure those troublesome customers that torture your toes."
   In thus expressly advancing the opinion that a hernia is not radically cured
by a truss in the majority of instances after the age of eighteen years, or after
the period when the patient's frame is well developed, I am fully aware that
others entertain somewhat less decided sentiments on the subject, and the
reader will therefore view the opinion as  that based chiefly upon individual
experience.  It may be that I  have been unfortunate in the  selection  of
cases, or that I was wanting in surgical skill, but as others may  be similarly
situated in this respect, I  humbly desire to prevent any young surgeon from
accidentally misleading his patients into  the belief that the use of a truss
will cure them, lest the result cause  them to charge him  either with igno-
rance or willful deceit, and induce them to place  him in the same class  with
the miserable characters who profess to cure all disorders.
   Although decided in my own views on this subject, I wish it to be un-
derstood  that my opinion  and that of Wood also differ  from  that  of the
committee appointed by the American Medical Association in  1852, to re-
port  on  the radical cure of herniae.   This committee—composed  of Hay-
ward, J.  M. Warren, and Parkman, of Boston—"regard compression, when
properly employed, as the most  likely means  of effecting  a radical cure  in
the greatest number of instances," and some of the French  surgeons coincide
with  them.   Many, however, both of the French and English school, have
dissented from this opinion ; and  the reader will, therefore, see that the ques-
tion is by no means settled, and should  so regulate his opinion as to protect
himself from the  suspicion of willfully misleading his  patient,  by  candidly
stating to him the uncertainty of the result.   Let  the adult fully understand
that while he wears a truss that is accurately fitted, he is as secure as he can
be against the dangers of strangulation ; that  his hernia will not be  so liable
to give him trouble as it was before the application of  the truss, no matter
what he may do;  that while he wears it there is a chance  of cure, but that,
in all probability, he will find  it  essential to  his safety to wear a  truss for
many years, if not for life.
   The other measures which have been resorted to in the attempts to  cure
herniae radically, date back to a very early period of the profession—Celsus,
Aetius, Gdy de Chauliac, and other surgeons having advised various means
of accomplishing it.  Few, however, seem to have presented unexceptiona-
ble facts, as each period appears to have been dissatisfied with the acts  of
its predecessors, and to have endeavored to remedy their operations, or sug-
gest others.  The application of a ligature around the neck of  the sac was
advised  especially by Guy de Chauliac,  a.d. 1360, who directed  that the sac
should first be laid  bare, in order to strangulate it with greater  certainty  at
its root.   The use of a leaden ligature, and  the approximation  of the sides
of the ring, as  advised  by Nott, of Mobile, present a modification of this
operation,  which may prove to have several  advantages over the old-fash-
ioned thread and the strangulation of the  neck of the  sac, and, as it  does not
constrict the cord, (being placed below it,) is worthy of further trial.   Of the
operation of Gerdy, I have only to say that my personal observation of many
* Western  Lancet, vol. xii. p. 277, et seq. 
408           PRINCIPLES AND PRACTICE OF  SURGERY.
of his cases in  the Parisian hospitals in the year 1839, did not induce any
confidence in its ultimate success; while the plans of Velpeau, Belmas  and
others  have not been  sustained by  general professional  experience.   1 he
modification of the plastic operations also, tried many years ago by Jameson,
of Baltimore, has been well thought of; but, though this patient was cured,
I am not aware that his operation has  been repeated.
  Summary.—Upon the whole, I  incline to the opinion that though any of
these operations, when followed  by the use of  the truss for two  years,  may
benefit the patient for the time, yet the result of the operations will ultimately
be unsatisfactory in the majority of cases  As these operations have, however,
succeeded, at least for some few  months, other surgeons may deem it proper
to repeat the trial.  If called on to select any one method, I should prefer the
plan of Wood, of Cincinnati, or the use of a leaden ligature below and around
the ring and neck of the sac, in a manner somewluit similar to that reported
by Nott, of Mobile; while, if a more simple operation was desirable, I should
resort to the use of the injection as practiced by Watson, Roberts, etc.  Many
of those most experienced in the result  of these operations are, it will be seen,
like myself, far  from being  satisfied  of their  ability to effect a radical cure.
Roberts  expresses the opinion,* based on the record of  his cases,  that, so
far as the danger of the operation is  concerned, he has yet to learn that any
existed, having seen the  intestines come down  the day after the operation
and returned without bad consequences.   He has also seen the oil of cloves
thrown into  the  sac when  the  omentum was there, and  retained  without
trouble.  Yet,  since the latter part of  1847, he has had so little confidence
in the operation as to have given it up, preferring to rely upon the introduc-
tion of a small seton at the external ring.   Wood also, it will be seen, was
not sufficiently  satisfied with his success, at the date of his  report, to recom-
mend his operation as a radical cure.
   In a valuable and recent  report on the statistics of herniae, by Samuel B.
Richardson, of Louisville, Ky.,f the following opinions are given from Ken-
tucky surgeons who  were applied to  by the reporter.
   Swain, of Ballardsville, " does not know that he ever  effected a radical
cure—supposed he had in one instance by a solid pad and truss."
   Chew, of Midway, "has effected a radical cure in one case, in a boy aged
15, by the wooden pad truss."
   Sutton, of Georgetown, "thinks he  has treated  in  all not exceeding a
dozen cases of hernia, mostly children, and successfully by retentive trusses
alone."
   J. B. Flint,  of Louisville, " has performed none  of the operations  pro-
posed for the radical cure of hernia—regards them  as opposed to the canons
of sound surgery, and not to be compared to a well-adjusted retentive truss."
   John C.  Richardson, of Lexington, "has cured radically several  cases of
hernia in young children, by simple compress and bandage."
   Among the advocates of a cure by Wutzer's operation,  is T. L. Ogier, of
Charleston,! who reports twelve successful cases, and  nineteen others, also
successful, but not reported.
   Nott, of Mobile, on the  contrary, reports  Velpeau  and Nelaton as ex-
pressing the opinion " that Wutzer's operation or any other on similar prin-
ciples is unreliable, the disease returning in the great majority of instances."
This, as before  stated, has beeu the result of personal observation since 1839,
and I have seen no reason to change my former estimate of the treatment.
* Southern Med. and Surg. Journ., vol. ix. p. 23»>
f Semi-Monthly Med. News, vol  i. p. 161.  Louisville, 1859.
j Charleston Journ., Jan. 1800. 
CHAPTER V.
                STRANGULATED INGUINAL  HERNIAE.

   Oblique or Indirect Inguinal Herniae, in the male,  consists, as before
stated, in a protrusion of some of the abdominal contents through parts which
have been left in a weakened condition  by the descent of the testicle from
the loins to the scrotum.   In the female, this form of hernia passes through
the openings left for  the passage of the  round ligament of the uterus in its
course to its insertion.  When  the protrusion occurs  directly through the
abdomiual parietes behind the external abdominal ring, and without follow-
ing the course of the inguinal canal, it constitutes the form of the complaint
which  has been designated as  Direct Hernia.   As Oblique  Herniae  is
the most common, a reference to the changes induced upon the parts by the
descent of the testicle will facilitate the comprehension  of the anatomical re-
lations of such portions as are directly connected with the operation required
for its relief when strangulated.
                             SECTION I.

               SURGICAL RELATIONS OF INGUINAL HERNIAE.

   The anatomical details of the abdominal parieties belonging to special
anatomy, and being generally among the elementary studies of every medical
student, I shall not now enter upon a description of the muscles, fasciae, etc.
which compose the abdominal walls, but limit  this account to a few of the
points especially connected with the surgical relations of inguinal hernia.
   The split or opening in the tendon of the external oblique muscle of the
abdomen, or the External abdominal ring, is found near the point where
the tendon or  ligament of Poupart is attached to the  spine  and symphysis
of the pubes.   This opening or ring being somewhat triangular in its shape,
has its base resting upon  the  pubis, while its summit is lost in the general
fibres of  the tendon of the external oblique.   It is covered by the skin and
fat as well  as  by the fascia superficialis abdominis of Camper, while the
space or opening contained between its sides is filled with loose areolar tissue
in the normal condition, though the existence of hernia may so thicken it as
to justify the name of intercolumnar fascia.   Through this  ring the sper-
matic cord of  the male  and  the round  ligament of the  uterus in the female
are transmitted, either to the scrotum or pubis, both of them inclining very
much to  the outer side—outer  column—of the ring.   In the integuments
over this  ring  we  find a small artery and vein—arteria et vena ad cutem
abdominis of Haller.  Behind the ring is the common insertion of the rectus
abdominis and pyramidalis muscles, which tends very much to  strengthen the
part and  prevent, except in ventro-inguinal hernia, the descent of the bowels
at this spot; but this common tendon does not constitute one of the cover-
                                                         ( 409 ) 
PLATE  XLIIT.
    SURGICAL RELATIONS OF THE PARTS CONCERNED IN HKKNL-E.

  Fig. 1. A view of the relation of the Internal Oblique  and Transversalis
Muscles to Inguinal Hernia;, showing the mode of formation of the Cremaster
Muscle.  1. The tendon of external oblique, a portion of the muscle and  its
tendon having been excised in order to show the parts beneath.  2. The fibres
of the internal oblique.   3. A  section  of the tendon  of  the  external oblique
everted  upon  the thigh, and showing the origin of the internal  oblique and
transversalis muscles from  Poupart's ligament.  4.  The common tendon of the
last two muscles.  5. The cremaster muscle as seen upon  the cord, but not ex-
tended upon the testicle, as is usually the case.    After Bernard and Huette.
  Fig. 2.  A view of the relation of the Transversalis Muscle and Fascia.
1. Transversalis muscle, as shown by the  removal of the parts above it.  2.
Circumflex ilii artery in its course to anastomose with the ilio-lumbar.   This
artery lies  between the transversalis and  internal  oblique  muscles.  3. The
femoral artery exposed by opening its sheath.  4. The femoral vein.
                                               After Bernard and Huette.
  Fig. 3. Formation of an Inguinal Hernia at the internal ring, and the relative
position of its  coverings.  1. Tendon of the external oblique everted.  2. Section
of the fascia transversalis.  3. Intestines seen through the peritoneum. 4. The
cord.   5. Mouth of the hernial  sac.               After Bernard and Huette.
  Fig. 4. Relative position of the coverings of an old Scrotal Hernia, as shown
by laying  open the part.  1.  Penis hooked back.   2, 2. Skin  pinned  back.
3, 3. Fascia superficialis.  4.  Dartos muscle.  5. Internal layer of dartos.  6.
Tendon of the external oblique, with  the  external  abdominal ring.  7. The
spermatic cord.  8. Tunica vaginalis communis, or fascia  propria.
                                               After Bernard and Huette.
  Fig. 5. Relative position of constituents of the Cord.  1. Tendon of the external
oblique.  2. The same slit open.  3. Fibres of the internal oblique and transver-
salis,  or the cremaster muscle.  4. Tunica vaginalis communis.  5. Probe passed
beneath the vessels of the cord.  6. Vas deferens.  After  Bernard and Huette.
  Fig. 6, Relations of the coverings of the Testicle.  1. Tunica albuginea.  2.
Tunica vaginalis testis.   3. Cremaster  muscle and tunica vaginalis communis
of the cord.                                    After Bernard and Huette.
  Fig. 7. Mode in which a Hernial Sac is formed.   1, 1.  Point of protrusion.
2, 2.  Intestine about to escape.  3, 3.  The peritoneum  as protruded in front
of the intestines.                                After Bernard and Huette.
        (410) 
Plate  43 .
Fio.3.
Fi6 .6
 
 
              SURGICAL RELATIONS  OF INGUINAL HERNLE.         411

 ings of herniae, as is stated by some  anatomists.   Extending obliquely up-
 ward and outward from this ring—for the extent of an inch and a half in
 the normal condition — is the  space or flattened passage designated as the
 Inguinal canal, though, except  when  distended  by a hernia, it cannot
 properly be spoken of  as a canal.   Behind,  it is bounded  by the rectus ab-
 dominis muscle and fascia transversalis, to which it chiefly owes its strength;
 below, by the crural arch ;  while  its  anterior and  inferior  boundaries are
 chiefly due to the imperfect fibres  of  the internal oblique  and transversalis
 muscles, to the tendon  of the external oblique, and to the fascia superficialis
 and  skin.   Throughout  its length, we find the spermatic  cord of the male
 and  the round ligament of the female, and when an oblique hernia descends
 through it, these structures will generally be  found behind, below, and within
 the hernia.   The upper, posterior, or external orifice of this canal is desig-
 nated as the Internal  abdominal  ring, or opening in the fascia transver-
 salis, though such  an opening never  exists  in the  normal condition of the
 parts, as a process of the peritoneum as well as of the fascia transversalis
 is extended upon the cord and into the  canal in its healthy condition; the
 presence of  the internal  ring is therefore always due either to dissection or
 to the pressure of a hernia by which its edges become defined.  On the inner
 side  of the internal ring, when it exists, or on the  inner side of the cord or
 round  ligament, is found the Epigastric Artery, which, running vertically
 upward, or nearly parallel with the fibres of the rectus muscle, has the peri-
 toneum behind it, and the fascia transversalis in front of it.   Through these
 structures the foetal  testicle and oblique inguinal  hernia descend in their
 course  from the abdomen to the skin, and in the course of this canal must
 the taxis be practiced, when the effort is made to restore a reducible hernia.
   The Spermatic Cord is composed of the vas deferens or duct of the testicles
 —the spermatic artery—veins  and  nerves, and of the tissues that are  made
 to cover them by the uormal  descent of the testicle from the loins to the
 scrotum.   As the oblique hernia follows the same course as  the testicle, the
 study of the descent of the latter  is essential to the comprehension of the
 coverings and relations of this variety of hernia.
  When the testicle of the foetus leaves the loins in its descent to the scro-
 tum,  it  pushes before it that portion of the peritoneal sac which lies in front
 of the intestine ; then  presses  in front of it, and extends  a portion of the
 fascia transversalis;  next a few fibres of the transversalis  muscle; then a
 few of those of the internal oblique  muscle, the two together constituting the
 cremaster muscle.   Passing then through the external abdominal  ring, it
 extends the portion of  the cellular  tissue  which is between the sides of the
 ring and the fascia  superficialis, and, lastly, drops into the pouch of the skin
 known  as the  scrotum.   When  in  the scrotum,   this  gland is, therefore,
 covered  by the  skin, fascia superficialis, cremaster muscle,  condensed
 areolar tissue,  (tunica vaginalis communis,)  and by  the peritoneum, (tunica
 vaginalis testis,) the cord  having the epigastric artery between the linea alba
 and the line of its descent in the thus  formed inguinal canal.
  Shortly after taking  its position in the scrotum,  the  tube-like process of
the  peritoneum,  which then extended  from the scrotum  to  the abdomen, is
obliterated, though sometimes it remains open, as in congenital  herniae, or
congenital  hydrocele, or is only closed  at points, as  in encysted hydrocele or
hydrocele of the cord. The process of the fascia transversalis (extra-peritoneal
areolar  tissue) which had been protruded in a pouch like the peritoneum,
but contracted into  a tube-like  prolongation  on  the  cord, is then  gradually
changed, and  loses its  dense characters, except on  the  surface next to the
peritoneum, where it presents a funnel-shaped depression at and  around the 
412
PRINCIPLES  AND  PRACTICE OF SURGERY.
 cord, while the remaining layers contract upon the cord and are diminished
 in character and distinctness.
   A  portion of intestine  or omentum (hernia) pressing against the perito-
 neum at the same point of the  abdominal parietes, does the same thing as
 the testicle did, that is, it pushes forward a portion of the peritoneum, unless
 the sac formed by the descent of the testicle has not been cut off  from its
 connections with the general peritoneal cavity, when it passes directly into
 the same sac as the testicle—congenital hernia.
   On reaching  the fascia transversalis, it also  slightly distends it into a sort
 of pouch;  but  as the pressure is continued, the edges of this  pouch at the
 point of pressure become  thickened, especially in old hernia, and  take on
 a defined  shape, thus  constituting  the internal ring, while  the  centre  is
 either absorbed or converted into a reticulated  structure—fascia propria—
 and then the tumor,  passing on, takes  a  position  in front of  the cord, but
 also a little toward the median line of the body.   Being here beneath the
 fibres of the transversalis  and  internal oblique muscles  that thus constitute
 the cremaster muscle, the hernia escapes through the external ring, pushes
 before it  the areolar tissue which usually fills up  this ring—intercolumnar
 fascia—and, pressing it against the superficial fascia, the two become blended
 in one, and there only remains the additional covering of the skin.    In oper-
 ating upon an inguinal hernia, there are, therefore, usually found the skin,
 the superficial fascia, cremaster muscle, fascia propria and sac, all of which
 must be divided before the contents of the tumor can be made  apparent.
  The only blood-vessels about this  class of tumors are the small artery and
 vein (ad cutem abdominis) before spoken  of  as being found directly beneath
 the superficial fascia, and  the epigastric  artery and  vein, which is  directly
 beneath the transversalis fascia.  The arteria ad cutem abdominis is therefore
 between the fascia superficialis and  the external oblique tendon, while the
 epigastric  artery is between the fascia transversalis and the peritoneum.
 In indirect or oblique inguinal hernia, the epigastric artery is toward the inner
 side of  the contents of  the tumor—that is, toward the linea alba—and runs
 parallel  with the external edge of the rectus abdominis  muscle, while in
 direct or ventro-inguinal hernia, or  that in which the  protruded  part does
 not follow  the entire course of the spermatic cord, it may be upon its outer
 side, Plate XLII. Fig. 3.   But as the pressure of the hernia upon the peri-
 toneum and fascia transversalis elongates the  first, and  causes a  thickened
 margin to the second, this artery is removed  a  line or two from the edire or
 margin of  the opening in this fascia, designated  as  the internal abdominal
 ring.   In the normal condition of the parts, the  distance between the  internal
 and external abdominal rings is about an inch  and a half, the internal ring
 being about  this distance exterior to the external ring,  or about  as much
 nearer to the anterior inferior spinous process of the ilium.  But  in hernia,
the traction caused by the protruded parts, especially in old hernia, approx-
imates these two rings, so that one is often  very m'arly in contact, and
 also behind the other, and  the  epigastric artery is brought  therefore more
toward the  external ring and the linea alba;  but unless an extraordinary
arrangement exists, it will yet run parallel to the anterior edge of the rectus
muscle, and be on the median or internal side of the  protrusion. 
TAXIS  IN REDUCIBLE OR STRANGULATED INGUINAL HERNLE.  413
                             SECTION  II.

            TREATMENT OF  STRANGULATED INGUINAL HERNIAE.

   The treatment demanded  by inguinal herniae consists in that  required for
 the restoration  of  reducible hernia, and that requiring  the  division of the
 parts by the knife for the relief of strangulation.


        \ 1-—Taxis  in Reducible  or  Strangulated Inguinal Herniae.

   Taxis, as employed for the purpose of replacing an inguinal hernia within
 the cavity of the abdomen, consists in manipulating the tumor so as to press
 the portion which  was last  protruded,  directly within the ring or opening
 through which it has  passed, the remaining part usually following readily
 the course of the first, if a judicious continuance of the  pressure is perse-
 vered  in.
   In  making the taxis in cases of strangulated  inguinal hernia, it is essential
 to success that the  parts through which the hernia has protruded  should be
 in a state of perfect relaxation, and  that the patient should  offer no resist-
 ance to the manipulation of the surgeon; but as a strangulated  hernia soon
 becomes painful, some  little opposition may always  be  anticipated, unless
 means are taken to prevent it.  The use of anaesthetics in these cases is,
 therefore, especially demanded, in order to obviate this resistance as well as
 to relax the muscles generally.  As the position of the patient also materially
 facilitates the operation of taxis, he should, before being etherized, or when
 the latter agency is not employed, be placed upon the back with the knees
 drawn up and the shoulders well raised and supported by  pillows, in order to
 relax  the abdominal parietes.  The surgeon, being then  placed upon the
 affected side,  should seize  the tumor with  one  hand, and draw  it  gently
 downward, so as slightly to elongate it;  then, placing his thumb and first
 two fingers at the upper part of the  tumor, so as to compress or squeeze it
 gently,  let him force back a portion of the intestinal contents, if  possible, so
 as to reduce the bulk of the  tumor, and, pushing the  portion last protruded
 upward and backward, compress the lower part of the  swelling with the
 fingers  and  thumb  of the  other hand, in  the same manner that he  would
 squeeze a caoutchouc bottle to empty it  of air.  If, after a short time, the
 tumor  diminishes in size, its  base may be  approximated  to the summit,  and
 the effort  made with the fingers of the hand near the  ring to  push into the
 abdomen some small portion of it, or this part  may be slightly  compressed
 by  these  fingers, while  the  others  endeavor to replace   another portion.
 Should the effort,  however,  not  succeed, the  fingers and thumbs of both
 hands should  be made  to  force upward and backward all portions  of the
 mass, kneading it so as to empty it of its contents;  or a  part of it  may, if
 possible, be inverted by pressing  the forefinger toward the ring, and then
 retaining it there a  few  seconds, Plate XXXIX.  Fig. 6.   If, after moderate
 manipulation  in  this manner, no diminution  of the  swelling is perceptible,
 the taxis  should cease, the  patient  be  allowed  to rest,  or his  position be
 changed to such a direction as might induce the intestines within the abdo-
 men to gravitate in  a different direction  from  the hernia, and thus facilitate
its return.   If, however, a  very small portion of the  tumor can be replaced,
the rest will usually follow; and when the protruding portion is intestine, a
distiuct gurgling sound will be perceived as the last part returns to the belly, 
414            PRINCIPLES AND  PRACTICE OF  SURGERY.
 in consequence of the liquid or gas which had been confined in the constricted
 portion again passing into the main channel.
    New Method  of making  Taxis.—After  vainly employing  the usual
 m?ans of reduction, as just detailed, Wise, of India, succeeded in restoring a
 strangulated  hernia  by the following plan, it  having been  suggested by a
 Mussulman gentleman, who had  seen it  successfully applied: "Place the
 patient on a  table, and having folded  a  long  sheet several times on itself,
 carry it around the lower part of his pelvis, twisting it on itself in front, and
 again at the sides, so as to enable the assistants, who stand on each side, to
 hold the extremities of the sheet, and pull them gently upward, or toward the
 patient's head, while a third assistant holds the feet, and the surgeon  makes
 the taxis.   As the gut immediately above  the  strangulated  portion is often
 superficial, and distended  with flatus and liquid, it  will be drawn upward
 from the hernial sac, while the return of the protruded portion  is favored by
 the taxis practiced by the  surgeon."
   If, after one or two trials of either or both of these  means of making the
 taxis, no change is effected, then it may become a question whether it is bet-
 ter to resort to herniotomy or to repeat the taxis.
   In small herniae, where the constriction is tight, the part painful, and  the
 patient vigorous, the repeated attempts at taxis, or a resort to anything like
 forcible pressure, is always  dangerous, and tends to the development of inflam-
 mation in the part. When, therefore, in such cases, no progress is made, notwith-
 standing a judicious employment of the anaesthetics and the adjuvants before
 alluded to, a repetition of the taxis can only tend to increase the patient's dan-
 ger.  But in large and old herniae, unaccompanied by much pain,  or where the
 hernial contents have occasionally been down before, but were reduced with
 some trouble,  the repetition of the trial may succeed, especially if cold applica-
 tions are made, as before directed, to the tumor in the interval of the attempts.
 In  recent and small  herniae, great  judgment in  the use  of pressure  will be
 required, and, as a general rule, it will prove  best not to employ the taxis
 too long, say  more  than twice, provided the manipulation is correctly prac-
 ticed, that is, in the line  of the axis  of the  tumor, or upward  toward the
 cavity of the abdomen and  in the line of the inguinal canal.   In  other cases,
 the demand for  a  prompt resort to the operation is not so urgent, as it has
 more than once happened that in these herniae, after everything has been tried
 and a resort  to the  knife  been decided on, a  slight and apparently hope-
 less effort has suddenly caused the tumor to disappear within the abdomen.
 With young surgeons, there is  apt  to be too much delay in  resorting to
 the knife, and  the force employed in the taxis is often too great.  It should
 always  be remembered that delicacy of manipulation will generally succeed
 better than force, and that the ultimate  success of the operations for the  relief
 of the strangulation has been most marked iu  those cases where it was not
 delayed until positive and  high inflammatory action was established.  De-
 sault assumed  it as a maxim that "success might always be  anticipated in a
 hernia which had not been touched before operating," and was often success-
 ful where strangulation had existed  five days,  but  almost constantly failed
 when strong eft'orts had been  previously made  in the taxis.  The resort to
cold combined with moderate pressure, such as  that  produced by placing a
 pound weight  on the tumor, when  continued for a half hour, has frequently
succeeded even when judicious taxis had failed;  and it may be readily accom-
plished by the  application upon the swelling of any substance of this weight.
But the dangers of  delay should be borne  in  mind,  even  when  these
means are employed, though they are less likely  to excite  inflammation than
the repeated pressure of the fingers in the taxis, it being generally admitted 
          HERNIOTOMY IN STRANGULATED INGUINAL HERNLE.     415

 "that  a surgeon may have occasion to regret  performing the operation too
 late, but never too early.''''
    In making taxis for the relief of strangulated  hernia, whether before or
 after the incision of the tissues, it  is important that the symptoms of stran-
 gulation should disappear when the reduction is accomplished.   Should they
 not do so, aud yet the restoration of the hernia within  the abdomen be cer-
 tain, it may become necessary to incise the canal and seek for the constricted
 tumor in the  abdomen, as the condition of the  parts concerned in the reduc-
 tion "en bloc" or "en masse," as  the French describe it, requires  prompt
 relief.
    Reduction of a Strangulated Hernia in Mass.—As death has sometimes
 ensued upon  the employment of the taxis, in certain cases of  strangulated
 hernia, in which, though the  contents of the tumor were evidently returned
 into the abdomen, the symptoms of strangulation  yet existed until the term-
 ination  of  life, the attention  of surgeons  was given at an early period  to
 the investigation of the  cause, and from  the  post-mortem appearances  of
 these cases, it was discovered that the symptoms were the result of the return
 of the whole tumor into the abdomen, while the stricture existed in the neck
 of the  sac.   This condition of things was so rarely met with  that, when
 it was  first reported by Ledran, Scarpa, and Louis, many of the surgeons
 of their time denied the  possibility of the occurrence.  Closer investiga-
 tion has, however, shown  that such an accident is not so exceedingly rare  as
 was at first supposed—Dupuytren,  Breschet, and Jobert, among the  French
 surgeons; Sir Charles Bell, Cooper, Lawrence, and Luke, among the Eng-
 lish; and Joseph Parrish, Cheeseman, and Blackman, of the United  States,
 having, at different periods, noted similar cases, and called  professional at-
 tention to them.
   Treatment.—In order to relieve a patient under these distressing circum-
 stances,  whether resulting from the taxis or from  an operation in which the
 sac has not been opened, the first efforts should be directed to obtaining, if
 possible, the reproduction of the hernial tumor.   Sometimes this is said  to
 have been  easily done;  but in  most of the cases reported  by  those whose
 attention has  been directed to this complication of hernia, it has proved diffi-
 cult, or  even impossible; and nothing has therefore remained but to open the
 canal freely, draw  out the sac, and divide the stricture which existed at its
 neck, an operation which has rarely terminated successfully.  In order to
 guard against the reduction "en masse," during the operation of herniotomy,
 the finger should be passed around the inner side of the neck of the  sac be-
 fore restoring the hernia.


     g 2.—Operation of Herniotomy in Strangulated Inguinal Herniae.

   The operation of Herniotomy,  or the  division of a stricture in order to
 relieve the strangulation of a hernia, consists in dissecting the different cover-
 ings of  the  tumor, and  then nicking the constricting part, so as to enable  it
 to yield  to the pressure subsequently made on the contents of the  tumor,
 avoiding a large  incision of the ring, lest the patient be afterward unneces-
 sarily exposed to a further escape of the viscera.
  Preliminary Measures.—Before commencing the operation, the surgeon
 should properly prepare such instruments as may be required, as well as the
 dressing.   In  most cases, he will find it useful to select one good scalpel,
 one sharp-pointed bistoury, one  director, one pair  of dissecting forceps,  one
 Cooper's  bistoury, Plate  XXXV.  Fig. 16, or one probe-pointed bistoury
wrapped to  within an eighth of an inch of its point, and not sharp; a tenacu- 
416           PRINCIPLES AND  PRACTICE OF  SURGERY.

lum, ligatures, needles, and sponges, together with adhesive strips, a piece
of linen spread with cerate, a compress, and a bandage  sufficiently wide to
form a spica of the groin.  Then the hair  should be shaved from  around
the tumor, so as to prevent its interfering with the subsequent dressings, the
bladder emptied of its contents, a narrow  table,  well covered, so  arranged
that the patient's hips can be brought near to its  end, and his  feet be sup-
ported on chairs, room  being left for the  operator to  stand  between the
knees.   Should the operation  be demanded  after  sunset, as is often the case,
several sperm candles  should  be added  to the other general arrangements.
Three assistants will prove useful: one to aid the operator in  his incisions,
one to sponge blood  from the wound, and one to  attend to the etherization
or the wants of the patient.
  Ordinary Operation for Strangulated Inguinal Herniae.—In commenc-
ing the operation of herniotomy for  strangulated  inguinal herniae,  the selec-
tion of a mode of incising the skin must depend  upon the abilities of the
operator.   If he is  dextrous,  its  division  may be effected by holding the
scalpel in the third position, or like a pen, Plate II. Fig. 5, and cutting in the
axis of the tumor from the upper to  the lower portion.   But  if this is  not
the case, and especially if the patient is fat and the skin thick, it will be better
for the surgeon to pick up a fold of  it transversely to the axis of the tumor,
Plate II.  Fig. 4,  between the thumb and fingers of his left hand,  while the
assistant raises the opposite end of the fold in a similar manner, Plate XLIV.
Fig. 4, and  thus keep the integuments elevated  from the subjacent parts.
Then, puncturing this fold in its middle, with a bistoury incise it by cutting
from within  outward, or  the reverse, so as  to  expose the fascia superficialis
to the full length of  the  proposed  incision;  or if the cut  thus  made is  not
long enough, then extend it at its angles by raising the sides of the incision
in the same manner.   After exposing the fascia, the  distinctive characters
of each of the subjacent layers may or may not be readily made out, accord-
ing to the changes that have been created in the part by the complaint.  To
guard against error, the  subsequent layers  should, therefore, be  picked up
with the forceps, so as to form a little fold  at the most prominent point of
the tumor,  Plate  XLIV. Fig. 5,  and this  being nicked  by pressing  the
scalpel against it, while the surface of the blade lies flat upon the tumor, an
opening may be made, and a director passed underneath the tissue, so as to
enable the operator safely to slit  the layer  up  and down to the extent that
may be desired.  Next, picking up another layer iu the same manner, treat it
likewise, Plate XLIV. Fig. 6,  and proceed  to  divide the  coverings until the
contents  of  the  tumor can  be distinctly felt, or perhaps indistinctly seen
beneath the serous  layer or sac, the latter being more  or less thickened,
according to circumstances, although it never presents the shining appear-
ance of peritoneum on its outside, owing to the  changes  produced by the
disorder.  In the division of each layer, attention  should always  be given
to its appearance,  and especially to the presence of muscular fibres, as these
will generally show the position of the cremasteric lamina, and serve as a
most important point of reference.  On reaching the last layer, or that which
is believed to be the sac, pick  it up  with the  forceps and rub it between
the thumb and fingers of the left hand, so as to be sure that there is no other
portion of structure included;  nick it, introduce the director, and  slit it up,
Plate XLIV.  Fig. 6, when the bowel or omentum will  be fully displayed,
the first presenting a sort of doubling or knuckle, and being more  or less of
a reddish-brown or  gray tint,  and the latter  looking  not unlike  a mass of
fat  and connective tissue, or like the  structure usually seen in  front of the
intestines  when in situ, unless  it has been very much engorged by the  con-
striction. 
         HERNIOTOMY IN  STRANGULATED INGUINAL  HERNLE.     417

  LTaving thus reached the  contents of the tumor, it only remains to divide
the stricture, the position of which, though varying somewhat, may gener-
ally be discovered by passing the forefinger into the wound in the line of the
spermatic cord of the male, or of the round ligament of  the female.
  If the stricture is seated, as is often the case, at  the  neck of the sac, it
may be felt at the external ring, or below it, or at the internal ring, the lat-
ter being, especially in old herniae, directly behind the external ring.  Then,
as it is sometimes difficult  to  tell  whether the hernia has been  direct or
oblique, and, of course, whether the epigastric artery is on the outer or inner
side of the neck of the sac, pass the forefinger as far  up as  possible, and en-
deavor to get the finger nail between the constriction and the bowel, depress-
ing the latter by bearing on it with the back of the finger, while an assistant
also keeps it as much as possible out of the way, or the director may be sub-
stituted for the finger, if the stricture is very tight.   With the probe-pointed
bistoury, wrapped to within a few lines of its point, or with Cooper's bistoury,
Plate XXXV. Fig.  16, and with the cutting  edge of it  rather dull  than
sharp,  the operator may now free the stricture  by  passing the blade flatwise
along the palmar surface of the forefinger, or along the groove of the direc-
tor, Plate XLIV. Fig. 9, and carrying the point beneath the stricture, when,
having accomplished this, it only remains  to turn its  edge directly upward,
so that it shall be parallel with the external margin of the rectus abdominis
muscle.   Then, depressing the handle, cause the edge of the blade to press
a little  against the sharp constricting border  of the ring, so as to nick it,
Plate XLIV. Fig. 7, or give the blade a gentle rocking  motion, so as to
repeat the cut, and when there is  the least sensation of rending, turn the
knife again  flatwise, withdraw it, and  strive to dilate the stricture by the
pressure of the finger, or endeavor to replace the intestine or omentum, if its
condition is  suitable, by making the taxis as before directed.   If the nick of
the stricture has not been sufficient, a similar manipulation of the bistoury
may then be repeated until  the opening is sufficiently enlarged to allow the
hernia to pass, though usually the ring will yield  to pressure as soon as its
thickened edge is  notched.
  After  freeing the stricture,  the condition of the  contents of  the tumor
should be attentively examined, before attempting either its restoration or
the dressing of the wound, and it is especially  important that the operator
should see that the stricture is not continued by the neck of the sac, or by a
band of omentum, etc.,  as is sometimes the case, and an instance of which is
related  by Parrish.   If there  are one or more  small  and  pea-like spots,
which present the appearance of  positive  sphacelation, these points should
be picked up  in  the forceps, and tied by encircling them  with  a fine  liga-
ture, which, after being cut  off close  to the  knot, should  be left upon the
part, and returned into the  abdomen with the intestine, when, by ulcerating
through the coats of  the latter, they will be discharged per anum, while the
opening that would otherwise  have  ensued will be filled with lymph, as the
result of the inflammation thus excited.  But  if the sphacelus is more ex-
tended,  say half an inch, then it may be advisable  to attach the coats of the
bowel to the side of the wound by a suture, lest the intestine escape into the
cavity of the  abdomen, a'nd the separation  of  the slough give rise to peri-
tonitis.   If fastened in the wound, the sloughing of the bowel can only pro-
duce an artificial anus, the  healing of which will  often be accomplished by
nature,  or may be effected by some  of  the means hereafter directed.  Many
experienced surgeons have, however, regarded the use of this suture with
distrust, Desault and others having shown that the inflammation  which pre-
ceded the gangrene caused  sufficient  effusion of lymph to retain the bowel
at the neck of  the sac:  the  resort to the stitch  is, therefore, a rare event.
     vol. n.—27 
PLATE  XLIV.
  A  VIEW OF THE  OPERATIONS PERFORMED FOR INGUINAL  HERNLE.

   Fig. 1. The first step in Gerdy's operation for the radical cure of Reducible
 Inguinal  Hernia?.  1. The needle, with an  eye near the point, in  the act of
 transfixing the integuments as inverted by the forefinger.  2.  The first loop of
 the ligature.                                     After Bernard and Huette.

   Fig. 2.  The second step in this same operation.   1. The needle about to form
 the second stitch. 2. The first loop  as placed.  3.  The second loop as drawn
 from the needle.                                 After Bernard and Huette.

   Fig. 3.  The last step in this operation.  Quills having been  placed in  the
 proper  position,  the ligatures have been tied  upon them so as to  retain  the
 pouch of  skin at  the ring.  1, 2. The quilled suture.
                                                After Bernard and Huette.

   Fig. 4.  The first incision of Inguinal Herniae.  A fold of the skin, having been
 raised transversely over the tumor, is about to be divided by the scalpel from
 without inward.   It  may be incised from within outward with safety, if the in-
 teguments are very thick,  or there is a deposit  of fat in the connective tissue.
                                                After Bernard and Huette.

   Fig. 5.  Mode of dividing layers.  A director having been introduced at  the
 opening made by  nicking the tissue, the scalpel or bistoury is passed along it so
 as to slit up each  layer to  a sufficient extent.      After  Bernard and Huette.

  Fig. 6.  Opening the Hernial Sac.  1. Forceps picking up a fold  of the sac,
 and drawing  it  from the tumor.  2.  The scalpel placed flatwise, and about to
 nick the portion thus raised.                      After  Bernard and Huette.

  Fig. 7.  One mode of dividing the stricture.   The forefinger nail being passed
 beneath the stricture, the  probe-pointed bistoury, wrapped to near its point, is
 passed flatwise upon the  finger as a director, and, its edge being turned  up,
 the nick is made  by  bringing the handle (2) toward the hand (1) so as to give
 it a gentle rocking motion.                      After  Bernard and Huette.

  Fig. 8.  Relations  of the Intestine  and Omentum in an  Entero-epiplocele.
 1.  Intestine.  2.  Omentum.  3. Director in the act of depressing the tumor so
 as to pass between the contents and the stricture.  After  Bernard and Huette.

  Fig. 9.  Mode of dividing the stricture upon  a broad director, when the con-
striction is too tight  to permit the passage of the finger beneath it.   1. The
director.   2.  The  bistoury.                      After Bernard and Huette.
       (418) 
Plate .14
Fig.
Fio.i

Fig. 3


ELiT
;-i|§its
Fxg.4
Fig.6.
Fig. 8.
fVfNfe
Fifc.7

;#;

.,<«-'&:"
3*.,
 
 
HERNIOTOMY  IN STRANGULATED INGUINAL HERNLE.      419
   Should the contents  of the tumor be omentum instead of intestine, and
 the strangulated portion of the former have  become sphacelated, then the
 mortified part should be ligated, and the portion beyond the ligature cut off,
 the remainder being left as a plug in the opening, after which the dressing
 may be made as before directed.
   Dressing—If the operation has been promptly done, and the intestine is
 simply congested, the middle and upper angle of the integuments should be
 united by a point or two of the interrupted  suture, leaving the sac in its
 place, a morsel  of lint  being introduced into the lower angle of the wound
 to prevent the skin healing, and also to preserve a vent for the subsequent sup-
 puration.  The adhesive strips, cerate, compress, and  spica bandage being
 now applied, the patient should be carefully placed in bed, the thigh being
 flexed on the  pelvis  by  folding a pillow and placing it beneath the ham.
   After-Treatment.—When the parts have been returned into the abdomen,
 and freed from the constriction,  it generally happens that the circulation is
 restored, and  the structure resumes its original  condition.   But, in  some
 instances,  inflammation is developed, and general peritonitis  follows the
 operation.  Under these circumstances, an active  and  appropriate medical
 treatment will be essential to the preservation of the patient.  When this is
 not the case, and there  is no reason  to apprehend perforation of the bowel,
 it will merely be necessary to  administer  a  laxative enema, or some mild
 purgative, as a cathartic pill or rhubarb and magnesia, on the second day, the
 patient being compelled to keep in bed, aud use a bed-pan or some other con-
 venience when the purge operates, the diet during the first week being strictly
 restricted to light and farinaceous articles.  When three or four days  have
 elapsed after  the operation, the condition of  the wound may be inspected,
 and its subsequent treatment regulated by the general principles applicable
 to the cure of wounds; but when suppuration is established, the diet should
 be increased to such meats as  are easy of digestion, the patient being con-
 fined to the supine posture until the part has healed sufficiently to bear the
 pressure of a  light truss over the compress and bandage.
   Complications  sometimes met with in Herniotomy.—In  the  account
just furnished  of the operation required for the relief of strangulated inguinal
 hernias, the effort has been  made to  limit the description to  such details as
 are most frequently  demanded.  Several complications have,  therefore, been
 intentionally omitted, lest reference  to them should  tend to  embarrass the
 mind of the young surgeon, and appear to render the operation a very difficult
 one.   A few of them may, however, now be briefly mentioned, as illustrative
 of the difficulty occasionally met with.  Among the  most common of these are
 the modifications of  structue due to  the changes that take place  in the sac:
 thus, the sac may be concealed by coagulated blood, especially when the  taxis
 has been employed violently for a long period ; or the distinction between the
 sac and the intestine may be rendered difficult by their close adhesion, or by
the presence of gangrene; or the areolar tissue outside of the sac may be heavily
charged with fat, so  as  to add very materially to the thickness of the cover-
ing of the hernia.   In one case,  I  estimated the thickness of the tissues
through which I cut at half an inch, before I found the sac.   At other times
the testicle has been found involved  in the  tumor,  or hydatids have been
found  in the sac, or the omentum has been forced out and strangulated by
a cancerous tumor of the mesentery.    Sometimes there have been two sacs ;
sometimes a very large  amount of serum, and a  very small portion of intes-
tine  etc. etc.  In  fact, every possible variety or  departure from  the normal
relations of the parts, or those usually given by anatomists, in  their account
of the position and  appearance of this region in the healthy condition, will
be met with in operating.   It should, therefore, be remembered  that all 
420            PRINCIPLES AND  PRACTICE OF SURGERY.
hernial are liable  to  peculiarities, arising either from  the duration of the
complaint, the size of the  tumor, the peculiar habit  of the  patient, or the
means employed in the treatment—as violent taxis—or from the existence
of other diseases—as hydrocele—or from the hernia being congenital, or from
adhesions, or from the formation of bands at the mouth of the sac;  but an
examination of any of the valuable monographs that have been presented on
this complaint will soon enable any medical man, who contemplates the pos-
sibility of performing this operation, to obtain a knowledge of these pecu-
liarities.  I must now pass them by.   Little has also been said of the  appear-
ances of the parts under different degrees of strangulation, as these, together
with  many  similar points,  would have extended this  account  beyond its
proper limits.  Let it therefore suffice to say that, in  every case where the
experience of the operator has not been sufficient to qualify him for contend-
ing with such difficulties, he should, if possible, obtain  the advantages of  a
consultation with  some older practitioner.  To  be able to anticipate every
peculiarity that may be met with in these cases, requires  a  combination of
fortunate circumstances that none  but those  who have  been widely engaged
in surgery, or enjoyed the observation  afforded by following the  cases in
large hospitals, or in the practice of old surgeons, can obtain.   But, as  a
general rule, the  well-educated practitioner will not err in the treatment of
strangulated herniae, if he opens the various layers cautiously,  divides the
stricture only so far as will  relieve the  obstruction to the circulation of the
part, and does not replace the contents of a hernia in the abdomen before
he is certain that its circulation  is being restored, as may  be told by its
brighter or  more natural color, a livid or ash  color usually indicating a tend-
ency to sphacelus.  The division of the  stricture, without opening  the sac,
has been sanctioned by Key, Liston, Gay, Teale, Luke,  and mauy of the
English school, who have reported very favorably of it:  thus, Teale reports
 32 cases operated on without dividing the sac, of  which  27 recovered ; and
 Gay reports* 125 operations in which the sac was not  opened, and  of  these
 73 recovered; while in 73 in whom  it was opened, 13 died.   The  dangers
 likely to  result from  reduction in mass should, however, be remembered as
 militating against the advantages of this mode of operating, and  the pro-
 priety of it, as an operation to be adopted by an inexperienced  surgeon,  is
 deemed by  many others a matter of doubt.    Thus, Cheliusf says "that the
 mode of  operating in which the hernial sac is not at all'opened, is in general
 to be rejected, or specially confined to cases in which it is certain the stran-
 gulation  is seated in the abdominal ring, as  in a  recently produced or very
 large rupture."   Sir Astley Cooper, though advising  this practice in large
 ruptures, after dividing the stricture  at the neck of the sac, does not recom-
 mend it as  a general rule.  Lawrence  prefers opening the sac, and SouthJ
 does not think any great advantage gained  by not opening the sac,  as he
 coincides with Lawrence in the opinion that the peritonitis originates in the
 congestion  near  the  seat of stricture, and that its dangers are not enhanced
 by the incision made into the sac in the restoration of hernia.   The greatest
 objection to  it is the risk that is  always run of reducing the  hernia " in
 mass," when, if  strangulated  by the neck  of the sac, death  will  probably
 ensue.    The subcutaneous division of the stricture, as  advised by Guerin,  is,
 in  ray opiuion, a dangerous  and uncertain  operation, as stated by South,
 and only to be  thought of in ruptures with recent strangulation  from the
 ring.  In strangulation by the sac, it is  not applicable.
* Brit, and For. Med.-Chirurg. Rev.. No. IV. p  167.
f Clielius's Surgery, by South and Norris, vol. ii. p. 303.        J Ibid., p. 307. 
FEMORAL OR CRURAL HERNLE.
421
                             \ 3.—Statistics.

  In order to present  some idea of  the usual results of this operation, the
following cases have been selected from various sources, and arranged so as
to readily indicate the mortality:—


       Statistics of Herniotomy in Strangulated Inguinal Herniae.

                                                   Cured.   Died.  Artif. Anus.
South*        reports.................................. 8 cases.      6     2       0
Astley Cooperf   •'   ..................................11  "        8     2       1
GeoghegauJ      "   .................................. 3  "        2     1       0
Lawrence^       "   .................................. 9  "        5     4       0
Brand||          "   .................................. 2  "        11       0
Petcival Pottfl    "   .................................. 1  "        10       0
Scarpa**        "   .................................. 7  "        6     1       0
Richterff        »    .................................. 1  <<        10       0

                                        42          30    11       1

  From this it appears that, out of forty-two cases of strangulated inguinal
hernia which were  operated on, more than two-thirds recovered.
       CHAPTER  VI.

FEMORAL  OR  CRURAL HERNLE.
  Femoral or Crural Hernia is that form of rupture in which the protru-
sion occurs at the anterior inferior portion of the abdominal parietes, or at
those points where the external iliac vessels pass from the cavity of the pelvis
under Poupart's ligament.   On  reaching this point, a hern;a will generally
follow the course of the sheath  of the femoral vessels and then pass out at
the openiug—saphenous opening—of a  superficial vein—vena saphena—
till, reaching the exterior surface of the aponeurotic expansion which covers
the muscles of  the thigh—fascia lata femoris—it takes  a position a little
below the line of the groin.   The contents of this tumor, like that described
in the  preceding chapter, may  be  either intestine  or omentum, the latter
being the least common, though, from  the position  of the caecum, a  portion
of the  large intestine  has occasionally been found  in  the sac on the right
side, and in  one  case, reported  by Van Buren, of  New York, even on  the
left side, instead of the smaller  bowels, as was the case in inguinal hernia.
Femoral herniae  are  most  common in females — are usually  smaller than
inguinal tumors—are  always found beneath,  and  not above,  the  line of
Poupart's  ligament—spread  sideways as  they increase, and have  their
greatest diameter to correspond with the  oblique line of the groin.

    * Cht-lius, by South, vol. ii. p. 312.
    •(■Treatment  and Anat. of Inguinal Hernia.
    t Commentary  on Treatment of Ruptures, by Ed. Geoghegan.
    g Treatise on Ruptures.                         || Cliirurgical Essays.
    | Treatise on Ruptures.
   ** Treatise on Hernia; also Arnuud.             ff See Scarpa. 
422           PRINCIPLES  AND PRACTICE OF SURGERY.
                            SECTION  I.

             ANATOMICAL RELATIONS OF  FEMORAL HERNLE.

  The boundaries  of the region concerned iu Femoral Herniae are formed
posteriorly by the iliacus internus and psoas magnus muscles, covered by a
condensed fascia, which, as  it follows the course of the first named  muscle,
is hence called the iliac fascia.   Anteriorly, we find the portion of the ten-
don of the external oblique muscle of the abdomen—Poupart's ligament—
which extends from the anterior superior spinous process of the ilium to the
horizontal portion  of the pubis, where it is attached by a broad  insertion,
the exterior edge  of this  insertion—Gimbernat's ligament—forming the
boundary of the opening for  the  passage of the  femoral vessels—femoral
or crural ring.   The attachment of the  anterior  parietes of the abdomen to
Poupart's ligament, and the continuity of these parts with  the fascia of the
thigh, constitute the remainder of the  structures forming  the front of this
region.   Of these, the extra-peritoneal fascia—fascia transversalis—in  its
course behind the abdominal muscles, is  brought  so closely in contact with
the fascia  covering the iliac muscle  as  to adhere to it, the two—iliac and
transversalis fascia—sending a  prolongation of their structure  upon the
course of the femoral vessels, and thus forming the commencement of their
sheath.   As the abdomen  is a considerable cavity, and the  space occupied
by the escape of the femoral vessels a long and narrow one, the relations of
these  parts have been compared to that of a funnel, of which the  abdomen
forms the body  and the course of  the femoral vessels the  spout; while the
extension upon  the vessels  of the process of the iliac fascia behind  and of
the fascia transversalis  in front, has giveu  to the portions of these  tissues
which surround the vessels  the  name of Infundibular Fascia.  It will now
be readily seen  that, as Poupart's ligament forms an arch in stretching from
the anterior superior spinous process of  the ilium to the  pubis, there would
be a considerable space between it and the bones—Plate XLV. Fig. 1—were
it  not filled up by the iliacus internus and psoas  magnus muscles,  and their
fascia.  These parts, by  diminishing the  distance  between the anterior supe-
rior spinous process and the pubis,  leave merely an opening for the  vessels
—crural ring—which is bounded behind and externally by the  iliac  muscle
and fascia, internally by Gimbernat's  ligament, and anteriorly by the fascia
transversalis, as well as by the  under edge of the tendon  of the  external
oblique—Poupart's ligament.  This opening, thus circumscribed, and giving
exit to  the  femoral or  crural  vessels, is  therefore  correctly designated as
the femoral opening or ring, and is the point through which  a communi-
cation is established between the thigh and the cavity of the abdomen.  In
health, the adhesions of the surrounding parts, together with the connective
tissue and lymphatic glands, close it  entirely; but the action of any of the
causes which would force  the abdominal  contents  toward this point, may
induce these adhesions to yield, and then the following results may be noted :
The abdominal contents,  being behind the peritoneal sac, must, in their
course outward, press before  them first a portion of the peritoneum—her-
nial sac—then  the connective tissue  of the opening, or the extra-peritoneal
areolar  tissue—fascia propria—in which  are found the small  vessels and
deep lymphatic glands of the part, and when the  tumor thus  formed escapes
from the abdomen into the course and  sheath of the femoral vessels, it has
no other covering except the integuments.  As  the psoas and  iliacus mus-
cles are on the outer side of the vessels  as they pass beneath Poupart's 
            ANATOMICAL RELATIONS  OF FEMORAL HERNLE.        423

 ligament—crural arch — the tumor naturally tends toward the pubis —
 Gimbernat's ligament—and  is, therefore, usually found on  the  pubic side
 of the vessels, the femoral vein being next to it, and the femoral artery out-
 side of the vein, Plate XLV. Fig. 4.
   If the sheath of the femoral vessels was perfect, the tumor  would continue
 to be covered by it;  but, in order to admit lymphatic vessels and the super-
 ficial veins, this sheath is perforated at numerous points—Cribriform Fascia—'
 through which the tumor, by gradual distention, is enabled to escape.  Here
 again the hernia would continue to be covered by the fascia lata of the thigh,
 were it not that the  latter is so arranged as to permit the saphena vein to
 pass beneath it and join the femoral vein, and  at the  point—Saphenous
 opening — where  this  vein enters, the tumor escapes, Plate  XLV. Fig. 3,
 and thus getting outside the fascia lata, lies directly beneath the fascia super-
 ficialis and the skin of the thigh, at a point close to but below the line of the
 groin, or Poupart's ligament,  Plate XLV.  Fig. 4.
   In the  minute  anatomical examination of femoral herniae, the peculiar
 arrangement by which the saphena vein gets through the fascia lata femoris
 has received considerable attention, and unfortunately been named in every
 possible point;  thus, though all the muscles of the thigh are covered by the
 fascia lata, the portion of it over the sartorius muscle has been designated as
 the Sartorial  Fascia,  while  that over the  pectineus muscle is called the
 Pectineal  Fascia.  The  sartorius muscle  being also above the level of the
 pectineus, the  portion of the fascia lata covering it is compelled to double
 itself aud take the form of a crescent, in order to expand upon the pectineus
 muscle;  and this  crescentic  margin  has, therefore, been named  by Burns
 the Falciform  Process of the fascia lata, while the extreme point of the
 horn or crescent has received the appellation  of Hey's ligament.  An ordi-
 nary observer will often  fail  to  notice  these  points; but a close  dissection
 and removal of the loose connective tissue, with some traction from the knife-
 handle, will make  them and  many other little details  perfectly apparent to
 any one  who will look for them.
   From  the looseness of the connective tissue between the fascia superficialis
 and the  fascia lata femoris  near the  pubis, this hernia is most apt to rise
 upward toward the groin, instead of following the  downward course of the
 saphena  vein,  and  it therefore approaches the outer aud lower edge of Pou-
 part's ligament.
   The relations of the different parts in this region are usually simple.   At
 the crural ring, counting  from the outside of the pelvis—anterior inferior
 spinous process—there is  first the  femoral artery, then the femoral vein, then
 the hernia, and  lastly Gimbernat's or Hey's ligament, the two being closely
 attached to each  other.  At the  point where the external iliac artery be-
 comes femoral, or  directly beneath Poupart's  ligament, we also usually find
 the epigastric  artery, which, consequently, is at the outer margin of the her-
 nial tumor, or above  it.
   The obturator artery, arising from the internal iliac, gets out of the pelvis
 at the thyroid foramen, and, sending a branch to the pectineus and adductor
 muscles,  may therefore  be at the  inner  side of the tumor, while the internal
 circumflex, if it should arise  from the epigastric, would be  in front of it.
 These  arteries  have sometimes arisen by a common trunk, and passed ante-
 rior to the  sac before they divided.
   Such an  arrangement is, however, very rare;  the  usual relations  of the
 vessels to the turnor being such as present  the femoral vein outside, the epi-
gastric artery also outside, but a little nearer to Poupart's ligament and the
obturator artery inside, or near  the edge  of Gimbernat's  ligament.  In
twenty-one preparations of crural  hernia, Sir Astley Cooper found the  obtu- 
424
PRINCIPLES AND  PRACTICE OF  SURGERY.
rator artery passing into the pelvis on the outer side of the neck of the sac,
and  therefore  entirely out of the risk of injury.  The femoral vein runs on
the outer side  of the sac. about  half an inch from the centre of its orifice.
Half an inch beyond the vein and exterior to it is the centre of the external
iliac artery.   The epigastric  artery  arises  from the  external  iliac, about
three-quarters of an inch from the centre of the sac, and, as it passes forward
and  upward, it approaches this point about a  quarter  of an inch  nearer.
The spermatic cord, or  the round  ligament, passes about half an inch ante-
rior to the  mouth of the hernial sac, being first situated on the outer side,
and  afterward crossing  its fore part.  The division of  any stricture at these
parts should, therefore,  be  made very slightly, but directly upward, and  at
the middle  of the  ring, especially in males, because the  position of  the'struc-
tures at the inner and  upper  side of the  ring  might,  in any  other incision,
expose the  spermatic cord  and vessels to  the edge of the knife.   Women
being, however, by far more subject to this  form of hernia  than men, the
division of  stricture  upward  and  a  very  little inward may be  practiced
without injuring  any artery, unless the obturator is very peculiarly placed.
But as variations  are occasionally found in the arrangement of all the vessels
near the seat of the stricture, it is a safer plan to  proceed cautiously, and feel,
if possible,  with  the  finger, the portion to be nicked,  or the  tissues around
it, before making any incision  at the ring.
                            SECTION II.

     TREATMENT OF REDUCIBLE AND STRANGULATED FEMORAL HERNLE.

  The treatment of Femoral Herniae, like those described in the other forms
of hernia, consists in the Taxis, and in the division of the stricture, or her-
niotomy.


      I  1.—Taxis and the Application of a Truss in Femoral Hernia.

  The general details of the  performance of the taxis having been  already
given in connection with  inguinal hernia, it is only necessary at present to
refer  to the peculiar direction  iu which  these efforts should be  made in a
Femoral Hernia.
  The greatest diameter of the tumor in a femoral hernia being transverse, in
consequence of the development of  the  subcutaneous areolar tissue of the
part permitting the tumor to expand more readily toward the anterior infe-
rior spinous process of the ilium than in any other direction, it is generally
requisite to resort to a special manipulation and position of the  patient, in
order to favor  this operation.   Thus, on  flexing the thigh on  the pelvis,
while the patient  is in the recumbent position, Poupart's ligament, or  the
front of the crural ring, will be  made less tense in consequence of the weight
of the viscera not being  thrown upon the abdominal parietes;  while  the
psoas and iliacus  muscle will be less apt to compress it from  behind.   By
adducting the limbs, or carrying the affected limb a little toward that of  the
other side, and  by  turning the toes of the foot on the hernial side very much
inward, the sartorius, pectineus, and adductor muscles will be  relaxed, and
the parts about the saphenous opening and  Hey's ligament placed  in as
favorable a position as possible.   Therefore, when the patient is thus placed,
and well etherized, it only remains for the surgeon to press the tumor gently
downward and inward, in the line of the saphena vein, in order to  free  the 
         HERNIOTOMY IN  STRANGULATED FEMORAL HERNLE.     425

hernia from the projecting edge of the falciform process of the fascia lata, or
that portion which, after covering the sartorius muscles, is extended toward
the pubis in order also to cover the pectineus  muscle, and then, with the
fingers of the other hand, to push it upward in the line of the femoral ves-
sels, Plate XXXIX. Fig. 7.   The tightness of the parts  through which
femoral hernia passes and the sharp edge of the  constricting part render,
however, every case of this kind of hernia much more dangerous than that of
the inguinal region,  and strangulation  therefore  usually supervenes  much
more rapidly.  Less  effort should also be made in the taxis of this form of
hernia than  in the preceding  class; and when the tumor does not readily
yield to the judicious application of the means just mentioned,  the opera-
tion of herniotomy should be promptly resorted  to in  order to  divide the
stricture.
   Trusses  in Femoral Herniae.—The directions for the application of a
truss for the retention of a femoral hernia do not differ materially from those
already furnished  in connection with all  classes of hernia,  and  detailed in
the general account of them.  Every truss should possess the  characters
there given, and be applied  on the general principles there laid down.  As
the shape of a pad for femoral hernia differs, however, from that required in
the inguinal  class, it  may prove  useful to call attention  to the  variations
noticed between these two  varieties of trusses.    In  the  truss for femoral
herniae, as the spring  has  to go round the pelvis in the same position which
it occupied in inguiual hernia, while the  seat of the protrusion is somewhat
lower in the groin, and also  a  little more outward, it becomes necessary
either  to bend the point of the spring more downward and outward, or to
attach the pad to it by means  of a different shaped neck.  As femoral herniae
also protrude beneath Poupart's ligament, while the inguinal variety is found
above it, the force which  acts upon the femoral pad must be applied more
directly upward.   The femoral pad should, therefore, be so shaped as to fill
in  the depression in the line of the  groin as well as adapted  to the inequali-
ties of the thigh between  the pectineus and sartorius muscles.   With  a pad
formed as thus directed, with its long diameter rather more vertical or oblique
than transverse, and so attached to the spring that it will press more directly
upward than backward, the thigh strap may be dispensed with, and the hernia
retained with much less difficulty than in the inguinal hernia, as there are in
this region less bony inequalities than are found nearer to the pubis.
  The radical cure of femoral herniae by an operation has  seldom been at-
tempted, owing to the proximity of the femoral  and epigastric  vessels, as
well as the other peculiarities of the sac, etc. in this variety  of hernia.
            § 2.—Herniotomy in Strangulated Femoral Hernia.

  As the tumor in a femoral hernia is formed by the sac and its contents
escaping at the saphenous opening, and then  rising up toward  Poupart's
ligament, it usually presents itself a little  below the line of the groin.   In
order to  expose its contents, various modes of proceeding have been recom-
mended,  all based  on the  general direction of incising the  integuments  in a
line parallel with the great diameter of the  tumor.  In the external incision,
this  direction has been  slightly  modified  by different surgeons; thus, Sir
Astley Cooper advised  that  the  skin, after  being shaved,  should  be cut
directly over the middle of the tumor, in a line nearly corresponding with the
line of the groin, the incision being extended  from the groin to a point a few
lines  below the lowest part of the tumor, either by picking up a  fold of
integument and dividing it  with  the bistoury  by  transfixing it, or, if the 
PLATE  XLV.
   PARTS CONCERNED  IN THE OPERATION  FOR  FEMORAL  HERNLE.

  Fig. 1. Position of the Crural  Rin? with the attachment of Poupart's Liga-
ment. 1. Anterior superior spinous process. 2. Ilio pectineal ridge.  3. Femoral
ring.  4. Septum between the femoral vessels and the iliac muscles diminishing
the size of the crural arch.  5. Poupart's ligament. 6. Anterior inferior spinous
process.                                        After Bernard and Huette.

  Fig. 2. A  view of the relations of the Superficial Fascia to Femoral Herniae.
1.  External  oblique muscle.  2.  Its  tendon cleared of the fascia.  3.  Fascia
lata femoris.  4,  4. Superficial femoral fascia everted.  5. Cribriform structure
for transmission  of lymphatics.   6, 6.  Superficial vessels.
                                               After Bernard and Huette.

  Fig. 3. A view of the deeper seated parts  of the same region.  1. The ex-
ternal oblique muscle.  2.  Its tendon.  3.  The fascia lata.   4. Its cribriform
structure raised up.  5. Sheath of the vessels. 6.  Femoral artery.  7. Femoral
vein.  8. Saphena vein.                         After Bernard and Huette.

  Fig. 4. Positions and relations of a Femoral Hernia.  1. Integuments of the
abdomen.  2. Tendon of the external oblique.  3. The muscle.  4. The sper-
matic cord.   5. Femoral artery.   6. Femoral vein.  7. Intestine  protruding at
the saphenous opening.  8. Hernial sac.  9. Sartorius muscle.  10. Pectineus
muscle.                                         After Bernard and Huette.

  Fig. 5. Position of  a Double  Hernial Sac.   1, 1. The ring.   2. Fundus of
the principal sac.  3,  3. Cavity  of .the peritoneum.   4. Fundus of the  second
sac.                                            After Bernard and Huette.

  Fig. 6. Commencement of the  formation of an Artificial Anus, showing the
relations of  the  Mesentery to the protruding knuckle.  1. Ring.  2. Intestine.
3.  Mesentery.                                  After Bernard and Huette.

  Fig. 7. Relative position of the Vessels in Inguinal and Femoral Herniae.  1.
Tendon  of external oblique. 2. Poupart's ligament. 3. Psoas and iliacus muscle
in  the course to their insertion.  4. Femoral artery. 5. Femoral vein. 6. Sper-
matic cord.                                     After Bernard and Huette.

  Fig. 8. A  posterior view of the reflections of  the Peritoneum  upon the  Ab-
dominal Parietes. 1. Bladder.  2. Reflection of the peritoneum over the round
ligament of  the bladder.   3. Reflection over the same on the opposite Bide.  4.
Reflection over the urachus. 5. Position of an indirect inguinal hernia.   6. An
oblique inguinal  hernia.  7. A ventro-inguinal hernia.  8. The femoral  artery.
9.  The femoral vein.                             After Bernard and Huette.
       (426) 
Plate  4f, ,
H
Fifc.2.
2. .fl:
Ifek,
FW . 3.
?  I- ,«  -1,. ij
Fiv
Fip . 8
Fig. 7.
 
 
          HERNIOTOMY IN  STRANGULATED  FEMORAL HERNLE.      427

tumor was so large as to render the skin tense and difficult to raise, by incis-
ing it with  the  scalpel as in an  ordinary dissection.  When the tumor is
small, or not larger than  an eg\r, a single  incision  may suffice to open  the
skin  over it; but in  larger protrusions, or in those found in  corpulent
patients, it will  be better to make a transverse  cut at the  base of the first,
like a reversed J_, so as to dissect off the two flaps laterally.   The saphena
vein, being behind and at the outside of the tumor, is not likely to be involved
in this manner of operating.
   Pelletan and  Dupuytren  preferred a crucial  cut  for the  division of  the
skin, and Lawrence one which,  beginning  an inch  above the crural ring,
ran  obliquely downward and outward.   After  freeing the  skin, the super-
ficial  fascia may  be recoguized  by its containing several  inguinal  glands
together with more or less fat, and from  infiltration or other causes is often
quite thick.  In order  to divide it, as well as the fascia propria, or, in order
to divide safely every structure  between the skin and the  sac, each layer
should be separately elevated by the forceps, and the portion raised  incised
by placing  the blade of the  knife flat to the surface of the  tumor, so as to
nick its coverings.  The director being then passed into  the opening and
beueath  the layer, the  probe-pointed bistoury should be carried along  the
groove of the instrument  until the parts are laid  open to near the same
extent as in the first  incision.   On reaching the sac, which may usually be
recognized  by the characters spoken of in connection with inguinal hernia,
it should be cautiously raised at the more depending portion of  the tumor,
where the serum usually found within it naturally gravitates and separates
the  peritoneum from  the intestines;  but, as the amount  of fluid  in  the
sac in femoral hernia is much less than that found in the inguinal  variety,
more caution is requisite, because the sac being  much nearer to the contents
of the tumor, the  latter are more liable to be wounded.  A nick  being now
made in  the portion raised in the forceps, a director should be introduced,
and  a bistoury carefully passed  along it, so  as  to open the sac freely in a
raanuer similar to that  pursued  in the division of the other layers.   On  ex-
posing the contents of the tumor, pass in the forefinger of the left hand and
feel for the seat of the stricture, which may generally be found as a sharp and
defined edge near the  interior and inferior portion of the circumference of
the ring, or at the points corresponding with Hey's ligament—point of cres-
centic edge of falciform process of the fascia lata femoris—or at the saphen-
ous opening, or  deeper and higher iu  the wound  at the seat  of Gimbernat's
ligament.   On finding the stricture, pass the  point of the  probe-pointed
bistoury  beneath  it, in  the manner directed  for  the  same step in  inguinal
hernia; or, if the stricture is so close  as to prevent the use of the forefinger,
resort to the director  found in  the pocket-case, or to  a  spatula, and thus
protecting  the bowel,  get the  bistoury  flatwise beneath  the constricting
margin, turn its edge up and nick the stricture very slightly upward,  if it is
introduced at the  middle of the ring, or  upward and a little  inward, if  the
nick is to be made at its inner margin.   But the best direction for dividing
the stricture has been a point on which  surgeons have often differed.  Law-
rence states that  Dupuytren and Ilicherand  preferred an incision upward
and  outward; Gimbernat advised the nicking of the edge of  the ligament
named after him; and Hey the  incisions of the most interior part of  the
stricture.
  In  order to comprehend these different opinions on a point which it might
be supposed would  be  certainly  settled  by daily observation, the varying
course of the obturator aud epigastric arteries should be recollected, as well
as the tendency  in all  operators  to insist upon the observation  of  certain
fixed rules, which  are often predicated  only on their  own modes of demon- 
428
PRINCIPLES  AND  PRACTICE OF SURGERY.
strating the anatomical relations of  the part,  As the stricture may gener-
ally be  overcome simply by pressure, after  its thick, sharp  edge has been
nicked, to speak of  the cut that is produced by the edge of  the bistoury as
a division is liable to mislead, as the so-called division of the stricture is in
most  cases only a notch in its  edge, which is intended to  facilitate such
subsequent laceration as will  permit the  restoration of  the  contents of  the
tumor.   The use of a dull bistoury, and  the direction  of its edge  upward
for merely a line  at several points of the ring, as advised by Velpeau, no
matter in what portion of the  circumference of the ring the stricture k most
marked,  will suffice for the relief of the constriction, as may be readily tested
on any subject
   The stricture being divided, the condition of the contents of the sac should
be inspected and treated  as  directed for inguinal  herniae,  after which  the
wound  should  be closed  by a suture, adhesive strips, cerate, compress  and
bandage, and the diet regulated as before directed.
   Complications of Femoral Herniae.—Femoral hernia, from its  peculiar
position, is liable to mislead  the surgeon in his diagnosis, and also to con-
fuse him in operating, in consequence of the changes produced by various
causes in the surrounding inguinal  glands and vessels.   Buboes, aneurism,
hydatid cysts, foreign  bodies—as needles—psoas  abscesses,  or one or more
sacs,  or the retention of the hernia in the sheath  of the  femoral vessels,  and
its being covered by the fascia lata, are all  cases  that have  been recorded,
and  may, therefore, reasonably be  expected to  present themselves again.
The frequency  of the position of the obturator artery on the front or inner
side of the tumor at the seat of stricture, as is the case  when it arises from
the epigastric artery, is quite marked, it having been found by Cloquet, after
examining two hundred and fifty subjects, one-half of which were females, to
be thus situated about once in every three cases.
   Owing to  these  circumstances, the  operation  on  a femoral hernia  is
usually regarded as more dangerous than that performed for the  relief of
strangulated  inguinal  herniae;  but with the anatomical knowledge  that
should be  possessed by every surgeon, and  with  proper caution and cool-
ness, this  operation cannot  be  considered as an  especially difficult  one.
With a patient in  a state of anaesthesia  there need certainly be no haste,
even if the  operator should deem it right under other circumstances;  and if
the  incisions  are slowly  and  cautiously  performed, they will doubtless be
safely done.   Should  a severe hemorrhage  result,  which cannot be  traced
directly to a wounded vessel,  the introduction of  a small  linen sac into the
crural ring, and the subsequent stuffing of it with  lint or  cotton, so as to
press like a finger on the bleeding point for a few  days, as advised by Boyer,
 may  suffice to  arrest it.
\ 3.—Statistics of the Operation of Herniotomy in Strangulated Femoral
                                Herniae.

  A reference to the subjoined table will prove that the operation for femoral
herniae has certainly succeeded better than most surgical operations, and prac-
tice will probably satisfy any medical man that the difficulties of it have been
much exaggerated. 
UMBILICAL  HERNIA.
429
Statistics of the Result of Herniotomy in Strangulated Femoral Herniae.
                                           Cases.      Cured.      Died.
     Gimbernat*............................................  4         4         0
     Lawrencef............................................   0         6         0
     Scarpa*................................................  2         11
     Monro, Sen.g..............................,.........  440
     C. Bell||.................................................  1         1         0

                                           17        16         1

  All but one of these operations were reported as successful.
CHAPTER  VII.
                      UMBILICAL  HERNIA

  The term Umbilical Hernia being generally applied to such protrusions
of the abdominal contents as occur immediately in the neighborhood of the
umbilicus, as well as to those seen directly in the course of the vessels of the
cord, there is a liability to error as regards the seat of this class of tumors, if
the surgeon does not recall the difference shown in the structure of the part, as
seen in the infant  and as found in  the adult.  This difference, having been
referred to in the general account of the complaint, need only be here briefly
hiuted at.  In the infant, umbilical herniae may protrude either, beneath the
skin at the margin of the umbilicus, or a little further on along the cord, where
it is usually surrounded simply by the envelopes of the latter.   In the adult,
these vessels  having been  removed,  and the surrounding parts firmly cica-
trized, a hernia can only escape by distending some of the openings in the
linea alba directly around  this firm cicatrix, the appearances of which must
be familiar to every dissector.  These openings being generally on one side
of the umbilicus, the point of protrusion is often  situated near the superior
portion of the circle.  As a hernia tends to sink by its own weight, the open-
ing into the abdomen will often be found  enlarged and  depressed, and thus
lead a careless observer to think  that the tumor  has really escaped at the
space left for the vessels of the umbilical cord or below it.
SECTION  I.
SURGICAL ANATOMY.
  After the umbilical vessels have entered the abdomen of the foetus at the
opening  left for them in the linea alba, the arteries run downward  toward
* New Method of Operating for Femoral Hernia, by Antonio de Gimbernat.
\ Lawrence on Ruptures.
\ Treatise on Hernia, by Antonio Scarpa.
\ Observations on Crural Hernia, by A. Monro, Sen.
|j Operations for Strangulated Hernia. 
430           PRINCIPLES AND  PRACTICE OF  SURGERY.
the bladder, while the vein courses over  to  the  right side along  the  free
margin  of the  suspensory ligament,  to  enter  the  umbilical fissure of the
liver,  where it terminates  in the left sinus of the  vena portarum.  Like the
other blood-vessels in the abdomen, the  umbilical arteries and vein are on
the outside of the peritoneal sac, and do not perforate this membrane; con-
sequently, any protrusion of a viscus at this poiut  must be covered by a layer
of the peritoneum, and have, at least in  its early stages, a perfect sac like
the other herniae.  The variety of opinions on this point, and especially those
of the distinguished surgeons who have doubted the existence of a sac, may
therefore all be explained by the fact that, under distention, the sac may be
perforated, as related by Sir Astley Cooper, or gradually thinned or absorbed,
as mentioned by Monro and others.
   The pressure of large and old  herniae in the adult may also lead to a
similar diminution in  the density of the  fascia superficialis abdominis, or
even the skin ; a case being related by Arnaud "in which the bowel adhered
so closely to the skin as to cause  it to be cut in  dissecting the parts  after
death."  No blood-vessels are situated near the  course of a hernia in  this
region,  except it may be abnormal  veins, as have  been seen by Manec,
Maniere, and Velpeau.
   As the opening through which  umbilical herniae escape is altogether in
the linea alba, there is no umbilical canal, nor is there much liability to the
production of a stricture at the neck of the sac.
          SECTION  II.

TREATMENT OF UMBILICAL HERNLE.
         \ 1.—Of the Palliative Treatment of Umbilical Herniae.

   The treatment of umbilical herniae  requiring that the contents of the
tumor should  be pressed into the  abdomen as soon as possible after their
escape, in order to  facilitate the cure, the taxis may, in reducible cases, be
readily accomplished by inducing  a  perfect state of anaesthesia, and then
manipulating the tumor so as to bring it to the level of the ring, after which,
portion after  portion should  be  restored by the action of the thumb and
fingers, as described  in the inguinal form of herniae, except that the contents
of the tumor should  here be  pressed directly toward the spine, and then a
little upward,  as the  mouth of the sac  is not in the centre of  the tumor, but
a little above it.  Having thus succeeded in entirely restoring  the  protru-
sion, it remains to decide whether it will be desirable to attempt only a pal-
liative cure by the application of  a  truss, or resort to the more severe oper-
ation  that has occasionally been employed in the attempts at a radical cure.
   The Truss  that is employed  for the palliative treatment  of umbilical
herniae will differ somewhat according to the age of the patient.   In  infants,
soon after  birth, or  within the first eighteen months, the application of a
compress formed by firmly wrapping a cent or half dollar in linen so as to form
a pad, and confining it to the  part by the ordinary flannel belly-band, or by
adhesive strips, is all that is requisite; but in the adult, the application of
the ordinary umbilical pad and truss of the shops will answer, the structure
of the pad being of  less consequence in this form of herniae than in the pre-
ceding varieties.   If the hernia  is large, it will prove useful  to  add the
ordinary laced bandage of the abdomen to the use of the truss, in order to
support the abdominal parietes  more thoroughly, and  prevent the lateral 
THE RADICAL  CURE  OF UMBILICAL HERNLE.
431
separation of the linea alba.  This separation is sometimes so great that, iu
one female subject  that I dissected, the linea alba was open from near  the
pubes to half-way between the ensiform cartilage and the umbilicus, the umbili-
cal ring being nearly three inches in diameter, and the intestines supported
only by  the skin and superficial fascia, the latter being very mnch thickened.
              | -•—The Radical Care of Umbilical Herniae.

  The radical cure of an umbilical hernia has been often accomplished in the
young subject, both by an operation and also by the use of the compress or
truss.  It should generally be attempted in every case of this form of hernia
in children, because in adults the attempt is of very doubtful utility.
  Desanlt's Operation.—The child being laid on its back, with the thighs
somewhat bent and the head inclined forward, return the protruded viscera,
and  press upon the opening with one hand while you raise the  sac with the
other, so as to ascertain  that no part  remains unreduced; then, passing a
waxed ligature several times around the base of the tumor, including  both
the integuments and sac as held in the fingers, secure each  turn  with a
double knot, drawn tight enough to occasion an  inconsiderable degree of
pain, and cover the tumor with lint, over which compresses are to be applied
and  secured  by a bandage and  shoulder-straps.   In a day or two after the
first ligature is applied, the shrinking of the parts will require the application
of a second ligature,  which should  be  tied considerably tighter, and even a
third may  become  necessary after  a few days.   In eight  or ten days the
tumor (skin and sac) will slough off, and leave a small ulcer, which speedily
heals, after which a truss or compress should be  worn for several months.
The  probability of the cure diminishes with the age of the child, and  in a
girl nine years old it failed entirely in Desault's hands.  In a case  operated
on by Joseph Parrish, of Philadelphia, the patient was cured,* though the
slough of the integuments did not separate until the seventeenth day.
  Operation of Physick, of Philadelphia.—In a large umbilical hernia, Phy-
sick proposed to effect a radical cure by opening the integuments by a  cru-
cial inci-ion as far as the neck of the sac. and then opening the upper part of
the sac >o as to see its contents, reducing them, if possible, without dilating
the ring;  but when this could not be done, to divide the stricture outside of
the sac.  After reducing the contents, he suggested that a ligature should
be drawn around the neck of the sac, with a view of closing its cavity.
  Remarks. — This operation  was  proposed by  Physick, but never  per-
formed by him, though Wistar is reported to have thus operated with suc-
cess.  In a case subsequently operated on by Gibson, of Philadelphia, death,
however, ensued.  Sir A. Cooper has succeeded  by similar  means  in  two
cases:+ but  subsequently he, together with Scarpa, Benedict, Richerand,
and others, rejected it on account of the pain and  inflammation it created,
as well as from the fact that pressure alone was generally able to accomplish
the cure.   In most cases of herniotomy in the adult, the application  of a
ligature around  the neck of the sac should be omitted, and the restoration
of the parts without opening the sac avoided,  as this exposes the patient to
death  from  internal strangulation, as was referred  to in the restoration of
hernia in mass.
* Parrish on Hernia, p. 190.
| Lawrence, p. 1?'.'. 
432           PRINCIPLES AND  PRACTICE OF  SURGERY.
           \ «.—Herniotomy in Strangulated Umbilical Herniae.

   The existence of Strangulated Umbilical Herniae being rare, except in
 the cases of adult females, the description of the operation may be confined
 to this class of patients.
   Operation.—The patient being placed in the recumbent position, and the
 proper preliminary steps taken, pick up a fold of the skin, if it is loose, and,
 rubbing it between the fingers, so as to be sure that no other tissue is  in-
 cluded, incise it with the bistoury from within outward as before directed.
 Bnt if, as is often the  case, all the coverings of the tumor  are evidently
 thinned, then the incision should be made in the line of the linea alba by
 light  touches  of the scalpel from  without  inward,  the  size  of the  tumor
 regulating the  selection either of a crucial, -r, or _L incision.   On opening
 and dissecting  back the  skin  sufficiently to expose the part to a moderate
 extent, the remaining tissues—to wit, superficial  fascia, fascia propria, and
 sac, or such of them as can be made out—should be most cautiously divided,
 as detailed in the  preceding classes of herniae, and any portion of the um-
 bilical  ring  or  opening in  the linea alba nicked  to  a sufficient extent  by
 means of a director and  probe pointed  bistoury, the  intestine  or omentum
 being  then  treated as  circumstances  may indicate, after which the  flaps
 should be united and dressed as directed in femoral hernia.
   Artificial  anus, though rare, may occur at the umbilicus as elsewhere, and
 be cured solely by cicatrization, of  which an example  has  been cited  by  R.
 G. Wharton, of xMississippi, as occurring in a negro child a few days  after
 birth.   Amyand, Pelletan, Scarpa, and others  have also seen this condition
 of the part in the adult;  but there is greater difficulty in healing it at this
 point than elsewhere, owing to the adhesions of the intestine to the abdom-
 inal parietes, and the absence of a canal like that seen in the groin.

 Statistics of the Result of Herniotomy in Strangulated Umbilical Herniae.

                                           Cases.      Cured.      Died.
      Lawrence...............................................   3          2         1
      Scarpa..................................................   110
      Desault.................................................   3         3         0

                                             7          0         1

   From this it appears  that, out of seven cases operated on, only one died;
 and, though representing a small number, this is probably a correct estimate
 of, or at least an approximation to, the  success of the operation in this form
 of hernia.


    Summary of the Operations for Herniotomy in the three forms of
                         Strangulated Hernia.

                               Cases.       Cured.       Died.     Artificial anus.
     Inguinal...........................  49         34        14         1
     Femoral...........................  17         16         1
     Umbilical..........................   7          6         1

   On examining the total of the cases thus collected, it  is seen that the
cures of Inguinal Herniae were only about two-thirds of those  operated on,
while in Femoral and Umbilical all but two were  cured.   The explanation
of this difference must be a matter of conjecture; but the facts, which have 
     ARTIFICIAL ANUS RESULTING FROM MORTIFIED INTESTINE.  433

been carefully collected during  an examination of the sources before men-
tioned, in the general references throughout the subject of Herniae, are those
now shown.

                I 4.—Frequency of the Forms of Herniae.

  From a  statement made by  Lawrence, as based on  the records of the
London Truss Society, for twenty-eight years, it  appears that of about
84,000 patients, nearly 68,000  were males, and about 16,000 females.   Of
these, 39,419  were  inguinal herniae, 6210  femoral,  2775 umbilical,  413
ventral, and 4 obturator hernias.
                         CHAPTER  VIII.

                       ARTIFICIAL ANUS.

   Artificial Anus is the name applied to two distinct conditions of the body,
in one of which an opening is  formed by nature from the bowels through
the skin, in consequence of the mortification resulting from a strangulated
hernia, while in the other, the opening is made by the surgeon from the skin
to the bowel, in order to give exit to such fecal contents as may have been
prevented by various causes from escaping at the orifice of the rectum.   As
the occurrence of the artificial  anus  which ensues from strangulation of the
intestinal contents  of a hernia is the  most frequent, and also that most
directly connected with the preceding subject, it may properly receive the
first consideration.

                             SECTION I.

         ARTIFICIAL ANUS RESULTING FROM MORTIFIED INTESTINE.

   Pathology.—When a portion of the intestine has been so strangulated at
the seat of stricture as to lose its vitality and run into sphacelation, the dead
portion is sometimes so limited that nature can throw it off in the  form of
a slough, and thus leave the bowel defective in its parietes.  In  the effort of
nature to separate the dead portion, sufficient inflammation is usually excited
in the surrounding parts to glue the gut fast to  the sides of the ring through
which it has been protruded, or to the abdominal parietes nearest to it, so that
after the  slough of the bowel has separated, the fecal contents pass  directly out-
ward to the skin, where an ulcer is developed that may present either one mod-
erate sore with a fistulous orifice, or numerous openings of the same character.
When the point of a knuckle of intestine,  like that found in the hernial sac,
is the seat of the slough, the opening through the anterior intestinal parietes
gives to the part the appearance  of a double-barreled  gun, the septum  be-
tween the two sections of intestine being  composed  of that  portion of  the
gut to which the mesentery is attached, Plate XL. Fig. 6.  But if,  instead
of a knuckle of intestine, it is the parietes of a straight portion of  the gut
which is opened, then there will be but a single tube, Plate XL.  Fig. 7.
When the opening in the integuments is large, there is also a tendency in the
mucous coat of the gut to prolapse, in consequence of which a tumor  formed
     vol. ii.—28 
434
PRINCIPLES AND PRACTICE  OF SURGERY.
by the everted mucous membrane is found  at the orifice  in  the skin.   The
double-barreled variety  of artificial anus  requires that the septum which
separates the two ends of intestine  should be removed, in order to allow the
fecal contents  to  pass from one tube into the other, without escapiug from
the end of the upper barrel; but the single-barreled variety, or that formed by
a single piece of intestine, demands merely the closing of the opening in the
parietes, in order to fit the gut for  the transmission of its ordinary contents.
The treatment of these two forms of the complaint is therefore quite differ-
ent, the first demanding  the closure of the orifice  until nature can  heal it,
the second requiring  the destruction of the septum  spur or buttress found
between the two compartments.  Owing to  the ulceration  of  the intestinal
parietes extending each way, it occasionally happens that the anterior edge
of the septum projects, and materially interrupts  the regular course of the
contents of the bowels.   To  relieve such cases, Desault resorted to press-
ure, which was applied against the  anterior  edge  of the  septum,  both in
order to force it backward  and also to compress it, tents and similar means
being introduced through the external orifice.
  Physick, having noticed that the existence of the septum between  the two
tubes of a knuckle of that  intestine in which the  artificial anus existed was
the great  obstacle to  the downward course of the fecal matter,  decided to
induce sufficient inflammation to glue together  the adjoining peritoneal sur-
faces of the gut, and then, when they were  adherent, to cut away the  septum,
which he did in the following manner:—
  Operation of Physick, of Philadelphia.—Having, in January, 1809, passed
a ligature through the septum in the intestine of Jno. Axillius, a patient in
the Pennsylvania Hospital, and thus formed a loop, he drew the  ligature
moderately tight by tying it upon the anterior edge of the septum, allowing
the thread to remain one week, so as to  keep the two sides of the bowel in
close contact.   Then cutting  away  a portion of the septum at the point of
union of the sides, so  as to create a hole, and  stopping  the anterior or ex-
ternal orifice, the feces  resumed  their natural channel,  and the  patient
recovered.*
  Operation of Dupuytren___In 1813, Dupuytren resorted to the operation
proposed by a German surgeon named Schmakhalden, in an inaugural essay
which he made public in 1798, to wit: to cut through the intestinal  septum
by means  of a ligature passed through it by a curved needle, when,  traction
being made upon the  ligature, it gradually cut its way out in a longitudinal
direction,  as is the case  in the  treatment  of fistula in ano.  Finding  that
there was risk of the needle going beyond the  projecting adhesions, and
opening a portion of the tube communicating with  the cavity of the peri-
toneum, Dupuytren resorted to pressure of the two peritoneal coats of the
intestinal  knuckle, iu order thus to induce inflammatory action.   To accom-
plish this, he invented an enterotome—Plate XXXV. Fig. 18—which acted
like a pair of forceps, the  blades of the  instrument being closed  by  a screw
in the handles, which  he employed  as follows:   After placing the patient in
the position for the operation of strangulated  hernia, he exposed the two
orifices of the intestine  by passing in two fingers or two female catheters,
and  turning  them over each other; the resistance to their approximation
indicating the position of the  septum.  Then taking one branch of the eutero-
tome, he passed it along the sound to the  depth of two inches or more, accord-
ing to the projection  of the septum, and let an  assistant hold it while the
other blade was introduced in the same  manner and to the same  depth into
  * Dorsey's Surgery, vol. ii. p. 96; also North Am. Med. and Surg. Journ., vol. ii. p.
269, in a paper by Benj. II. Coates, M.D. 
     ARTIFICIAL  ANUS RESULTING FROM MORTIFIED INTESTINE.   435

the other orifice.  Then gently turning the screw at the handles, so as to com-
press the portion of intestine between the blades—Plate XL. Fig. 2—colicky
pain supervened, but usually soon pass off, though each turn of the screw
seemed liable to produce the same pain.   As  the  length of the parallelism
of the tube was increased, solid adhesion of the two sides was induced, and
about the eighth day the instrument became movable and fell off, leaving a
brown, dry eschar in the wound, of the same length  as the portion compressed
by the instrument.  When  this separated, the remainder of the septum was
felt as a hard and undulated  ridge  at each side  of the opening, through
which the passage of the feces was favored by the free use of enemata.*
  After-Treatment.—After both the operations just  described,  the opening
left in the integuments requires careful treatment,  in  order to favor its clos-
ure ; and this may be attempted by the use of such means as will favor the
healing of fistulous orifices  generally, such as cauterization by the nitrate of
silver or sulphate of copper,  or by compression, or the quilled suture,  or
by anaplasty.  In most cases, a  certain amount of pressure  upon  the ab-
dominal parietes near the seat of the  opening will prove useful, and I have
more than once seen great benefit derived from the  application of a truss over
a greased compress placed  upon the ulcer, after cauterization by sulphate of
copper.
   Operation of J. B,. Lotz, of Pennsylvania.f—An  ingenious  modification
of the instrument and  operation  of  Dupuytren  has been made  by Lotz,  of
New Berlin, Pennsylvania.  His instrument consists  of  two  blades  with
fenestra, each of which is about an inch long and  a quarter of an inch wide,
and surrounded  by a solid rim about a line thick, the whole length of the
instrument  being  about six inches, and its weight  nine drachms.

                                 Fig.  426.
             12                   12                     3
  Fig. 426.__A side view of Lotz's instrument for the cure of Artificial Anus. 1,1. Pins to keep the blades
parallel.  2,2. Screws to approximate the blades.  3. The fenestrated branches that compress the "speron,"
or spur-like process of the intestine. After union lias been induced by the compression of the coats of the,
bowel, the intermediate portion can be cut by a bistoury passed through the fenestra.  The blades are intro-
duced separately into the intestine, and subsequently closed and approximated by the screws.  (After the
instrument.)

  Operation.—The two blades, being introduced separately, are to be brought
together and closed by means of two  screws, so as to  preserve the parallel-
ism of the blades, after which the plates may be gradually approximated or
slackened, according as they induce pain or nausea. On the third day after the
introduction of the plates, the patient having continued comfortable, the por-
tion of bowel compressed between the fenestra may be divided by means of a
gum lancet, and  an opening at once established in the septum at the point
which  corresponds with that existing in the blades of the instrument.   The
compression being now gradually removed, as it had  been gradually applied,
the instrument may be taken away, when the patient will be found to have  a
smooth round hole, of about the dimension of an inch, with the sides of  the
bowel  firmly adherent all round it.
  Operation of J. Mason Warren, of Boston.—A female, aged thirty-four
* Malgaigne, p. 428.   Philad. edit.
■j- Am. Journ. Med. Sciences, vol. xviii. p. 367. 
PLATE   XLVI.
A VIEW OF THE  OPERATION FOR THE FORMATION OF  AN ARTIFICIAL
                                 ANUS.

   Fig. 1.  A front view of the surgical relations of the Colon.  1. Integuments.
2. External oblique muscle.  3. Internal oblique.  4.  Transversalis muscle.  5.
Lower edge of the  liver. 6.  Distended caecum. 7. Transverse colon.  8. Descend-
ing colon, with sigmoid flexure seen below.        After Bernard and Huette.

   Fig. 2. A posterior view  of the parts concerned, as shown by removing the
dorsal structures.  1. The peritoneum.  2. The kidney. 3. The mesentery.  4.
The bowels. 5. The colon.  6. The spine.         After Bernard and Huette.

   Fig. 3. Littre's Operation for the formation of an Artificial Anus at the right
groin. 1, 1. Outline of the colon.  2, 2. Extent of the inguinal incision in the
integuments.  3. An instrument passed beneath the distended colon in order  to
bring it to the front of the wound.  4. The point of the bowel which is  to be
perforated.                                     After Bernard and Huette.

   Fig. 4. Amussat's Operation, or the formation of an Anus in the left lumbar
region.  1,1. Outline of the  descending colon.  2, 2. Incision in the integuments.
3. Instrument placed beneath the bowel to render it prominent.  4, 4. Ligatures
passed through the bowel in order to attach it to the sides of the wound before it
is perforated.                                    After Bernard and Huette.

   Fig. 5. Shape and appearance of the Anus formed by Littre's Operation.  The
long diameter of the opening corresponds to the line of the groin, and the bowel
is so attached to the edges of the incision in the abdomen as to prevent contrac-
tion of the orifice or the escape of the bowel into the abdomen.
                                               After Bernard and  Huette.

  Fig. 6. Appearance of the Artificial Anus formed in Amussat's Operation,
showing the position of the sutures and the character of the opening.
                                               After Bernard and  Huette.
       (436) 
Plate  46
Ke-.l
Fig.6.
13^
fig. 3
Kg. 4.
 
 
STATISTICS  OF ARTIFICIAL ANUS.               437
years, in whom an artificial anus formed after strangulation of a crural hernia
of the right side, the feces, in a very liquid state, were constantly running
out through two openings in the groin, and three in the posterior part of the
thigh; the limb being drawn up nearly to a right angle with  the body, and
the whole thigh much enlarged and hardened.  The skin was also thickened
almost to callosity,  and excoriated, and the openings were so small as hardly
to admit a common director.  To relieve this, Warren operated in  the fol-
lowing manner:—
  Operation.—After dilating the principal openings by sponge-tents, applied
very gradually, and  continued for a month, the two ends of the  intestine were
discovered.   A gum-elastic bougie being then passed into the upper orifice,
and  another into the  lower, the two were made to penetrate a thick callous
mass of integument, and then passed through the  abdominal parietes for
about an inch, when the septum or spur which separated the two ends of the
bowel was encountered and with difficulty entered, being so closely  applied
to the abdominal parietes as to prevent the least passage of matter from the
upper into the lower part of the bowel.   As the intestinal ends seemed to
lie parallel to one another, the exploring bougies made a very slight angle
at their extremities.
  Having now made sure of the position of the lower opening by the intro-
duction of a director, the male branch of Dupuytren's enterotome was car-
ried  into the lower  intestine, the director withdrawn, and the female branch
readily introduced  into the upper; but as the two parts of the instrument
occupied nearly the whole calibre of the dilated passage leading to the gut,
it was necessary to  separate and loosen them, and this was  found  to be im-
possible, as the jaws of the female  portion would not allow  of sufficient mo-
tion at the hinge to lock with the  other blade.
   This  instrument  was therefore withdrawn, and another, which was about
two inches shorter than Dupuytren's, introduced; but this instrument, instead
of having one blade received  into a groove in the other, was serrated like
polypus forceps for the space of three  inches.  The blades being now intro-
duced and locked without difficulty, were therefore at once brought together
as tightly as the screw would permit.  For a few  hours the patient  com-
plained, but next day was free from pain; the fecal matter passed by the
side  of the instrument; warm water was injected daily into the  wound to pre-
vent any obstruction, and she  also had  an enema administered,  to keep the
lower bowel in action.
  Three days after  its application the instrument came away,  bringing with
it a blackish slough two  inches and  a half long, four  lines wide, and about
three thick, which had the impress of the teeth of the instrument.
  The finger being now passed into the orifice, readily distinguished an open-
ing between the two ends  of the intestine,  corresponding in  size to the
slough, the edges of which were greatly thickened and fleshy, and unlike the
delicate valvular septum which previously existed.
  On the following day there was a discharge per anum;  a  compress was
applied  to the orifice of the wound, and the patient  ultimately recovered.
                    \ 1.—Statistics of Artificial Anus.

  According to Dupuytren, the following is the result of his  experience in
artificial anus:—
  Of forty-one  cases treated by himself and others, thirty-eight were cured,
and three  died.
  Of the thirty-eight cured, twenty-nine were radically cured in from two to 
438            PRINCIPLES AND PRACTICE  OF SURGERY.
six months, and the remaining nine continued to suffer from fistulous orifices,
notwithstanding every effort to heal them.  The  mortality following the use
of his enterotome was one in fourteen.
   Remarks.—As  the  palliative treatment of artificial anus,  when  conse-
quent on strangulated hernia, affords only temporary relief, and is the result
of the application of a compress or truss to the ulcer at the external  orifice,
such means do not require much notice; but  as the  radical  cure,  by the
means  above  detailed,  was an operation which relieved the patient  from a
most loathsome complaint, it naturally excited considerable attention at the
period when it was introduced;  and the claims  to priority of invention on
the part of Physick and Dupuytren  have, therefore, been strongly contested.
In the United States, no one  questions the originality of the operation of
Physick, the thesis of Schmakhalden having, in all probability,  been limited
in its circulation, and not  extended  to  a  country the  intercourse of which
with Europe  was  at that  time very limited.   But, while advocating  the
rights  of Physick, the  advantages of each mode of operating need not be
overlooked.   From an examination of various facts, there is good reason to
think that, from the different  degrees of obliquity seen in the  two tubes iu
different instances, the selection of any operation must be decided  by the
peculiarities of the case.   As a general rule, I would give the preference to
the instrument of Lotz, of Pennsylvania, (which is, as has been  shown, a
modification of that of Dupuytren,) in all cases where the two tubes are not
perfectly parallel; but  when they are thus  situated, the operation of Physick
has the following  advantages over that of  Dupuytren:—
   1st  There is no incouvenience caused to the patient, by having an  instru-
ment projecting from a tender ulcer during the period of eight days.
   2d.  There is a better chance of exciting solely adhesive inflammation by
the use of the ligature, than there is  by compressing the structure, the  slough
created by the instrument of Dupuytren being liable to extend  beyond the
width of the blades of the instrument.
   3d.  The division of  the septum by a  cutting instrument, as practiced by
Physick, is preferable to the irregular orifice produced  by the separation of
the slough formed between the blades of the enterotome of Dupuytren.
   In cases where the obliquity of the bowel does not present anything like
an intermediate or double-barreled septum, neither of the  preceding opera-
tions for the  radical cure would be available, the treatment in  this case re-
quiring merely a  palliative operation,  or such  a one as would favor the
contraction aud cicatrization of the orifice in the intestine as well as in the
skin.

                             SECTION II.

                  FORMATION  OF AN ARTIFICIAL ANUS.

   The formation of an artificial anus, in order to give vent to such contents
of a bowel as have been prevented from  pursuing their natural course, either
iu consequence of a congenital defect of the natural anus, or by the develop-
ment of an obstruction in the lower part of the intestinal canal, is purely the
result of surgical skill,  based upon an accurate anatomical knowledge of the
position of the portions of the canal which  are best  adapted for the safe
formation of such a vent as will give exit to fecal matter with the least pos-
sible inconvenience to the patient.
   Without alluding to the various causes which may render this operation
necessary, or  explaining at present the steps of such methods as are de-
manded by congenital occlusions of the  rectum, it is  proposed to call the 
         FORMATION OF  AN  ARTIFICIAL ANUS AT THE  GROIN.     439

reader's attention to two operations, in both of which the intestine is opened
at points more or less  closely connected with the regions at which hernia
may be developed.


            § !•—Formation of an Artificial Anus at the Groin.

  As the details of the relative position  of  the abdominal viscera to the
groin were presented in connection with  hernia, there is but little  occasion
for more than a brief allusion to the part of the intestine usually opened iu
the formation of an artificial anus.
  The colon, arising in the right iliac region by the caecum, passes upward
on the right side,  as high  as  the lower portion of the right hypochondriac
region, then transversely through the lower portion of the epigastric region
and across the abdomen, to the lower portion of the left lumbar region, when
it descends to the left iliac region, where it terminates by the sigmoid flexure.
As the groin presents a point to which the attention of the patient may be
readily given, it has generally been regarded as furnishing the most favora-
ble point for the formation of an opeuing, which must subsequently be closed
by artificial  means, and which must require the patient's personal attention,
in order to  preserve proper cleanliness.   At these points the caecum or the
sigmoid flexure is  covered only by the  abdominal parietes, Plate XLVI.
Fig. 1.   Thus we  find the  skin,  superficial fascia, tendon of the external ob-
lique muscle of the  abdomen,  internal  oblique  and transversalis  muscles,
fascia transversalis, and peritoneum presenting here  the same relative layers
that have been referred to in connection with hernia.   Through these layers,
an incision should therefore be made in such a direction as would present the
long diameter of the wound in the line of the groin, the intestine attached
to the sides of the wound,  and then such a perforation  practiced  on its coats
as will permit the  subsequent contraction of the parts, and give sufficient
vent to the  obstructed contents  of the bowels.
  This operation  dates back to the year 1720, when it was suggested  by
Littre,* since which period it has been performed by many other surgeons;
some of whom, either through ignorance  or inadvertence of the  proposition
of Littre, have considered  themselves as  the originators of the idea.
  Operation of Littre.—The patient being placed upon the back, with the
thighs extended, and the surgeon standing in a position similar to that de-
manded for  the operation of strangulated hernia, commence the incision on
a level with the anterior superior spinous process of the ileum, and carry it
inward and  downward toward the pubis,  in the line of the groin, for the ex-
tent of two or two and a half inches.  After incising the skin and superficial
fascia,  make a small opening in  the tendon of the external  oblique, pass iu
a director, and incise the tendon upon the latter instrument by  means of a
probe-pointed bistoury.   After  incising in a similar  manner the fibres of the
internal oblique and transversalis muscles, and tying any branch of the cir-
cumflex iliac artery that accident may bring  into the line  of the  incision,
next cautiously divide the fascia transversalis, and then with the same caution
the peritoneum, incising both upon the director or finger in order  to avoid
the intestines.  If the  gut, which is usually distended with feces, now pre-
sents itself, it may be distinguished from the small intestiues by its reddened
color, if congested, or by the yellowish-green appearance  which  is often
noted in this bowel after death, as well as by its peculiar shape.  By passing
the finger around it, the bowel  may now be  brought well  forward—Plate
* Velpeau, Med.  OpSratoire, tome iv. 
440
PRINCIPLES  AND  PRACTICE OF  SURGERY.
XLVI. Fig.  3—into the opening, and a ligature being passed through the
mesocolon so as to prevent its escape, a puncture may be made into the gut,
and then this opening enlarged  by an incision  parallel with that in the in-
teguments.  The contents of the bowel being now evacuated,  the ruesoeolic
thread should be securely fastened to the parietes of the  abdomen, and the
intestine thus left until  the  third  or  fourth day, when,  adhesions having
formed between the surface of the colon and the front of the peritoneum, it
only  remains to prevent the tendency of the wound to contract and close the
opening, by the use of a tent.
  The subsequent dressing should be such as will protect the  skin from ex-
coriation, and guard against  the tendency to eversion of the mucous coat of
the intestine, as well as against the constant escape of the fecal matter.   It
may  be usually  accomplished  by a compress and  bandage, or  by a truss, if
the parts can tolerate it.


       \ 2.—Formation of an Artificial Anus  in the Lumbar Region.

  The descending colon,  passing  from  the left hypochondriac  region to the
left sacro-iliac symphysis, is covered by the muscles of the loins behind, and
by the peritoneum in  front, the attachment of  the latter to the muscles im-
mediately around the crest of the ileum being by a loosely-developed cellular
substance.  "In  its general  course, this bowel corresponds to  the groove
between  the quadratus lumbornm and  transversalis muscles,  and as this is
near to the external  border of the common mass of the sacro-lumbalis and
longissiraus dorsi, it may be easily recognized in  moderately fat subjects.
Sometimes the colon is more internal, and, in  great part, concealed by the
quadratus lumborura,"* Plate XL VI. Fig. 2.
  The layers to be divided in the formation of an artificial anus in the loins,
are the skin  and subcutaneous fat, the latissimus dorsi muscle  behind, the
external  oblique  muscle  of the abdomen in front, then the internal oblique
and  transversalis muscles, then the fascia transversalis, then fat, and lastly
the intestine itself;  the left colon being devoid  of peritoneum in the poste-
rior third of its circumference, especially when distended.
  Operation of Amussat.—This operation is a  valuable modification of that
proposed by  Callisen, and is performed as follows : The patient being laid
on his belly,  and slightly inclined  to the right side, a transverse incision
should be made in the skin, two fingers' breadth  above the crest of the ileum,
commencing at the external border of the mass common to the sacro-lum-
balis and longissiinus dorsi, and following it outward to  the extent  of four
or five fingers'  breadth.   After incising the skin and subcutaneous tissue
divide the latissimus dorsi transversely in the posterior third of the  incision,
the external oblique in the anterior two-thirds, and then the internal oblique
and transversalis muscles and fascia, cutting them transversely and then ver-
tically, so as to obtain a  crucial  incision.   On  reaching  the adipose tissue
which envelops the colon, raise it cautiously and search carefully for the in-
testine, which may be told  by percussion,  or  by its color, or by feeling the
resistance caused by its contents.
  After  certainly recognizing it, traverse the  exposed  portion with  two
needles, so that the bowel may be stitched with  two loops of thread about an
inch  apart, and pierce it  in the interval of the loops and divide the intestinal
parietes crucially, so as to secure a free evacuation of its contents,  aiding
this,  if necessary, by injections of warm water.  Then drawing the intestinal
* Malgaigne. 
STATISTICS  OF THE OPERATION.
441
opening well forward by means of three torsion forceps, fasten it to the skin
by four points of the interrupted suture, Plate XLVI. Fig.  4.
  Remarks.—The formation of an artificial anus for the purpose of giving
vent to the fecal contents of the bowels, when prevented from escaping by
the natural orifice, is an operation which has been practiced in adults in con-
sequence of cancerous or other permanent obstructions of the rectum, and in
children from malformation of the natural opening of the rectum.  At first
sight it would appear that this operation must evidently expose the patient
to loss of life, and can, at best, prolong it  only at the expense of a most
loathsome condition.   That the bowels may be thus  opened, is certainly an
evidence of the efforts of the surgeon toward relieving the defects of nature;
but the results are by no means positive that the operation can secure to the
patient even a continuance of a miserable existence.
                     \ 3.—Statistics of the Operation.

   In the United States, the formation of an artificial anus has been attempted,
but, as far as I can learn,  without  much success.  In a case operated on by
Warren, Senr., the patient died.  In one operated on by J. M. Bush, of Ken-
tucky, the patient also died on the fourteenth day; and of eight cases reported
by Velpeau, six died and two recovered.  But the results furnished by Haw-
kins, of England, as obtained from an analysis of  44 cases, shows that this
operation is not quite so hopeless as might have been supposed.  Thus, of
44 cases which he refers to, 22 were counted as recoveries; of these, 1 lived
It years ; 9 about a year; 5 died in 6 months subsequently, and 8 were either
alive  or lost sight of at the end  of 12 months: 21  patients were from 40 to
60 years old, of whom 11  died;  and 12 were from 20 to 40 years of age, of
whom 6 died.   Age does not, therefore, exercise any special influence on the
operation.
  But even with these results, it may be doubted whether it is advisable to
induce an adult to submit to this operation, and whether, if left to nature,
the chances of life might not be quite as  great as  those resulting from the
operation.   The inflammation, extending from the  distended bowel to the
surrounding parts, might  obviate the chances  of a general peritonitis, and,
if the  patient's strength  could sustain the sloughing consequent on a rupture
of the intestine, nature would doubtless  make for herself an external vent.
In such hopeless circumstances, the  judgment of each one  at the  moment
can alone decide upon the value of an operation.  As regards the special
advantages of an operation,  as practiced in  the  groin, or  in the  lumbar
region, Hawkins concludes that the decision  may  be left to the judgment
of the surgeon, provided he operates on the left side of the body. 
CHAPTER  IX.
                LIGATION OF  THE ILIAC ARTERIES.

  The application of a ligature  to the Iliac Arteries has been successfully
performed at various points, from the origin of the common  iliac along the
main trunks of both its internal and external branches.
                            SECTION  I.

                         SURGICAL ANATOMY.

  The Primitive Iliac Arteries arise about the lower part of the fourth or
fifth lumbar vertebra, and extend to within an inch of the sacro-iliac symphy-
sis, where they divide into the Internal and External Iliacs.   In this course,
each Primitive Iliac Artery is bounded on the outer side by the psoas mag-
nus muscle, behind by the primitive  iliac vein, and, when of full length, is
crossed at its lower part by the ureter.  The right artery crosses  in front of
the root of the left iliac vein, Plate XLVII. Fig. 1.
  The Internal Iliac Artery extends from its origin near  the front upper
part of the sacro-iliac symphysis to the lower part of the same articulation,
being bounded  behind by the sacral plexus of nerves, and being  about one
inch in length before it gives off any branches.
  The External Iliac Artery extends from the bifurcation  of the primitive
iliac to Poupart's ligament along the internal margin of the psoas magnus
muscle.  In the commencement of its course it is  anterior to the external
iliac vein, but gets to its outer margin as it approaches Poupart's ligament.
At this point it is about half way between the anterior superior spinous pro-
cess of the ileum and the symphysis pubis, having the vein on its inside, and
the anterior crural nerve half an inch from its outer margin, Plate XLVII.
Fig. 1.
  These  arteries are behind the Peritoneum, the attachment of which to sur-
rounding parts is generally by loose connective tissue.


                            SECTION II.

                 OPERATIONS UPON THE ILIAC ARTERIES.

  The interruption to the circulation of the blood through these arteries, by
means of compression, has occasionally been resorted to, and, in some  in-
stances, with partial success, the great objection to its employment arising
from  the proximity of the iliac veins, causing also an interruption in  the
venous circulation, with all the dangers and inconveniences which  usually su-
pervene on such obstructions.  The ligature must, therefore, be regarded  the
       (442) 
LIGATION OF THE  EXTERNAL ILIAC ARTERY.         443
best mode of treating the disorders of these blood-vessels, though this opera-
tion especialy demands operative  skill, while compression requires rather
good surgical  judgment than manual dexterity.
               § 1.—Ligation of the External Iliac Artery.

  The ligation of the External Iliac Artery was first performed by Aberne-
thy unsuccessfully in 1796, and again successfully in 1806.  His operation
was performed as follows :—
  Operation of Abernethy.—The patient being laid on his back, and a lit-
tle inclined toward the sound side, so as to relax the abdominal muscles and
throw the intestines from the incised side, an incision  should  be made about
four inches long in the adult, commencing an inch and a half from and on
the inner side  of the anterior superior spinous process of the ilium, and ex-
tending obliquely toward the outer column of the  external abdominal ring.
After incising the skin and superficial  fascia, tie  any of the small arterial
branches that may  require  the ligature, open  the tendon of the  external
oblique, and introducing a  director, divide the tendon in the course  of the
external incision.  Then, carrying the forefinger beneath the  fibres of the in-
ternal oblique and transversalis muscles, divide them with a probe-pointed bis-
toury,  and, commencing at the iliac margin  of the wound, press the perito-
neum toward the median line of the body so as to overcome its cellular attach-
ments  to the iliac fascia.  After exposing the artery about  two inches above
Poupart's ligament, pass the aneurismal needle under it, from within  outward,
or from between the vein and artery toward the  ileum, Plate XLVII. Fig 3.
   Operation of Dorsey, of Philadelphia.—This operation, which was the
first of its kind in the United States, was performed in 1811,  as follows : An
incision three  inches and a half long  was made, beginning an inch and a half
above  the anterior superior spinous process and one inch within it,  and also
four inches  and a half distant from the umbilicus,  so as to extend obliquely
downward, and terminate about one inch above  the aneurismal tumor, which
was situated immediately below Poupart's ligament. After dividing the skin,
superficial fascia,  and external oblique tendon,  the internal  oblique muscle
protruded at the wound, and, together with the inferior edge of the trans-
versalis, was divided nearly up to the highest point of the  wound.   The cel-
lular adhesions of the peritoneum being then overcome by the forefinger, the
artery  was readily felt pulsating,  and  was then separated gently  from the
adjoining parts without denuding much of it, when the vessel was secured by
Physick's needle and forceps, Plate XLVII. Fig. 3.
  Three knots being made upon the ligature, the ends were left at the exter-
nal wound;  and a strip of adhesive plaster, a pledget of lint,  and a compress
completed the dressing.   The patient  was then put to bed  with the thigh
moderately flexed on the pelvis, and the limb covered with carded wool and
flannel.  On the thirteenth day the ligature separated, and on the twentieth
he was able to rise  in his bed.
  Operation of Wright Post, of New  York.—A laborer,  aged  forty-one
years,  entered the New York Hospital,  October, 1813,  with an  inguinal
aneurism of the left side.   After general treatment, the operation  was  per-
formed, January, 1814, (it being the second of its kind in the  United States,)
as follows:  An iucision being made through  the integuments with some
degree of obliquity, beginning a short distance above the tumor, and extend-
in^ upward externally to a middle line between the umbilicus and  superior
anterior spinous process of the ilium, so as to  give it a length of between
three and four inches, the abdominal muscles were cut through, until the peri- 
444           PRINCIPLES AND PRACTICE  OF SURGERY.
toneum, at the lower part of the  wound, was fully exposed.  An endeavor
was then made to detach this membrane from the crural arch, so as to get at
the artery without opening the cavity of the peritoneum, but failed, as the
strength and thickness of the membrane, at this point, were much greater
than usual, and its adhesion to Poupart's ligament was so firm that the separa-
tion, which is usually so easy, was found in this case to be impracticable, in
consequence of the pressure caused by the tumor.   It was, therefore, neces-
sary to cut through the peritoneum in order to  arrive at the artery, which
was done on  account of the difficulties before referred to.  The omentum pro-
truded was easily replaced, and the artery felt;  but every effort to  detach
the peritoneum from the sheath of the  artery, by means of the  finger  nail,
failed, and  it only remained to pass a ligature under  the artery by pushing
the needle through the coverings of the vessel.   To effect this, the point of
the finger was placed on the inside of the artery, and a needle being conveyed
along this  as a director, it was made to pierce the coverings of the vessel,
pass under the artery, and come out on  the outside of it, by employing the
forceps of Physick.   After tying the ligature with  care, so as to avoid in-
cluding any  portion of the intestine, the wound was closed with adhesive
strips,  lightly dressed,  and the patient put to bed,  the limb being covered
with cotton.  Pulsation returned in the tumor, but the aneurism did  not in-
crease, the  ligature upon the artery not having arrested the circulation in the
tumor, but only lessened it, though the patient ultimately recovered the use
of a limb which had before been of no service to him.
  Operation  of Mott, of Xew York.—The skin and superficial fascia being
divided by a  curvilinear incision, which, commencing just above the external
abdominal  ring, extends outward  and parallel with Poupart's ligament to a
poiut a little  above the anterior superior spinous process of the ileum, the
tendon of the external oblique muscle will be fully exposed;  then, this  tendon
being cautiously divided to the extent of the external incision, separate it
from the internal  oblique muscle and turn up the flap,  and, carefully detach-
ing the edge of the internal oblique and transversalis muscles from Poupart's
ligament, turn them  up also, when  the  tubular  portion of the fascia trans-
versalis, which invests the cord, will be  readily seen.   Picking this process
up in the forceps, rub  it  between the fingers and  nick it transversely  with
the point of the knife; then, introducing the finger at the opening,  pass it
along the cord to the internal abdominal ring, when  the  pulsation of the
artery will  be felt behind  and below this ring, the cord serving  as a guide,
and rendering it certain that the finger  passes below the peritoneum,  or be-
tween it and  the artery, without any injury to either.   When you dilate the
wound with broad spatulae, get a  good view of the artery, and, separating it
from the vein, which is below and on its inner  side, to an extent only suffi-
cient for the  passage of the needle, pass the former around the artery from
within outward, or so that its point will  pass from and  not to the vein, when
the artery  may be ligated  about one inch above Poupart's ligament, care
being taken not to include any nervous filaments in  the ligature.
  After-Treatment.—Close the edges of the wound by a suture and adhe-
sive strips, leaving both ends  of the ligature hanging out of the lower angle,
but do not apply  any bandage which can constrict the part; after which the
patient should be placed in bed, with the thigh slightly flexed on a  pillow,
while cotton or some other good non-conductor of heat is placed all round the
limb, from the toes to the groin, so as to cherish  the heat and vitality of the
part.
  Operation  of Cooper.—This surgeon  began his incision near the anterior
superior spinous process of the ileum, and continued  it to  a point a little
above the iuner edge of the external abdominal ring, giving it a semi-ellipti-
cal shape. 
LIGATION OF THE EXTERNAL ILIAC ARTERY.
445
  After dividing the tendon of the external oblique, he followed the course
of the spermatic cord with his finger, entered the internal abdominal ring, and,
depressing the peritoneum, isolated the artery as before.
  Operation of Bogros.—By an incision two  or three inches long, equidis-
tant at each end from the pubis and spinous process of the ileum, and imme-
diately over Poupart's ligament, the skin and superficial fascia were divided,
a director passed beneath the tendon of the external oblique,  the spermatic
cord raised, and its adhesions separated, the finger following the course  of the
cord to the internal ring where the epigastric artery may be  readily found
on the inside of the ring.  Tracing with the finger the course  of this artery
to its  origin, it only remained to push aside the adhesions of the areolar tis-
sue, and ligate the vessels.
  Remarks.—By reference to the Bibliographical Index at the end of this
part,  it will be seen that the operation of ligating the external iliac artery
has been frequently performed with success in the United States, the names of
Whitridge, of Charleston,  Nathan Smith, of  New Hampshire, Jameson, of
Baltimore, Stevens and Rodgers, of New  York, Warren, of Boston, and
Barton and  Randolph,  of Philadelphia,  being associated with  the earlier
operations, while  those of  many others are connected with the subsequent
operations on this vessel.
 \ 2.—Statistics of the Application of a Ligature to the External Iliac Artery.

   The results of the operation of ligating the iliac arteries have varied some-
 what according to the branch tied, though the external iliac, from being the
 most superficial as well as that most directly connected with the femoral and
 popliteal arteries, has been more  frequently ligated than either or both of the
 others.   As the circulation can be readily carried on  by other vessels when
 this  branch of the iliac is tied, the subsequent difficulties have been less, and
 the success attendant on the operation such as establishes the propriety and
 advantage of ligating this vessel for aneurism, or wound of the femoral ar-
 tery.
   The following cases have been collected from the works of the  surgeons
 whose names are mentioned:—


                 Ligation of the External  Iliac Artery.

                                             Cases.      Cured.      Died.
    Abernethy*..................................................   4          2         2
    Freerf........................................................   3          3         0
    John C. Warren %..........................................   4          3         1
    Moti£.........................................................   7          4         3
    Other'American surgeons...............................  22         17         5

                                              40         29        11

   From this summary, it appears that of forty cases operated on, twenty-nine
have been cured and eleven died, or more than two-thirds of the cases  oper-
ated on have been cured.
   Of one hundred and eighteen cases reported by Norris, eighty-three were
cured and thirty-three died, three who  recovered undergoing amputation,
which also shows that more than two-thirds were cured.

          * Observations on Aneurisms, by J. Abernethy.
          f Ibid., by George Freer.                       % MS.
          \ Transactions Am. Med. Assoc, vol. iv. p.  269. 
PLATE  XLVII.
VIEW OF THE TARTS CONCERNED IN THE OPERATION OF LIGATING THE
                            ILIAC ARTERIES.

   Fig. 1. Surgical anatomy of these Arteries.  1. Aorta.  2. Right primitive iliac.
3. Right external iliac.  4. Left primitive iliac vein.  5. Ascending vena cava.  6.
Spermatic vessels.  7. Ureter crossing the iliac artery.  8. Internal iliac artery.
9. Lymphatics and glands.  10. Anterior crural nerves.  11. Section of the abdo-
minal muscles.  12. Anterior superior spinous process. 13. Fascia lata.  14. Psoas
muscle.  15. Iliacus internus.  16. Circumflex iliac artery. 17. Epigastric vessels.
18. Sheath of the femoral vessels.  19. Saphena vein.  20. Lymphatic vessels  of
the thigh.  21. Spermatic cord.  22. Bladder.       After Bernard and Huette.

   Fig. 2. Appearance and position of an Aneurismal Tumor of the Femoral Ar-
tery, showing the effect upon  the superficial vessels, etc.  Ligation  of the exter-
nal iliac was required.                                         After Auvert.
   Fig. 3. Ligation of the External Iliac Artery.  1. The  artery distended, and
with the needle beneath it.  2. Incision of the skin. 3, 4. The divided edges of the
muscles  and fascia of abdomen.  5. The peritoneum everted.  6. The external
iliac vein.                                       After Bernard and Huette.

   Fig. 4. Operation of ligating the Primitive Iliac Artery, as shown upon the
subject.  The artery has been raised a little by a ligature toward the orifice of
the wound, in order to show it more distinctly.                  After Nature.

   Fig. 5. Ligation of the Internal Iliac Artery, as shown upon the subject, the
arteries  being filled with wax.                                 After Nature.

   Fig. 6. A view of the condition of the Blood-vessels, as found after death in
the patient upon whom Peace tied the right Primitive Iliac Artery, showing by
what means the circulation was  carried on. 1. Aorta.  2. Primitive iliac, that on
the right side, as well as the right external  and internal iliacs, being obliterated.
3. Middle sacral much enlarged. 4. Aneurismal sac.  5. Epigastric artery much
enlarged.  6. Enlarged  ilio-lumbar artery.  7. Circumflex iliac.  8.  Obturator
artery.  9, 9.  Lumbar arteries much enlarged.                   After Nature.

   Fig. 7. A view of the left Iliac Vessels  of the same patient.  1. Aorta.  2, 2.
Primitive iliacs.  3.  Middle sacral, as seen in the previous drawing. 4.  Left inter-
nal iliac, with all its branches  much increased and anastomosing freely with right
side.  5. Left external iliac. 6. Left epigastric displaced in the preparation.  7.
Poupart's ligament.  8. Left femoral artery.                    After Nature.
       (446) 
Plate 47
Fifc.3.
 
 
LIGATION OF  THE  PRIMITIVE ILIAC  ARTERY.
447
                            SECTION  III.

              LIGATION OF THE PRIMITIVE ILIAC ARTERY.

  The Ligation of the Primitive Iliac Artery is one which dates back only
to the year 1812, when  it was first performed  for the arrest  of traumatic
hemorrhage, by Gibson, of Philadelphia, (then  residing in Baltimore,) but
without success.   The first successful ligation of this artery for  aneurism was
accomplished by Mott, of New York, in 1827.
                         \ 1.—Surgical Anatomy.

  The Primitive Iliac Arteries, being the terminating branches of the ab-
dominal aorta, are about an inch long where they divide into the external and
internal iliacs.  Most commonly, each primitive illiac arises about the fourth
lumbar vertebra, though sometimes it comes off as low as the inferior edge
of the fifth.   These arteries rest upon the parts about the alae of the sacrum,
or side of the sacro-vertebral  angle, having the psoas magnus muscle upon
the outer side, and being crossed  at their lowest portion by the ureter. On the
right side, the primitive iliac vein is outside, and then behind the artery, but
on the left, the vein lies upon the inside of the vessel, though it does not reach
this point until it  has passed under the root of the right iliac artery.   The
peritoueum covers  the vessels, and they are easily approached simply by over-
coming with the finger the loose attachments of this membrane to  the part.
          \ 2.—Operation of Ligating the Primitive Iliac Artery.

  The approach to the Primitive Iliac Artery may be accomplished by a slight
extension of such incisions as have been recommended for the ligation of the
external iliac. In the operation of Mott, in 1827, which was the first success-
ful operation ever performed, as well as the first done for the relief of aneurism,
the following plan was pursued :—
  Operation of Mott.—The aneurismal tumor, though of only ten days' stand-
ing, occupied the whole extent of the  external iliac, extending from within
Poupart's ligament to some distance above the origin of the  internal  iliac
artery, was  of large size, and protruded the belly considerably at the  iliac
region.
  By an incision parallel  with and about half an inch above Poupart's  liga-
ment, and extending from the  external abdominal ring to one or two inches
above  the crest of the ilium, the skin  and  muscles  were  cautiously divided,
and turued  up as in the operation upon the external iliac artery,  when the
peritoneum  was  cautiously detached with  the  fingers, as in the preceding
operation, without being injured.  The artery being then examined,  the aneu-
rismal  dilatation  was found to cease at about half the distance between the
bifurcation of the aorta and the origin of the internal iliac branches.   The
ligature  was, therefore, passed around the vessel from the outside—so as
to avoid the iliac  vein — by  means of Parrish's needle, great care being
taken not to injure the ureter,  or the iliac vein, Plate XXXV. Fig. 2, when-
after tying the knot, the wound was held open in order to satisfy those pres-
ent of the exact situation of the ligature, which was seen to be just below the
bifurcation of the aorta, and on the side of the  sacro-vertebral promontory. 
448           PRINCIPLES  AND  PRACTICE OF  SURGERY.
 The wound being lightly dressed, the patient was put to bed, and the means
 previously mentioned employed to preserve the heat of the limb until the cir-
 culation was restored,  the patient being ultimately cured.
   In the case operated on by Gibson, in  1812, the artery was tied by means
 of a ligature passed  around it  by an ordinary eyed  probe,  the  original
 wound being enlarged  to the extent of seven inches.  This patient died, on
 the fifteenth day, of hemorrhage, and, on dissection, it was proved that two
 ligatures had been  placed on the  common iliac artery of the left side, about
 half an inch below the bifurcation of  the  aorta.  The upper  ligature was
 found  detached, but no union had  occurred in the vessel.*
   Operation of Peace, of  Philadelphia, f—A man, aged  thirty-six years,
 was admitted into the Pennsylvania  Hospital, in  August, 1842, with an
 inguinal aneurism of the right side, created by a strain in lifting  stone, to
 relieve which it was decided to ligate the common iliac artery.
   Operation___An incision seven inches long was made through the integu-
 ments, commencing  at a point on  a level  with the  umbilicus, two inches
 within and three inches above the  anterior  superior spinous process of the
 ilium, approaching to within an inch of Poupart's ligament, and terminating
 one-half inch above the external ring.  This divided the arteria ad cutem ab-
 dominis, which was twisted by the  artery forceps.  The superficial fascia being
 next divided, the tendon of the external oblique was nicked  and incised  upon
 a director the whole length of the  first incision  as far inward as the spermatic
 cord.  Considerable difficulty was now experienced in raising the lower edge
 of the tendon of the internal oblique and transversalis, owing to the indura-
 tion of tissue from the pressure of the tumor,  but this was finally accomplished
 by means of the knife-handle, and, the parts being then carefully divided, the
 peritoneum was reached.  When this was cautiously detached from the tumor,
 the latter was found to involve a  large portion of the external iliac artery,
 but by raising the  peritoneum a sound  part  of the artery was noticed, about
 half an inch above the  bifurcation of the common iliac.
   The artery being now separated  from  the vein by the finger nail, a silk
 ligature was passed around it by Gibson's needle, Plate XXXV. Fig. 12; but
 notwithstanding the precautions taken to evacuate the bowels, and the length
 of the incision, it was difficult to see the point of the needle under the artery,
 on account of the protrusion of the bowels and the projection of the tumor.
 Finally, by means of broad, curved spatula?—Plate XLVII. Fig. 4—the  parts
 were seen, aud the ligature being tied with a double knot, both  ends  were
 allowed to hang out of the wound, which  was then closed by adhesive strips,
 three points of the interrupted suture, lint, etc.  The patient was then placed
 in bed, with his shoulders slightly raised,  his body flexed and inclined to the
 affected side, and the limb flexed  upon a  pillow  under the knee.  In fifteen
 days the ligature came  away, and the patient recovered perfectly.
   This patient dying subsequently,  Peace succeeded, after much trouble, in
 injecting the blood-vessels, and in  making a dissection of the part.   Al-
 though, from the opposition of the patient's  friends, the preparation was im-
perfectly made, it yet shows the means by which the  circulation was carried
on.  From this preparation I  have been  enabled, through  the politeness of
the operator, to have the two sketches made  as represented in Plate XLVII.
 Figs. 6, 7, and from inspection of  the collateral branches  of the  artery as
seen after the operation, as well as from the minuteness with which the opera-
tion has  been detailed by the operator, much valuable information may be
 gained by those who may hereafter  desire to repeat it.
* Med. Recorder, vol. iii. p. 185.
f Am. Journ. Med. Sciences, vol.  v. N. S. p. 269. 1843. 
LIGATION OF  THE  INTERNAL  ILIAC ARTERY.         449
   Remarks.—A knowledge of the great amount  of the circulation which
 would be cut off from the lower extremity, by the application of a ligature
 to this vessel,  at first led surgeons to believe that it would be impossible to
 preserve the vitality of the limb after this operation.   The credit of demon-
 strating the contrary is, therefore, due to the surgeons of the United States,
 who, in the cases operated on, conclusively showed  that nature was able to
 remedy even this serious obliteration of the natural channel of the blood to
 the lower extremities.       \


               § 3.—Statistics of Ligation of Primitive Iliac.

   Since  the primary operation  upon tjie Primitive Iliac Artery, thirteen
 others have been reported, as follows •* Crampton, in 1828 ; Liston, in 1829;
 Guthrie, in  1833; and Syme, 1838, in England; by Salomon, of St. Peters-
 burg, in 1837; Deguise, of  Paris, in  1840;  by Bushe, of  New York, in
 1832; Post, of New York, in 1840; and Pirogoff, of Russia;  by Peace, of
 Philadelphia, in 1842 ; by Hey, of England, in 1843;  by Stanly, of London, in
 1846 ; two by Garviso, of South America; and one recently by Wedderburn,
 of New Orleans.*
   Of the seventeen cases before specified, eight were cured and nine died;
 showing, as it is thought, the justifiable character of the operation under cir-
 cumstances  similar to those which have before  required it.


                \ 4.—Ligation of the Internal  Iliac Artery.

   The Ligation of the Internal Iliac Artery has been occasionally performed
 for the relief of aneurismal tumors in its gluteal or ischiatic branches.  As
 there is an ample supply of vessels through which the circulation may be con-
 ducted, the  application of a ligature to this artery  would not, in all proba-
 bility, be attended by serious consequences, were it not from the risk of peri-
 tonitis necessarily created by the operation.
  The plans proposed for the application of the ligature have varied con-
siderably from  those suggested in connection with the external iliac, chiefly
 because the  latter vessel  has been most frequently tied in its lower part.  As
the external and internal arteries come off at  the same point, it is evident
that a slight prolongation of the ordinary operation upon the external branch
of the artery would enable the operator also to tie the internal.  But as the
 plans employed have differed materially from  those  pursued in  ligating the
former vessel, the ligation of this vessel has, therefore, taken the position of
a distinct operation.  The operation was first performed by Stevens, of Santa
Cruz, then by Atkinson, of England, and then by White, of New York, as
hereafter shown.
  Operation of Stevens, of Santa Cruz.—In the case of a negress who
labored under an aneurismal tumor of the left buttock, of the size of a child's
head, Stevens proceeded as follows :—
  Operation.—By an incision, five inches in length, made in the course but
a little to the outer side of the epigastric artery, the abdominal parietes were
divided, the attachment of the peritoneum, from the spine of the ilium to the
left sacro-iliac symphysis, overcome by pressing upon it with the finger, and
the origin of the artery being felt by the forefinger, the internal iliac was tied
by passing a ligature around  it, about half an  inch  below its origin.   This

          * Norris,  Am. Journ. Med. Sci.,  vol. xiii. N. S. p. 24.  1847.
     vol. ii.—29 
450           PRINCIPLES  AND  PRACTICE OF  SURGERY.
 patient was cured in three weeks;  and, ten years afterward, when she died,
 the preparation was sent to London, but the aneurism was found to have been
 in  the ischiatic instead of the gluteal artery, as had been supposed.
   Operation of S.  Pomeroy White, of New York.—It being decided to tie
 the internal iliac artery in order to relieve a gluteal or  ischiatic aneurism,
 White operated as follows, without any knowledge of  the operation of Atkin-
 son, although  aware that Stevens had previously succeeded in his opera-
 tion :—
   Accordingly, he  made a semicircular incision, seven inches long, and with
 its convexity  toward the ileum, commencing two inches to the left of the
 umbilicus and  ending at the  external ring, so as to  divide the skin, areolar
 tissue, and  fascia superficialis.   Then, the tendon of  the external oblique
 muscle  being exposed, it was carfully divided, as were also the external ob-
 lique and transversalis muscles, as well as the transversalis fascia.   The  peri-
 toneum being now detached by the  fingers from the iliacus  internus and psoas
 magnus muscles, it  was pressed with its contents toward the right hypo-
 chondriac region, when the external iliac artery being felt and traced by the
 finger toward the sacro-iliac  symphysis, the internal iliac  was distinctly rec-
 ognized, and, being exposed with the handle of a scalpel, was ligated by car-
 rying the thread around it with Parrish's needle, the knot being firmly tied
 by  Hosack's knot-tier, and the wound  subsequently closed with sutures and
 adhesive strips.  The patient soon afterward recovered.
  Remarks.—This operation was among the earliest of those practiced upon
 this artery, and was certainly indicative of remarkable coolness and skill on
 the part of one who was  at that time a young surgeon.  Considerable diffi-
 culty was experienced by him in consequence of the  constant protrusion of
 the peritoneum, from the abdominal compression caused by the struggles  of
 the patient.  The modern discovery of anaesthetics has,  however, obviated this,
 and the ligation of this vessel, like many other operations upon the abdomen,
 may now be performed without any such annoyances, as the patient will
 remain  perfectly tranquil, and the bowels  have little or no tendency to  pro-
 trude when the anaesthesia is  complete.
  Operation of H.  J. Bigelow, of  Boston.—A  middle-aged woman being
 stabbed by her husband in the right buttock, the injury led to the formation
 of an aneurism of the gluteal artery, to relieve which the internal iliac was
 tied as follows :—
  By an incision above but parallel  with Poupart's ligament, Plate XLVII.
 Fig. 5,  the skin, muscles, and fascia were divided,  the peritoneum separated
 from its attachments to the iliac fossa, and the artery readily attained and
 tied, instantly relieving  the aneurismal symptoms; but the  patient died of
 peritonitis on the eighth day.   The autopsy exhibited the ligature as placed
 around  the internal  iliac, just above its branches, with a satisfactory clot
 extending from this point  to the bifurcation at the  common iliac artery.
  Operation of Hilman Kimball, of Lowell.—A patient, with a pulsating
 tumor on the back of the  thigh, so  high up as to cause inconvenience when
sitting, having  exhibited all the symptoms of gluteal  aneurism, the internal
iliac artery was tied in the following manner: The patient being placed in a
convenient position in bed, and rendered insensible by chloroform, an incision
six  inches long was made immediately  above and nearly parallel with Pou-
part's ligament, beginning at a point just external to the spermatic cord as it
passes through  the external ring, and running outward for three inches, and
then turning more upward, so as to terminate at a line about midway between
the  anterior superior spinous  process of the  ileum  and the umbilicus.  The
abdominal muscles and fascia being then carefully divided, and the peritoneum
pushed off from its inferior attachments, the external iliac artery was brought 
OPERATIONS  PRACTICED ON THE BACK.            451
 into view, when the peritoneum was still further raised from its pelvic con-
 nections by running the forefinger along the inner edge of the  psoas muscle,
 till it reached the promontory of the sacrum.  The internal iliac artery being
 now readily traced in its descent from its origin, the forefinger was kept upon
 it while the ligature was carried around it by means of Scarpa's needle, and
 the vessel tied, by an assistant, about an inch from its origin.  No accident or
 embarrassment occurring during the operation, and no vessel being cut that
 required the ligature, the wound was closed by two or three sutures and adhe-
 sive straps, and covered with lint kept wet with water, as in the water-dress-
 ing.  Secondary hemorrhage supervening on the fourteenth day, the patient
 died on the sixteenth.   At the autopsy,  the portion of the artery between
 the ligature and the bifurcation being slit open, was found entirely empty and
 without signs of inflammation on its inner surface, or of a coagulum, while
 the part immediately around the seat of the ligature had begun to give way,
 disclosing a very small aperture, but one sufficiently large to account for the
 fatal hemorrhage.  As there were no efforts at the formation  of coagulum
 above the ligature, the question was raised, whether these results were not
 connected with the  large amount of chloroform  inhaled  during the  oper-
 ation.
   Remarks.—The internal iliac artery was first tied successfully in the United
 States by S. Pomeroy  White, then of Hudson, but now of New York; and
 subsequently by Mott, also successfully, although the peritoneum was opened
 during the operation; the  operations of Bigelow and Kimball, of Massachu-
 setts, were unsuccessful. The great dangers of the operation are to be found
 in the tendency to peritonitis, and in the injury to the vein in the immediate
 neighborhood of the artery.
   Statistics.—Of ten cases of ligation of this artery as reported by  Norris,
 in his table  on the ligation of the iliacs, and also referred to in the  Biblio-
 graphical Index of this part, to wit, one by Stevens, of Santa Cruz;  one by
 Atkinson, of England; one each by S. Pomeroy White,  Mott, and J. K.
 Kodgers, of New York;  one each by Thomas, White, and Arendt, of Eng-
 land ; and one each by Bigelow and Kimball, of Massachusetts, four were
cured and six died, all the operations being performed for aneurism.
                           CHAPTER  X.


               OPERATIONS PRACTICED  ON  THE BACK.


   The posterior surface of  the trunk presents no points of structure which
require  more than  a passing allusion, the great number  and mass  of the
muscles, together with the  arrangement of the vertebrae,  being  matters of
general anatomical  knowledge.  The operations, also, which are performed
upon this  region do not demand any special caution, unless it may be in the
complaints due to the disorders of the spinal canal.  In order, however, to
preserve the unity  of description which  has been  desired  in  the arrange-
ment of this work, some of the more important cases requiring operative aid
will be detailed, as illustrating the operations required in the complaints of
this region. 
452
PRINCIPLES AND PRACTICE  OF SURGERY.
                            SECTION  I.

                  SUPERFICIAL TUMORS OF THE BACK.

  The integuments and muscles of the back are liable to very much the same
class of tumors as are found in similar tissues elsewhere, and require for their
removal precisely the same means,  to wit,  such an incision of  the  skin and
subsequent dissection as will create as little disturbance  as possible of sur-
rounding  parts.   As illustrative of the operation demanded by the wens of
this region, the following case is cited:—
  Removal of a large Steatomatous Tumor, by Dorsey, of Philadelphia.—
The  patient, a negress, aged about forty-five  years,  was  admitted into  the
Pennsylvania Hospital, in 1815, with a tumor upon the back, the dimensions
of which were as follows:—
          Circumference at the narrowest  point,  2 feet 10 inches.
                         "   thickest part,     3   "    9   "
                             horizontally,     3   "    l£ "
   The weight of the tumor, after removal, was twenty-five pounds, Plate
XLVIII. Fig. 3.
   Operation.—After administering an opiate, the patient was placed upon
her face on the table for fifteen minutes, while assistants  elevated the tumor
so as to empty it as completely as possible of blood.   Then external incisions,
calculated to preserve sufficient skin to  cover the surface, being made, the
skin was dissected off from the tumor and  turned back, and the tumor freed
from its attachments by large and rapid incisions, although it adhered some-
what to the spinous processes of the vertebrae, and  to the  muscles and ten-
dons  near the spine.  After cleansing the parts thoroughly,  the skin was
closed by adhesive straps and a bandage, and the wound  healed to a consid-
erable extent by the first intention.
   Remarks.—Steatomatous, encysted,  and hygromatous tumors are also
sometimes found upon the back of  the neck, as well as upon the  shoulders,
and  may be treated by very much  the same method.  Some caution, how-
ever, is requisite in forming a diagnosis in these cases, lest they be confounded
with  Spina Bifida, the  development of which is occasionally seen in  the
median  line of this region, while the tumors before referred to are most fre-
quently seen  on either side.
   In Plate XLVIII. Fig. 2 may be seen an example of one of these  tumors
— Hygroma — which caused doubts in  the mind of Auvert as to its true
character.
   In wounds and fractures of the vertebral column, the surgeon may also find
it necessary to deliberate upon the propriety of such mechanical interference
as may afford the hope of relief, though generally the chances of success will
be quite as good when the case is left to nature as  when any attempt at an
operation  is  made  by the  surgeon.   In cases of depressed fracture of the
spinous processes, the soft tissues have been incised, and  an attempt made to
draw out the fractured portion;  but there is so little  reason to anticipate
any permanent benefit from  such operations, that it must  suffice merely to
mention the  fact of their  having been performed.   Wounds of the  spinal
marrow, by the introduction  of foreign bodies, have also done well when left
to nature, an instance in  which a chisel divided the  spinal  marrow, and yet
the patient recovered, having been reported by Eli Hurd, of Niagara County,
New York. 
OPERATIONS  FOR  THE  CURE  OF SPINA BIFIDA.        453
                            SECTION II.

            TUMORS OF  THE SPINAL  CANAL, OR SPINA BIFIDA.

  Spina Bifida, or Hydrorachis—uSu>p, water, and />«/£?, the spine—is a dis-
ease characterized by the presence of a soft, fluctuating, and often transpa-
rent tumor, formed in consequence of the membranes of the  spinal marrow
being distended by liquid, and  caused to protrude beneath the integuments
or directly upon  the  back, Plate XLVIII. Fig. 4, owing to  a congenital
deficiency of some of the spinous  processes of the vertebrae, whence the
name of spina bifida, or bifid spine.   From the  observations of Chaussier,
it appears that of one  hundred and thirty-two children born during a period
of five  years, twenty-two  suffered from spina bifida; and Billard has seen
this complaint seven  times in one year among the  children  in the Found-
ling Hospital of Paris.
  Symptoms.—Soon after birth there is noticed at some point of the spinal
column, and most frequently in the lumbar region, a tumor of variable size,
which is then diaphanous, and evidently filled with liquid ; usually the tumor
is  uncovered by the integuments of the  part, or if they cover it, they are
sometimes extremely attenuated.  If gentle pressure is made on the tumor,
its  contents will pass  into the spinal canal, and the tumor will  more or less
thoroughly disappear; but the attempt should be cautiously made, lest paral-
ysis or death supervene from  the pressure of the liquid thus  forced into the
spinal canal.  Spina bifida is often combined with hydrocephalus.
   Diagnosis.—The size and trauslucency of the tumor, with its position and
the age and history of the  patient,  render the diagnosis usually easy.  If
doubt exists, the  exploring needle carefully introduced will give exit to a
drop of serum.
   Prognosis.—The prognosis should be guarded;  cures have occasionally
been  obtained, but failures are very common.   The disorder, when left  to
nature,  is usually fatal after a time.
  Treatment.—Various plans of treatment have been resorted  to, among
the most successful of which maybe mentioned pressure and acupuncturation.
              § 1.—Operations for the Cure of Spina Bifida.

  The various methods of treating this  complaint, as practiced in Europe,
seemed to  have gained but a very limited success;  and the following re-
sults obtained by surgeons in the United States  are, therefore, more deserv-
ing of attention, especially as they have occurred under circumstances where
there could be no doubt in regard to the nature of the changes induced by
the disease, or in the correctness of the diagnosis.
  Operations of Trowbridge, of New York, in 1829.—A child, aged twenty-
one  months, was presented for  advice in June,  1827, laboring under spina
bifida. The tumor was seated over the lower cervical vertebrae; was as large
as an eg^;  entirely covered with a cellular substance, and fluctuating.
  Operation.—A small  silver wire being placed in a loop around the  base
of the tumor, the ends were passed through a short canula and drawn mod-
erately tight, so as  to produce slight inflammation on the surface at the base.
Forty-eight hours having elapsed without any bad symptoms, the wire was
then drawn tight  enough to destroy  all circulation  in the tumor;  twelve
hours  after which, the child became  restless and  feverish.  In forty-eight 
PLATE  XLVIII.
    EXTERNAL CHARACTERS OF TUMORS OF THE NECK AND  BACK.

  Fig. 1. Congenital Tumor of the Veins about the Neck.  This child was
twelve months old ; the tumor filled the whole neck ; projected beyond the chin,
and felt like a coil of vessels folded in every direction on each other, or like a
bundle of round worms.                                     After Warren.

  Fig. 2. A view of the appearance and position of a Large Hygroma of the
Back of the Neck.  This tumor was noticed in a child some months after birth,
and was supposed to be due to an injury of the part, caused by the application
of the forceps.   It was relieved by puncture.                  After Auvert.

  Fig. 3. Appearance presented  in Julia Richards,  a negress, who had a large
Sarcomatous Tumor upon the back, which was successfully removed by Dorsey,
of Philadelphia, in 1815.  The tumor had existed eighteen years, grown gradu-
ally, and never  been painful, but its size compelled her to walk as  if carrying a
large  and heavy sack upon her back.  The surface of the tumor was tolerably
regular, but very large and numerous veins were seen in various parts of it.  The
narrowest part of the tumor was  thicker than the patient's waist, and its base
was very extensive.   After being emptied of blood, its weight was twenty-five
pounds.  The dimensions of the tumor are  stated in the text.    After Dorsey.

  Fig. 4. A view of the position and external characters of Spina  Bifida in the
loins.  This tumor was of very considerable  size, the drawing  representing it
as only one-fourth of its natural size. It was seated in the lumbar region, nearly
on a line with the crest of the ileum, and was accompanied by a deficiency in the
spinous processes of several of the adjoining vertebrae.        After Froriep.
(454) 
Plate  4r>

Fig,.?
n^
 
 
OPERATIONS FOR  THE  CURE OF SPINA BIFIDA.        455
 hours more, the tumor was dark colored ;  suppuration had commenced around
 the wire, and the latter disappeared in  the divided integuments, when, the
 tumor being excised  above the loop, the  wire came off, and left an inflamed
 portion three-quarters of an inch in diameter, with an aperture  through
 which there was discharged  turbid lymph or serum, with a slight arterial
 hemorrhage, which required  the use of lint.   A preternatural opening into
 the spinal canal being now discernible, situated between the two lower cer-
 vical vertebrae, the dressing of lint was left on for forty-eight hours, and then
 changed, as the fluid continued to discharge ; but in twelve days more the
 wound had healed, and the child was subsequently as healthy as other chil-
 dren.
   In a second case, aged two years and six months, the tumor was  situated
 over the three lower  cervical vertebrae, was represented as having been very
 large at  birth, and now measured seven inches in  circumference at its outer
 portion, something less at its base, and was about  four inches in height.   It
 was covered with integuments and  natural  skin,  and fluctuation was quite
 distinct.
   Being operated on  in the  manner just detailed, the ligature was allowed
 to remain four days  after its first application, and drawn tighter three days
 after this, the child suffering from symptoms of phlegmonous inflammation.
 Nine days after the  application of the ligature, the sphacelated tumor was
 excised ;  a  wineglassful of turbid and bloody serum spouted out through the
 opening, and bleeding from an artery followed, which required  the ligature.
 Under similar treatment to that first detailed, the  fluid was discharged from
 the  aperture for  eight days,  after which  the  opening gradually diminished,
 and in four  weeks from the operation the whole wound  had cicatrized.   A
 spinous process was  found wanting in the vertebral column, and there was
 an  opening through  the vertebras which  admitted the  point  of the little
 finger.
   In a third case, aged four years and three months, the tumor, which was
 situated over the sacrum  and three of the lower lumbar vertebrae, measured
 thirteen inches in circumference at the base, and seven in  its projection from
 the back.
  Operation.—Incisions  being made through the  integuments, which were
 about an  inch thick,  from the upper portion of the base quite to the lower
 part over the sacrum, sufficient flap was left to cover the wound  in a manner
 similar to that pursued in excising the female breast. On  dividing the integ-
 uments, a cavity was  found which contained several cysts filled with fluid,
 and attached to the spinous processes of the third lumbar vertebra.  The spi-
 nous processes above  and below were wanting. There being no communica-
 tion with the spinal canal, the cysts were dissected  out, and the child recov-
 ered perfectly.
  Remarks.—Trowbridge reports having  seen about thirty cases of spina
 bifida in all  points of the vertebral column, and has tried puncture, compres-
 sion, ligature, incision, etc., and  often  failed, but  "prefers the  ligature, as
above directed, in all  cases where the base of the tumor admits of its appli-
cation."  By not tightening  the  ligature too much at first, only moderate
inflammation is induced and the sympathetic disturbance is diminished.
  Operation of Skinner, of North  Carolina.—The  patient, aged  seven-
teen months, presented a tumor on the spine more than three  and a half
inches long, two and  a half wide, and one and a half deep, extending from
a level with the iliac crest to near the verge of the anus, the contents of which,
by firm pressure, could be mostly compressed into the spinal canal.  At first!
a puncture with a very fine needle  drew off a  few drops of liquid; two days
subsequently a larger  needle drew  off  a drachm;  at another period half an 
456            PRINCIPLES AND PRACTICE OF SURGERY.
ounce, then an ounce, and then an ounce  and a half, after which pressure
was applied around the base of the tumor.   After about  seventy punctures
had been made without any serious accident, and the tumor had become re-
duced to one-fourth of its original size, an indiscretion of diet induced diar-
rhoea, under which the patient sank.
   Operation of Stevens, of New York.—A child, eight months old, presented
a tumor nearly similar in position  and size to that just described.   Being
punctured with an iris knife,  about four ounces of clear serum issued from
the opening, without causing inconvenience.  Three  days subsequently the
operation was  repeated, but not more than an ounce escaped.  The next day
it  was again punctured in three places, and about four ounces escaped with-
out bad symptoms, and continued to ooze for nearly twenty-four hours after
the operation,  the child showing some febrile symptoms, which were thought
to be partly due to teething.   Evaporating lotion was then kept applied to
the tumor, and the sac was  not again  punctured.   These febrile symptoms
soon disappeared, and the child, when seen several months afterward, showed
nothing of the disorder except a small lump of indurated and corrugated in-
tegument.   In this case the fluid was always evacuated very slowly, that is,
at the rate  of  about three drops in a second, about one-third  being  left in
the sac, and slight pressure being made after each operation;  and  much of
the success  of the treatment is ascribed  by Stevens  to this mode of pro-
ceeding.
   Operation of Brainard.—An idiotic girl, aged thirteen years, had a tumor
at the  top of  the sacrum nine  inches  in circumference, and about  three in
height, with thin walls; had been paralytic in her lower limbs, but recovered
a partial use of them a short time  previous to the  operation.  All her dis-
charges were passed without attention  to cleanliness.  Under these hopeless
circumstances  the operation was thus performed.
   A small puncture being made with a lancet on the sound skin about half
an inch from the base of the tumor, a trocar and  canula the size  of a common
knitting-needle were carried into the sac.   Through the canula a solution of
iodide of potash gr. j, iodine gr. ss, and water 3j, was thrown into  the  sac,
and the instrument withdrawn.  A severe pain followed, but soon subsided;
compresses  and a bandage were applied to prevent the escape of the fluid,
and the child was laid in bed.   Redness, heat, and tension of the tumor, with
tenderness and some fever,  supervened; but in  the course of a week these
symptoms subsided, and  the tumor became soft,  yielding,  and diminished in
size.   Compression was then applied with as much force as could be borne.
Fifteen days after the operation the tumor was  half its original size, when
a second injection, half the  strength of the first, was  thrown in, and caused
but little heat  and pain, compression being continued.  Nineteen days sub-
sequently the  fluid was  so far absorbed as to render it  easy  to press the
tumor nearly to the level of the surrounding  skin,  when a spring truss was
applied to the part, and under this the child improved.
   Remarks.—The success attending the treatment of the cases just recited
is  certainly sufficient  to  justify the surgeon in resorting  to similar  means
when proper circumstances  demand it.   The suggestion of an injection of
iodine into the cavity of  the tumor, as made by Velpeau, and  practiced by
Brainard, is due to the analogy supposed to exist between spina bifida and
hydrocele, and the result it was hoped would authorize a repetition of this
operation;   but as this  resemblance is not  perfect,  great care  should be
employed, lest death  ensue  from inflammation  of  the  spinal canal.   In  a
paper subsequently published by Brainard, he states that the number of in-
jections used in this case  was fifteen, and that the time required for the cure
was ten months, the patient  being  in  good health two years subsequently. 
            OPERATIONS  FOR THE  CURE  OF SPINA BIFIDA.         457

In encysted spina bifida, or that in which  the communication  between the
sac and the cavity of the spinal canal is obliterated, this  injection  may
again succeed, and prove to be an excellent plan of treatment.  But in spina
bifida complicated with hydrocephalus, or in that where the medullary canal
is pervious, inflammation of the  pia  mater, or of the spinal  marrow itself,
should be anticipated, and then the propriety o exposing the patient to  such
a risk carefully considered.  In the case of an infant a few days old, treated
by Brainard, in 1849, by the same injection, death supervened in about seven
weeks;  and in another three months  old, treated by him, in 1850, death fol-
lowed in about four weeks.  In  another child, four days old, laboring under
spina bifida and hydrocephalus, both the cavities of the spine and cranium
were injected at different periods, and the injections repeated several times.
In this case there was good reason to hope  for success, as the child exhibited
great tenacity of life, but in the seventh month of  the treatment this child
also died in convulsions.  Brainard, however, regards spina bifida as a curable
disease, by a similar treatment; although success, as he says, must not always
be anticipated.   A careful perusal of his paper compels me, however, to dis-
sent from this opinion; and I regard  the operations of Trowbridge, Skinner,
and Stevens as safer and better adapted to  the cure of most of the eases
that may be presented  for treatment. 
458
PRINCIPLES  AND  PRACTICE  OF SURGERY.
AMERICAN PAPERS ON THE DISORDERS OF, AND OPERATIONS ON,
                          THE  ABDOMEN.
      OPERATIONS ON  THE ABDOMEN.

   Case of Incision of the Intestines, and Re-
^     moval of a  Silver Teaspoon which had
      been  swallowed,  (cured,) by Samuel
      White. M.D.  Hudson, N. Y.— New York
      Med.  Repository, vol. x. p. 307.    1807.
   Case of Evacuation of Water from the Ab-
      domen by the Umbilicus, (with a propo-
      sal to tap at that point,) by Samuel Ag-
      new,  M.D.   Harrisburg.— Philadelphia
      Med.  Museum, vol. i. N. S. p. 159.  1811.
   A Remarkable Case of Encysted Dropsy
/     and Paracentesis Abdominis, (635 pounds
      being drawn off in eleven months,) by
      Amos Holbrook, M.D.  Milton. Mass.—
      Med.  Communications and Dissertations of
      Mass. Med. Soc, vol. ii.  p. 29.   Boston.
                                     1813.
   Experiments, to show that the Inflamma-
 /    tion which supervenes on the Surface of
      Wounded Cavities is the Consequence of
      the Change and Diminution of Tempera-
      ture caused by the Admission of Air into
      them, by James Cocke, M.D.  Maryland,
      1804.— Am. Med. Record., vol. ii. p. 489.
                                     1819.
   Case of a Scirrhous Tumor of the Caecum,
      mistaken for an Aneurism of the  Right
      External Iliac Artery, by Theophilus E.
      Beezley,  M.D.  Salem,  New Jersey.—
      Phila. Journal Med. and Phys. Sciences,
      vol. vi. p. 350                   1823.
   Wound  of  the  Stomach, (St. Martin,)  by
      Joseph  Lovell, Surgeon-General  U. S.
      Army.—Am. Medical Recorder, vol. viii.
      p. 14.                          1825.
   Experiments  on Digestion, (St.  Martin,)
      through  a  Wound in the Stomach,  by
      William Beaumont, M.D.  Fort Niagara.
      —Am. Medical Recorder, vol. ix. p. 94.
                                     1826.
   Case of Excision of a Part of the Spleen,
      (the patient recovered after Peritonitis,)
      by  W. B.  Powell.  M.D.  Kentucky.—
      Am. Journ. Med. Sciences, vol. i. p. 481.
                                     1828.
   Case of Penetrating Wound of the Abdo-
 '    men and Section of the Intestinal Canal,
      successfully  treated  on the  Plan  of
      Ramsdohr, with Remarks, by Zina Pitch-
      er,  M.D., U. S. A.—Am.  Journ. Medical
      Sciences, vol.  x. p. 42.            1832.
   Case of  Hepatic Abscess, in which Tapping
/    was performed before Adhesion of the
*
/
  Liver to the Side had happened, and the
  Appearances after  Death, by  Wm.  E.
  Horner, M.D. Philadelphia.—Jim Journ?
  Med. Sciences, vol. xiv. p  83.      1834.
Notes of a Case of Fistulous Opening of the
  Stomach, successfully treated, (by Pres-
  sure,  etc.,) by  J. H. Cook, M.D.—Am.
  Journ. Med. Sci., vol. xiv. p. 271.  1834.
Case  of Abscess  of the Liver,  Operation
  and Recovery, by Chas. A. Savery, M.D.
  Hopkinton, N. Hampshire —Boston Med.
  and Surgical Journal, vol. xvii. p. 56.
                                  1837.
Case of Ascites, cured by the Injection of
  a Stimulating Fluid into  the Peritoneal
  Cavity, by John B. Sherrerd, M.D.  New
  Jersey.--Am. Journ. Med. Sciences, vol.
  x. N.  S. p.  525.                  1845.
Case of Removal of seventeen inches of the
  Small Intestines, Recovery of  the Pa-
  tient, by  A. Brigham, M.D.  Utica —
  Am Journal Med. Sciences, vol. ix N. S.
  p. 355.                          1845.
Case of Gastrotomy, (successful,) by J. E.
  Manlove, M.D.  Tennessee.—Am. Journ.
  Med. Sciences, vol. x. N. S. p  532; also
  Boston  Medical and Surg. Journ., July,
                                  1845.
Sequel to the Case of Removal of seventeen
  inches of the Intestines,  and Recovery
  of the  Patient, by A. Brigliam, M.D.
  Utica.—Am. Journ. Med. Sciences, vol. xi.
  N. S  p. 44.                      1846.
Case of Ascites, in which the Patient was
  tapped 186 times in ten  years, and had
  751 5 gallons of water drawn off. by John
  H. Griffin, M.D.  Virginia.—Am. Journ.
  Med. Sci., vol. xix. N. S. p. 401.   1850.
Perforation of the Abdomen (four inches
  long) by  a fence-rail, intestines  pro-
  truded, covered with dirt, cleaned and re-
  placed, (recovery,) by Robert G J ennings,
  M.D.  Church Hill, Va.—Stethoscope, vol.
  i. p. 490.                        1851.
Case of Ascites, tapped thirty-nine times,
  Removal of 140 gallons of Fluid, by T.
  D. Lee, M.D.   New  York.—New York
  Journ. Med., vol. v.  N. S. p. 50.   1851.
Case  of Puncture of  the  Stomach,  with
  Protrusion  of this Organ for six hours,
  (aperture about three-fourths of an inch,
  nearly the  whole  stomach  protruded:
  wound in the stomach closed by fine su-
  ture, gently retained near the puncture
  of the abdomen, water-dressing, cure,)
/
# 
PAPERS ON  DISORDERS  AND  OPERATIONS  ON  THE  ABDOMEN.  459
        by Chas. Wm. Ashby, M.D.  Culpepper
        C. H.,  Va..—Stethoscope, vol. i. p. 660.
                                        1851.
      On Hydatids of the Liver, Operation, Cure,
        by J. Edward Weber, M D.  New York.
        —New York Med. Times, May,     1852.
      Three Cases of Ascites cured by  Tapping,
        by J. Hayward, M.D.  Boston—Amer.
        Journ.  Med. Sciences, vol. xxiv. N. S. p.
        348.                             1852.
      Wound of the Small Intestines, Recovery,
        (at one part nearly cut in two by a bowie-
        knife,  at another,  cut an  inch long,
\    closed  by glover's  stitch  with cat-gut;
    /   intestine returned,  wound in  abdomen
        closed  by silk sutures, water-dressing,)
        by L. A. Dugas, M.D.   Augusta, Ga.—
        Southern Med. arid Surg. Journ., vol. viii.
        p. 407.                          1852.
  'y  Wounded  Intestine, (treated by suture,)
        with Recovery, by  J. J. Chisolm, M.D.
        Charleston.—Charleston Med. Journ.  and
        Review,  vol. viii. p.  615.          1853.
      Incised Wound of the Left Side, (three inches
        long,)  between the Eighth  and Ninth
        Ribs, followed by Protrusion of the Sto-
        mach  and  Strangulation of  the Organ,
        Reduction, and Recovery of the Patient,
        by W.  W. Hart, M.D.  Mississippi.—
        Western Journ. Med. and  Surg., vol. xi.
        p. 496.                          1853.
      Case of Abdominal Wound, by Thomas P.
        Bailey,  M.D.   North  Santee, S. O—
        Charleston Med. Journ., vol.  ix. p. 604.
                                        1854.
      Wound of the Small Intestine successfully
 y^    treated by the Interrupted  Suture, by J.
r      C. McGee, M.D.  Caddo Parish, Louisi-
        ana —New Orleans Med. and Surg. Journ.,
        vol. xi.  p. 23.                    1854.
      Perforation of the Stomach,  Recovery, by
  U     C. Happoldt, M.D.  Charleston, S. O —
 "Jr     Charleston Med. Journ., vol.  x. p. 341.
                                        1855.
      History of a Carcinomatous Tumor,  (of
        Abdomen,) by W. C.  Hicklin. Alabama.
        —New  Orleans Med. and Surg. Journal,
        vol. xii. p 235.                  1855.
  II Wound  of the Stomach,  Recovery, by C.
  if*    Happoldt, M.D.   Charleston,  S. O—
        Am. Journ. Med.  Sciences,  vol. xxx. N.
        S. p. 273.                       1855.
     Statistics  of Abscess  and other  Diseases
       Consequent upon the Lodgment of For-
       eign Bodies in the  Appendix Vermi-
       formis, with  a table of Forty Cases,  by
,       George  Lewis, M.D.   New York.—New
        York Journ. of Med.,  vol. i. Third Series,
       p. 328.                          1856
     Rupture of the Right  Rectus Abdominis
       Muscle from Muscular Efforts, Operation
       and Recovery, with  Remarks, by T. B.
       Richardson, M.D.  Louisville, Ky.—Am.
       Journ. Med. Sciences,  vol. xxxiii. N. S. p.
       41.                             1857.
     Ascites successfully treated by the Estab-
  lishment of a Fistulous Opening, by E.
  P. Bennett,  M.D.   Danbury, Conn.—
  Am. Journ. Med. Sciences, vol.  xxxiii.
  N. S. p. 556.                    1857.
Gunshot Wound of the Heart and Stomach,
  by J. H. Grant, M.D.   Charleston, S. C.
  —Am. Journ. Med.  Sciences, vol. xxxiv.
  N. S. p. 292.                     1857.
Punctured  Wound of the Abdomen, Pro-
  trusion of the Intestines,  their return
  obstructed by a  Band, by A. Fleming,
  M.D.   Philadelphia.—Am. Journ. Med.
  Sciences, vol. xxxiii. N. S. p. 321.   1857.
Post Fascial Abscess originating  in  the
  Iliac Fossa, with a New Method of Treat-
  ment, by Gurdon Buck, M.D. New York.
  —New York Journ. of Med., vol. ii. Third  y
  Series, p.  147.                   l%h~\f
Incised  Penetrating Wound  of  the Abdo-
  men with Wound and Protrusion of Intes-
  tines, Recovery, by J. J.  McElrath, M.D.
  Arkansas.—New Orleans Med. and Surg.
  Journal, vol. xv. p.  182.          1858.
Intestinal Wounds, by J. J. McElrath, M.D.
  Camden,  Ark.—New Orleans Med.  and
  Surg.  Journal, vol. xvi. 205.      1859.
             ON HERNLE.

 Case of Strangulated Crural Hernia, oper-
   ated on according to the method of Don
   Antonio Gimbernat, with some Observa-
   tions on  the  Treatment  of Hernia, by
   John C. Warren,  M.D.   Boston.—Med.
   Communications Mass. Med. Society, No. 2,
   Part 2, p. 44.                    1790.
 Case of  Strangulated  Femoral  Hernia,
   where the Operation succeeded after the
   Obstruction had continued ten days, by
   John Hahn, M.D  Philadelphia —Phil-
   adelphia Med. Museum, vol. iv. p. 26.  1808.
 Case of Strangulated Hernia, with Obser-
   vations on  the  Treatment of Mortified
   Omentum, by Joseph Parrish,   M.D.
   Philadelphia.—Eclectic Repertory and An-
   alytical Review, vol. i. p. 98.       1811.
 Practical Elucidation of the Nature of Her-
   niae, etc., with  an Explanation of  the
   Cures of certain Instruments, by  G. A.
   Hull, M.D , late President of the Oneida
   Medical Society.  New York.—New York
   Med. and Phys. Journal, vol. iv. p. 435.
                                  1825.
Case  of  Strangulated  Umbilical  Hernia,
   cured by an Operation, by  T. S. Hewson,
   M.D.  Philadelphia.—Am. Med. Record.,
   vol. xi. p. 106.                   1827.
Case of Hernia,  in which the Stricture re-
   mained at the Mouth of the Sac, after the
   Intestine was  returned by Taxis, by N.
   Snead, M D.  Virginia. — Transylvania
  Journ. of Med., vol. ii. p. 525.     1829.
Case of (Inguinal) Hernia, (in a man eighty-
  four years of age,) in which there was no
  evacuation from the Bowels for seventeen 
460             PRINCIPLES AND PRACTICE  OF SURGERY.
  days before the Operation, (treated suc-
  cessfully,) by John J. Abernethy, M.D.
  Hartford, Connecticut.—Am. Journ. Med.
  Sciences, vol. xi. p  31.            1832.
Case of Strangulated Inguinal Hernia,  at-
  tended with some Peculiarities, (Omen-
  tum strangulated  and  forced  out  by a
  Cancerous Tumor of the Mesentery,) by
  Horatio  G. Jameson,  M.D.  Baltimore.
  —Maryland Med. Recorder, vol. iii. p.  54.
                                  1832.
On a Congenital Hernia, (cured by an Oper-
  ation,) by  Alexander H. Stevens,  M.D.
  New York.   Reported by Alfred C. Post,
  M.D.  New York.—New York Medico-
  Chirurgical Bulletin, vol. i. p.  19.  1832.
A Case of  Strangulated Inguinal Hernia,
  successfully treated, by Hunting Sherrill,
  M.D.  Dutchess  County,  New York.—
  New York Medico-Chirurg. Bulletin,  vol.
  i. p. 20.                         1832.
Case  of  Strangulated  Umbilical Hernia,
  with Removal  of the Cyst, followed by
  a Radical Cure, by J. W. Huestis,  M.D.
  Mobile.—Am.  Journ. Med. Sciences,  vol.
  xvi. p. 380.                      1835.
Case of Strangulated Umbilical Hernia in
  a child  seven years old,  (died,)  by P.
  Fahnestock, M.D.  Pennsylvania.—Am.
  Journ. Med Sci., vol. xvii. p. 368.  1835.
Case of Hernia, (with Remarks,) by Frank
  H.  Hamilton,  M.D.   Rochester,  New
  York— Boston Med. and Surg. Journal,
  vol. xxv. p. 57.                  1841.
Of a new Knife for Dividing the  Stricture
  in Cases of Strangulated  Hernia, by F.
  Campbell Stewart, M.D.  New York.—
  Am. Journ. Med. Sciences, vol.  v. N. S. p.
  497.                             1843.
Case of successful Operation for  Strangu-
  lated Femoral  Hernia,  (with  two Sacs,)
  by  J.  Heaton,  M.D.   Boston.—Boston
  Med. and Surg. Journ.,  vol  xxx. p  35.
                                   1844.
Case of Radical Cure of a Hernia, by includ-
  ing  the  Neck of the Sac  and  External
  Ring in  a Leaden Ligature,  by J. C.
  Nott, M.D.   Mobile.—Am. Journ. Med
  Sciences,  vol. xiv. N. S. p. 402.     1847.
Case of Strangulated Inguinal Hernia, pa-
  tient operated on while  under the influ-
  ence of  Chloroform,  (died seven days
  after the Operation,) by James  D. Trask,
  M.D.  White  Plains, New  York. — Am.
  Journ. Med. Sciences, vol.  xviii. N. S. p.
  90.                              1849.
On the Reduction of Strangulated Herniae,
   "en  masse,"  or " en  bloc,"  by Geo. P.
  Blackman, M.D. New York—Am. Journ.
  M"d. Sciences, vol. xii. N. S. p. 336, 184.1;
  also, N. Y. Journal of Medicine, vol. v.
  p. 367.                          1850.
Two Cases of Strangulated Hernia, having
  the Structure in  the Neck of the Sac,
   (cured.) by T. Wood,  M.D.   Cincinnati.
  —  Western Lancet, vol. xi. p. 417.   1850.
Inguinal Herniae treated by Injection, by
  Henry J. Bigelow, M.D. Boston. — Boston
  Med. and Surg. Journ., vol. xliii. p. 339.
                                   1850.
Reduction of Strangulated Herniae in Mass,
  by Geo. C. Blackman, M.D.   New  York.
  —N.  Y Journ. Medicine,  vol. v. N. S. p.
  367, et seq.                       1850.
Hernia, (its radical cure not accomplished
  by  Chase's  Truss,) by  T.  Wood,  M.D.
  Cincinnati.— Western  Lancet, vol. xii. p.
  273.                             1851.
Strangulated Herniso, importance of oper-
  ating early,with Cases, (eight.) by Alfred
  Hitchcock,  M.D.   Fitchburg,  Mass.—
  Boston Med. and  Surg. Journ., vol. xiv.
  p  89.                            1851.
Remarks on Strangulated  and Reducible
  Herniae.  (showing results of  attempts to
  cure radically,) by Alden March, M.D.
  Albany.— Wr.xtern  Lancet,  vol. xiii.  p.
  373.                             1852.
Strangulated Crural  Hernia,  terminating
  in  Artificial Anus, by  John C.  Clark,
  M.D.  Ohio.— Western Lancet, vol.  xii.
  p. 613.                           1852.
A singular  Case of Strangulated Hernia,
  (fold of the Intestine and a portion of the
  Omentum badly strangulated; another
  large portion of the Omentum not  stran-
  gulated, but healthy,) cured, by Wm. H.
  Robert, M.D.   Orion, Alabama —South-
  ern Med.  and Surg. Journ.,  vol. viii. p.
  533.     •                        1852.
On  the Radical Cure of Reducible Hernias
  by Injection, (of Tinct. Canth.,) by Jno.
  Watson, M D.  New York.—N. Y. Journ.
  Med., vol. ix. N. S. p. 290.        1852.
Case of Strangulated Hernia, presenting a
  peculiar difficulty in the Operation, (old
  Hernia, composed of more than 12 inches
  of the Large Intestine completely agglu-
  tinated, congested, and tumefied, with a
  hypertrophied and indurated Mesoco-
  lon,) recovery, without  fever,  by S. N.
  Harris, M.D.  Savannah,Ga—Charleston
  Med. Journ., vol. vii. p. 19.        1852.
Strangulated  Scrotal Hernia,  (cured.)  by
  Charles Bell Gibson, M.D.  Richmond.—
  Stethoscope, vol. ii. p.  139.         1852.
Report on the Permanent Cure of Reduci-
  ble  Herniae, by Drs. Hayward, Mason,
  Warren, and Parkman.—Boston Med. and
  Surg. Journ., vol. xlviii.  p. 79.     1853.
Operations  for the Radical Cure of an In-
  guinal  Hernia, by Jos.  S.  Jones, M.D.
  Boston. — Boston  Med. and Surg.  Journ.,
  vol. xlviii. p. 510.                1853.
Strangulated  Umbilical Hernia, Operation
  under  Ether,  by  N. L. Folsom,  M.D.
  New Hampshire.—Boston Med. and Surg.
  Journ.. vol. xlix. p 317.         1853.
Case of Strangulated Scrotal Hernia (died)
  of unusual size, on the Left Side; pres-
  ence of  Caecum in the  Hernial Sac. by
  Wm. II. Van Buren,  M.D. New York.— 
PAPERS  ON  DISORDERS AND OPERATIONS ON THE ABDOMEN.   461
  N. Y. Journal of Medicine, vol. x. N. S. p.
  56,1853, extracted from Rep. N Y. Path.
  Society.                          1853.
Case  of Strangulated  Inguinal  Hernia
  cured by Operation, (under Chloroform,)
  by E. B.  Moore, M.D.  Boston.—Boston
  Med. and Surg. Journ., vol. xlvii. p. 525.
                                  1853.
Remarks on an Operation, (injection of Oil
  of Cloves or Tinct. Canth. into the Ca-
  nal, and immediate application  of  a
  Truss, failed in  numerous   instances,
  hence prefers a small Seton at the Ex-
  ternal Ring,) by W. H. Roberts,  M.D.
  Orion, Alabama.—Southern Medical and
  Surg. Journal., vol. ix. p.  133.    1853.
Radical Cure of Inguinal Herniae after the
  method of C. W. Wutzer, M.D., of Bonn,
  Prussia,  by J.  E.  Weber,  M.D.—New
  York Journ. of Med., vol. xii. N. S. p. 34.
                                  1854.
Strangulated Inguinal Hernia of an enor-
  mous size,  Operation by  C.  A. Pope,
  M.D., St. Louis, Renewed escape of  the
  Hernia  after Operation,  Recovery,  re-
  ported by Wm. Taussig, M.D. Caronde-
  let, Mo.—St. Louis Med. and Surg. Journ.,
  vol. xii.  p. 404.                  1854.
Strangulated Inguinal Hernia, the testicle
  on  the ruptured side never having de-
  scended from the Pelvis, Operation, Cure,
  by  F. M. Robertson, M.D.  Charleston,
  S. C.—Am. Journ. Med. Sci., vol. xxix.
  N.  S. p.  127.                     1855.
Case of Diaphragmatic Hernia, by Charles
  W.  Chancellor, M.D.  Alexandria, Va.—
  Am. Journ. Med.  Sciences, vol. xxx. N. S.
  p. 404.                           1855.
Strangulated Femoral Hernia, containing
  the < )vary and Fallopian Tube, by Willard
  Parker,  M.D  New York.—New  York
  Journ. of Medicine, vol. xv. N.  S. p. 152.
                                   1855.
Hernia Treated by Scarifying the Inguinal
  Canal, by F. Major, M.D.  Ohio.— West.
  Lancet,  vol. xvi. p. 451.           1855.
Vaginal Rectocele, and Vaginal Hernia, by
  Thos Carroll, M.D.  Cincinnati.— West.
  Lancet,  vol. xvii. p. 321.          1856.
Wutzer's Operation for the Radical Reduc-
  tion of Herniae, by G. A. Blackman, M.D.
  Ohio.—Am. Journ. Med. Sci., vol. xxxiv.
  N S.  p.  292.                      1857.
Peritonitis, Simulating Strangulated  Her-
  nia, Operation, Death, and Post-mortem
  Examination, by  W.  M. McPheeters,
  M.D.  St. Louis.—St.  Louis  Med.  and
  Surg. Journ., vol. xv. p. 366.      1857.
Strangulated  Ventral  Hernia,  Operation
  and Recovery, by H. F. Campbell. M.D.
  Georgia.—Southern Medical and Surgical
  Journ., vol. xiii. N. S. p.  131.     1857.
Successful Operation for Strangulated Fe-
  moral Hernia,  by S. C Muscroft, M.D.
  Cincinnati.— Western Lancet,  vol.  xviii.
  p. 637.                           1857.
Observations on Herniae, and Obstructions
  in the Bowels, by Warren Stone,  M.D.
  New  Orleans.—New  Orleans  Med. and
  Surg. Journ., vol. xv. p. 79.       1858.
Case  of Herniae, by Robert Lane,  M.D.
  New Hampshire.—Am. Journ.  Med. Sci.,
  vol.  xxxv. N. S. p. 560.           1858.
Radical Cure  of  Inguinal  Hernia by the
  use of a Truss, by W. T.  Leonard,  M.D.
  Baltimore.—New Orleans Med. and Surg.
  Journ., vol. xv. p. 378.           1858.
Remarkable Case of Strangulated Hernia,
  by Walter F. Atlee, M.D.  Philadelphia.
  —Am. Journ. Med. Sciences, vol. xxxvii.
  N. S. p. 275.                    1859.
Inguinal Entero-Epiplocele, the Bowel Re-
  ducible and the Omentum Adherent, Ex-
  cision of the Hernial Sac and Omentum,
  Recovery,  by T.  G.  Richardson,  M.D.
  New Orleans.—New  Orleans  Med. and
  Surg. Journ., vol. xv. p. 683.      1859.
Radical Cure of Herniae, by J.C. Nott, M.D.,
  of Alabama, and Bennet Dowler,  M.D.
  New Orleans.—New  Orleans  Med. and
  Surg. Journ., vol. xvi. p. 474.      1859.
       ON ARTIFICIAL ANUS.

Two Cases illustrative of an Operation for
  the Cure  of Artificial  Anus, by John
  Rhea Barton, M.D.  Philadelphia.—Am.
  Med. Recorder, vol. vii. p. 356.    1824.
Case in which a new and peculiar Opera-
  tion for Artificial Anus was successfully
  performed  in January, 1809, by P. S.
  Physick, M.D. Drawn up for publication
  by B. H. Coates, M.D.  Philadelphia.—
  North  American  Med. and Surg. Journ.,
  vol. ii. p. 269.                   1826.
Singular Case of Artificial Anus, success-
  fully treated  by George  W. Campbell,
  M.D.   Tennessee.—Transyl.  Journ. of
  Med., vol. ii. p.  425, 1829;  also Mary-
  land Med. Recorder, vol. i. p. 336. 1829.
Account of a successful Operation for Arti-
  ficial Anus, accomplished by the Aid of
  a Novel Instrument, and  performed  by
  J. R. Lotz,  M.D., of New Berlin, Pa.,
  with Observations  on  the  Apparatus,
  etc., by  Reynell Coates, M.D.  Phila-
  delphia.—Am. Journ. Med. Sciences, vol.
  xviii. p. 367. C^v v/   A ..-~v> 1836.
Case of Artificial Anus, (at Ae Umbilicus,)
  by R. G. Wharton, M.D. Mississippi.—
  Am. Journ. Med. Sciences, vol. vi. N. S.
  p. 256.                          1843.
Case of  Operation  for Artificial  Anus,
  (cured,)  by  J.  Mason  Warren, M.D.
  Boston.—Am Journ.  Med. Sciences, vol.
  xvi. N. S. p. 116.                1848.
Amussat's  Operation for Artificial Anus,
  performed by J. M. Bushe, M.D.  Lex-
  ington, Ky.—Am. Journ.  Med. Sciences,
  vol. xix. N. S. p. 275.           1850 
462
PRINCIPLES AND  PRACTICE  OF  SURGERY.
Successful Operation for the Relief of Arti-
  ficial  Anus, by  T.  T. Robertson, M.D.
  Winnsboro', S.  C.—Charleston Medical
  Journ., vol. ix. p. 323.           1854.
Spontaneous Cure of Artificial Anus after
  an Operation for Strangulated  Femoral
  Hernia, by D.  Leasure, M.D.   New
  Castle, Pa.—Am.  Journ. Med.  Sciences,
  vol. xxxvi.  N.  S. p. 79.           1858.
 LIGATION OF  THE COMMON ILTAC
              ARTERIES.

Case of Wound of the Common Iliac Artery,
  in which that vessel was tied, (being the
  first case known; the patient lived only
  fifteen days,) by William Gibson, M.D
  Philadelphia.—Amer. Med. Recorder, vol.
  iii. p. 185.                       1820.
Case of Ligation of the Common Iliac at
  its origin,  (cured,)  by Valentine Mott,
  M.D.—Phila. Journ. of Med. and  Phys.
  Sciences,  vol. xiv. p. 176.          1827.
Case of Ligation of the Right Common Iliac
  Artery in a Child six weeks old, (di  , )
  by George Bushe, M.D.  New  York.—
  New  York Medico-Chirurgical Bulletin,
  vol.  i p. 55.                     1832.
Ligation of the Primitive Iliac Artery, suc-
  cessfully performed, by Edward Peace,
  M.D.  Philadelphia.—Am.  Journ. Med.
  Sciences,  vol. v. N. S. p. 269.      1843.
Ligation  of  the  Primitive Iliac  Artery,
  (died,) by A. J. Wedderburu, M.D. New
  Orleans.—New  Orleans Med.  and Surg.
  Journal,  May,                   1852.
Aneurism of the Femoral Artery, for which
  Ligatures were successfully applied to
  the Femoral, Profunda,  External, and
  Common Iliac,  by Gurdon  Buck, M.D.
  New York.—New York Journ. of Medicine,
  vol. v.  3d S. p.  305.              1858.
Ligation  of the Common Iliac Artery for
  Aneurism, Use of Silver Ligature, (death
  on twenty-sixth day from  Exhaustion by
  Dysentery,) by Warren Stone, M.D. New
  Orleans,  La.—Am. Journ. Med. Sciences,
  vol. xxxviii. N. S. p. 570.         1859.
Ligation of the Ischiatic Artery for Aneu-
  rism of this Vessel, and subsequent Liga-
  ture  of the Primitive Iliac Artery, with
  Remarks, by L. A. Dugas,  M.D. Georgia.
  —Southern Med. and Surg.  Journ , vol.
  xv. N. S. p. 651.                 1859.
LIGATION OF THE  INTERNAL ILIAC
              ARTERY.

Successful Case of Ligation of the Internal
  Iliac Artery, by S. Pomeroy White, M.D.
  New York,  (formerly of Hudson.)—Am.
  Journ. Med. Sciences, vol. i. p. 304.  1827.
Case of Ligation of the Internal Iliac Ar-
  tery for a  Traumatic  Aneurism  of the
  Gluteal, (died.) by H. J. Bigelow, M.D.
  Boston.—Am. Journ. Med. Sci.. vol. xvii.
  N. S. p. 29.                      1849.
Case of Ligation of the Internal Iliac Ar-
  tery, (died,)  by Gilman  Kimball,  M.D.
  Lowell, Mass.—Am. Journ. Med. Sciences,
  vol. xx. N. S. p. 92.              1850.
Ligation of the Gluteal and Internal Iliac
  Arteries, by  Charles S.  Tripler, M.D.,
  U. S.  Army.—Am. Journ. Med.  Sciences,
  vol. xx vii. N. S. p. 365.            1*54.
Ligation of the  Gluteal Artery, by D. War-
  ren Stone, M.D.   New  Orleans.—Am.
  Journ. Med.  Sciences, vol. xxix. N. S.  p.
  564.                             1855.
Ligation of the  Internal Iliac Artery.  Re-
  covery, by V. Mott, M.D.  New York.—
  Charleston  Med. Journ.,  vol. xi. p. 689.
                                  1856.
LIGATION OF  THE EXTERNAL ILIAC
               ARTERY.

Ligation  of  the  External Iliac  Artery,
   (cured by tying the artery in the pelvis,)
   by John Syng Dorsey, M.D.  Philadel-
   phia, August,  1811.   (This was the first
   successful  operation reported  in  the
   United  States, but the seventh ever per-
   formed; the six preceding having been
   done in England, the first being that by
   Abernethy.)—EclecticRepert. and Analyt.
   Review,  vol. ii. p. Ill, 1811 ; also, New
   Eng. Journ. of Med. and Surg., vol. i. p.
   66.                             1812.
A  Case of Inguinal Aneurism (successful
   ligation) of the External Iliac, (by means
   of Physick's  needle,) by Wiight  Post,
   M.D. New York.—Am. Med. and Philo-
  sophical Register, vol. iv. p. 443.    1814,
Ligation of the External  Iliac Artery, by
  J. B. Whitridge, M.D.   Sacketts Har-
  bor —New Eng. Journ. of Med. and Surg.,
  vol. iv. p. 318.                   1815.
Case of Ligation of the External Iliac  for
   Inguinal Aneurism, (cured.) by Nathan
   Smith, M.D., of Yale College.—Philad.
  Journ. of Med. and  Phys. Sci., vol. i. p.
  415.                             1820.
Ligation of the  External Hiac, by H. G.
  Jameson, M.D.  Baltimore.—Am. Med.
  Recorder, vol. v.  p. 118.           1822.
Case of Ligation  of  the  External Iliac,
   (cured,) by Alexander H. Stevens,  M.D.
   New York.—N. Y. Med. and Phys. Journ.,
  vol. i. p. 112.                    1822.
Case of Ligation  of  the  External Iliac,
   (cured,) by John C. Warren, M.D.  Bos-
   ton.—New Eng. Journ. of Med. and Surg.,
   vol. xii. p. 225.                  1823.
Case of Inguinal Aneurism, (into which an
  Empiric plunged a lancet,) reported  by
  John Rhea Barton, M.D.   Philadelphia.
   Philada. Journ. Med. and Phys. Sccinces,
   vol. i. N. S. p.  127.               1825. 
PAPKRS  ON  DISORDERS AND OPERATIONS ON THE ABDOMEN.   463
 Ligation of the External Iliac, (cured.) by
   David L. Rogers, M.D. New York.  Com-
   municated  by P. Cadwallader,  M.D.—
   Am. Med. Recorder, vol. ix. p. 269  1826.
 Case of Aneurism of the External Iliac Ar-
   tery, treated successfully by tying  up
   the Vessel, by J. Randolph, M.D.  Phil-
   adelphia.—Am. Journ. Med. Sciences, vol.
   iii. p. 489,  1829;  also. North  Am. Med.
   and Surg. Journ., vol. vii. p. 206.   1829.
 Case  of Diffused Femoral Aneurism, for
   which the External Iliac was tied, (cured.)
   by Valentine Mott,  M.D.  New York —
   Am. Journ. Med. Sciences, vol. viii. p. 393.
                                    1831.
 Case in which the  External  Iliac Artery
   was successfully tied, by James C. Hall,
   M.D.  Washington. — Am. Journ. Med.
   Sciences, vol. x. p. 90.             1832.
 Case  of Aneurism  of the External Iliac
   Artery, Ligation of this Artery, (died,)
   by J. C. Warren,  M.D.  Boston.—Am.
   Journ. Med. Sciences, vol. xix.  p. 541.
                                    1836.
 Case of Inguinal Aneurism, in which the
   Right External Iliac Artery was success-
   fully tied,  by William  H. Ruan,  M.D.
   St. Croix, West Indies.—Am. Journ. Med.
   Sciences, vol. xviii. p. 43.           1836.
 Case of Ligation of the External Iliac Ar-
   tery,  (cured; the ligature coming away
   on the thirtieth day,) by Edward Peace,
   M.D. Philadelphia.—Med. Examiner,vol.
   i. N. S. p. 645, 1842; also, Am. Journ.
   Med. Sciences, vol. iv. N. S. p. 250.  1842.
 Femoral Aneurism, Ligation of the Exter-
   nal Iliac, death on  the fifth day, by W.
   Power, M.D.  Baltimore.—Am. Journ.
   Med. Sci.. vol. iv. N.  S. p. 511, 1842; also,
   Maryland Med. and  Surg. Journ., Sept.,
                                    1842.
 Ligation of the External  Iliac  Artery for
   Aneurism of the Femoral Artery, (cured,)
   by J.  M. Boling, M.D. Alabama.—Am.
   Journ. Med. Sci., vol. vii.  N. S. p. 359.
                                   1814.
 Ligation of the External Iliac Aitery, (for
   Aneurism of the Femoral, died,) by A.
   Wedderburn,  M.D.   New Orleans.—Am. I
   Journ.  Med. Sciences, vol. xiii. N. S.  p. I
   219,  1847;  also, New Orleans Med. and
   Surg. Journ.,  Sept.                1846.
Ligation of the External Iliac of one side,
  and soon after of the  Femoral of the oppo-
  Bite Limb,  (both  successful,) by  C. Bell
  Gibson,  M D.  Baltimore.—Am.  Journ.
  Medical Sciences, vol. xiv. N. S. p.  535.
                                   1847.
Case of true Inguinal  Aneurism ; attempt
  at Manual Compression of the  External
  Iliac;  subsequent ligation,  (cured,) by
  William H. Van Buren, M.D.  New York.
  —N. Y. Journ. Med., vol. ii. N. S.  p. 168,
  1819; also, Am. Journ. Med. Sciences, vol.
  xviii. N. S.  p. 540.                1849.
Case of Inguinal Aneurism, Ligation of the
   External Iliac, (cured,) by George Fox,
   M.D.   Philadelphia.—Am. Journ. Med.
   Sciences, vol. xviii. N. S. p. 377.   1849.
 Case of Ligation of  the External Iliac,
   (patient  died,) by  Dr.  Stedman.   Re-
   ported by S. Packman, M.D.  Boston.—
   Am. Journ. Med. Sciences, vol. xix. N. S.
   p. 73                            1850.
 Successful Ligation of the  External Iliac
   Artery to relieve Secondary Hemorrhage,
   by J. Hastings, M.D.  San Francisco.—
   Am. Journ.  Med. Sciences, vol. xxiv. N. S.
   p. 564.                           1852.
 Diffuse Aneurism of the Femoral Artery,
   following a wound,  ligation of the  Ex-
   ternal Iliac Artery, (recovery,) by A. H.
   Agard,  M.D.   Summit Co. Ohio.—Am.
   Journ. Med. Sci., vol. xxxi. N. S, p. 388.
                                   1856.
 Ligation of the  External Iliac, for Aneu-
   rism of the  Femoral  Artery, by Dr. Mer-
   cier  New Orleans.—Am. Journ.  Med.
   Sciences, vol. xxxiii.  N. S. p. 574.  1857.
 Aneurism of the Crural Artery.   Ligation
   of the External Iliac, by H. Daret, M.D.
   New Orleans.—New  Orleans Medical and
   Surg. Journ.,  vol. xiii. p. 471.     1857.

     OPERATIONS ON THE BACK.

 Gunshot Wound, Ball  lodged in the pos-
   terior part of the Neck, and subsequently
   discharged by Stool,  by William  Hening,
   M.D., late Surgeon  U.S.A.—Eclect. Re-
  pert, and Analyt. Review, vol. vii. p. 246.
                                   1817.
 On the Use of Caustic Alkali in  Tetanus,
   by Joseph Hartshorne, M.D.  Philadel-
   phia.
 [The caustic was rubbed firmly on an oval
   space 2\ inches wide by \\ inches long,
   over the  cervical vertebrae, and the pa-
   tient was relieved in less than two hours.]
  —Eclec. Repert. and Analyt. Review, vol.
  vii p. 245.                       1817.
Case of Steatomatous Tumor,  weighing
  twenty-five  pounds,  removed from  the
  upper part of the Back, by J. S.  Dorsey,
  M.D.   The  circumference of the neck,
  or narrowest part of  the tumor, was two
  feet ten inches. Thickest part vertically,
  three feet nine inches.  Thickest  part
  horizontally, three feet one inch and a
  half.  Thickest part of waist, after re-
  moval of the tumor, two feet nine inches.
  —Am. Med. Recorder, vol. i. p. 400.  1819.
Case of Lumbar Abscess, attended with
  Artificial  Anus at the Groin, (opening
  in the colon,)  by Wm.  E.  Horner, M.D.
  Philadelphia.—Philad.  Journ.  Med. and
  Phys. Sciences, vol. i. p. 141.      1820.
Case of Gunshot Wound, in which Tetanus
  was controlled by a Caustic Issue to the
  Spine, by David M. Reese, M.D.   Balti-
  more.—Am. Med. Recorder, vol. viii. p.
  548.                             1825. 
4G4             PRINCIPLES AND  PRACTICE  OF  SURGERY.
Case  of  Fistula in the  Lumbar Region,
  communicating with the Bladder, by L
  Proudfoot, M.D.—American  Journ. Med.
  Sciences, vol. i. p. 241.            1827.
Cases in which  portions  of three Dorsal
  Vertebrae were removed with partial suc-
  cess for the relief of Paralysis from Frac-
  ture, by Alban G. Smith, M.D.  Danville,
  Kentucky.—North Amer. Med.  and Surg.
  Journ., vol. viii. p. 94.            1829.
Case of Fractured Spine,  with  the removal
  of  depressed  Spinous  Process, by  an
  Operation,  (patient  died,) by  David L.
  Rogers, M.D.   New York.  (Communi-
  cated by S. R.  Kirby, M.D.—Am. Journ.
  Med. Sciences, vol. xvi. p. 91.     1835.
Case of Division  of the Spinal  Marrow (by
  a Chisel accidentally driven in opposite
  the Spinous Process of the lower Dorsal
  Vertebrae,  causing  Paralysis,) the pa
  tient recovered, by Eli  Hurd, M.D.  Ni-
  agara  County, New York.—Am. Journ
  Med. Sciences, vol. x. N   S. p. 531, 1845:
  also A'. York Journ. of Med.,  Sept., 1845.
Extensive Caries  of the Vertebrae, (death,)
  Autopsy, by Louis Bauer, M.D.  Brook-
  lyn.—New  York  Med.  Journal, vol.  xii.
  N. S p. 44.                     1854.
Excision  of an Atheromatous Tumor on the
  Back, by Juriah Harris, M.D.  Augusta,
  Ga.—Southern Med. and Surg. Journ., vol
  xi. N. S. p. 397.                  1855.
Apparatus for the treatment of Curvature
  oftheSpine, by J. A. Wood, M.D. Boston.
  —New York Journal of Medicine, vol. iv.
  3d series, p. 292.                 1858
Cystic Tumors on  the Nates Obstructing
  Delivery, by Dr. Keller.  Philadelphia.
  —Am.  Journ.  Med. Sciences, vol. xxxvi.
  N. S. p. 291.                     1858.
          ON  SPINA BIFIDA.

Three Cases of Spina Bifida successfully
  treated; two of them by means of Wire
  Ligatures, and the other  by the Knife,
  by AmasaTrowbridge, M.D. Watertown,
  N. York.—Boston Med. and Surg. Journ.,
  vol.  i. p.  753.                    1829.
Case of Spina Bifida, with Remarks, (punc-
  tured seventy times without bad conse-
  quences, butdied ultimately ofdiarrhoea,)
  by Charles Skinner, M.D.   North Caro-
  lina.—Am. Journ. Med. Sciences, vol. xix.
  p. 109.                           1836.
Case of Spina Bifida, (cured, by Punctures
  and  Pressure,)  by  P.  H.  Hurd, M.D.
  Oswego.—Boston Med. and Surg. Journ.,
  vol.  xviii. p.  109.                 1838.
Case of Spina  Bifida  successfully treated
  by  Repeated  Puncture, by Alexander
  Stevens, M.D.  New York.—Am  Journ.
  Med. Sciences, vol. vi. N. S. p. 527, 1843;
  also  N. Y. Journ. of Med. and Collateral
  Sciences, No. 2                   1843.
Case of Spina Bifida treated by the Injection
  of Tincture of Iodine, by Daniel Brainard,
  M.D.  Chicago.—Am. Journ. Med. Sci.,
  vol. xvi. N. S.  p. 262, 1848; also Illinois
  and Indiana Med. and Surg. Journ., Jan.
                                  1848.
A Case of  Spina  Bifida  of the Occiput,
  (opened by a bistoury,) death, by Rich-
  ard L. Howard, M.D.  Columbus,Ohio.—
  Ohio Med. and Surg.  Journ., vol. v. p.
  214.                             1853.
Spina  Bifida cured by Excision, by J. C.
  Nott, M.D.  Mobile,  Ala.—Am.  Journ.
  Med. Sci.,  vol.  xxx. N. S. p. 77.   1855.
Spina  Bifida, with  Malformation  of the
  Genitals, by S. Kneeland, M.D.  Boston.
  Am.  Journ. Med. Sciences, vol. xxxiv. N.
  S. p. 292.                        1867.
Spina Bifida, (three cases from one mother,)
  by E. M. Pendleton, M.D.   Sparta, Ga.
  —Southern Med.  and Surg.  Journ.,  vol.
  xiii.  N.  S. p. 215.                1857.
Remarkable Case of Malformation, Spina
  Bifida,  etc.,  by Wm.  A. Green, M.D.
  Starksville, Ga.—South. Med. and Surg.
  Journ.,  vol. xiv.  N. S. p. 451.     1858. 
PAET  XV.
DISORDERS OF, AND OPERATIONS  ON, THE GENITO-
            URINARY  ORGANS AND  RECTUM.
                         CHAPTER I.

        DISORDERS OF THE MALE GENITO-URINARY ORGANS.

  The Genito-Urinary Organs in man being intended for the performance of
two distinct functions, to wit, the conveyance of sperm into the female, and
the evacuation of the  urine, occasionally demand the aid of the surgeon,
either in order to remedy congenital defects, or to relieve the  evils resulting
from disease.  Of the operations performed upon these  organs, some are
intended  for the relief of deformities, and are limited solely  to the body of
the penis; while others, being intended to favor urination, are confined to
the urethra.   Some are limited to the testicles, and others to the removal of
foreign bodies from the bladder.  The latter having a special importance,
will be referred to in a distinct chapter.
  From the varied character of the structures concerned in these operations,
it is apparent that anything like a detailed account of each part would ne-
cessarily lead into the domain of special anatomy;  but as it may facilitate
the reader's  comprehension of the disorders as well as of the  steps of the
operations required for their  relief, I shall present  a brief account  of the
general relations of the parts to each other.


                           SECTION I.

              SURGICAL  ANATOMY OP THE MALE  ORGANS.

  The Genito-Urinary Organs of man consist of the testicles and vesiculae
seminales, and of the penis, urethra,  and bladder, the penis being formed
both for the function of procreation and urination.


                           § 1.—The Penis.

  The Penis is attached to the front of the bones of the pelvis, at and below
the symphysis pubis; it is formed of skin, loose connective tissue, corpora
cavernosa, corpus spongiosum, and the urethra, and varies in size  accord-
ing to the vascular condition of the corpora cavernosa.
    vol. n.—30                                        (465) 
466            PRINCIPLES AND PRACTICE OF SURGERY.
  The skin of the penis is loosely attached to the body of the organ  by a
connective tissue that permits great freedom of motion.  At the glans penis,
or anterior extremity of the organ, the skin is thrown into a duplicature or
fold—prepuce—the  inner layer of which is  blended or lost in the mucous
membrane covering the glans penis.  In consequence of this arrangement, the
prepuce consists of two lamina?, the inner of which is inserted at the base of
the corona glandis.  Between these two layers is a loose  connective tissue,
liable to a serous or lymph-like infiltration, which sometimes materially inter-
feres with  the mobility of the part.  Ordinarily, the prepuce may be retracted
or drawn forward so as to expose or cover the entire glans, though congenital
defects or diseased  action  may so limit  this movement  as to prevent the
exposure of the glans  to any extent.  The corpora cavernosa  and corpus
spongiosum are not sufficiently connected with the operations usually prac-
ticed on this part to  require further reference at present.
                           \ 2.—The Urethra.

  Although the Urethra is actually a portion  of the structure of the penis,
the direct connection existing between it and the bladder has led anatomists
to describe it as if it were an appendage of the bladder.   The  importance
of the canal, and the danger ensuing upon its obstruction, owing to its being
the only channel for the escape of the contents of this viscus, have, however,
led surgeons to a  specific study of it, and to the establishment of certain
regional divisions,  the limits of which are useful, though purely optional.
  The extent of the  penis  being very  varied, a considerable diversity of
opinion exists in reference to the  average  length of the urethra, or the true
distance from its orifice to the neck of the bladder.
  According to Blandin,* its length varies  from eight to nine inches, as
measured in a median section of  a flaccid penis while laid upon the abdo-
men, aud, of course, a little elongated.
  Malgaigne,f on measuring  it also in the flaccid condition, but  hanging
down upon the scrotum, found it to be, on an average, six, or six inches and
two-fifths long.  In old men, hypertrophy of the prostate augments it two-
thirds of an inch, or even more.
  PancoastJ has found that, in  the negro or mulatto,  the  average length
is  about seven  inches, measuring from the end of the urethra to the neck of
the bladder in the  flaccid penis, and about one  inch more when elongated by
moderately stretching the organ;  but as the genital organs of the negro are
generally more developed than those of the white, it may be safely inferred
that  six,  or six and a half inches, in white men, measuring from the orifice
of the urethra, should suffice to place the point of an instrument within the
neck of the bladder.
  The regional division of the urethra into fossa navicularis, bulbous, pros-
tatic, and membranous portions, having reference to certain points of the
genital organs through  which the canal  passes, does not require  detailed
reference in connection with operative surgery, but belongs more especially
to the descriptions of special anatomy.  It  must, therefore, suffice to say
that, according to  Malgaigne,§ the prostatic  portion of the  urethra is from
seven to eleven lines in length, and the membranous from six to nine lines, the
bulbo-cavernous portion being the only part  which is influenced by stretch-
ing the penis.
* Anat. Topographique, p. 384.          f Op. Surg., Philadelphia edit., p. 467.
X Pancoast, Wistar's Anat., vol. ii. p. 170.  § Op. citat., p. 469. 
PHYM0SIS.
467
   Henry Thompson, of London, in a recent work,* after many trials, gives
the following accurate data:  The greatest length of the urethra is 9 inches,
and the least 7f.  The length of the spongy portion 6£ inches, of the mem-
branous |  of an inch, and of  the prostatic  portion  1£  inches, the  average
length of sixteen urethral being 8£ to 8f inches—in the dead subject;  but
in the living he regards the statement of Briggs  as correct, to wit,  that the
average length of the living urethra is 7^ to 7f inches.


                           § 3.—The Testicles.

   The Testicles, being suspended from the abdomen by the spermatic cord,
are covered by a serous coat—tunica vaginalis testis—as well as by the
dartos and scrotum.
   The tunica vaginalis testis  is generally a clear, smooth, and translucent
serous membrane, which in the  healthy condition secretes merely sufficient
halitus  to  facilitate  the motion of the gland,  though it  may be rendered
thick, firm, and even osseous by disease, and, in one instance, under  my own
observation, was fully two lines thick, and as firm as cartilage.   Under such
circumstances, great caution is requisite, in treating its disorders, to  prevent
a mistake in diagnosis.
   The cord  is formed by the vas deferens, spermatic artery, veins, nerves,
and lymphatics, covered in by the fatty and  connective structure designated
as tunica vaginalis communis, and by the fibres  of the cremaster muscle.
   The spermatic artery comes out of the  abdomen and pursues a tortuous
course to the testicles, being surrounded  by and adherent to the spermatic
veins throughout the extent of the cord.   The  spermatic veins extend from
the testicles to  the abdomen;  are larger than the artery, anastomose freely
with the superficial veins of the scrotum,  and, enveloping the  vas deferens
and  the artery, constitute  the  great  bulk of the cord.   They are  without
valves and largest on the left side, in consequence probably of the pressure
made upon them in their passage behind the sigmoid flexure of the colon.
   The surgical relations of the  bladder and perineum of the  male  will be
reserved for the account of Lithotomy, in the ensuing chapter.
                             SECTION II.

                       OPERATIONS ON THE PENIS.

   The operations practiced on the Penis consist of those required for phy-
mosis and paraphymosis, with division of the fraenum, and  amputation of
the organ.

                             \ 1.—Phymosis.

  When,  from congenital defect, the prepuce  is unnaturally elongated, and
at the same time so much contracted at its orifice that it  cannot be  drawn
back so as to uncover the glans penis, or when the orifice  of the prepuce is
diminished by serous and fibrinous deposits in the cutaneous areolar tissue, it
constitutes Phymosis—?i,u«c, a muzzle—and the patient is liable to be incom-
moded either in voiding the urine or in sexual intercourse.   The  constric-
tion of the glans  penis also induces a partial  atrophy or defective develop-
* Pathology of Stricture, Jacksonian Prize, 1852. 
468            PRINCIPLES AND PRACTICE  OF SURGERY.
ment of the organ.   To  relieve  this state  of the parts, several operations
have been  suggested, that of circumcision, as  practiced by the Jews, or as
slightly modified by surgeons, being the most ancient.
  I. Circumcision.—In  the  operation  of circumcision, as originally per-
formed, the prepuce, after being drawn forward, in advance of the end of the
glans, by the fingers of the operator, was inserted  in  the cleft  of a sort of
spatula, the protruding  portion  excised  by the sweep of  a  knife, and  the
mucous lining torn open  to the corona glandis;  a strip of linen, to prevent
adhesion, completing the dressing.
  As usually performed by surgeons of the present day, circumcision is ac-
complished as follows:—
  Operation.—The prepuce being first drawn  well  forward, the projecting
portion is seized in a pair of dressing-forceps, and  then excised on a level
with the blades of the instrument, either by means of a bistoury or scissors;
a few stitches of the  interrupted suture, to unite  the mucous  coat  of the
skin, and a piece of lint, completing the dressing.
  Remarks.—Several slight modifications of this operation have been sug-
gested  by Velpeau and  Ricord,  but as  they  are  sufficiently explained in
Plate XLIX , further reference is here unnecessary.
  II.  Incision.—Various plans of slitting up  the prepuce have been sug-
gested  by different operators, in order to free the glans, and  yet not create
deformity.   The selection of one  method rather than another will therefore
depend  mainly on  the complications of the case, and especially on the ex-
istence of chancre.  When chancre is present, the performance of the opera-
tion exposes the patient to a new inoculation by the freshly divided surfaces.
  Ordinary Operation.—In the mode of operating resorted  to under ordi-
nary circumstances, the patient is so placed that he cannot move from the
surgeon, when the  latter, after carefully introducing a director between the
prepuce and  the glans, as far back as the corona  glandis, passes a  sharp-
pointed bistoury along it, punctures the skin from within outward at the end
of the director, and then slits open the membrane from behind forward in the
median line, upon the  dorsum of the organ, Plate XLIX. Fig. 2. The glans
being thus  exposed, it only remains to unite the fold  of skin and mucous
membrane together by three stitches of the interrupted suture, and treat the
wound  as a simple sore.
  Operation of J. Cloquet.—In consequence of the wings  or lateral lumps
left by the  preceding  method, Cloquet suggested the following operation,
which has since  been  frequently performed by Liston  and  others, and often
spoken of as Liston's  operation :—
  Introduce a director between the glans penis  and prepuce, on the inferior
side of the organ, and place it parallel with and alongside the fraenum, taking
care that it is not by any mischance carried  into the urethra.  Then passing
a sharp-pointed bistoury  along it to the corona glandis, transfix the prepuce,
and slit it up from behind forward on the side of the fraenum, when the glans
will be fully exposed, Plate XLIX.  Pig. 4.  After this, a point or two of the
interrupted  suture,  made so as to unite the skin and  mucous membrane on
the free side  of the flap, completes the operation.
  Operation of  Cullerier.—As the  constriction of the preputial  orifice is
often dependent on a contracted condition of  the lining  membrane of the
prepuce, this surgeon  operated by incising only the mucous membrane, com-
mencing at its free edge  and cutting backward  to a sufficient extent to per-
mit the free expansion of the skin.
  Remarks.—Although  the operations for the relief of phymosis are simple,
the future usefulness of the organ and the absence of evident deformity will
depend somewhat upon the plan selected.   Where the defect is a congenital 
PARAPHYMOSIS.
469
one, the selection of the method is entirely in the power of the surgeon, and,
under these circumstances, the advantages of the different  plans should be
well considered, especially if the patient is an adult.  In the  operation of cir-
cumcision, as usually practiced, the cicatrization of the wound is apt to leave
such a constriction of the mucous membrane as prevents the free exposure of
the gland, and has occasionally led to the production of a new phymosis.  To
obviate this, it will  therefore be found advantageous, where circumcision is
practiced, to pursue the Jewish plan of operating, and, after excising the skin,
to tear up the mucous membrane longitudinally on the dorsal surface of the
penis, or, as suggested by Maisonneuve, of Paris, after circumcising the skin
alone, simply to incise  the membrane on the dorsum of the  penis to the  ex-
tent of a centimetre, and cut off the angles of these flaps, uniting them after-
ward with the skin, as by this means the constriction of the cicatrix is pre-
vented, in consequence of the more prompt union of the surface, and the sepa-
ration of each side from the other after the angles of the wound have been
removed.
   Frequent opportunities of testing the  advantages of the  plan of Cloquet
having satisfied me of its value, I do not hesitate to recommend it as that best
adapted to the adult, because it fully exposes the glans, and leaves little or
no lateral deformity, as is frequently the case in the dorsal incision.   Should
the existence of chancres near the fraenum, or other circumstances, prevent its
performance, and compel the adoption of the dorsal cut, I should  prefer ex-
cising the two flaps and uniting the mucous membrane and skin at the line
of the corona, so as to leave the glans permanently uncovered; but it is  im-
portant to  recollect the general rule, that "all incisions about the generative
organs of a patient with chancre or  gonorrhea should be avoided, the wound
augmenting the  danger of syphilitic inoculation or being exposed to slough-
ing from the irritation  of the discharge that flows over it."
                           \ 2.—Paraphimosis.

   The word Paraphymosis—-apa, back, and (fiiwaiq, a bridle—is employed
to designate that state of the penis in which the prepuce is drawn back and
contracts behind the corona glandis, so that it cannot be again brought for-
ward.   In many  instances, this condition is owing to a difference between
the development of the  two layers of the prepuce, the  mucous membrane
being the narrowest, though it may be caused by the constricted margin of
the prepuce of a phymosis  being  so distended by the shape of the head of
the penis, that it readily slips over  to the  corona, but cannot subsequently be
drawn forward, in  consequence of the congestion  and enlargement of the
glans which ensue upon its constriction.
   When paraphymosis is allowed to continue, the  prepuce may slough, or
adhesions form, so as to render the thickened folds behind the glans a great
deformity.  To obviate this,  two means of treatment may be resorted to: one
—compression—having for  its object the diminution of the bulk of the head
of the penis, and the immediate anteversion of  the retracted prepuce;  the
other—incision—the division of the constricting ring or margin of the pre-
puce, or, if necessary, its dissection from  the attachments formed behind the
corona.
   I. Compression.—After bathing  the part in cold water, or keeping cold
cloths constantly on it for an hour or more, compression, which is the sim-
plest of these  operations, may be attempted as follows:—
  Operation.—Place a piece of soft linen upon the retracted prepuce, seize
it just behind  the glans between the first and second finger of each hand,  so 
PLATE   XLIX.
                OPERATIONS PRACTICED ON THE  PENIS.

   Fig. 1.  Section of the Fraenum when too short.   1.  The bistoury transfixing
 the prepuce, so as to shave it off from behind forward.
                                               After Bernard and Huette.

   Fig. 2.  Ordinary operation for Phymosis.  I. The director carried between
 the glans  penis aud  the prepuce, as  far back as the coroua glandis.  2. The
 bistoury puncturing the prepuce behind, and about to slit it open on the median
 line from  behind forward.                        After Bernard and Huette.

   Fig. 3.  Excision of the  flaps created  by the  preceding  operation.  1.  Rat-
 tooth  forceps holding both the  mucous  lining and skin of the prepuce.  2.
 Scissors in the act of excising the flap.            After Bernard and Huette.

   Fig. 4.  Cloquet's operation, sometimes assigned to Liston, but also described
 by Celsus. 1.  The director passed between the glans and prepuce, alongside of
 the fraenum.  2.  The bistoury slitting up the prepuce.
                                               After Bourgery and Jacob.

   Fig. 5.  Ricord's operation for  Circumcision.  The forceps holding the  pre-
 puce  in advance  of the glands.  2, 2. Ligatures passed through  the prepuce
 for the purpose of subsequently uniting the  skin and mucous membrane.
                                               After Bernard and Huette.

   Fig. 6.  The second stage of this operation.  1.  Rat-tooth forceps drawing
 the prepuce forward.  2. The bistoury in the act of circumcising the prepuce.
                                               After Bernard and Huette.

   Fig. 7.  Appearance of the Prepuce after Circumcision.  1,1, 2, 2. The liga-
tures for uniting the wound.                      After Bernard and Huette.

   Fig. 8.  Completion of the operation.  1. The first suture  as applied.  2.  The
second ligature.                                 After Bernard and Huette.

  Fig. 9. Reduction of Paraphymosis by Compression.   While the thumbs of
the operator push back the glans, the first and second fingers draw the prepuce
forward over the corona.                         After Bernard and Huette.

  Fig. 10.  Amputation of the Penis.  1.  Left hand of the surgeon holding the
penis enveloped in a cloth.   2. Hand of the assistant.  3. The bistoury.
                                               After Bernard and Huette.
       (470) 
 
  SS'


tie'
retra
then
tarn1
 tare
 alio
 ifte
   I
  BO I
  Id!
wi

 {(

 i 
AMPUTATION  OP THE PENIS.
471
as to draw it forward, and at the same time apply the thumbs against the ex-
tremity of the  glans, so as  to knead and force it  backward, when, after a
gentle perseverance, success will be  obtained in most instances, especially if
the attempt is  made within two or three hours after the occurrence of the
retraction, otherwise it will be more  difficult, Plate XLIX.  Fig. 9.  Where
there is much oedema of the prepuce, and the mucous membrane is highly
tumefied, it may be necessary, and I have often found it advantageous, to punc-
ture the membrane at numerous points, so as to  give exit to the serum an'd
allow of the more ready movement of one layer of the prepuce upon the other,
after which compression should be made as before  directed.
   II. Incision—When the constricting prepuce is so tight or the adhesions
so close that it cannot be made to  yield  to the force applied through the
fingers, it may  become necessary to resort to the knife.
   Operation of Incision.—Let one assistant retract the skin of the penis as
much as he can toward  the pubis with one hand, and draw the prepuce for-
ward with the other so as to display, if possible, the seat of stricture, after
which the surgeon may nick it with a bistoury, either by cutting from behind
forward, or introducing a director and dividing the stricture upon it; or,
what is more easily done, make a vertical cut through the prepuce from above
downward and  from the raucous membrane to the skin, until the constriction
is freely removed.  The latter operation, by enlarging the prepuce, prevents
a reproduction  of the disease.
                     § 3.—Division of the Fraenum.

   When from congenital defect the  fraenum  extends  as far forward as the
extremity of the urethra, it may depress  the point of the  glans, and cause
inconvenience in sexual intercourse; or the  irritation and laceration of the
part, or mental anxiety in regard to the defect, may lead the patient to insist
upon its division.  Under these circumstances, the operation for its relief may
be performed as follows :—
   Operation.—After arranging the patient  so that his motions can be con-
trolled, retract the prepuce, and let an assistant hold it back and support the
penis,  while the surgeon, drawing the fraenum from the glans  with his left
hand, transfixes it with a bistoury held in  the right, Plate XLIX. Fig. 1, so
as to cut from behind forward and shave it off.   A piece of linen to prevent
adhesion is all that is subsequently requisite;  or the surface may be lightly
cauterized.

                      § 4.—Amputation of the Penis.

  Amputation of the Penis  may be demanded by cancer, gangrene, etc.,
though cancer is the most frequent cause of its performance.  As the symp-
toms, etc. of cancer have been already alluded  to,* attention  may now be
given  solely to  the  operation  sometimes  practiced for its  relief,  with the
result usually attendant on operations for cancer elsewhere.  When demanded,
the anatomical relations of the organ should  be borne in mind, especially the
loose attachment of the skin, and the tendency of the penis to shrivel up and
contract upon itself, after being stretched.  The latter circumstance is often
a source of trouble where means are not taken to obviate  it,  the surgeon
being worried by the unexpected difficulty found in arresting the bleeding, or
annoyed by the excess of skin over the stump, in consequence of his elonga-
* Vol. i. p. 405. 
472
PRINCIPLES AND PRACTICE  OF SURGERY.
ting the organ during his incisions.  When the amputation is to be performed
low down, or near the pubis, especial care should be taken to avoid drawing
the skin too much forward, lest that over the  pubis or scrotum be removed
unintentionally.
   Operation.—Having prepared a small  catlin, together  with ligatures,
tenaculum, and forceps, the hair should be shaved from around the part, and
the glans and free end of the organ wrapped in  a bandage so as to give the
operator a good hold upon the member.  Then, while the patient is in a con-
venient position, the surgeon, without drawing upon the portion held in his
left hand, should pass the  catlin rapidly round so as to divide the skin, Plate
XLIX. Fig. 10; then cut through  the upper part of the corpora cavernosa,
ligate the  arteries, and, resuming the knife, finish the operation by dividing
the remainder of the organ at one sweep.
   Dressing.—After arresting the hemorrhage, the mucous membrane of the
urethra should be fastened to the outer margin of the  stump by two or three
points of the interrupted metallic suture, when a catheter should be passed
into the urethra, and the  stump dressed  like any other stump, the catheter
serving to  keep the patient dry and steady the  organ during the dressing.
As, however, the urine will do no harm to the wound, and irritability of the
bladder may render  the use of the catheter  objectionable, a resort to it must
be decided upon  at the moment by  the judgment of the operator.
   Operation by the Ecraseur.—Chassaignac, of Paris, advises the amputa-
tion of the penis by  the ecraseur, and it has been frequently employed satis-
factorily both in  Europe and the  United  States,  there being but very trifling
hemorrhage, and the union of the stump being prompt.   In its use inclose
the penis in the  loop of the instrument, and  constrict it slowly for twenty
minutes, or until it cuts through  the organ.
   Remarks.—The performance of amputation of the penis at the pubis does
not differ  materially from  the plan just  detailed for the  operation upon the
body of the organ.   An elliptical incision will, however, be  preferable to the
circular one above  mentioned, care being taken to avoid encroaching too
much upon the skin of the scrotum.  When the penis is removed near the
pubis,  the patient is also  more apt  to be annoyed by the urine passing upon
his thighs  and perineum,  unless  he places himself in a  sitting position, or
employs a funnel of metal or gutta-percha adapted to the part,  as advised
by Ambrose Pare.   Under all circumstances, the mental  depression after the
operation  is often sufficient to prevent proper digestion and assimilation, and
the return of a malignant disorder being thus hastened, it may be doubted
whether, in the case of cancer, anything  is  gained by the operation.  In one
patient, in  whom I amputated the  entire penis,  though life lasted for nearly
two years after removal  of the organ in  consequence  of cancer, his exist-
ence was one of extreme unhappiness, the man being constantly distressed by
mental anxiety and  bodily pain, and the disease  showing itself in the stump
in a few weeks after the amputation.  The operation  by the ecraseur has no
advantage over the  other  methods, except  the few days'  shorter time that is
required for the healing process.


                            SECTION  III.

                     OPERATIONS  ON THE URETHRA.

   The necessity of  passing through the urethra in order to accomplish the
treatment of some of the  complaints of the bladder, has caused many opera-
tions to be placed under this head that do  not strictly belong to this region; 
CATHETERISM.                         473
such, therefore, as involve disorders of adjacent parts maybe advantageously
referred to a subsequent section.  At present, those of catheterism, stricture,
and congenital malformations of the canal will alone be considered.
                            \ 1.—Catheterism.

   The evacuation of the bladder through the hollow tube called a catheter
constitutes the operation of Catheterism, and is  one which, in the normal
condition of  the canal, and in  skillful hands, is easily performed.   Various
details may,  however, be  given, in  order to facilitate  the progress of those
who are inexperienced.
   Catheters.—The selection of the catheter—either of silver or  caout-
chouc—is so purely a matter of personal opinion,  that nothing need be said
in reference to the material, except to discountenance the use of gutta-percha,
which is  dangerous from  its brittleness.   When the surgeon,  especially in
the country, is so placed as to find it desirable to evacuate a patient's bladder
while unable to  obtain the  regular instrument, the following practice, sug-
gested and occasionally advised by  Physick, of  Philadelphia,  may prove
worthy of being noted.   In a case of great emergency, this distinguished
surgeon  resorted to a  common article of dress, and formed a  catheter by
regularly extending the elastic spiral wire often found in the suspenders of
gentlemen, covering it with a piece of muslin  which had been dipped in
melted beeswax, and then cutting eyes near the point.
   Another excellent contrivance, suggested by a surgeon in the United States
whose name  has escaped my recollection, is to hammer out a piece  of sheet-
lead,  and, rolling it round a large  knitting-needle, afterward make eyes in
it as required.
   A method of  treatment that has proved effectual in cases  of  retention of
urine from spasm, and which may be employed even when the surgeon cannot
obtain a catheter, is the injection of warm sweet oil into the urethra, as sug-
gested by Hewson,  of Philadelphia.   The point of an injection syringe being
introduced into the urethra, and the canal held closely around it by an assist-
ant, gentle and  steady pressure upon the piston will  force the  warm oil to
the neck  of the  bladder, where its pressure will often suffice to induce relax-
ation  of  the  spasm.  The bladder may also sometimes  be induced to void
itself  by pouring, slowly, cold water upon  the sacrum and loins for a few
seconds, so as to excite the spiual nerves; but most frequently it is easiest to
employ a catheter.
   Ordinary Operation of Catheterism.—While the patient is lying down,
with the shoulders elevated, the knees flexed, and breathing freely, so as to
insure relaxation of the abdominal muscles and prevent straining, the surgeon
should place  himself upon the left side of the patient, oil the instrument, and
seize  the corona glandis between  the ring and second  fingers of the  left
hand in a state of supination, Plate  LI. Fig. 1, or between the forefinger and
thumb.   Then seizing the handle or end of the catheter with the right hand,
so that the back of the fingers may be below or next to the abdomen and the
thumb on top, introduce the  point of the instrument into the urethra, hold-
ing the penis  perpendicularly to the pubis, and  the  body of  the instrument
parallel with  the median line of the abdomen, with its concavity presenting
to the pubis.   After passing the point a short distance into the canal, gradu-
ally elevate the right hand, and, keeping the point of the instrument in con-
tact with the superior  side  of the  urethra,  press the catheter  toward the
bladder, bringing its  handle  or free end from the horizontal to the perpen-
dicular position, so  as to  cause the point to pass through the  bulb of the 
PLATE L.
           INSTRUMENTS FOR OPERATIONS  ON THE URETHRA.

   Fig. 1. A Male Silver  Catheter.  The eye  is better than the perforations
 usually made, as such an opening will not clog  with mucus.   Kolbe's pattern.

   Fig. 2. Curve of the Catheter adapted to old  men with enlarged prostate.
                                                              After Dorsey.
   Fig. 3. Small Silver Sound for the purpose of dilating or detecting a stricture
 of the urethra.                                              Kolbe's pattern.
   Fig. 4. Largest size sound for same purpose.                   "     "
   Fig. 5. Smallest size of the instrument.                        "     "

   Fig. 6. Flexible Lead  Bougie for dilating strictures; it may be retained in the
 bladder many hours without creating irritation.                Kolbe's pattern.
   Fig. 7. French Bougie, with a "porte empreinte" for taking a cast of a stric-
 ture.  1. The " porte empreinte,"  or mould.              From the instrument.

   Fig. 8. Amussat's instrument as applied  to  dilate a  stricture; being  intro-
 duced closed, the loop is expanded  by the screw.              Kolbe's pattern.

   Fig. 9. Chew's Stylet for dividing stricture; it is to be introduced into a silver
 catheter, like Fig. 14.                                        Kolbe's pattern.
   Fig. 10. French pointed  Gum-elastic Bougie for dilating stricture.
                                                      From the instrument.
   Fig. 11. Physick's Stylet for incising stricture in the spongy portion of the
 urethra.  1.  Slide to move the blade.                         Kolbe's pattern.

   Fig. 12. Steel Bougie silvered, and of double curve, to  dilate strictures ; there
 are two ends, of different sizes, embraced in each instrument.   Kolbe's pattern.

   Fig. 13. Lallemand's Porte-caustic for  cauterizing the urethra.   1. Cup for
 the caustic.                                                 Kolbe's pattern.
   Fig. 14. A Curved Catheter and Stylet for dividing strictures near the neck
 of the bladder.                                               Kolbe's pattern.
   Fig. 15. Extra end of another curve.                            «     «
   Fig. 16. Physick's Bougie Catheter for entering the bladder in cases of stric-
 ture-                                                         After Dorsey.
   Figs. 17, 18.  Shape of the piece  of waxed cloth before it is rolled into the
bougie, and attached to the catheter.                           After Dorsey.
   Fig. 19. The  complete  instrument.                              »     «
        (474) 
—-..----h
 
 
CATHETERISM.                        475
 urethra.   Then, gradually depressing the handle  so  as to  bring the shaft
 parallel with the thighs of the patient, cause the point thus to mount over the
 triangular ligament, when  the gush of urine may be checked by  the thumb
 placed over the orifice of the  instrument until a vessel is held to receive it.
 In this movement, the end of the instrument should be made to describe the
 arc of such a circle as will  enable the point to pass readily behind the pubis,
 as is shown  in  Plate LI. Fig. 4.   After evacuating  the bladder, keep  the
 end of the catheter closed  with the thumb until the instrument is removed
 from the patient and held over a vessel, when, on freeing it,  the urine which
 has filled  the instrument will escape without soiling the patient.
   The "Tour de Maitre," or "Master-stroke,"consists in passing the cathe-
 ter through  the spongy and bulbous portion of the urethra, with its mouth
 presenting to the patient's feet and with  the convexity of the instrument
 toward the pubis.   Then, on reaching the perineum, turn the catheter rapidly
 around so that its concavity will be toward the pubis, and, rapidly depress-
 ing the handle of the  instrument,  slip  its point quickly into the bladder.
 This ad captandum movement does not possess a single advantage over  the
 plan just described, and savors somewhat of charlatanism.  All rapid move-
 ments in  the introduction of  instruments into  the urethra  should be dis-
 couraged, as they unnecessarily expose the patient to danger  from the lacera-
 tion of the canal, or from the creation of a false passage.    Some surgeons,
 when passing the catheter,  prefer that the patient should stand  up, with his
 back against a  wall, while  they seat themselves in front of him, but the re-
 cumbent posture of the patient has always been the most convenient to me.
 In the introduction of the catheter in irritable patients, even  when  not labor-
 ing under any organic change  in the course of the urethra, the mere passage
 of the instrument with all possible gentleness will sometimes be followed by
 severe constitutional disturbance, such  as  rigors and fever, or by  symptoms
 of local irritation, as a muco-purulent discharge  or  epididymitis.   These
 symptoms, being usually evidence of neuralgic irritation transmitted to the
 spinal system of nerves, may be best alleviated by warm hip-baths;  by ano-
 dyne enemata, such as laudanum and starch; by a full dose of Dover's powder,
 and by rest  in  a  warm bed, with the testicles  supported by a suspensory
 bandage;  or by leeches to the  perineum, and the application  of warm cloths,
 though most frequently rest and an  anodyne will suffice without the employ-
 ment of the other measures.   Should the  chill and fever  be  reproduced on
 the second or third day, a full  dose  of quinine will be  demanded as in ordi-
 nary intermittent fever.   When difficulty has been experienced in  the intro-
 duction of a catheter, it may be retained in the bladder for two or three days,
 by attaching tapes to a ring or bandage around the penis, a plug being placed
 in the instrument so as to prevent the constant escape of the  urine.
   Under ordinary circumstances, or  when the urethra is in its normal condi-
 tion, the introduction of the catheter cannot prove a difficult operatiou to any
 one who is familiar with the anatomy of the urethra.   As a certain amount
 of dexterity is,  however, only to be  gained by practice, the  student should
 endeavor to introduce an instrument into  the bladder whenever he has the
 opportunity in the dissecting-room.   In a healthy subject, practice will soon
 give the hand its cunning, while the difficulties occasionally met with in the
 patient may be  prepared for by a little study of the diseases  of  the urethra
 as found in the  monographs on this subject, or  by a reference to  the brief
mention of them to  be found in the following section.
  Obstacles to  Catheterism.—Although,  as just stated,  the introduction
of an instrument into the bladder is, under ordinary circumstances, a very
easy operation to one perfectly familiar  with the anatomical relations of 
476
PRINCIPLES AND  PRACTICE OF  SURGERY.
the part, it may be rendered one of great difficulty in consequence of certain
peculiarities which will now be mentioned.
  If the instrument is a fine one, its  point is liable to enter and be held by
an enlarged lacuna:  to obviate this difficulty, withdraw the catheter a little
and elongate the urethra by stretching the penis.   Or the point of the instru-
ment may pass readily as far as the membranous portion of the urethra,  and
hitch there in consequence of its  being made to bear too much on the inferior
side of the urethra, from the too sudden elevation of the handle; or the point
may be carried so as to strike against the lower edge of the triangular liga-
ment.  In these cases, when difficulty is experienced, the young surgeon should
be especially cautious as to the amount of force that he employs to overcome
it, as it is very easy to drive an instrument through the membranous portion
of the  urethra, and thus  carry it between the bladder and rectum, or  make
a false passage and create a perineal fistula in consequence of the point of
the instrument being thrust  into the  perineum, or even, as I  saw in one in-
stance  in the  hands of an ignorant  practitioner, brought out at the  tuber
ischii.    Again, especially in old men, there may be such  a condition of  the
third lobe of the prostate as will prevent the entrance of the instrument into
the bladder, in consequence of this enlargement of the gland, a fact that may
be partially diagnosed by feeling the prostate through the rectum.
  To overcome the difficulty created  by an enlarged lobe  of the prostate, it
is absolutely necessary that the point  of the catheter  should be made to curve
upward  a little more behind the pubis than is usually required, and various
means  of accomplishing it have therefore been suggested.  The simplest of
these is to introduce the left forefinger into the anus and press up the point
of the  instrument,  while its free  end  is gently depressed to the level of  the
thighs; or where the flexible  catheter with  a  wire stylet is employed, to
resort to the expedient by which Hey, of England, accomplished the same
object, that is, gently withdraw the wire a little, and push the catheter  on-
ward,  a practice which has often proved successful.   The proper shape of a
metallic catheter for an  enlarged prostate may be obtained  by introducing
the point of its curve or the  end of the wire, if an elastic instrument, into  the
tube of a key for the extent of a quarter of an inch, and then gently bending
up the  point.
  Asa flexible wax bougie, by adapting itself to the condition of the part,
will often pass more readily than a catheter, Physick was  accustomed to
attach  a bougie point to  the ordinary catheter in the following manner:—
  Physick's Bougie Catheter.—Cut off the point of a flexible French (gum-
elastic) catheter, so as to leave  the canal open throughout the instrument;
then rolling up a piece of waxed linen so as to form a conical pointed bougie,
make a slit half an inch long in  its lower end, so that the rolled part may
be inserted into the catheter.  The other portion of the linen being now
wrapped around the outside of the instrument, and fastened  with  a strong
thread, Plate L. Fig.  16, the latter should be  stitched through the end of
the bougie and brought out  of the open end of the catheter, so as to secure
the extraction of the point, if accidentally broken off.  This bougie catheter
is readily made, and will  often serve  the purpose of evacuating the bladder
better than any other instrument.
  With patience and gentleness combined with practice, most of the diffi-
culties  attendant on the passage of a catheter through a diseased urethra
may be overcome.   Those consequent on irritability of the canal, or a spas-
modic contraction of the perineal muscles, or, as it is sometimes called, a spas-
modic stricture, yield usually to gentle and continued pressure of the catheter,
especially if the patient is  etherized, and offers no  resistance to the use of
the instrument.  Those  due to stricture  of the urethra require the means 
STRICTURES  OF THE URETHRA.
477
spoken of under this latter head.  In all cases requiring the use of a metallic
or bougie catheter in cold weather, it will prove useful  to warm the instru-
ment and grease it thoroughly with lard in preference to oil before using it.
   Occasionally it  happens that a catheter, even when  well placed in the
bladder, will not evacuate its contents, in consequence of the over-distention
of the viscus.  As this effect is due to temporary paralysis of the muscular
coat, it may be necessary for the surgeon to  make gentle pressure over the
pubes in order to aid in the evacuation of the urine.
   Iu some instances, it happens that a surgeon is called upon to pass the
catheter in a patient who  has previously been injudiciously treated, and
whose urethra has been torn by the forcible attempts at the introduction of
an instrument so as to create a false passage.  In treating such cases, great
care is necessary in order to obviate the tendency of the catheter to enter
the false route instead of passing along the true one.    With an accurate
knowledge of the urethra and a light touch, any deviation of the point of the
instrument may, however, be readily told and obviated  by withdrawing the
instrument a  little, elongating the urethra, and then passing the catheter
onward, while its point is  kept closely applied to the upper or lateral por
tions of the canal, the false route being nearly always found on the inferior
surface of  the urethra in consequence of the practitioner bearing the point
of the catheter too much toward  the perineum, after it  has passed the  bulb.
Two-thirds of the false passages will also be found  at or  near the bulb, or
in the  membranous  portion, or in advance  of the  triangular ligament, in
consequence of the too rapid elevation of  the instrument from the level of
the abdomen.

                            SECTION  IV.

                      STRICTURES OP THE URETHRA.

   Stricture of the Urethra consists in such a diminution of the normal cal-
ibre of the canal  as interferes with the proper performance of its function.
As the spasmodic stricture has been alluded to under the head of Catheter-
ism, the permanent variety now demands attention.
   Permanent Strictures of the Urethra, as already stated,* are those which
are due to such morbid changes in the parietes of the canal as result in diminu-
tion, until at last it offers a marked obstacle to the escape of the urine from the
bladder. The latter variety  of strictures, being due to chronic inflammation in
the part, is usually designated as permanent strictures, and may be developed
by any cause capable of inducing inflammatory action in or around the mucous
coat of the canal.  Whether this action produces a  simple bridle or thread-
like deposit, or one of greater breadth and extent, there is usually noted more
or less thickening of the mucous membrane, as well as solidification or  indu-
ration of the  adjoining tissues.   In front  of a  stricture there may be but
little departure from the normal condition of the  lining  membrane of the
urethra up to the  edge of the obstruction;  but  behind  it the canal is  often
considerably dilated, either throughout its circumference or on one side,  while
the adjoining lacunae  and entire  mucous coat indicate  the effects of  these
changes, by their  various departures from the natural  state.  It has also
been asserted that softening and dilatation are often present at one or more
points adjacent to the stricture of the urethra as well as in that of the
oesophagus.
   Diagnosis. — The  existence of stricture, though often indicated by the
* Vol. i. p. 310. 
478
PRINCIPLES  AND  PRACTICE OF SURGERY.
 marked symptoms previously stated, can only be accurately told by such an
 exploring operation as brings an instrument directly in contact with the ob-
 struction.  To do this correctly it is essential that the operator should have a
 correct knowledge of the natural relations of the part; that the bougie, sound,
 or catheter first employed be  sufficiently large to distend the canal and thus
 enable its point to escape the orifice of any enlarged lacuna, and that the ordi-
 nary difficulties referred to in  catheterism be borne in mind, especially the lia-
 bility to error caused by depressing the handle of the instrument too soon, or
 before its point has reached the triangular ligament of the urethra. Two other
 sources of mistake in regard to stricture, and which  may  lead us to infer
 their presence when they  do not exist, must also  be remembered.  One is
 that the flaccid state  of the urethra is liable to produce transverse folds in
 the canal, especially near the bulb, which folds may stop the  end of a bougie,
 while a deep depression, naturally existing at the back of the prostate, will,
 by receiving the  point of the  instrument, arrest its progress.  A careful
 examination with the finger introduced into the rectum is necessary in  order
 to prevent or correct  both of these errors,  and enable us to pass the instru-
 ment onward.  After establishing the seat of a stricture it  is also  essential
 that its extent, character,  and permeability be accurately learned before de-
 ciding on the plan of treatment.
   Various means have been suggested in  order to  demonstrate accurately
 the character, situation, and condition of  a  stricture, among which the use
 of soft bougies, or those formed of waxed linen, have been the most promi-
 nent.  When  one of these instruments—of the full size—is oiled, carried
 down to and pressed  firmly against a  dense  stricture for a  few minutes, it
 softens by  the heat of the body, and takes such an impression as will  show
 accurately the position of the  obstruction.   But as the less dense strictures
 are incapable of  marking their own position upon such  an  instrument, the
 following plan, which is a slight deviation from that suggested by Ducamp,
 will prove serviceable :—
   To take a Cast of  a Stricture.—Take a piece of silk ribbon about two
 inches wide and three inches long, and cut it obliquely across, Plate L. Fig;
 17 ; then pull out all the  transverse  threads to within three-fourths of an
 inch of the length of the  piece; next melt  equal parts of beeswax, shoe-
 makers' wax, and resin in  a cup; fasten  the  sound part  of  the  ribbon to a
 wax bougie by a  stitch, or by  thread wound around  it, and, dipping it into
 the melted mixture, saturate the longitudinal threads of the  ribbon with the
 wax; dip this into cold water,  and  then  mould  it, by pressure  with the
 thumb and fingers, into a conical shape, Plate L. Fig. 7.   On carrying a
 bougie thus armed down to  a  stricture and pressing it gently against it, a
 perfect cast of the part may be taken, provided the  bougie  and waxed end
 are large enough  to fill up the canal.
   Treatment.—Having thus learned  the character and  position of the dis-
 ease,  attempts may now be made to overcome it, either by dilatation,  inci-
 sion, or the use of caustic, the selection of either plan being decided by the
character of the  obstruction, or the  peculiar circumstances of the case.
Dilatation is especially applicable to  recent, and not very contracted stric-
tures, or to patients who can be kept under treatment a considerable length
of time, or have sufficient intelligence and judgment to enable them to con-
tinue  the introduction of an instrument after they have left  their  surgeon.
Incision should seldom be employed  except in old, dense, and  almost im-
permeable strictures, where the patient can be subsequently watched ; and
caustic proves most useful in similar  cases where, from the  position of the
stricture, its puncture would be attended  by great uncertainty, as  in  the
membranous portion of the canal, or in those patients  in whom the altera- 
STRICTURES  OF THE  URETHRA.                 479
tive effect of the caustic may lead to a modification of the surrounding tis-
sues and the possibility of continued dilatation.  The value of these different
means of treating  stricture have  been  variously estimated, some surgeons
preferring one plan, some another, and some a combination of  all.   I shallj
therefore, describe them separately, and state the estimate of their value
subsequently.
  I.  Dilatation.—Dilatation of a stricture consists in expanding it by the in-
troduction of such an instrument as is capable of entering within the limits of
the constriction, and can only result from the application of a force which shall
act from within.   It is evident, therefore, that this mode of treating the com-
plaint is only applicable to such strictures as are sufficiently patulous to
permit the entrance  of the dilating instrument, and sufficiently flexible to
allow of the distention of the  parietes of the canal.  Dilatation is, there-
fore, usually accomplished by first passing a large metallic sound or flexible
bougie down to the  stricture, in  order  to  show its distance from the fossa
navicularis;  then  passing one sufficiently fine to penetrate  it,  and  then an-
other, each of them  being allowed to remain a few  minutes at a time, unless
they cause great irritation, or constitutional disturbance, when they should
be withdrawn, and not replaced until next  day.  If they do not excite too
much irritation, each sound may be followed  by one of greater bulk, until
at last the stricture is sufficiently distended to permit the free passage of the
urine.   In some instances, surgeons have advised the employment of special
dilators;  thus, Arnott, of England, employs  an instrument which he terms
a "fluid dilator;"  Perreve, of Paris,recommends a two-bladed steel dilator,
the blades of which are introduced closed, and then  made  to  expand  by a
screw at the free  end.   A similar  one  hf s  been  also advised by Holt, of
England; while Wakley,* of London, uses a series of hollow tubes, each of
which is passed over the one first introduced, so as gradually to increase its
thickness.  Parrish, of Philadelphia, recommendedf a tapering silver bougie;
but I have invariably employed  the ordinary medium  size round-pointed
silver catheter, and  deem it more certain and safer than all  other instru-
ments.
  Bougies made of the bark of the Ulmus Fulva have also been suggested
within the  last few years  by  Waters, of  Maryland, and  by McDowell, of
Missouri, as especially advantageous  in  dilating  strictures;  but  personal
experience has shown me that  they are brittle, dangerous, and have no ad-
vantage over the  bougie of gum-elastic.   Those  of  gutta-percha  are  also
brittle, and have broken off in  the canal.
  Operation of Dilatation.—In  order to treat a stricture by dilatation, the
surgeon should  first give his attention to  the preparation  of the  general
health of the patient, and especially to the condition of his digestive organs,
so that there may  be no  irritation subsequently excited by the passage of
phosphatic, or  otherwise disordered urine.   Then,  if the patient is irritable,
let his nervous system be quieted by gentle anodynes and the use of the hip-
bath, with rest, or let anaesthetics  be employed during the operation.   Having
thus attended  to  the  constitutional treatment, let such an instrument be
selected as the operator deems best—my own preference being for  the solid
metallic bougies, with a broad handle like a sound, and a smooth and slightly
tapering point, Plate L.  Figs. 4, 5—and after warming and greasing it, carry
it down to, and if possible  within, the stricture, retaining it there for a few
minutes; or, if this cannot be accomplished, carry  it to the face of the stric-
ture, and allow it to remain there as long as the patient can bear it without
inconvenience, whether it be five minutes or two hours,  though usually few
* London Lancet, vol. i. 1851.
f Surgical Observations, p. 295. 
480
PRINCIPLES  AND  PRACTICE OF SURGERY.
 persons will be able to sustain the pressure of the  instrument either within
 or against a stricture more than half an hour at a time, and some, only half
 a minute.  If the patient, on the contrary, is "case-hardened," most of these
 precautions may be omitted, and the instrument be passed to the stricture,
 held there a few minutes, removed, and then the patient permitted to attend
 to his ordinary avocations, if  not of too laborious a kind.   Many patients
 walk to the surgeon, have a bougie passed, and travel about all day without
 inconvenience; while others  will have rigors and the constitutional disturb-
 ance referred  to  in  connection  with catheterism, from the gentle introduc-
 tion of the most highly-finished instrument.   Sudden and forced dilatation
 of  a stricture has been advised  by some of the European  surgeons,  and
 occasionally proved useful; but it  is a dangerous  plan of  treatment, even in
 skillful hands, and no others should attempt it, as it has very often resulted
 in a "false passage."  Very often the single introduction of a bougie through
 a stricture will be followed by benefit, but generally the operation must be
 repeated for many months, until absorption removes the disease.  The further
 observations  on  the treatment of dilatation will  be reserved for the end of
 this section.
  II.  Internal Incisions.—The internal division of stricture is  especially
 applicable to  such cases as are too dense to admit of dilatation, or so tight
 or so  situated as to render it difficult or impossible to enter them with a
 bougie.   In these cases, it has been suggested to cut through the induration
 by means of a lancet applied so as to act through the urethra itself.  Such
 an incision is especially demanded in cases where it is required to  evacuate
 the bladder promptly, or in  those  where  the  resistance forbids  the hope of
 any advantage from dilatation.
  Instruments.—Among the  various instruments resorted to by surgeons
 for the purpose of dividing a stricture in the canal, I shall select as especially
 useful the lancet or stylet catheter of Physick, of Philadelphia, and that of
 Chew, of New Orleans.
  Physick's Stylet Catheter  for Dividing  Strictures___This instrument
 consists of a silver catheter, curved so as to pass readily as far as the stric-
 ture, in which  is concealed a lancet that may be protruded  at pleasure Plate
 L. Figs.  11, 14.
  Operation.—The catheter  being passed down to the  stricture, is pressed
 against the obstruction, the lancet  protruded to the extent of two or three
 lines, so  as to cut  into  the thickened part,  the blade retracted, and  the
 catheter again pushed forward in the opening thus made, until at last it can
 pass beyond the obstruction, and restore the permeability of the channel.  A
 common catheter being afterward introduced, should be allowed^to remain a
 few days,  until the  incisions have  healed; when, by repeated introductions
 of a dilating  bougie, the subsequent contraction of the  part may be  pre-
 vented.
  Chew's Instrument for Incising and Dilating a Stricture___A useful
 modification of the  stylet of  Physick  may be found in  the  instrument of
 Chew, of New Orleans, Plate L. Fig. 9.   This instrument consists of a silver
catheter, open at the point, and split so as to permit a double-edged knife
to be projected from it.   The point of the knife is blunt, and pierced for the
 passage of a probe-pointed wire.  The knife  and probe being closely with-
drawn within the point  of the catheter, the  latter  is passed down to  the
stricture, the  probe, gradually protruded,  passes within  it,  and the knife
guided in the proper course  by the  probe, pushed  on gradually . until it
?u  i? ?/ stncture » wheD> being retracted, the  catheter is pushed on  into
the bladder, and the  parts  subsequently  dilated  by the constant use  of 
STRICTURES  OF THE  URETHRA.
481
    Maisonneuye's Method of Dividing Strictures  from within.*—The
 patient lying in the  usual position, an elastic bougie  is introduced through
 the stricture.   " This bougie is slightly tapering, having upon its  greater
 end a metallic  ferrule.   As soon as the stricture has been fairly passed, a
 small-sized silver instrument, looking like a  nearly straight catheter, is to be
 screwed on to the metallic ferrule of the bougie, and then gradually introduced
 into the urethra, pushing the  bougie before it, so that the latter curls itself
 up in the bladder, after having  acted as a pioneer or guide  for the  silver
 instrument.  The silver instrument, having passed through or well into the
 stricture, is then to be  held  steadily until  a  stylet sliding in  a groove  is
 passed down the catheter to the  stricture, which it partially divides.   This
 cutting instrument has an almond-shaped edge, which cuts from the lower
 side of the grooved canula, and not from its end, as that is obstructed by the
 insertion of the ferrule of the bougie.  The  stricture being  now partially
 divided, the whole apparatus is then withdrawn,  and another flexible bougie,
 which  is generally conical, having the calibre of its main body considerably
 larger  than the bougie  first used, is then  passed in the same manner as the
 preceding,  and  with  about the  same ease, owing to  the  already partially
 divided condition of the stricture.   The large urethrotome is then screwed
 upon the bougie, as the other  was in the first  instance, and pushing, in the
 same manner, the bougie  before it, enters the stricture.   The  urethrotome
 being passed sufficiently  through the constriction, the  concealed blade  is
 opened, and the stricture divided completely.   The urethrotome and bougie
 being  then  removed, a large-sized  steel sound can be readily introduced.
 *   *    *   *  The proportion of deaths is said  to be one out of every four
 thus treated."
   Remarks.—The advantages of the treatment of stricture by internal in-
 cision,  like that by dilatation, being also a point on which there is a diversity
 of sentiment, the estimate of its value will be deferred till after the consider-
 ation of the other means of treatment.   Should the operation of internal
 incision create severe  constitutional disturbance, it must be counteracted by
 the employment of the means  advised in the use of the catheter.
   III.  External Incisions.—In  some cases of  stricture where it has been
 found impossible to pass  an instrument, and especially in patients who had
 stricture in  advance of the bulb, the older surgeons  made a  button-hole
 incision from without inward, as follows :—
   Operation.—A director or sound, being passed down to the stricture, was
 there held by an assistant, while the surgeon made an  incision, through the
 inferior portion  of the  parietes of the  urethra, to the point of the  sound.
 Then directing the patient to endeavor to urinate, the surgeon passed a probe
 in at the bottom of the  wound, and searched for the portion of the urethra
 behind the stricture, or cut backward until he found it; after which a catheter
 was carried  into  the  bladder  through the  penis,  and  the opening  in the
 urethra closed upon the  catheter by sutures.
   Remarks.—This operation  having been  occasionally demanded, its per-
 formance has been followed by results of a satisfactory kind  in a class of
 cases which appeared otherwise to be hopeless,  and under slight modifica-
 tions has been  recently brought  again into notice  by Syme, of Edinburgh,
 and excited warm discussion as to its dangers and  advantages.   The modi-
 fication  of Syme, and his advocacy of its merits, having  given this operation
the authority derivable from the name of him who so warmly urged its value,
the modified operation is frequently  spoken of as Syme's operation.  A
  * Letter from Paris, by G. Luckley, M.D., N. Y. Journ. of Med., vol. iv. 3d series,
341, 1858.
    VOL. II.—31 
482            PRINCIPLES AND  PRACTICE OF  SURGERY.
similar method was, however, practiced in the United States, and ably advo-
cated by Jameson, of Baltimore, in  1828, but was generally received with
little favor, owing to the  difficulties attendant on its performance, even in
able hands.                                                  ,     .
  Syme's  Operation.—Introduce a grooved director through the stricture,
which  mav generally be dilated to receive this  instrument.  Then, placing
the patient upon his back  at the edge of the bed,  and with his knees held up,
make au incision about an inch aud a half long  in the middle line of the
perineum,  (in advance of  the bulb of the urethra,) so as to admit the  knife
to the groove in the director, and slit up the thickened texture to the extent
of an inch or  two, if necessary.   Then  passing a  No.  8 catheter into the
bladder, retain it there for  at least two, but not more .than three days.  After
the withdrawal of the catheter, the urine will now and then escape through
the wound, but it soon diminishes to a few drops, and gradually resumes its
proper course.   A full-sized  bougie must, however,  be subsequently passed
every three or four weeks,  in order to maintain the cure.
  A curious train of symptoms, consisting of severe rigors,  bilious vomiting,
suppression of urine, aud delirium, have sometimes  supervened on the with-
drawal of  the  catheter; but  Syme thinks them of slight  importance, as it
only requires, in his opinion,  time and patience to remove them.
  Miller, of Edinburgh, who attended a patient  with Syme, thinks them, on
the contrary, very serious,  having found  these operations to be  followed by
a perineal abscess which  required to be opened, by a pelvic abscess which
opened into the rectum, and  by a painful as well as protracted  and critical
recovery.
  Remarks.—The treatment of strictures of the urethra by external incisions
is a question which has lately been warmly discussed, especially in connection
with the method of operating, which, as just  stated, is named after  Syme,
though the principle is quite  an ancient one, having been recommended and
practiced in  1650, and revived in 1811 by Chevalier, again by Arnott in 1822,
and again by Sir B. Brodie, as well as by Jameson, of Baltimore, in 1828.
Many objections have been raised to this operation, and supported to some
extent by  cases which indicate  its dangers, such  as the risk of  hemorrhage,
of perineal infiltration, and of abscesses.  The opinion  of  most surgeons in
the  United States coincides, I think, entirely with that expressed by Solly,
of London,  in  relation to this  operation, to wit, that where it is possible to
introduce  a grooved director, it is also possible to pass a bougie  and relieve
the  patient  by dilatation.   As Syme only claims  the  applicability of his
operation to cases where  the stricture is in advance of the bulb, many will
be found to which it is not  suited.   In patients who have stricture  of  the
membranous portion  of the urethra, or who have the canal  almost entirely
obliterated at the seat of  stricture, or who have the winding corkscrew stric-
ture sometimes seen, or  have perineal fistula, this operation cannot be
readily employed.   But when the  stricture is in advance of  the  bulb, when
the submucous and spongy structures around the canal are converted into a
hard fibrous mass, or when the  constriction seems to be composed of a fibro-
elastic tissue  like India-rubber, which,  though  readily  dilatable, yet soon
contracts, the external  incision may be, in the  opinion of Coulson, advan-
tageously resorted to.  It should, however, be  recollected  that in  Syme's
operation death has ensued from purulent infection, as  well as from hemor-
rhage, and that it has almost followed the subsequent  perineal  and  pelvic
abscesses.   If with these  results before him, the  surgeon yet deems the other
means of  treatment objectionable, he should bear in mind the importance of
preventing the urine from escaping within the perineal fascia, and infiltrating
the  surrounding parts.   As  in any incision, dilatation  is  requisite in order 
STRICTURES  OF THE URETHRA.
483
to maintain the cure after the operation, I would generally prefer to use the
stylet catheter of Physick, before  mentioned, rather than make an external
wound.  But if an external incision is essential, and a director can  be passed
through the stricture, it is, of course, much  safer to operate in the manner
directed by Syme, that is, by cutting on the point of  a sound, previously in-
troduced into the canal, and, if possible, into the stricture itself.
   IV.  Caustic  in  Strictures.—The removal of permanent  stricture by the
creation of a slough from the application of caustic, is a mode of treatment that
has much to recommend it, as it destroys the  extreme sensibility of the canal,
and stimulates local cell action to a change of structure.  By the slight cau-
terization  of the urethra  by the nitrate of silver, its extreme  sensibility is
sometimes so diminished that an instrument will pass without much difficulty
in the so-called  "irritable strictures."  But in most cases of permanent stric-
ture a more active caustic is demanded, and may be applied by means of vari-
ous instruments, according to the character, position, and extent of the stric-
ture ;  the  principal object being to retain the caustic in contact with the
constricted part sufficiently long to produce an eschar. When caustic potash
is employed, twenty seconds will usually be sufficient; after which  its further
action should be arrested by injecting sweet oil.  If the nitrate of silver is
used to create a marked slough, from  one to two minutes may be  required,
the time varying according to the density of the stricture and the  inflamma-
tory tendency of the patient; but great care is necessary to insure the proper
application of any  caustic, and limit its action to the diseased structure.
   The  instruments  employed  to  introduce  these caustics have  been  very
varied, but need  not be specially referred to, the selection of any one  being
influenced  mainly  by the judgment of  the  operator.   I  shall,  therefore,
merely mention  the mode of applying caustic  recommended  by  Ambrose
Pare and Hunter, as it is one which experience has  taught  me is sufficient
for the ordinary varieties of  stricture at any point where an instrument can
be applied.
   Operation.—Select a metallic canula or catheter, open at  both ends, of
sufficient size to distend the urethra to its utmost extent, and pass it down
to the  obstruction  ; then  arm securely a smaller canula with a  morsel of
caustic, so that it may project ab»ut two lines beyond the canula.   Pass the
smaller within the larger canula carry it down to the stricture, retain it in
contact with the obstruction for the time above  directed, and, withdrawing
it, inject oil, if caustic potash has been used, or salt and water, if the nitrate
of silver has been applied, into the urethra through the larger canula, before
the latter is withdrawn.   After the  caustic has been  applied in this manner,
at intervals of from three to  eight days, according to  the inflammation which
may have been induced, forcible catheterism and dilatation, if judiciously per-
formed, will generally perforate the  obstruction ; after which, lateral cauter-
ization, occasionally performed with  Lallemand's or some  similar instrument,
will diminish the risk of subsequent contraction.
   Remarks.—The treatment of strictures of the urethra by any of the means
just detailed is an operation requiring  much  judgment  on the part of the
operator, lest the force—either in dilatation, internal incision, or  the intro-
duction of the armed bougie—applied to a stricture through the instrument
lead to a perforation of the walls of the urethra and the production of a false
passage.  But when the surgeon is guided  by a correct knowledge of the
structure concerned, as well  as of  the  changes induced in the canal by dis-
ease, any of the  plans just mentioned may be safely employed ; the selection
of one rather than another being mainly the result of the peculiarities of the
case, or of individual experience and tact.
  In  estimating  the value of any method of treatment in strictures of the 
PLATE   LI.
              OPERATIONS  PRACTICED ON THE URETHRA.

   Fig. 1.  Catheterism.  The  penis is held  in the left hand between the thumb
and forefinger, so as slightly to elongate the urethra, and prevent the formation
of folds of the mucous membrane, while the second and third fingers push back
the prepuce.  The point of the  catheter is about to enter the  orifice of the
urethra.                                        After Bourgery and Jacob.

   Fig. 2. A section of the pelvis and abdominal parietes, to show the relations
of the parts and the position of Lallemand's porte-caustic, while passing through
the prostate, in the operation of cauterization.
                                             After Bourgery  and Jacob.
   Fig. 3. A similar section, showing the position of a catheter when being in-
troduced into the bladder.   The vertical line represents the plane of the sym-
physis  pubis.  The first position of the catheter, when its point has reached the
membranous  portion of the urethra, makes  an arc of from  60° to 80°, as at 1.
Depressing it yet more, about 25° or 30°, as at 2, elevates the point beneath the
pubis, and carries it into the neck of the bladder.  The circle 1, 2, 3 shows the
line of motion of the mouth of the instrument; if the mouth is depressed more
than the angle marked at 3, the instrument %ill  drag on the suspensory liga-
ment, and may injure the third lobe of the prostate and  the bladder.
                                               After Bourgery and Jacob.
  Fig.  4. Puncture of the  bladder through the urethra by means of the Stylet
Catheter of Physick.   1. Course  above the prostate, in  consequence of the too
early depression of the mouth of the instrument.  2. Puncture through the pros-
tate near the natural line of the urethra.  3.  Course below it.
                                               After Bourgery and Jacob.
  Fig.  5.  A button-hole opening made in order  to remove a stricture in the
urethra.  1.  A director passed down the urethra  to the front of  the stricture.
2.  Another director introduced through the perineal puncture.  3. The bistoury
enlarging the perineal incision.                   A/ter Bourgery ^ ^

       (484) 
 
 
STRICTURES OF THE  URETHRA.
485
 urethra, it  should, however, be recollected that a  permanent  stricture is a
 diminution  of the  urethra due to inflammatory thickening;  that this thick-
 ening or obstruction often  presents us with a species of inodular tissue, or
 organized lymph similar to it;  and that, like ordinary cicatrices in the skin,
 the parts about it do not lose their contractile tendency for months.  If, then,
 even in a  moderately tight stricture, dilatation  is resorted to, and forced
 catheterism practiced, a passage  may  be created  and gradually enlarged
 under mechanical  force, and yet so little change effected in the vital action
 of the part that, on the cessation of the dilating means, the stricture will be
 liable to return, as is daily seen in cases where  the occasional  use of  the
 bougie is not pursued by the patient after leaving the hands of the surgeon.
 When, therefore, patients who, with a small and  tight stricture, are usually
 barely able to urinate, but yet, when treated by dilatation, are enabled to
 void a full  stream, and to receive readily a full-sized instrument, are about to
 leave their  surgeon, they should not be allowed to return home under the idea
 that  they are certainly cured ; but should be made aware of  the risk they
 will incur if they neglect the introduction of  the bougie, as it is not  uncom-
 mon  to find them, in twelve months, more or less afflicted by a reappearance
 of many of  their old symptoms.   Dilatation, therefore, though very  prompt
 and useful in many cases, is a plan of treatment liable to induce false  secu-
 rity, as it merely palliates, but does not radically remove the complaint, unless
 persevered  in for a long period.
   When incisions  are made through a stricture—either by internal scarifica-
 tion, as  practiced with the  stylet of Physick, or by the button-hole  incision
 of the older surgeons, or by that which  has lately been so highly lauded by
 Syme, of Edinburgh—there is also little change effected in the action of the
 part  that can induce a hope of the permanent removal of  the obstruction.
 As a means of insuring the prompt evacuation of the bladder, incisions  are
 highly serviceable, and that resulting from the use of the stylet of Physick
 may  do  away with the necessity of tapping the bladder through the rectum ;
 but  alone these operations will do  little toward curing a  stricture, as  the
 operation by internal or external incisions necessarily gives rise to new cica-
 trices, and  these cicatrices ultimately increase the  tendency to contraction.
 Although an incision is useful as  a means of forming a communication with
 the  bladder, I  would yet caution  the  inexperienced operator against  the
 omission of dilatation for  a  long  period after the passage  is apparently
 perfectly permeable by a cutting instrument, as the cicatrix resulting from
 the incision will almost invariably contract, and tend to reproduce the com-
 plaint.
   The application  of caustic is, I think,  the best means of removing the dis-
 eased structure, and has many points worthy of deliberate and unprejudiced
 consideration.  When a superficial eschar is formed, either by the rapid action
 of the potassa  fusa, or by the slower  effects of nitrate of  silver, a  certain
 amount of action is induced in the surrounding parts, which increases the  ac-
 tivity of the tissue  cells, and hastens a permanent  cure.  But even when  the
 application  of the caustic is not made with a view of creating an eschar, its
 effects will yet prove useful by modifying the action in the canal, stimulating
 the absorption of  the fibrous deposit, allaying  irritation, modifying vascular
 action, and  inducing a return of healthy action.  Enlargements of all kinds,
 even of bones, have often yielded to a similar stimulus, while the ulceration
 resulting from the separation of the eschar always tends to union by granu-
 lation rather than  by actual contact, as is the case in incisions.   The appli-
cation of caustic requires, however, much care, as its action may extend  to
 the sound parts unless carefully watched,  and on this account its employment
 is  objected  to  by many operators.  By fully distending the sides  of the 
486
PRINCIPLES AND  PRACTICE OF  SURGERY.
urethra in the manner before mentioned, and  applying the article as above
directed, it is, however, difficult for the caustic to touch any other part than
that which is directly in front of it, while the introduction of oil  after the
use of caustic potash, or of salt and water after that of the nitrate of silver,
will effect such  a change as will  neutralize either article.   In the treatment
of old and dense strictures, I prefer the treatment by cauterization ; in those
which are small and recent, the employment of dilatation by means of those
metallic bougies which, by having a broad  handle, prevent any deviation of
the point of the instrument, the solid bougies of all  kinds  being  preferable
to the flexible oues as dilating instruments; but in impervious strictures, or
in a bad case of retention  of urine, I resort to Chew's stylet, if it is possible
to pass it with reasonable  caution; and if not, I  should cut into the bladder
from the perineum, relying chiefly upon a knowledge of the anatomy of the
structures concerned.   Such  an operation  is, I well know, a very difficult
one, and one in which no surgeon who was not  an experienced  anatomist
would  be likely to  succeed; but, with  correct  anatomical and  practical
knowledge, it has been done, and could, of course, be repeated by others.
   The treatment of stricture of the urethra, to  be judiciously  conducted,
must  be the result of a minute study of the anatomy of the parts, of the
etiology and  pathology of the complaint, as well as of an accurate diag-
nosis, lest the  obstruction be  supposed  to be due to a different  condition
of the canal from that which actually exists.  The subject  of stricture  of the
urethra is one  which  has engaged special attention, and been  most ably
treated in monographs of  considerable extent.   A full account of the com-
plaint  must  not, therefore, be  sought in works which, like this, are of a
general character, and I  can  now only append to this account a summary
of the opinions of  some of the  more  recent writers on the varied forms of
treatment.
   Dilatation, as beiug attended by the least inconvenience to the patient, is
the treatment usually preferred by a majority of practitioners, though a large
number of experienced surgeons regard it with distrust, aud look upon  "a
cure by dilatation" as a very temporary one, the disease often returning soon
after the cessation of the treatment.  Among the latter is  Henry Thompson,
of Loudon, who, in a work* on strictures of the urethra, which attained the
Jacksonian prize for the year 1852 from the College of Surgeons, remarks
iu relation to dilatation as a means of treatment:  "That although  there
are few cases in which, with care and perseverance, an instrument  cannot be
passed through the  stricture, and prove the most safe,  efficient, and gener-
ally applicable  of all the  means of treatment, there are yet some in which
its effects are so temporary that its claim to be  regarded  as a cure must be
disputed.  The contraction often reappears, and  that so  rapidly that, in
order to maintain a canal sufficiently patent for  the performance  of its func-
tions,  an  instrument  must be passed  every  other day  or oftener, aud the
patient be thus submitted to perpetual treatment."
   The same surgeon, speaking of the use of caustics, also  expresses the
opinion that the nitrate of silver is useful in a very limited number of cases;
that neither  it  nor the caustic potash  should be used as an escharotic; but
that  the  potassa, when applied  in very minute quantities, "possesses  a cer-
tain power to  loosen  and dissolve  the tough fibrous tissues of  some stric-
tures."!
   In  summing up  the treatment of strictures,  Thompson thus concludes :|
  * The Pathology and Treatment of Strictures of the Urethra, by Henry Thompson,
p. 205.  London, 1854.
  f Op. cit., 220.                                  % Ibid-t P- 28^- 
PUNCTURE OF THE ELADDER.                  487
"That dilatation has been found successful in the great majority of cases,
but that it is certainly  inefficient for  the cure of some  old and extensive
strictures, as well as for  some which  are  accompanied  by a highly irritable
condition of the urethra; that cauterization is a useful adjuvant to dilatation,
especially where much irritability exists, though wholly inapplicable to  the
removal of old and extensive contractions; and that the internal division of
strictures (incision)  is particularly suited to those  last-named cases  when
situated in the anterior or middle part of the urethra."
   G-uthrie* gives as the  result of his experience that "a hard and elastic, or
intractable stricture, is never permanently cured by dilatation, or by the  ap-
plication of caustic,  although it  may be relieved by the regular periodical
use of a dilating instrument; and that the strictures generally deemed most
difficult to cure, may be best removed by cutting through  them," though  he
also expresses the opinion  that  the division of an old, hardened, or elastic
stricture through the perineum will not usually be followed by a permanent
cure unless dilatation is subsequently continued, and he  therefore prefers the
internal  incision, or the division  of a stricture  by a stylet, especially in  old
and fat patients, as it creates less constitutional disturbance.
   Many other writers might be quoted who object to  all  incisions; but as
their  statements  would  only show the diversity of opinion that exists in
regard to the best plan of treatment, I shall omit them.
   I have now only  to repeat  my individual preference  for the following
plans:   First, to  try  dilatation,  and continue it in permeable strictures;
second, to  render  strictures which are very dense, or  nearly impermeable,
more easy of dilatation  by the  therapeutical or alterative effects of either
caustic potash or the nitrate of silver;  and, third, to attempt to cut through
all impermeable strictures  by the stylet, if they are seated anterior to  the
membranous  portion of the canal, or by the perineal  section,  when seated
farther back or in the membranous structure.
                             SECTION  V.

                      PUNCTURE OF THE  BLADDER.

   When, in cases of stricture, it is  found  impossible  to  evacuate the con-
tents of the bladder through the urethra, or by the urethral section, or the
surgeon is  unwilling to expose  his patient to the risks of a perineal  opera-
tion—cases which, in truth, are very rare in the hands of an experienced sur-
geon—the  contents may be evacuated either by puncturing it through  the
perineum or rectum, or through the  abdominal  parietes above the pubis.
   I. Puncture through the Perineum.—Place the patient in the position
of lithotomy, and let  an assistant hold  up the scrotum and press upon the
bladder above the pubis.  Then, while standing in front of the  perineum,
place the left forefinger  on the left side of the  raphe, half an  inch in front
of the anus, and  between the bulb  and the  ramus of the ischium, so as to
render the  perineum tense, and, with a straight trocar and canula, at least
seven inches long, puncture the integuments.   Then, passing  the left fore-
finger  into  the rectum,  so  as  to preserve the bowel untouched, push  the
trocar  toward the  bladder, so that its  point  may reach the base of this
viscus near its neck, or behind the prostate  gland, by passing through  the
skin, fascia, fat, and anterior edge  of the levator  ani  muscle.   When  the
want of resistance, and the greater mobility of the point of the trocar indi-
* Lancet, June, 1851. 
488            PRINCIPLES AND PRACTICE  OF SURGERY.
cate that the instrument has entered the bladder, withdraw the finger from
the rectum and the trocar from its canula, when, after evacuating  the urine,
the canula may be corked and fastened in position by tapes, which should be
attached to  a double T or split perineal bandage.  In very urgent  cases
the bladder may be evacuated by puncturing it through the perineum with
a lancet, as was once done  by Sir A. Cooper,  and also by Jones, of Phila-
delphia.*
  II.  Puncture through the Rectum.—As the  bladder, when  distended,
encroaches very much upon the  rectum, forming  there a tumor which may
be  felt  from the gut, and  as  there is  no structure of consequence on  the
median  line  of the bladder immediately  behind its neck,  the urine may be
evacuated through the rectum in the following manner:—
   Operation—Place the patient in the position for lithotomy, and pass the
left forefinger, well oiled, into the rectum, and it will readily reach  the prostate
gland, immediately above and behind which it will feel the distended bladder
lying nearly in contact with the rectum, a little cellular tissue alone intervening
in the median line. Then, with the curved trocar and canula  sold by the cutlers
for this  purpose, the puncture may be made as follows: Withdraw the trocar
within the end of the canula,  and passing it along the forefinger first intro-
duced into the rectum, bring its end to the protruding portiou of the bladder,
and then thrusting the trocar forward,  puncture the anterior  coats of the
rectum,  the intervening cellular tissue, and the posterior coats of the bladder.
On withdrawing the trocar,  hold  a vessel to  receive  the urine, and after
evacuating it, plug up the canula and fasten it in  its position  by means of
tapes attached to a T-bandage, as before described.
   After-Treatment.—The patient being  kept in the horizontal position, the
canula  should  be accurately retained at each stool, and if required  to be
worn  longer than three days,  changed by slipping a small  catheter through
it into  the  bladder,  and this catheter changed by slipping another or the
canula again over it.  When the urethra can subsequently be rendered per-
vious, a catheter should be kept in the bladder  through the urethra, in order
to favor the healing of the rectal fistula which is apt to supervene.
   III.  Puncture above the Pubis.—The patient being placed  on his back,
and the hair shaved off, make an incision, an inch  and a half long, through
the skin, fascia, linea, alba, and between  the recti  muscles, so as to expose
the fascia behind the muscles and immediately  over  the distended viscus, the
peritoneum in these cases being reflected from  the bladder to the abdominal
parietes in such a manner as to prevent its being involved in the  operation.
Then puncture  the bladder with  the curved trocar and canula used for the
puncture through the rectum, or have  one made with a curvature of a seg-
ment  of a circle seven inches in diameter, so as to adapt it more readily to
the curve behind the pubes.   After evacuating the urine, fasten  the canula
by tapes to a T bandage, and pass an  elastic catheter  through the canula,
so as to prevent its end  irritating the coats of the bladder.  If the instru-
ment is  worn several days, it should be withdrawn while the catheter remains
in order to cleanse it, and then replaced by slipping it over the catheter as
a director.
   Remarks.—As all these operations are liable  to be followed by death or
serious  inconvenience, they should never be resorted to without a consulta-
tion, if  it can be had, and until every means has been tried to overcome the
obstruction in the urethra.   The advantages possessed by one of them over
* Dorsey's Surgery, vol. ii. p. 173. 
FISTULA IN PERINEO.
489
the others is shown by the following table of Mondiere, given in the Revue
Medicate, April, 1841, and quoted by Gross* :—

                        Cases.      Cured.      Fistula.    Infiltration.     Death.
    Perineal......................    9         6         10          1
    Recto-vesical...............  28        19         3         3          2
    Supra-pubic................  55        49         0         0          6

                         92        74         4         3          9

   The recto-vesical operation is thus shown to  be the least  fatal, but  the
most frequently followed by fistula and  infiltration, while the perineal and
supra-pubic operations have each been followed by one death  in nine opera-
tions.  The proportion of deaths after all the operations is, however, remark-
ably small in this table, and much less than has generally been supposed to
be  the case.   The operation of  puncturing the  bladder must, however,  be
very rarely necessary, as I have never, during a period of nearly thirty years,
seen a case requiring it or a patient on whom it had been performed.
  IV. Puncture of the  Bladder in  the  Female.—The  straightness and
short extent of the female urethra render  the operation of catheterism, as
hereafter detailed, usually an easy one.   Should it, however, be ever requi-
site, the puncture of the female bladder may  be made  by  introducing a
trocar and canula through the vagina,  and healing the fistula subsequently
left by touching it with the nitrate  of  silver.
                         § 1.—Fistula in Perineo.

   Pathology.—When the existence of a deep-seated stricture  has led to a
 dilatation and rupture of the urethra  behind it, the following effects may be
 noted:  The urine, when expelled from the bladder, escapes into  the sur-
 rounding  areolar tissue, and  either  creates such  violent inflammation as
 results in gangrene, or, in more favorable cases, leads to the formation  of an
 abscess,  which,  breaking outwardly, leaves  an  ulcerated  opening,  through
 which most or all  of the  urinary secretion is subsequently voided.  This
 opening constitutes a Perineal Fistula, and continues because the flow of
 urine prevents such adhesive action as would heal it.  Sometimes the fistula
 communicates directly with the urethra, though most frequently the harden-
 ing, contraction, and adhesions of the  surrouuding parts give it a more wind-
 ing course, and render it difficult to trace it with a probe.  When a perineal
 fistula has  existed for a few weeks, the urethra in front of the stricture is
 often disposed to contract and close up, so that a channel, which was previ-
 ously quite pervious, not unfrequently becomes directly the  reverse, render-
 ing it impossible to enter the bladder  by the usual route, and requiring high
 operative skill in order to restore  its permeability.
   Operation for Perineal  Fistula.—When a perineal fistula is so situated
 as to permit the introduction of a director into the bladder, and of a probe
 into the  urethra in front of the stricture—Plate LI. Fig.  5—the formation
 of the button-hole opening, before referred to, will frequently prove  suffi-
 cient to restore the continuity of the canal, especially if the subsequent use
 of the catheter is persevered in until the fistula has healed.   But when there
 is a considerable distance between the bladder  and the permeable portion of
the urethra, the  indurated perineum will sometimes defy all attempts to trace

  * Diseases of the Urinary  Organs, p. 315, from Am. Journ. Med. Sciences, vol. iii. N. S.
p. 495. 
490            PRINCIPLES AND PRACTICE  OF SURGERY.
the course of the fistulous canal into the bladder, and the surgeon will be
compelled to open the perineum, as in the operation of lithotomy, and divide
all  the portion which intervenes between the neck of the bladder and  the
spongy portion of the urethra.   As this  operation is one in which  anatom-
ical knowledge is of the utmost importance, the  incisions  being  regulated
entirely by the judgment of the  operator, it is  usually regarded as one of
the most  difficult in  surgery,  and  as surpassing  that  of lithotomy.  In
many instances, surgeons have preferred trying other means, and, when these
failed, have left the result to  nature;  but, as a cure can be  accomplished,
it is the duty of every one to acquire such experience as is essential  to its
success.  In  three instances,  though satisfied of its difficulty, I have been
pleased with the result, all the  patients being cured both of the fistula  and
stricture.  As characteristic of  this operation, I cite the following method,
as described by Wm. E. Horner, of Philadelphia,*  and based upon his own
dissections of the parts concerned.
  Operation of Horner.—Anatomy.—By repeated observation, Horner has
found that, from  the top of the symphysis pubis to the  anterior end of  the
membranous  part of  the urethra, the distance  is  two   and  three-quarter
inches; to the posterior end of the bulb of the  urethra, three and three-
quarter inches; and to the urethral opening in the triangular ligament, three
inches.  These measurements should be firmly impressed on  the mind,  lest
in the subsequent stages of the operation  the surgeon be  unable to recognize
his position in the perineum.   Then confining the patieut's hands and  feet
together, as in the lateral operation for stone, commence the perineal incision
on  the raphe, just at the posterior plane of the scrotum—say,  by  meas-
urement, two  inches and a half below the  superior face of the symphysis
pubis—and  carry it back three inches to a point exactly in the mid-space
between the tuber ischii  and  the anus, on the left of the patient.   Having,
by a series of careful incisions, separated the corpus spongiosum, covered by
the accelerator, from the crus penis, expose fairly that side of the triangular
ligament of the urethra, upon  the anterior surface of  which, immediately
under the union of the corpora cavernosa, lies the membranous part of the
urethra.  By measurement, the membranous part of the urethra will be found
precisely two and a half or three-quarter inches below the top of  the  pubis,
or half an inch  below the inferior margin of the inter-pubic ligament.
  When the operation is thus far done, pass a staff along the urethra; and,
as the stricture is generally behind the scrotum, just in  or near the  mem-
branous part of the urethra  divide the stricture  on the point of the staff,
cutting freely along the membranous part of the urethra,  as in lithotomy.
But let this division be done upon the upper middle line, instead of the lower
or lateral  one, as the eventual healing is more favored by the opening being
closed by parts in direct contact.   If the staff cannot be used in the  way
indicated, open the membranous part of  the  urethra just where it joins the
corpus spongiosum, and divide  the stricture from behind  forward.  The col-
lapsed state of the membranous part makes its division obscure and difficult;
care and skill will, however, surmount the obstacle.  If the membrane be really
opened, a common probe may be passed  into the bladder from the opening.
Upon this a small tin director  should be passed  into the bladder, and the
probe then withdrawn.   Upon  this tin  director,  which   is of semi-cylindri-
cal shape, another, but larger  director, should be  passed into the bladder,
and the first director withdrawn; upon  the second director,  a third is to
be  passed after the same rule;  upon the third, a fourth.  The route  to the
bladder is now so well opened that a lead catheter of large size should  next
* Horner, in MS. 
HYPOSPADIAS AND EPISPADIAS.                491
be condncted along the urethra from the glans penis, through the spot where
the stricture was, iuto the tin director, and fairly lodged in the bladder.
   It is best to keep the  perineal incision open for a few days, so as to pre-
vent the urine from getting into the old fistulae; this may be done by dress-
ing it with lint down to the mucous membrane of the urethra.  But to make
this more certain, it would be better to draw a loop of silk or of thin gum-
elastic over the catheter in the urethra, and let the other end project beyond
the  lips of the wound.   Another  mode of accomplishing the  same is by a
second catheter introduced through the perineum into the bladder; but this
makes the neck of the  bladder  rather uneasy, and if it be resorted to, the
first catheter should be small and also flexible.
   The catheter becomes obstructed in a few days, and must be cleansed  or
renewed in every case; but before the catheter is withdrawn, pass a director
through  the perineum into the  bladder.   This director is to  be used as a
guide for the reintroduction  of the  catheter, until the urethra  is so much
dilated and repaired that the route through  it is perfectly easy.   A leaden
catheter is the best and the least irritating.
                   \ 2.—Hypospadias and Epispadias.

  An imperfect condition of the urethra is  occasionally found as the result
of a congenital defect,  iu which the canal terminates or opens by a slit upon
some point between the scrotum and head of the penis.  When the opening
is upon the inferior portion of the penis, it takes the name of Hypospadias,
but when situated on the dorsum, it is called Epispadias.
  Hypospadias, being the more common of the two, may be taken  as  the
type of this deficiency.
  Hypospadias  may be found at any point, but it  is especially seen at the
fossa navicularis, near the middle of the penis, near its root, or between the
penis and the scrotum.
  Operation.—When  the opening is near the glans, and  the anterior por-
tion of the canal is impervious,  puncture the point  of the glans with a  bis-
toury,  and push in a small trocar  and canula  until the perfect urethra is
reached, taking care not to push the point of the instrument either  toward
the  dorsum or under surface of the organ.  After creating the canal,  keep a
catheter constantly in it until the parts have healed.  The contraction con-
sequent on cicatrization is, however, apt to cause a  considerable diminution
in the  size of the new urethra.
  When the opening is seated near the middle of the penis, and the urethra
is patulous to near the fossa navicularis, the trocar may be introduced into
the  orifice and carried forward to the point of the glans.
  Sometimes  the defect  has consisted in a mere fissure, around which the
corpus spongiosum was deficient.   Although this is almost a hopeless case,
the  surgeon  may deem it advisable to  attempt  a plastic operation,  freshen
the  sides of the fissure, and unite the skin of the part over the catheter.
  The rarity of hypospadias in such a position and to such an extent  as pre-
sents  much chance of success renders it difficult to  assign  any value to the
modes of operating that have been described, few  of them having  accom-
plished perfect cures.   In a little  patient of eighteen  months, who  had an
opening near the  middle of the penis, but in whom the urethra was  other-
wise perfect, I have, however,  succeeded in closing the fissure by freshening
the  edges and uniting them by  the  hare-lip suture; and Mettauer, of Vir-
ginia, has also reported  a case  of rare deformity  of the  penis, which  was 
492
PRINCIPLES  AND  PRACTICE OF SURGERY.
relieved by an operation. As his account also contains an excellent descrip-
tion of some of the usual forms of this defect, the reader will derive much
valuable information by referring to it.*


                            SECTION  VI.

                  AFFECTIONS OF THE SPERMATIC CORD.

  Varicocele—Varix, a distended vein, and xrjXrj, a tumor—or Circocele—
xtpqos, a varix, and xr,Xrh a  tumor—are  terms  often  indiscriminately  em-
ployed by writers to designate a varicose enlargement of the spermatic veins,
varicocele being that mostly used.
  Etiology.—The causes of varicocele are varied, being any that will induce
congestion of the veins of the cord by interrupting the circulation through
them, such as tight waistbands, or other ligatures around the abdomen, con-
stipation,  and occasionally extreme  continence.   It may also follow the
improper application of a hernial truss.
  Varicocele most frequently affects the veins of the left testis, a result—as
explained by Brinton, of Philadelphia—"of the existence of a very  perfect
valve, that he discovered at  the  entrance of the right spermatic vein, into
the vena cava, which thus supports the column of blood on the right testis,
while there is no valve at the termination of the  left spermatic in the emul-
gent vein."
  Symptoms.—Varicocele is generally attended  by a sense of fullness in the
scrotum, with a dull, heavy pain in the back, as well as in the line of the cord,
when the  patient stands some time, but which is relieved by lying down, or
by holding  up the  testis.  The  patient is also often depressed in  spirits,
thinks constantly of copulation, is fearful of losing his virile  powers, and
notices  especially the diminished size  of the testicle on the affected side, as
well  as the relaxed condition of the scrotum.   On seizing the  scrotum and
cord between the thumb and  forefinger, a  collection of enlarged vessels can
be felt, which give a sensation that has been compared  to that caused  by a
number of earth-worms in a bladder.   Hydrocele sometimes, though rarely,
supervenes; while, in rare cases, the  testis also  becomes atrophied,  though
seldom permanently so.
  Diagnosis.—Varicocele  is a very common affection  which is  not unfre-
quently confounded with omental hernia, as it moves when the patient coughs.
But a diagnosis may be made by  placing the patient in the horizontal  posi-
tion, when both a  reducible  hernia and a varicocele will disappear.   If a
finger is now firmly pressed on the external abdominal ring, and the  pntient
stands up, the  hernia  will  be prevented from escaping from the  abdomen,
while the veins will gradually fill, and reproduce the  varicocele, notwith-
standing the pressure.
  Prognosis.—The prognosis of varicocele is favorable. When due to engorge-
ment of the testis, the stimulus of occasional sexual intercourse will  usually
relieve  it; while, if the  enlarged veins are  operated on, a cure may be ob-
tained, and  the testicle resume its natural size  and function.   Its existence
is occasionally a source of trouble by inducing relaxation of the scrotum and
chafing of the latter against  the  thigh  in long  marches; hence, when very
large, it is regarded as unsoundness in recruits.
  Treatment.—The cure of varicocele may often be accomplished without an
operation, though frequently this is necessary.  When dependent on constric-

            * Am. Journ. of Med. Sciences, vol. i. N. S. p. 43, 1842. 
AFFECTIONS  OF THE SPERMATIC CORD.            493
tion of the abdomen, or constipation, or on a badly applied truss, or extreme
continence, the removal of the cause will, if persevered in, suffice for the cure.
Advantage, under these circumstances, will also be derived from the use of
a suspensory bandage,* and from bathing the scrotum  and loins, night and
morning, in a  basin of cold  water.  But if the  enlarged veins have existed
for a long  time, and the testis is atrophied, an  operation for  their oblitera-
tion will be demanded, such as ligation of the veins or  compression.
   In all the operations upon the veins of the cord, it is important that the
surgeon should first separate the vas deferens and spermatic artery from the
bundle of veins.   This may be readily done by  gently compressing the  cord
between the thumb and fingers of one hand, and causing the  vessels to slip
laterally, when the vas deferens, which may be told by  its cartilaginous con-
sistence, the artery being known by its  pulsation, will readily pass to the inner
side of the cord.  The veins  being then rendered distinct  by the patient
standing up, any of the following operative processes may be selected.
   Ordinary Operation of Ligation of the Spermatic Veins.—The patient
either sitting  in  a chair,  standing,  or lying down, as most convenient,  with
the scrotum entirely divested of hair, grasp it from behind with the left hand,
and make a vertical incision, nearly an  inch long, over the anterior part of the
tumor, down to the enlarged veins. Then carefully isolating  these from the
vas deferens, artery,  and  nerves, by a few touches of the point of a scalpel,
pass a  short,  thick, straight needle underneath two or three of the larger
trunks,  and, winding  around it  a stout  thread, either  elliptically or in the
form of the figure 8, draw it with great firmness, so as to indent the coats of
the vessel, and stop the circulation, after which  the wound may be closed by
adhesive plaster, or a twisted suture.    The patient being now put to bed,
and the scrotum supported,  he should be kept on light diet.   At the end of
twenty-four hours, when the blood in the veins is sufficiently coagulated, pass
a sharp-pointed and  narrow bistoury  underneath the veins, with its back to
the needle, and divide them.  Should symptoms of inflammation arise about
the parts, cold lead-water or the cold water-dressing may be demanded.  In
five or six days, the patient  may sit up, and in  a few more will be permitted
to walk about.
   This  operation, which  is  that of Celsus, has  always  been found  adequate
to the cure of the complaint.
   Operation  of  Jno. Watson,  of New York.—The  varicose veins being
soft and swollen in a  lump as large as a hen's  egg, the pain  and uneasiness
led the  patient to seek relief  by an operation, which was performed as fol-
lows :  The whole of  the free integuments  that could  be  embraced without
much stretching, being included in  the blades of a very long and slender for-
ceps, which passed over the cord, and obliquely down  to the lower part of
the scrotum on  the  opposite side, the included  part  was removed  by one
sweep of the  bistoury, leaving a wound which  gaped so much as to expose
both  testicles, covered  only by  the tuuica vaginalis.   The  external pudic
artery, near the upper angle of the wound, was the only vessel that required
the ligature, and five  or six  stitches of the interrupted suture  were  necessary
to coaptate the integuments over the  cord, and so  on, below the testes.   The
patient suffered  but  little,  was dressed with the water-dressing, confined to
bed for several days,  and, before the end of the month, had  the wound per-
fectly healed,  and the varicocele cured.
   This  operation, though a modification of Sir Astley Cooper's, acts rather
by drawing the cord  laterally than by elevating the testes, as was the object
* Vol. i. page 128. 
PLATE  LI1.
        OPERATIONS  PRACTICED ON  THE TESTICLE AND CORD.

  Fig. 1. Ligation of the Spermatic Artery.   1. The director passed beneath
the arterv.                                      After Bernard and Huette.

  Fig. 2. Velpeau's operation for Varicocele. 1. The pin as passed behind the
vessels.  2. The figure  of 8 ligature thrown around it.
                                               After Bernard and Huette,

  Fig. 3. Ricord's operation for Varicocele.  1.  The first loop of a double lig-
ature carried between the veins and the skin.       After Bernard and Huette.

  Fig. 4. View of the Veins and Ligatures before the  latter are drawn tight.
1. The enlarged veins.  2.  The vas deferens.   3. The  posterior ligature.   4.
The anterior.                                    After Bernard and Huette.

  Fig. 5. A view of the Knot formed by  drawing on the ends of each Ligature,
after they have been passed  through the opposite  loop  and are  about to con-
strict the veins.                                 After Bernard and Huette.

  Fig. 6. Operation of Vidal de Cassis for  Varicocele.  1,  1.  The enlarged
veins.  2, 3. The two  silver wires passed in  front and  behind  them, so as  to
compress the vessels when they are  twisted.   4. The vas deferens.
                                               After Bernard and Huette.

  Fig. 7. A view of the arrangement of  the wires.  The larger one remaining
firm, the smaller twists  around and compresses the vessels upon it.
                                               After Bernard and Huette.

  Fig. 8. The Veins as constricted, shortened, and rolled up by the twisting of
the silver wires.                                 After Bernard and Huette.

  Fig, 9. Breschet's operation.   1,1. The compressors.
                                               After Bernard and Huette.

  Fig. 10. The  operation of Castration.  1. The scrotum drawn back to favor
the enucleation and dissection of the testicle.       After Bernard and Huette.

  Fig. 11. A side view  of the operation of Tapping in Hydrocele.  1. Position
of the left hand as it compresses the sac.  2. The right hand holding the trocar
aDd canula'                                     After Bernard and Huette.
       (494) 
 
*> 
AFFECTIONS  OF THE SPERMATIC CORD.             495
of Cooper's operation.  As it compresses the veins in their long diameter, it
soon diminishes their calibre.
   Operation of Velpeau.—After picking up the enlarged veins between the
thumb and fingers, a pin  is passed through the skin behind the veins, and
surrounded by a figure  of 8 suture, so that the scrotum and the veins may
be compressed by the ligature upon the pin, Plate LII. Fig. 2.  After two
or three days  have elapsed, and there is evidence of inflammation, this  pin
may be removed, as in the ordinary hare-lip suture.  But, as the compres-
sion of the integuments even for this period seemed to be  liable to induce
erysipelatous inflammation, Velpeau subsequently modified the operation by
passing a double ligature in front of the veins beneath the skin, and, placing
the pin behind the vessel, slipped the loop of the ligature over one end of the
pin, and tied its two  ends around it so as to compress the veins directly upon
the pin.
   Operation of Ricord.—After isolating the veins, Ricord  operates as fol-
lows :  Two needles  being  prepared, each threaded with a double  ligature,
the surgeon passes one of them behind the veins, so that the loop of the lig-
ature projects a little outside of the scrotum, Plate LII. Fig. 3, and removes
the needle.  Then, passing the point of the second needle from the opposite
side of the scrotum, but through the same puncture as that made by the exit
of the first needle, he carries  the second ligature in front of the veins,  and
thus forms two loops, one on each side  of the scrotum.  On  passing the free
ends of each ligature through the opposite loop, and drawing upon them,
the vessels will be constricted by the approximation of the loops beneath the
skin, Plate LII. Figs. 4, 5, the tightness of the  compression  by each ligature
being preserved by tying its  ends upon a small plate or pledget outside the
skin*  After the constriction has been thus practiced for forty-eight hours,
uutie the  ends of  the ligature from over the pledgets, and, pushing upon the
threads, loosen the  loops,  or introduce fine-pointed forceps, and draw them
out, or attach a single and colored thread to the centre of each loop before
drawing it into the wound.
   Operation of Vidal de Cassis.—This surgeon combines the subcutaneous
ligature of the veins with diminution of their length, so as to prevent the
subsequent return of the circulation, in the following manner: A silver thread
being passed with a needle behind the cord, another larger wire is  made to
pass through the  same opening  in front of it, Plate LII.  Fig. 6,  and the
veins being thus  placed between the two wires, beneath the skin, their ex-
tremities are twisted, until by the torsion they  are  brought closely together
and .strangulate the veins.   By continuing  the torsion, the  metallic  cord in
its rotation draws  in the parts comprised between the wires, so that the veins
are rolled around  them until, as the twist is continued, the testicle itself is
raised, Plate LII. Fig. 7, its ascent  being  facilitated  by the relaxed con-
dition of  the parts.
   Finally, the two ends of the metallic cord are knotted on a pledget upon
the skin, and, a director being passed beneath the knot, the whole is  twisted
more and  more, from day to day, until the  wires cut through the skin and
veins.t The advantages claimed for this mode of operating are a diminution
in the length of the spermatic cord, and the section of the veins at the sev-
eral points where  they  have been twisted.
   Operation of Breschet.—By means of a  pair of clamps  or compressors,
the circulation was interrupted, and sloughing  of the vessels induced by the
following operation:—
* Op cit.
f Diet, de M6d., tome xxx. p. 560. 
496           PRINCIPLES AND PRACTICE  OF SURGERY.
   Pick up a fold of the scrotum, so as to include the enlarged veins, and
inclose it in a  branch of the forceps, Plate  LII. Fig. 9, applying another
pair in a  similar manner, a short distance above the  first.  By tightening
the screws from day to day, the constriction is sufficiently increased to result
in sloughing, after which the ulcer is healed by the usual means.
   Remarks.—The danger  arising from operating upon varices in the limbs
does not appear to follow the operation performed for the relief of varicocele,
while the difference in the anatomical relations of the  spermatic veins, and
the absence of the free anastomoses that exist between  the different veins of
the extremities, usually render  the operation much more successful in this
region than it is in the veins of the leg.
   Compression, as advised by  Breschet, has resulted in death* in  several
instances, and is now seldom or never resorted to.   Indeed, it may be useful
to the young surgeon to offer a word of caution in regard to the performance
of any operation for varicocele, until cold astringent washes, the constant
use of  a suspensory bandage, and the exercise of the function of the testicle
have been fully tried, as these means usually suffice for  the cure of the  com-
plaint.
                           SECTION VII.

                     OPERATIONS ON THE SCROTUM.

  In  cases  of tumors  of the  encysted  variety, or in hypertrophy of the
scrotum, the same principle should be carried out as would be applicable to
similar tumors elsewhere.  Hypertrophy, or elephantiasis of the scrotum, has
sometimes required  very extended dissections, although limited generally to
the  scrotum.   In a case reported in 1837,f by Picton, of New Orleans, the
weight of the tumor was fifty-three pounds, while it reached nearly to the
patient's feet.   In two months the man was cured, and the tumor is now in
the  Wistar and Horner Pathological  Museum of the University of Pennsyl-
vania, at Philadelphia.
* Philad. Med. Examiner, vol. iii. 1840.
f See Curling on Testis, Philad. edit., p. 537. 
CHAPTER  II.
                   AFFECTIONS OF THE TESTICLE.

  The disorders of the  testis not previously described are such as result in
an effusion of water or of blood into its serous coat, these being named re-
spectively Hydrocele and Haematocele.
                             SECTION I.

                              HYDROCELE.

  Hydrocele is a collection of serous  fluid  within the cavity of the tunica
vaginalis testis, the term being derived  from  two Greek words—udwp, water,
and y.r,Xrj, a tumor—signifying a watery tumor.
  Anatomical  Relations of the Tunica Vaginalis.—The tunica vaginalis
testis, as mentioned in connection with  the subject of hernia, is that portion
of the peritoneum which  was  originally  pushed before  the testicle in its
descent from the abdomen into the scrotum.   In its new position this  por-
tion forms,  therefore, a double  envelope for the testicle, and its  connection
with the abdomen having  been obliterated,  it constitutes a closed sac,  as is
the case with other serous membranes.   Like  these,  the  tunica vaginalis
testis also secretes a certain amount of halitus or  moisture  in the natural
condition of the parts, which serves to  lubricate and facilitate the motion of
the testicle; without which the delicate structure of the  testicle would be
exposed to contusion whenever the patient crossed his thighs.
  Etiology.—Various  disorders may  cause the natural secretion  of the
tunica vaginalis testis to become inordinate in quantity,  and so create a
hydrocele.   Thus,  inflammatory  action may produce it, as  is the case in
hydrocele  which ensues upon epididymitis,  orchitis, or blows.  Or it  may
occur suddenly  in consequence of the congestion created by great muscular
exertion, as  in  a patient under  my care, in whom  a very considerable hy-
drocele  resulted in the course of half an hour  after he  had  lifted a barrel
of flour from the ground into a wagon.*  Other cases are also  on record,
and should be borne in mind, lest a tumor from hydrocele, of sudden occur-
rence, be confounded with hernia.  Generally, however, the causes of hydro-
cele  may be stated  to be those which  are likely to  develop  chronic inflam-
matory action in a serous membrane.
  Symptoms.—When fluid accumulates in the tunica viginalis testis, a tumor
is formed, which, beginning at  the bottom  of the scrotum, gradually  rises
upward, until it may extend all along the cord, as high as the external ab-
dominal ring; or the tumor may form along the course of the cord, and pre-
sent the symptoms hereafter detailed.
  When the effusion is limited to the proper tunica vaginalis testis, the tumor
       * See Am. Journ. of Med. Sci., vol. xiii. N. S. p. 85, 1847.
vol. n.—32                                          ( 497 ) 
498
PRINCIPLES AND  PRACTICE OF SURGERY.
begins below, and gradually ascends, becoming larger and larger, though it
does not enter the external abdominal ring, and unless it is complicated with
hydrocele of the cord, produces no thickening of the cord itself.   To the
touch, hydrocele presents generally a sense of fluctuation, such as might be
expected from any collection of fluid.   But if the parts  are excessively dis-
tended,  or if, as sometimes  happens, the tunica vaginalis  has become dense,
and more or less indurated or ossified, the sense of fluctuation may be par-
tially or entirely absent; a fact which should be  borne in mind, in order to
prevent the confounding of such  a case of hydrocele with other tumors of
the testis.  As a general rule, then, the  symptoms of a hydrocele may be
stated to be:  1.  The formation of a tumor at the bottom of the  scrotum.
2. The  sense of fluctuation.   3. The translucency of  the tumor.   The last
is the most positive  sign, and  may be employed to facilitate the diagnosis
by the following arrangements: Let the room be darkened, and the patient
seated upon a table, chair, or edge of the bed; then grasping the tumor  in
the hand, so as to force the fluid well down into the scrotum, hold a candle or
a lamp upon the opposite side from the eye  of the  surgeon, when, if the tumor
is a hydrocele, it will appear sufficiently translucent to enable the surgeon
to recognize the position of the testicle as a dark mass,  this being generally
of the normal size, and  in the posterior  part of the scrotum.   This test,
however, is not an infallible one;  as it may happen that  the tunica vaginalis
testis is thickened  by  disease, or the  fluid distending  it may be rendered
opaque, either by the presence of blood  in consequence of the rupture of
some small blood-vessel, or from some other cause.   In this case, the light
will not be transmitted.  As a general rule, however, the fluid of a hydrocele
is of  a pale-straw color, and  the test of transmitted light is an exceedingly
satisfactory one, showing  not only the character of the fluid, but also  the
position of the testicle.
  Diagnosis.—It has  been already mentioned that hydrocele may be con-
founded with  scrotal hernia.   The latter, however, begins  at the  external
abdominal and  descends,  creating,  moreover, a tumor to which  a certain
amount of succussion is communicated  when the  patient coughs, which is not
the  case with hydrocele, except  in  congenital  hydrocele, in which, as was
stated in connection with the subject of henrla,  the communication between
the  peritoneum and the tunica vaginalis  testis  is not closed, and in which,
therefore, the same  succussion is perceptible when the patient coughs.   If
the hernia is reducible, its  reduction by the taxis will dispel any doubts that
may  exist as to the nature of  the case.
   Hematocele, or a collection  of  blood within  the scrotum, as hereafter
described,  will, at times, present the symptom of fluctuation which might be
confounded with that of hydrocele.  Generally, however, a diagnosis can be
 made by means of transmitted light.   The fluctuation of hsematocele, more-
 over, is usually much less distinct than that of hydrocele; but obscure cases
 will sometimes present themselves, in which it may be necessary to resort to
 an acupuncture needle, or to a small trocar and canula, by means of which
 a diagnosis may certainly be  made, for, if the tumor is a haematocele, nothing
 but blood  will escape from the puncture.   Should it, however, be a  hydro-
 cele, the escape of  the characteristic straw-colored fluid will at once reveal
 the nature of the case.  Should  it happen, as is sometimes the case, that a
 hernia is present, and is punctured with the little trocar  or needle, the trifling
 wound thus made will  generally heal without doing any serious mischief; but
 such an event should if  possible  be  avoided.
    The tumor formed by a hydrocele, if of any extent, is usually smooth, the
  distention having  completely obliterated all the wrinkles of the scrotum,
  though this condition is also produced by other tumors as well as by hydro- 
HYDROCELE.
499
 cele. ^ A hydrocele is often of such size as to bury the penis completely, the
 position of the organ being only marked by an irregular depression, similar
 to that made by the umbilicus.
   Prognosis.—The prognosis of hydrocele will depend upon circumstances.
 As it is generally possible to evacuate the fluid which distends the tunica
 vaginalis, the prognosis, in most  cases,  will be  favorable as regards the
 result of the operation.  But, unless some  means  be resorted to  for pro-
 ducing inflammatory action, and thus gluing together the walls of the cavity
 in which the accumulation of fluid has taken place, after the manner here-
 after directed in the operations for a radical cure, a fresh accumulation  will
 occur, and  all the inconvenience of the disease be  reproduced.  The prog-
 nosis of the  operations  for the radical cure is generally favorable;  the
 dangers being either of the inflammation going too far and producing slough-
 ing, or that it shall not go  far  enough, when a reproduction of the disease
 is apt  to  follow.  If the disease be  not  treated at all, yet is its prognosis
 favorable so far  as  the mere question of mortality is concerned;  though it
 may produce inconvenience from its size, and often  interfere materially with
 the proper performance of the generative  functions.
   Treatment.—The  treatment of hydrocele may be  either  palliative or
 radical.
   The  palliative treatment  consists  in the  puncture of the tumor with a bis-
 toury, a trocar  and canula, or  some similar instrument,  and the evacuation
 of its contents.   Such a  puncture should be boldly made  in  the  direction
 hereafter stated, so  as to  penetrate  the tunica vaginalis testis,  and not per-
 mit the instrument to slip into the areolar tissue between the  skin  and the
 tunica vaginalis.  After the evacuation of the liquid, the patient will at once
 be enabled, with  the  aid of a suspensory bandage, to resume his ordinary
 avocations;  and, in some few cases, may go  a year or even  eighteen months
 before another tapping will  be required, though usually the interval is only
 a few weeks.  The radical cure may be accomplished by any of the following
 operations:—
   Ordinary Operation.:—After being satisfied of the position of the testicle
 and the presence of the fluid, the patient should be  made to sit upon  the
 edge of a bed, table, or chair,  with  his thighs widely separated, or  else per-
 mitted to lie on his  back in bed with the limbs in the same position.   The
 surgeon, then seizing the  tumor with his left hand,  and compressing it so as
 to render the scrotum perfectly tense, Plate LII.  Fig. 11, takes the trocar
 and canula and punctures the swelling in front, but a little below its middle,
 directing the point of the  instrument upward and obliquely  backward, in
 order to avoid  the  testicle, which is  generally situated  behind and below,
 though  occasionally it is in front or  at the top of the  swelling, where  its
 position may be readily told by the sensibility shown on compression of the
 part.  As soon as the free motion of the point of the instrument shows that
 it is within  the cavity of the tunica vaginalis, the assistant should hold the
 empty bowl, and the surgeon,  retaining the canula in  his left  hand, should
 withdraw the trocar with  the right, and allow the liquid to escape.   After
 the evacuation is completed, the nozzle of the syringe—charged with an in-
jecting  fluid of a stimulating character, the  best of which  is Lugol's solu-
 tion of iodine, a half ounce of which is usually sufficient—should be adapted
 to the canula, and the liquid  iujected by an assistant, while  the  surgeon,
 retaining the end of the canula in its position, takes especial care  that  the
 liquid is not thrown into the connective tissue of the scrotum instead of the
 vaginal cavity.  After creating sufficient pain to render the patient slightly
 faint and cause uneasiness in the lumbar region, the liquid may be allowed 
500
PRINCIPLES AND  PRACTICE OF  SURGERY.
to escape, the canula withdrawn, and the patient placed in bed  with the
testicle supported.                                                   .
  After-Treatment.—As the object of this operation is to induce adhesion
of the  sides of the tunica vaginalis, care  is required to guard  against too
much inflammation, and a moderate antiphlogistic treatment may, therefore,
occasionally be demanded.   After the lapse of about five days, moderate
compression by a bandage, or by adhesive strips, will prove useful by aPProJ-
imating the sides of the inflamed cavity and favoring adhesion.   Should the
lymph, which is sometimes effused into the adjacent parts, leave  the testicle
considerably enlarged after  the operation, the induration may be  made to
yield to the use of iodine or mercurial ointment.
  Cure by the Seton.—Operation.—Puncture the tumor with a seton-needle
and a few strands of silk; allow the silk to remain  until it  excites sufficient
inflammation; and then withdrawing it by a few threads at a time, so  as to
leave one or two to secure the continuance of the opening, pursue the treat-
ment just referred to.  Sometimes the trocar  and canula  are made to  enter
the tunica vaginalis from below,  and  pass  out of the scrotum above, when,
the trocar being withdrawn,  a probe,  armed with silk, will readily carry the
seton  through the canula;  and, the  latter being withdrawn, the seton will
be left in position.
   The use of the silver or iron wire as a seton has been recommended.
   Treatment by  Incision.—Operation.—Etherize the  patient;  puncture
the tumor from above downward with a sharp-pointed bistoury, and, intro-
ducing the forefinger or director into  the cavity, enlarge the opening down-
ward ; after  which,  charpie, lint, or balls of dough may be placed in the
 cavity to excite irritation, and left there until discharged by suppuration.
   Treatment by Excision.—After operating, as  in the  preceding method,
remove  a  portion of the vaginal tunic either with the scissors or knife, and
close the wound in the scrotum by a few stitches of  the metallic suture.  As
the attachment of the tunica vaginalis to the scrotum is loose, the excision
of the largest portion of the tunica vaginalis is easy,  and the wound which
is thus made heals usually under  the water-dressing in about  twelve  days,
there being no possibility of a return  of the disorder.
   Remarks.—The operation for the relief of hydrocele, though apparently
simple, occasionally  fails to  evacuate the liquid, or does not accomplish a
cure.
   The first is usually the result of carelessness on the part  of the  operator,
and may arise from an error of diagnosis, or from his not rendering the scro-
tum sulficiently tense to cause the trocar to puncture the tunica vaginalis,
the instrument passing between  the scrotum and this tunic.  Such an acci-
 dent is by no means rare with inexperienced operators, the puncture  being
 made  and the trocar withdrawn without any fluid  escaping.  If the tunica
 vaginalis is thickened, or slightly ossified, or if the  sac is not rendered tense
 by compression, or if the trocar is not sharp at its  point, or if  the canula is
 not well adapted to  the shoulder of the trocar, the perforation  of the  sac is
 apt to fail, the tunica vaginalis  being pushed before the instrument instead
 of being punctured.   The evacuation of the fluid, and the consequent con-
 traction of the scrotum, are also  liable to displace the point of the canula,
 so that, on attempting the injection,  if this method is resorted to, the fluid
 passes with difficulty,  and, instead  of inflaming  the cavity of the tunica
 vaginalis, infiltrates the scrotum,  and  induces  sloughing  or  gangrene.
 Every precaution should, therefore, be employed to prevent such mishaps in
 this apparently easy operation.   In the  selection of a plan of treatment, I
 prefer either the metallic seton, leaving  it in the cavity for several days in
 order to insure a vent for any liquid which may accumulate, and thus prevent 
CASTRATION.
501
the approximation of the walls of the cavity, or the operation of extirpation
or excision  of the  tunica  vaginalis—the latter  being preferable in  most
chronic cases.

                            \ 1.—Castration.

   Castration, or the removal of the testis, although a comparatively easy
operation, is one that should not be performed without serious deliberation,
and only resorted to when  such degeneration is found as establishes the use-
lessness of the organ beyond a doubt, or the risk of further contamination
of the system by its existence.   In order to avoid the removal  of the gland,
ligature of the spermatic artery, or the excision of the vas deferens, has been
practiced by Maunoir and  Morgan, of Europe, and Jameson, of Baltimore ;
but in the cases where these  means would  be advisable, it may be doubted
whether castration would not be preferable, because it accomplishes the same
object more effectually.
   Ordinary Operation of  Castration.—The patient being placed upon  his
back, and the parts shaved of hair, the surgeon should seize the tumor in  his
left hand, with the palm presenting anteriorly, and force it toward the front
of the scrotum, or an assistant may hold it so as to render the skin tense.
Then, commencing  an elliptical incision  through the skin a little below  the
external abdominal ring, let  him continue  it below the tumor, or to the  in-
ferior part of the scrotum, so as to insure the escape  of pus, the two halves
of the incision being made  to include as much of the scrotum as it is desired
to remove.  Then, seizing the margin of either half, dissect off its loose con-
nective tissue from arOund the tumor, until the latter can be turned out of  the
pouch,  Plate LII. Fig. 10.
   After isolating the cord  from the surrounding parts, feel for  the vas def-
erens, which may be told  by its cartilaginous consistence, and, with  a  few
longitudinal touches of the scalpel, separate it from the cord.   Pass a liga-
ture around the remaining portion, draw it firmly, tie it in a double knot,
allow the ends to remain, and  then divide the entire cord below this liga-
ture,  especially  if  carcinomatous disease  has  demanded the  operation.
Some surgeons  prefer to ligate the vessels of  the cord separately as they
divide them, but as cancer is the most frequent  cause  of castration,  the
general ligation of  the cord,  excepting the vas deferens, is preferable.
   Dressing.—In order to insure a vent for the  pus that will promptly col-
lect in the  scrotum,  introduce a small piece of lint or linen into the lower
angle of the incision, unite the centre of the wound by the metallic sutures,
and close also its upper angle,  applying  subsequently the water-dressing, as
in simple incised wounds. 
CHAPTER  III.
                     STONE   AND   GRAVEL.


  The next of the affections of the genito-urinary organs  to which  atten-
tion may be directed, is that known as Gravel or Stone, terms  used  to de-
signate the formation and arrest, in various parts of the urinary passages,
of certain particles of sabulous matter which, when  arrested  in  these  pas-
sages, are liable to  accumulate  from fresh particles being added  to them,
and thus present themselves in the form of gravel, or attain such  size and
solidity as justly entitle them to the name of stone.


                             SECTION I.

                               GRAVEL.

  Varieties.—The sabulous matters found in the urinary passages have been
variously classified;  in the  first place  they are divided according to their
size, being, when finely pulverulent, spoken of as sand, sediment,  or de-
posit, the last two terms  being, however, objectionable, because there may
be a sediment or deposit in  the urine, which  does not consist of calcareous
matters,  it being caused by the presence of blood, mucus, pus, or semen.
The term sand, as expressive  of the general  character of the  disorder, is
therefore preferable.  When sand aggregates to a moderate extent, it is
called  gravel, the larger masses resulting from still  further aggregation
receiving the name of stone or calculus.
  Etiology.—The disposition  to the formation of gravel in the urine is to
be found in connection with a state  of the kidneys by no means  precisely
understood.  Very often it is hereditary, father and son for many genera-
tions laboring under the complaint.  As the disease consists essentially in a
vitiated action on the part of the kidney, any cause capable of producing or
sustaining  this disordered action may become the cause  of the complaint.
Thus, it will  be found that among the predisposing causes  are certain kinds
of food, especially those which abound  in the nitrogenized elements, while
certain drinks are also said to aid the diathesis in favoring the formation of
stone; persons who  use much  hard cider being said to suffer, while the dis-
order  is also thought to  be  more common in districts where  the water  is
highly impregnated  with  limestone  than  elsewhere, though statistics have
not  proved this opinion to be correct.   Climate, clothing, or any  chauge  of
circumstances which, by modifying the action of the exhalents of the skin,
throw  an increased burden  upon the kidney, may also become the cause of
stone.
   These facts are important, because after a  stone  has been  removed from
the bladder by operative interference, if the patient be  not watched, and the
exciting causes removed, or the tendency of the  diathesis carefully counter-
       (502) 
URIC  ACID  AND  THE URATES.                503
acted, the calculus may be reproduced.   It  should, therefore, be borne  in
mind that the kidney is the source from which the mischief comes, patholog-
ical observations having often revealed the  fact that, in patients laboring
under gravel or stone, this gland is diseased  to a considerable extent, every
possible variety of disordered action being seen in it that could be the result
of inflammation.
  Chemical Composition.—The  chemical composition of gravel is varied,
though it generally consists of the combination of uric, oxalic, or phosphoric
acids, with certain bases, such as lime, ammonia, magnesia, soda,  silica, iron,
etc., or  with a  peculiar substance,  recently described  under the name  of
Cystine.
  To that peculiar state of the constitution which predisposes to the forma-
tion of these compounds in the urine, the terms Lithiasis, Lithogenesis,  or
stone-producing diathesis, are applied;  and, in speaking  of  the specific
deposit which the diathesis induces, the name of the acid that predominates
in the gravel is usually prefixed to  it:  thus  we have  the uric or lithic acid
gravel, as well as that of oxalic and phosphatic acid.
  Constituents  of Gravel.—The following classification, made by the most
recent authorities on the urine, and condensed from them, presents a concise
view of the more important  ingredients, whether of sand, gravel, or  stone,
found as the result of disordered action of the urinary apparatus:—
     1. Uric Acid.—Free,  or combined  as a Urate of Ammonia, Soda, etc.
     2. Phosphates of Ammonia and Magnesia, or of Lime.
     3. Oxalate of Lime.
     4.  Cystine.
     5. Uric Oxide.
                     \ 1.—Uric Acid and the Urates.

  Uric Acid, called also  Lithic Acid, or Urylic Acid, is a normal con-
stituent of the human urine, about eight grains of it  being  excreted daily
by a healthy adult.   As  it is quite insoluble in water,  it does not exist free
in the  urine, but in the state of a soluble bi-urate, probably of soda, though
perhaps also of lime, ammonia, etc.
  Sand or  gravel may be  composed of free uric acid,  or of its compounds,
the urates, and may  be separately described.
  I. Sand or  Gravel composed of Free Uric Acid.—Free uric  acid  is in-
variably  found in the urine  in  the  crystalline form.  The crystals may be
large enough to be recognized as such by the naked eye, or they may be so
small as to require the use  of the microscope for their recognition.
  In color, this variety of  sand may be of any shade  between a pale fawn
color and  yellow, yellowish-red, or red.  It is hence  familiarly known as
yellow or  red sand  or gravel.   It  may be visibly crystalline, or, from  the
minuteness of the crystals,  may appear amorphous to the naked eye.   The
urine is  always  acid, and is generally of a high color and considerable
density.
  The term Uric Acid Gravel should  properly be restricted  to  those cases
in which the uric acid forms small concretions, from one-twentieth of an inch
in diameter to the largest size capable of escaping through the urethra.   A
variety of this form of gravel is  presented in the concretions called  "fusi-
form,"  which are  often expelled in great numbers by individuals who have
passed the  period of middle life.   They are frequently exceedingly numer-
ous ; their form globular; their surface smooth ; their color yellow, reddish,
or brown. 
504
PRINCIPLES AND  PRACTICE OF  SURGERY.
   Chemical Characters.—Deposits of uric acid are not dissolved  by heat-
ing the urine; they are insoluble in acetic or hydrochloric acids, but soluble
in concentrated nitric acid.   They are soluble in hot  liquor potassae, from
which  solution they are again  thrown down in a crystalline  form on the
addition of an acid.
   Portions of the sand washed and dissolved in nitric acid, yield, on evapo-
ration, a residue of a beautiful pink color, which becomes purple on exposure
to the vapor of ammonia.   Heated  in a platinum  spoon, uric  acid readily
burns with the odor of bitter almonds.
   Microscopical Characters.—The crystals of uric acid present, as seen by
the microscope, innumerable varieties in  their form, all of them, however,
                              being referable to some modifications of the
                              rhombic prism.   The most frequent of these
                              forms may be described as  rhombic plates,
                              shapes  approximating the  cube,   spindle
                              shapes,  elliptical forms, forms resembling
                              the flower of the " lily of the  valley," etc. As
                              they occur in urine, they are always colored
                              of  a fawn,  yellowish, or reddish hue.   The
                              crystals  may be unattached to each other, or
                              they may cohere  together in little stellated
                              masses, which are in fact minute calculi, and
                              which are generally  large enough to be seen
                              by the naked eye, resembling grains of Cay-
                              enne pepper, Fig. 427.
                                Etiology.—We have seen that uric  acid
                              exists normally as a soluble urate in healthy
                              urine. If, therefore, we add to healthy urine
                              any acid stronger than  the uric  in its affini-
                              ties, as nitric, hydrochloric, or even acetic or
                              lactic acids, the whole of the  uric acid will be
                              precipitated in an insoluble crystalline form.
                              In  this simple experiment, which the student
                              may readily repeat for himself, is to be found
                              the key  to the  process by which these de-
                              posits are produced.  Invariably the deposit
                              is the consequence of the appearance in the
                              urine of some acid capable of decomposing
                              the soluble urates,  this being  probably in
                              most cases Lactic Acid, which  is frequently
                              developed in healthy urine after it has been
                              passed some hours.   This, uuiting with the
                              bases, forms lactates, setting the uric  acid
                              free.   Acetic acid is probably developed, at
                              times, in the same manner, and  produces the
                              same results.  This process, which in healthy
                              urine does not usually commence for several
                              hours after the urine is passed, is designated
                              by  Scherer as the acid or sour fermentation
of the  urine, to distinguish it from  the alkaline fermentation which sets in
later, and which will be described  in connection with the etiology of phos-
phatic  deposits.
   The acid fermentation and consequent precipitation of uric acid, which
nominally does not take place for some hours after the urine is  passed, may,
in consequence of constitutional or local conditions which are  not yet com-
Crystals of Uric Acid. (After Bird.) 
SEDIMENTS OF  THE  URATES.
505
pletely understood, occur preternaturally early, beginning immediately after
the urine is passed, or even before it is voided, in the bladder, or, in extreme
cases, in the kidneys.   It is, of course, only in these latter cases, in which
the uric  acid is precipitated in a crystalline form in  the  body, that there is
danger of  the formation of calculi.
  It will then be perceived that the condition determining the precipitation
of the uric acid is the  preternatural acidity of the urine, and not any excess
of the  nric acid itself.   Indeed, deposits of uric acid, if the urine be unnatu-
rally acid, may occur in cases in which the total  quantity of uric acid passed
in the twenty-four hours is actually diminished; and conversely, the quantity
of uric acid may be considerably increased, and yet no crystals may be pre-
cipitated, provided  the  necessary condition of acidity be  absent  from the
urine.    The necessary acidity of the urine does,  however, sometimes coexist
with excessive production of uric acid, which will then make its appearance
in copious crystalline deposits.
  The condition  in which excessive production of uric acid habitually occurs
is designated as the Uric Acid Diathesis.  As uric acid is not formed in the
kidney, but exists preformed in the blood as absolute urate, the origin of the
uric acid diathesis is to be sought, not in  local,  but in constitutional condi-
tions   Excessive indulgence in animal food,  dyspepsia,  chronic  skin dis-
eases, rheumatism, etc. are  among  the conditions which are most frequently
accompanied by its excessive formation.
  The conditions which  determine  the unnaturally early  acid fermentation,
by which the uric acid is set free after its secretion as a urate, are not under-
stood.    Sometimes  the  condition is hereditary,  father and  son  for  many
generations suffering under the complaint.
  Treatment.—As the invariable condition determining  the deposit of free
uric acid is an unnatural acidity of the urine, (acid fermentation,) the first
indication  is to resort  to those remedies by means of which the urine can be
rendered alkaline.   In many cases this can be effected by  limiting the pa-
tient to  a vegetable diet, which has also the effect of diminishing the actual
quantity of uric  acid  formed in the twenty-four hours.   Where,  however,
this is not convenient, or is ineffectual, the urine  can be rendered alkaline
and the  uric acid held in solution by the administration of the alkalies, their
carbonates, or, preferably, their salts, with  the vegetable acids: as the liquor
potassae, in  the  dose  of half a drachm, three times  daily; bicarbonate of
potassa,  in doses of a  scruple to half a drachm, three times daily;  acetate
of potassa, in half-drachm doses, thrice daily, etc.
  Where, however,  the amount of  uric acid actually  secreted in the  twenty-
four hours  is excessive, (which can only  be affirmed after acidulating the
whole  urine of the twenty-four hours  with nitric acid to  make sure that  all
its uric acid is precipitated, and washing, drying,  and weighing the sediment,)
an attempt must be made to  diminish  the quantity.  This is to be done by
abstaining from animal food; by attention to the functions of the skin;  by
restoring the tone of the digestive organs, if these are disordered;  and  by
moderate exercise in the open air.
                      2 2.—Sediments of the Urates.

  According to Prout and Golding Bird, the usual sediments of Urates have
ammonia  for their base, while soda is regarded  as the  base  by Lehmann,
Wedl, and other continental authorities.   Hassal and Thudichum are prob- 
506            PRINCIPLES AND PRACTICE OF SURGERY.
ably correct when they state* that their composition is variable, presenting
different proportions of the bi-nrates of ammonia, lime, soda, and potash.
  Appearances to the Naked Eye.—The urates occur as amorphous sedi-
ments, which may be whitish, fawn-colored, pink, purple, or brick-red.  The
latter form constitutes the well-known lateritious sediment of fevers, rheuma-
tism, gout, etc.  The paler forms might be  mistaken  by the naked eye  for
sediments of pus; but are readily distinguished by the chemical tests.  Con-
cretions and minute calculi of the urates may also occur.
  Chemical Characters.—The urates are decomposed, with the subsequent
precipitation of pure uric acid in crystals, on the addition of any strong acid
in the urine.   If the urine containing  them  be  gently heated over a lamp
they disappear, on account of their greater solubility in hot than in cold
water;  but they reappear when the  urine  again  cools.   This is  the most
reliable chemical test.
  Microscopical Characters.—The urates present, under  the microscope,
innumerable varieties of excessively minute  globules, frequently  adhering
                         together in a linear manner.  An  admixture of
                         crystals of uric acid is very  common, Fig. 428.
                           Etiology.—As the  urates are more soluble in
                         hot than in cold  water, it frequently happens that
                         urine which is perfectly clear, as first passed, de-
                         posits a precipitate of amorphous orates as it cools.
                         This may occur on  account  of an actual increase
                         in the quantity of  urates formed in the twenty-
                         four  hours, in consequence  of any of the causes
                         which were mentioned in connection with the  in-
                         creased daily formation of uric acid.  Or the daily
                         formation of urate  remaining normal, a deficiency
                         of the water  of the urine may occur to such  an
UrateCr°of8ct"em(After itl.?* *""   extent that  the  normal quantity of urate is  no
                         longer soluble in it when cold.   In either case
the precipitation  most frequently occurs out of the body on the cooling of
the urine; it is only occasionally that the scantiness of the  urine, or the ex-
cessive quantity of the urate is so decided that the  precipitation takes place
within the body, and the  urine is passed already turbid.  It is in this latter
case only that there is danger in the formation of a stone of the urate.
  Besides the  above cases, it must be noted  that in ammoniacal  orine the
urates, even if normal  in quantity, are precipitated along with the  phos-
phates ; they then assume microscopical forms unlike those above described,
(dumb-bells, globules, potatoe forms, etc.,) and may enter with the  phos-
phates into the formation especially of the  outer layers of  stone.
  Treatment.—Where a deposit of the  amorphous  urates  coexists  with
scanty urine, simple dilution, as by copious drinks, with or without the use
of diuretics, will cause the  precipitate  to  disappear.   Where the deposit
occurs in cases in which the quantity of urine is normal, excessive produc-
tion of urates may be inferred,  and should be treated on the general  princi-
ples above laid down for  diminishing the formation of  uric acid.
                        § 3.—Of the Phosphates.

  Phosphoric acid, combined with several bases in the form of phosphates
invariably exists in the healthy urine.   Under  circumstances which will be
* Lancet, p. 163, Sept. 1858. 
OF THE PHOSPHATES.
507
discussed hereafter, some of these compounds are precipitated, and give rise
to phosphatic sand or gravel.
  Appearances to the Naked Eye.—Deposits of the phosphates are always
whitish or yellowish-white, except when they are stained with blood.   They
frequently exist when conjoined with the excessive production of mucus or
mucoid pus, and the sediment is then tough and stringy.
  The urine is generally pale, of a low specific gravity, and alkaline, and is
often ammoniacal.   When the bottle is held between the eye and the light,
brilliant points can often be seen that are due  to the reflection of light from
the angles of the crystals.
  Chemical Characters.—These deposits are not dissolved when the urine
is heated; they are insoluble in hot liquor potassae, or in aqua ammonise, but
are  soluble in dilute hydrochloric or nitric acids.  The presence  of pus,
mucus, or blood may materially interfere with the results of these tests, in
 which case a microscopical examination becomes necessary.
  Microscopical Characters.—The microscopical examination of phosphatic
sediments shows two distinct orders of form : one of which is the amorphous
powder, (generally the phosphate of  lime,) and the other the prismatic  crys-
tals.  The most abundant of the crystals are modifications of the three-sided
prism, and are a compound of phosphoric acid with ammonia and magnesia,
—ammonio-phosphate of magnesia.
  Less abundant but sufficiently common are  the four-sided prisms, which,
except in the number of sides, sufficiently re-
semble  the above.   They  are  composed  of           Fig. 429.
phosphoric acid in combination with  ammonia
and  soda, (ammonio-phosphate of soda.)
  These crystalline forms, especially the  for-
mer, which  is  most  abundant, are  generally
embraced under the common designation of
the "triple phosphate."
  The ammonio-phosphate of magnesia occurs
also in foliaceous  and stellated  forms, which,
however, belong to the  same system of crys-
tallization as the prisms.
  Etiology.—In order  to  appreciate the eti-
ology of phosphatic deposits, it must be borne   Crystal8 of the Ammoniaco.magne3ian
in mind  that phosphoric acid is a normal in-        Phosphates. (After Bird.)
gredient of  healthy urine, about 56  grains of
the acid  per day being excreted  by the adult.*
  In healthy urine this  acid  exists combined with four bases, forming phos-
phates of soda, potassa, lime, and magnesia.   Of these, the  phosphates of
soda and potassa (alkaline phosphates) are soluble; while the  phosphates
of lime and magnesia (earthy phosphates)  are insoluble in water,  but are
held in solution in urine by the  acid  phosphate of soda.f in the solutions of
which they are freely soluble.  If now the urine be rendered alkaline by any
cause, the acid phosphate of soda being neutralized, the earthy phosphates
are no longer  held in solution, but are at once precipitated.   If the alkali
be a fixed one, as soda or potassa, the precipitate consists of an amorphous
powder merely; but if the alkali be ammonia, it forms with it in neutralizing
the  acid phosphate of soda, the four-sided prisms  of the ammonio-phos-
phate of soda, which, being insoluble, are precipitated, while another portion
of the ammonia, combining with  the phosphate of magnesia, forms the three-
* Thudichum, p. 416.
f Ibid. 
508
PRINCIPLES AND  PRACTICE OF  SURGERY.
sided prisms of the ammonio-phosphate of magnesia.  The phosphate of
lime precipitates as an amorphous powder.
  These changes, which can readily be produced artificially by the addition
of ammonia to urine, occur spontaneously when healthy urine putrefies.  It
was stated, in connection with the etiology of uric  acid, that healthy urine
undergoes a process of change if allowed to stand, which is designated as the
acid fermentation; after the  acid fermentation has continued for a period
which is shorter in warm than  in cold weather, a new process  is set up, by
which, the mucus of the urine acting as a ferment, ammonia is formed at the
expense of the  urea,  and not  merely renders the urine alkaline, but causes
a precipitation of the phosphates, as above described.  This process is known
as the alkaline fermentation of urine, and is accompanied, when the devel-
opment of ammonia is considerable, by a precipitate of the urates as well as
of the phosphates.
  Alkaline fermentation of the  urine does not usually occur until after the acid
fermentation is complete, and not until  some time after the urine is passed.
In certain morbid conditions of the urinary passages, however,  the mucus or
mucoid  pus produced appears to act as an energetic ferment, determining the
decomposition of urea into ammonia, with precipitation of the  phosphates
and all the  phenomena of alkaline fermentation.   This premature  alkaline
fermentation is especially frequent in  the  chronic cystitis so common in old
men, which  is hence often described as phosphatic cystitis.  The  same phe-
nomena occur in the cystitis set up by the presence of a stone in the bladder;
and hence it is that the outer layer of stones of the most variable composi-
tion is  so  often composed of a  phosphatic  crust.   Alkaline  fermentation
within the body, and consequent  phosphatic deposits, is  also common in
cases of paralysis, of  antero-posterior curvature of the spine, etc.
  Other causes may render the urine alkaline, when voided, besides the pre-
mature  development of alkaline fermentation.  In the latter case, the alka-
linity will be due to the presence of  fixed alkali, and not of ammonia or a
volatile alkali.  Exclusive vegetable diet and the administration of alkalies
or their salts may be mentioned as the prominent causes of this condition.
  It will  be seen, from the above remarks, that abundant phosphatic de-
posits may occur in the bladder, even giving rise to the formation of  stone,
without any excessive secretion of phosphates, and consequently without the
existence of any true phosphatic diathesis.  Various causes, however, may lead
to an actual increase of the quantity of phosphates secreted.  Among these
causes may  be mentioned the  excessive ingestion of animal matter rich in
phosphates, and, perhaps, excessive mental exertion or anxiety, which, by in-
creasing the tissue metamorphosis of the brain, gives rise to this effect  Excess
in the quantity of phosphates  secreted does not necessarily determine phos-
phatic deposits, though they may coexist if the urine from any cause becomes
alkaline.  In any case, quantitative analysis alone, and not the presence or
absence of a deposit, can determine the excessive or deficient secretion of the
phosphate.
  Treatment.—As the condition determining the phosphatic deposit is the
alkaline reaction of the urine, the first indication is to restore the  urine to
its natural acidity.  Unfortunately this is not always  easy, or even possible.
The internal administration of the mineral acids, though valuable in improv-
ing the general  health, and thus indirectly benefiting the patient, will  not
render the urine acid, and cannot, therefore, be  relied upon for the purpose
of putting a stop to the deposit.
   If alkaline urine has resulted  from exclusive vegetable diet, the discreet
employment of animal food will often  restore the desired acidity.   If its
cause has been the use, for medical purposes, of the salts of the alkalies, they 
OXALATE  OF LIME.
509
must be abandoned.   But, in the majority of cases, the urine is alkaline from
the presence of ammonia, and as the cause of the premature alkaline ferment-
ation  which constitutes the  essence of the disease is to be  sought in  some
disorder of the urinary passages,  and especially of the bladder,  the  local
treatment addressed to the local lesion becomes most important.  If the local
lesion be due to the presence of a stone, little benefit can be anticipated until
this is removed,  and in many cases  the  trouble is simply chronic cystitis,
recognizable by the admixture with  the  urine of pus or mucoid pus.   The
symptoms and treatment of such cases, as detailed in connection with  acute
cystitis,  is perfectly applicable to these  cases—the  use of injections into
the bladder being especially serviceable in the cystitis complicated with stone
For this  purpose,  lukewarm water is generally sufficient; and it may be
thrown in by means of a double canula catheter, the bladder being  thus com-
pletely washed out.   The operation  may be  repeated two  or three times a
week with the happiest effect.*

                         § 4.—Oxalate of Lime.

   The only compound of oxalic  acid which  gives rise to the formation of
urinary deposits  or of calculi is the oxalate of lime.
   Appearances to the Naked Eye.—The crystals of the  oxalate of lime are so
minute, and  their transparency so great, that  the  deposit due to their pres-
ence  might readily  be overlooked  by the  naked eye.   When the  glass con-
taining the urine is held between the eye and the light, the deposit appears,
however, as a faint, mucous-like cloud, in which  minute shining points  can
sometimes be  seen, due  to the refraction of light from  the  angles  of the
crystals, but these appearances may be completely masked by the presence of
an amorphous deposit of the urates, or by the  admixture  of the urine with
blood, etc.   The urine is acid  in its reaction when first passed, and presents
no special characteristics.   Small concretions of  the oxalate of lime some-
times occur.
   Chemical Characters.—When  oxalate of  lime is passed in the  form of
 minute  gravel-stones or calculi visible to the naked eye, it is easily recog-
nized by chemical tests ;  but no chemical process is  available for  the detec-
tion  of the ordinary deposits  of  oxalate of lime, these being readily recog-
nized by microscopic examination.
   Microscopical Characters.—The oxalate of lime  appears in two diverse
forms,  octahedra and dumb-bells, the
 octahedra and their modifications being               Fig. 430.
 the most frequent.   These  octahedral
 crystals are exceedingly minute, and  in
 their most  common  form  resemble
 squares marked by a cross.  The dumb-
 bells are less frequent.  Bird regarded
 the latter not as an oxalate, but as an
 oxalurate of lime;  while  Frick, of Bal-
 timore, denies that dumb-bell crystals
 are composed of a lime salt, declaring     0xa,ate of  Li(AVrnBirdohe Mlcr°8cope-
 them to consist of uric acid.   It  is
 highly probable, therefore, that several varieties of dumb-bell crystals, as yet
 insufficiently studied, may occur in the  urine;  but the evidence  at present
 preponderates in favor of the opinion that among these we may  enumerate
 dumb-bells of the oxalate of lime.
* Bird on the Urine, p. 265, last edit. 
510            PRINCIPLES AND PRACTICE OF SURGERY.
   Etiology.—Crystals of the oxalate of lime very frequently form in perfectly
 healthy urine during the process of the acid fermentation.  According to
 Scherer, whose views have been adopted by Owen Rees and others, this is due
 to the formation in the urine, during the acid fermentation, of oxalic acid, which
 did not exist in it when passed; just as lactic acid is formed in the urine under
 similar conditions.   The oxalic acid thus produced combines with lime, and
 is precipitated generally in octahedra.   This process, which  usually does
 not occur until  some time after the urine is passed, may take  place imme-
 diately afterward, or even before the  urine is evacuated,  in the bladder or
 the kidneys.  According to this account, which appears to have the weight
 of evidence, and such names as Lehmann, Scherer, Bence Jones, and Owen
 Rees in its  favor, the presence of the crystals of the oxalate of lime in the
 urine when  passed, is no  evidence of a special diathesis, but simply an indica-
 tion of premature acid fermentation; and the  formation  of these crystals
 after the urine has  passed, is to be regarded as  a mere indication of the
 chemical changes  of fermentation,  and of no practical  importance to the
 surgeon.
   Nevertheless, admitting this view to be correct, and that crystals of the
 oxalate thus formed  are to be found in an immense number of the specimens
 of perfectly healthy urine within a few hours  after it has been evacuated, it
 cannot be denied that copious deposits of these crystals in  the urine before,
 or immediately after it is passed, are  frequently associated with a peculiar
 form of dyspepsia, accompanied by lumbar pains and various phenomena of
 nervous  irritation, as first indicated by Golding Bird;  though the  precise
 relation between the constitutional condition and the local deposit  has yet
 to be determined.   It is to  this condition that the term oxalic  diathesis,
 or oxaluria, should  be restricted.   Oxalate of lime may also appear in the
 urine temporarily after  the ingestion of the soluble oxalates.  Thus, a
 copious deposit of oxalate  of lime can  be  produced at  pleasure  by the
 internal administration of the binoxalate of potash, and the same may also
 occur after  eating rhubarb  pies, or other vegetable food rich in  soluble
 oxalates.
   Treatment.—If the crystals form only after the urine is passed, no treat-
 ment  is required, and  the deposit is not to be regarded as a morbid  con-
 dition.  Where, however, the copious  deposit of oxalate of lime is  accom-
 panied by the dyspeptic  symptoms  above alluded to, these must be treated
 on the general principles applicable to such  cases.  It is in this condition
that  the  internal  administration of the  nitromuriatic  acid (or the other
mineral acids) has proved so useful, its exhibition being sometimes speedily
followed by  disappearance of the deposit.
                             § 5.—Cystine.

  A rare form of calculus, first described by Wolaston, is that composed of
the peculiar crystalline compound, rich in sulphur, which has received the
name of Cystine.  Since that time it has been occasionally noticed, both in
calculi  and as a deposit, in Europe and this country.
  Appearances to the Naked Eye.—Deposits of cystine are white or fawn-
colored in  appearance, and  sometimes much resemble phosphatic deposits.
The urine is usually yellow, of high specific gravity, and neutral or alkaline
in reaction.
  Chemical Characters.—These deposits further resemble those of the phos-
phates in being undissolved when the  urine is heated, and soluble in nitric 
CALCULUS, OR STONE.
511
and hydrochloric acids.  But they can be at once distinguished by their ready
solubility in aqua ammonia.
  Microscopical Characters.—Cystine presents under the microscope the
appearance of transparent six-sided tables, variously aggregated together.
  Etiology.—The  etiology of these rare deposits  is quite unknown, and
nothing available in the way of their treatment has been, as yet, proposed.
                             \ 6.—Uric Oxide.

  Still rarer and less understood are the deposits and calculi of Uric Oxide.
This substance, which is normally excreted in the urine of spiders and scor-
pions, has never been  met with in human urine, except as the ingredient of a
few calculi and  rare urinary deposits.   It was first noticed as a calculus by
Marcel, and afterward by a few other observers.   It has been observed in
deposits by Berzelius, Morin, of Geneva, and one or two others.
  The characters of these deposits have not been accurately described, and
nothing is known of their etiology or treatment.
SECTION  II.
                          CALCULUS, OR STONE.

   When any of these sabulous deposits find in the bladder a nucleus, such
as a drop of blood or of mucus, or a grain of wheat, a bit of straw, or any
substance which the morbid imagination of a patient may have led him to
introduce, or which has entered accidentally, they accumulate upon it, and
go on to such an extent as to result in the formation of a true stony mass or
Calculus.  The calculi thus formed are to be regarded as foreign bodies, and
act as such, producing irritation of a serious character in the mucous mem-
brane of the bladder, the effects of which are felt by the whole system.  The
vesical irritation and inflammation thus resulting may even be so severe as
to cause the death of the patient, post-mor-
tem  examinations  showing   pathological
changes in the coats of the bladder caused
by this irritation, the coats being sometimes
enormously thickened, while the ureter is dis-
tended  and  sacculated, and the whole uri-
nary apparatus presents appearances which
almost prevent the recognition of its original
structure.
   Varieties of Calculi.—The various kinds
of calculi may be thus briefly described:—
   That of uric or lithic acid, and its com-
pounds,  is the  most common, constituting
two-thirds of all calculi.   They are seen of
various colors, often presenting  a fawn or
yellowish hue,  though  sometimes  they  are
so dark  as to  deserve the appellation of a
mahogany color.  They are generally of a
flattened oval  shape, and  if  a  sectiou  is
made,  they  will  be  observed to consist of
concentric laminae, arranged around a central
nucleus; each layer showing its distinct character by a variation in the color,
 Uric Acid Calculus, showing ita finely
tuberculated surface. (After Gross.) 
512
PRINCIPLES  AND PRACTICE  OF  SURGERY.
Fig. 437.   The surface is either faintly tuberculated, Fig. 431, or more soft
and smooth.   In size they vary from the circumference of a hazelnut to that
of a hen's-egg.

           Fig. 432.              Fig 433.               Fig. 434.
  Fig. 4"2.—Nucleus surrounded by Oxalate of Lime, and this covered by concentric layers of Urate of Am-
monia. (^ After Gross.)
  Fig. 433.—Triple l'hosphat6 surrounding a Mulberry Calculus. (After Gross.)
  Fig. 434.—Oxalate of Lime, or Mulberry Calculus. (After Gross.)

  Tests.—Calculi containing uric acid or its compounds may be recognized
by the following chemical tests : They will  dissolve in nitric acid with effer-
vescence, and this solution, being evaporated  to dryness, will give a  pink
color,  which will  become violet  when held over the fumes of  ammonia.
They also dissolve in caustic potassa, from which, by the addition of an  acid,
colorless crystals of uric acid may be obtained.
  The Calculus of Oxalate of Lime is next in frequency, and generally pre-
sents itself in the form which, from the character of its surface,  is described
as the mulberry calculus.  It is tuberculated, but irregularly  spherical, and
is nearly always single.
  Its color  may be  almost white, but more frequently brownish or brown,
with sometimes  an approach to dark-olive green.
  In its formation it frequently has a nucleus of some foreign substance, or
of some other variety of urinary concretion, especially uric acid.
  The tuberculated surface is often rough and sharp  pointed, thns indncing
marked irritation when the bladder contracts closely  upon them.   Hence it
is that the  symptoms of this variety are generally more severe, in propor-
tion to the size of the calculus, than those  of any other class  of stone.
  In  size these  calculi  are seldom  larger  than  a walnut or small egg.   In
texture they are extremely hard, and are  susceptible of a fine polish.
  Tests.—If a small portion of one of these calculi  be heated  on platinum
foil with the blow-pipe, it first becomes black, from the charring of the inter-
mixed organic matters,  but, as the heat continues, it becomes white.
  The residue is alkaline to test paper, and effervesces with the dilute acids ;
it is a mixture of carbonate of lime with caustic  lime,  the oxalic acid having
been decomposed by heat.
  The Stone formed by the  phosphates has generally a grayish-white color,
and  is quite soft, so  that  it can easily be  crushed.   Phosphatic layers are
also frequently observed incrusting nuclei, or alternating with  layers of some
other deposit.   Stones  formed entirely of  phosphatic matters may be com-
posed wholly of phosphate of  lime, or of triple  phosphate, or,  by far  more
frequently,  of a mixture of the two.
  Tests.—Stones consisting of a  mixture of the triple phosphate with phos-
phate of lime are known as Fusible Calculi, from the readiness with  which
 
CALCULUS, OR STONE.                     513
they melt before  the blow-pipe.   They are  soluble in dilute mineral  acids,
from which they may be  precipitated  by  the addition of ammonia.   The
same chemical test applies to calculi composed of the phosphate of lime or
of the triple phosphate  only;  but these calculi are fused with the greatest
difficulty, and  may thus be discriminated.   Calculi of phosphate of lime, if
dissolved in acetic  acid, will precipitate oxalate of lime on the addition of
oxalate of ammonia, which will  serve for the differential diagnosis between
them and the triple phosphate.

             Fig. 435.                            Fig. 437.
  Fig. 435.—Calculus of Ammoniaco-Magncsian Phosphate, entire, exhibiting its shining crystalline surface.
 (After Gross.)
  Fig. 436.—Cystic Oxide Calculus. (After Gross.)
  Fig. 437.—Section of an Alternating Calculus, chiefly composed of uric acid. (After Gross.)

   Calculi of Cystine are rare; they are yellowish and wax-like, greenish-gray
 or greenish-brown.   They  may be recognized by their solubility in aqua
 ammonia, from which solution six-sided crystals of cystine  may be obtained
 on evaporation.
   Calculi of uric oxide* are still rarer than  those  of cystine.   They much
 resemble in  appearance  those of uric acid, but assume a waxy appearance
 when  polished.  They have  been so seldom observed—in  three cases only,
 according to Thudichum—that it is unnecessary to occupy space by describ-
 ing their chemical peculiarities in this place.
   Symptoms.—As  it is apparent that calculi originate in the  kidney, the
 earliest symptoms of the tendency to the formation of these bodies will usu-
 ally be found in connection with this gland ; thus there will be pains in the
 loins, this pain being at times much more severe than at others, and resem-
 bling,  when  at its  height, the pain of colic, for which  it may be mistaken,
 particularly  when  accompanied, as it sometimes is, with  vomiting, and a
 peculiar sense of constriction in the epigastric region as if the patient was
 bound around the stomach with a cord, the urine being scanty, high colored,
 and often mixed with blood.  There is also very apt to be  a burning sensa-
tion in the urethra, due  to sympathetic irritation.
  When gravel or a pebble passes into the ureter, if  its  size is such as to
present any obstacle to its free passage, a new train of painful symptoms are
               * Synonyms, Xanthine or Xanthic Oxide.
vol. n.—33
Fig. 436.
 
514            PRINCIPLES AND PRACTICE  OF SURGERY.
rapidly developed : thus there will be pain in the course of the ureter, violent
spasmodic contraction of the cremaster muscle, the testicle being often drawn
quite up to the external abdominal ring, a fact which is of  much value as a
means of diagnosis ;  while, if these symptoms continue for from twenty-four
to forty-eight  hours, there will  very often be  present more or less febrile
reaction, heat  of skin, and diminished secretion, this condition  being usually
terminated by sudden relief.   The  suddenness of the relief experienced by
the patient is  another diagnostic sign of importance, and  is caused by the
passage of the stone from the ureter into the bladder.   All these symptoms
are sometimes so severe as well to deserve the name which is  often applied
to them of Nephritic colic.
  Treatment  of Gravel, or Nephritic Colic—As  the passage of a pebble
through the ureter is very painful, it requires prompt and efficient treatment,
the indications of which are to allay the pain and favor the passage of the
pebble by such means as will induce relaxation of  the system, the quickest
mode of doing which is by the administration of anaesthetics.  In the relaxation
induced by partial anaesthesia—for it is not necessary to carry it to the fullest
extent—the passage of  the calculus will be  favored both by gravity and by
the action of  the urine.   If,  however, anaesthetics  are  not at hand, or are
from any cause contraindicated, the  same result may be  obtained,  though
not so promptly, by the use  of  opiates, and if, in spite of these measures,
the calculus lingers in its passage through the  ureter, the effect of an active
purgative may be tried.
  One point in the treatment is of great importance, and yet is often over-
looked, and  that is, until  the pebble has passed completely from the kidney
into the bladder, and the patient is  entirely  relieved for the time, the use of
diuretics should be carefully abstained from, for it will readily be understood
that the great danger in the passage of the pebble through the  ureter is that
it may cut through it, and thus  give rise to urinary infiltration into the ab-
dominal  cavity, or that,  blocking up the ureter, it may dam  up  the urine,
which, accumulating behind  it, may produce distention and rupture of the
canal, the latter danger  being greatly increased by the increased secretion of
the kidney while the pebble is in the ureter; but after the pebble has passed
into the bladder, mild diuretics  and diluents will often be useful by allaying
pain and irritation.
  Having reached the bladder, the  pebble  may afterward,  if not too large,
be passed by  the urethra, and to favor this the mild diuretics  and diluents
above spoken  of are also serviceable. But most frequently  it remains in the
bladder without causing any inconvenience  until attention is directed to  it
by the gradual setting in of all the symptoms of stone in the bladder.
  Stone in the Bladder may be  found in all ages, in all climates, in patients
of all habits  and temperaments,  and in both sexes, though more  frequent
in the  male  than in  the female, on  account of the larger  size and  shorter
length of the  female urethra, which  therefore  permits  an incipient calculus
to escape.
  Stone has also been found, in children at birth, of such a size as proved that
it must have  existed for some time  in the foetus in the womb; while it has
been found in  old men, as well as in all intermediate ages.   Children, how-
ever, are rather in the majority,  as of 5376  cases recorded by  Civiale,' 2416
were in children,  2167 in adults, and 793 in  very old persons.
  Of the children, 1946 were under  10 years of age.
  This complaiut also prevails in all climates, though some seem more favora-
ble than others, owing to a variety of causes, among which the character of
the waters of certain streams perhaps  plays  an  iraportaut part.   In the 
CALCULUS, OR  STONE.                     515
United States, according to the work of Gross,* the disease is most common
in Kentucky, Ohio, Tennessee, and Alabama; less frequent in Pennsylvania,
Delaware, Maryland, Virginia, North  and South  Carolina, Louisiana, and
Arkansas; in New England, Canada, Texas, Mexico, and  California it is
more rare;  while Missouri, Iowa, Michigan, New York, etc. are compara-
tively exempt.
   As regards the color of the patients, the white man suffers more than the
black, and  it is said to be a rare thing to see a negro affected with stone.
Out of a very large number of cases seen by me in this country and in Europe,
including a close observation of Civiale's wards  for many months, I  do not
remember to have noticed more than two cases in the negro.
   Symptoms.—The symptoms which generally accompany the presence of
stone in the bladder are as follows : There is a differeuce  to be observed in
the manner of urinating, the stream being frequently and suddenly arrested
by the stone coming over the orifice at the neck of the bladder and closing it.
In a few moments after, the stream will again begin to flow freely, as the stone
has rolled away.  The patient now begins to complain of pain, and this pain
—which is due to the irritation about the neck of the bladder,  like many
other irritations upon the course of nerves which are referred to their periph-
eral extremities—is noted at the head of  the penis.  This pain at the head
of the penis, due  to irritation in the neck of the bladder, is not merely one of
the symptoms of stone, but is generally found to accompany any irritation
of the neck of the bladder produced by other causes.  Thus, it is often found
accompanying the  neuralgia of the  neck of the bladder, which sometimes
occurs in connection with  spermatorrhoea; and is also found as one of the
symptoms of cystitis.  The pain  at the head of the penis is, however, more
marked in cases of stone  than in the other disorders, owing to the perma-
nency of the cause, and leads the patient, particularly if a child, to  handle
the penis, aud pull upon the prepuce constantly.   As a result, the prepuce
becomes very much elongated, and phymosis is induced, so much so that it is
sometimes difficult to introduce a sound, while the fingers of the little patient,
from the constant  dribbling of urine,  have the  cuticle macerated, and the
finger-tips  shriveled, so  as to resemble  a washerwoman's fingers.  As the
rectum is closely in contact with  the bladder, it shares in the vesical irrita-
tion, and there is tenesmus, this tenesmus being not unfrequently accompa-
nied with prolapsus ani.
   The urine at first is clear,  and  may or  may not present, when allowed to
cool, characteristic deposits.  But by and by it becomes muddier or dark
colored from an  admixture of mucus  or of  blood, and  may contain little
particles of stone, which have been broken off and escaped.
   All these symptoms are liable to be much aggravated in  spells, there being
then intense  pain and great  constitutional disturbance,  accompanied some-
times by more or  less febrile  reaction.    Under these circumstances,  the
patient is said to be laboring under a fit  of the stone.
   The symptoms of stone in the bladder, though  often  very marked, are
sometimes quite obscure, and the  surgeon has occasionally no reason  to sus-
pect in the least  the presence of  a stone, until it is accidentally discovered
by an instrument passed into the bladder for some other purpose.  Very often,
although the symptoms are such as fully to justify a belief in the presence of
a calculus, and the "fits of the stone," so called, are frequent and severe, the
general health of the patient  does not appear to suffer; the bloom still rests
  * A Practical Treatise on the Diseases, Injuries, and Malformations of the Urinary
Bladder, the  Prostate Gland, and the Urethra, by Samuel D. Gross, M.D.  Philadel-
phia, 1855. 
516
PRINCIPLES AND  PRACTICE OF  SURGERY.
on the cheek of the child, and the frame of the adult preserves its strength,
while in other cases the constitution suffers greatly, and the patient emaciates
and sinks rapidly.
  Diagnosis.—The diagnosis of stone will be given in connection with the
description of the operation.
  Prognosis.—The prognosis  of stone in the bladder will depend very much
upon the circumstances of the case ; thus, if the  health of the patient is good,
the stone moderate in size, and the case one suitable for lithotripsy, the prog-
nosis will be favorable; while if the general health of the patient is exhausted
and broken down,  the prognosis will be grave.   If lithotomy is required, the
dangers of the operation must  always be taken  into consideration in giving a
prognosis;  while in  both  operations it should be recollected that, after the
removal of the stone, if the diathesis is notcombated and overcome, the patient
will be liable to a re-formation of the stone.
  Treatment.—The treatment of stone is of two kinds—the first being pal-
liative and the second curative.
  As the irritation of a fit of the stone is very great, a palliative plan of treat-
ment becomes necessary to relieve its violence.  Thus  an attempt may be made
to render the surface of the stone smooth, if it  is rugged, by the injection of
mucilages into the bladder, or the free administration, by the mouth, of alkalies
and diuretics.  When the patient is suffering acutely, resort may be  had to
various other plans of obtaining relief.   Of these the simplest is to seat him
in a warm hip-bath, which is generally useful by relaxing the spasmodic con-
tractions of  the bladder.   If this is not sufficient,  an anodyne injection, con-
sisting of a proper  amount of laudanum in a little starch water, may be given,
or a suppository of opium introduced into the  rectum, or resort may be had
to a moderate use of anaesthetics.
  In the curative  treatment, the operations of lithotripsy or of lithotomy,
as hereafter  stated, will be demanded for the removal of the calculus.
                          CHAPTER  IV.

   OPERATIONS FOR THE REMOVAL OF STONE FROM THE BLADDER.

  Two operations have been suggested for the removal of a calculus from the
bladder  and the relief of the symptoms  created by its presence:  the one__
Lithotomy—consisting in making an incision through the  neck of the blad-
der by perforating  the perineal structure; the other—Lithotripsy—being
accomplished by instruments introduced  into the viscus through the urethra,
by means of which the stone is crushed, and voided in fragments through
the urethra.
  In the selection of either, the surgeon should be mainly guided by the pecu-
liarities  of the case.   If the patient is in  feeble health, with disordered diges-
tion, a  diseased bladder, and  thickened, muddy, or  muco-purulent  urine,
lithotomy may present the best chance;  but if the stone is soft and friable,
—as may be told by the sensation given to the sound—if  the bladder  is ap-
parently healthy, and the general constitution not much impaired, lithotripsy
should be selected, as being attended with  less risk, and also as least  likely
to give  rise to trouble in the execution of the functions of the bladder and
testicles at  a subsequent period. 
            SURGICAL  ANATOMY OF  THE  MALE PERINEUM.        517

  The operation of incising the male perineum and extracting a calculus has
always been regarded as one of the most important efforts of an operator,
and the anatomical relation of the parts cannot, therefore, be too often re-
ferred to by those contemplating  its execution, and will now be given.
                              SECTION I.

               SURGICAL ANATOMY OP THE MALE PERINEUM.

   The Perineum—Tttpt, around, and veo<;, a temple—is formed entirely of such
 soft tissues as fill up the inferior outlet of the pelvis, and has in the male no
 openings except those for the urethra and rectum.
   In its general outline, the perineum may be limited to the space included
 between the bones forming the inferior strait of the pelvis, though for the
 purposes of regional anatomy, it has sometimes been circumscribed yet more,
 by being described as "the isosceles triangular space formed by the bones of
 the arch of the pubis, and by a line drawn transversely from the tuberosity
 of one ischium to the other, in  advance of the anus."
   The tissues entering into the composition of the perineum  are the skin,
 superficial fascia, loose connective tissue, loaded with fat, and varying very much
 according to the general condition of the patient, the perineal muscles, the
 triangular ligament or middle  perineal fascia, and the deep or  pelvic fascia.
   In the middle of this region, as thus bounded, we  should notice that the
 larger triangular space above  described can be readily subdivided into two
 equilateral triangles by the raphe", this line  being the boundary of the sym-
 metrical portions found on each side.
   Of these we should note the root of the corpus cavernosum, the erector
 penis muscle, the transversus perinei, and sometimes the transversus perinei
 alter, part of the levator ani, or muscle of  Wilson, as well as the branches
 of the internal pudic vessels and nerves.
   In the middle line of the perineum, we also find, in addition to these muscles,
 the skin and fascia, the accelerator urinae, the sphincter ani, the bulb of the
 urethra, its membranous portion, the triangular ligament, the rectum, prostate
 gland, and the orifice of the neck of the bladder.
   The  dimensions of the perineum in man have been  carefully studied by
 surgical anatomists in order to  decide how large a calculus can be extracted
 through this part.   According to Dupuytren, the transverse diameter of the
 perineum varies from two to two and a half inches, while its depth, or antero-
 posterior diameter, is about four inches.  The distance of the peritoneum from
 the skin, on a level with the recto-vesical depression between it and the verge
 of the anus, varied from two inches and eight lines to three inches and six
 lines, as examined upon twelve subjects, and from the mucous surface of the
 neck of the bladder to the raphe, ten lines in advance of the anus, it was from
two inches to two inches and eight lines.*
   The relative position of the prostate gland, and its capacity for dilatation,
have also been  accurately studied in consequence of its necessary division  in
the extraction of calculi through this  region.  According to Velpeau.f the
prostate gland is situated about eight lines from the symphysis  pubis, and its
sides about an equal distance from the rami of the pelvis.
   " The transverse incision on one side of the prostate, as ascertained by the
measurement of the gland by Bell, in more  than  forty subjects, can only be
about ten lines  in  length,  give an entire opening of two inches  and nine
* Blandin, Anat. Topograph., p. 383.
f Anat. Chirurg., tome ii. p. 236. 
PLATE  LIII.
              INSTRUMENTS  EMPLOYED  IN LITHOTOMY.

  Fig. 1. A strong Round-bellied Scalpel for the first incisions of the perineum.
                                                          Kolbe's pattern.

  Fig. 2. A Sharp-pointed Bistoury  to open the membranous  portion of the
urethra  and expose the groove  of the staff, which  it  will do better than the
scalpel.   In using it, the  membranous portion of the urethra should be punc-
tured as near to the prostate as possible, and  then  laid open from behind for-
ward                                                     Kolbe's pattern.

  Fig. 3. Dupuytren's double Lithotome Cache.  1. The beak  adapted to the
groove of the staff.  2, 3. The blades  expanded laterally, but shutting up in the
body of the lithotome.  4 The  lever for expanding the blades.   5. A screw  to
regulate the expansion of the blades.                     Charriere's pattern.

  Fig. 4. A side view of Physick's Cutting Gorget, the blade being detached  at
pleasure from the handle.  1. The handle.  2. The  ste ) -beak.  3. The cutting
edge. 4. The screw to fasten the blade to the beak and handle.
                                                          Kolbe's pattern.

  Figs. 5, 6, 7, 8 represent other blades, which may  be adapted to the  same
handle,  and selected in reference to the width of the perineum in each patient;
they vary from one-fourth of an inch to one inch, increasing by fourths or eighths,
at the option of the  operator.   The size and angle of the blade and handle are
similar  to that of the common gorget. The length from the beak to the angle of
the handle is four and a half inches, and the handle is four inches.  As the blade
can  be  readily detached, it may  be perfectly and readily sharpened, and made to
cut  directly up to the beak of the instrument.

   Fig.  9. Barton's Stone Forceps with fenestra to diminish the expansion  of the
blades  when holdiDg the  stone.                                Kolbe's pattern.

   Figs. 10, 11. The ordinary Stone  Forceps, of different sizes.

   Figs. 12, 13.  Different forms  of the Scoop.                  Kolbe's pattern.

   Fig.  14. Barle's Forceps for crushing calculi which are too  large to be  ex-
 tracted whole.   1. The screw to close the handles.              Kolbe's pattern.
(518) 
 
 
OPERATION OF  PERINEAL LITHOTOMY.             519
lines in circumference, and allow of the exit of a spheroidal body ten or eleven
lines in diameter.  The oblique incision downward may be from eleven lines
to an inch long, create an opening three inches and  a line in circumference,
and be large enough for a calculus one inch in diameter.
   " When the prostate is incised on both sides, the transverse incisions being
each nine or ten lines long, there will be an opening four inches five lines and
a half in circumference, which therefore permits the extraction of a calculus
one inch and a half in diameter. Two perfectly oblique incisions will form an
isolated triangular flap, the base of which is one  inch and three-fifths in ex-
tent, and  lay bare, when the flap is lowered in  front,  a triangular opening
altogether a little less than four inches, and consequently less than the trans-
verse opening.   An oblique incision to the  left side, eleven  lines or an inch
long, and another transverse  one to the right, ten  lines long, permits the
largest opening, and  with the  dilatation of the urethra, gives an opening of
four inches  and eight lines, while it is one which can  be easily  expanded.
This last is  the incision preferred by Senn."*
   The membranous  portion of the urethra  is ten lines  long, and is situated
behind the triangular ligament, and in front of the prostate.
   The bulb  of  the urethra is attached to the anterior face of the triangular
ligament, is formed by a spongy or erectile tissue, which is  nearly deficient
in children, fully developed at puberty, and is longer  than its width in old
men.f
   The transversus perinei artery supplies the bulb of the urethra, and passes
to it fourteen  lines in  advance of the anus.  The  branches of the venous
vesical  plexus, which surround the  neck of the  bladder, lie outside  of the
prostate in  the thickness of its sheath.
                             SECTION II.

                  OPERATION OF  PERINEAL LITHOTOMY.

   Perineal Lithotomy may be performed in three ways: in one, the incision
opens the  membranous portion  of the urethra and the prostate on the left
side of the perineum, and is called the Lateral operation; in the second, both
sides of the prostate gland are divided, constituting the By-Lateral operation;
and in the third, it is divided  in the line  of the raphe, and is therefore
termed the Median operation.

                        \ 1.—Preparatory Steps.

   Before  proceeding to employ any of the  means that are proper, as pre-
liminary  measures,  in the  operation  of lithotomy, it  is  essential  that the
presence  of the stone be positively established.
   Diagnosis of Stone in the Bladder.—Various symptoms  have been re-
corded by surgical writers as pathognomonic of the existence  of a calculus;
but, though useful as aids in diagnosis, they cannot be  relied upon by them-
selves ; sounding, or the.direct contact of an instrument with the stone, being
the only certain sign of its presence.
   Sounding.—To  prove the existence of a  stone by sounding, the surgeon
should select two steel sounds of different curves, and with smooth polished
handles, warm  and oil them,  and  then introducing one into the  bladder  in
* Malgaigne, Op. Surg., Philad. edit. p. 497.                f Blaudin, p. 386. 
520            PRINCIPLES AND PRACTICE  OF SURGERY.
the manner directed for catheterism, move its point about until he can cause
it to touch the calculus, when the sensation which will be communicated to
the fingers will prevent a mistake.  The advantages of employing sounds witb
different curves will be found in the facility with which the smaller curve may
be made to sweep the  bas-fond of the bladder, when the greater convexity
of a more curved  instrument  might cause the instrument to pass over the
stone without touching it.  When a  sound is in the bladder its point should
be  gently turned from side to  side as well as to the top and  bottom ot the
viscus, lest the stone be encysted or concealed behind a fold of the raucous
membrane owing to the  thickening of this  coat, or to its being  rendered
prominent by the hypertrophied condition of the muscular coat.
  In order to obtain an accurate touch, the broad handle of the sound should
be  perfectly smooth, and held between  the  thumb  and forefinger, so as to
obtain as great a surface of contact  as possible.  By attaching a flexible
stethoscope  to  the  handle of  the sound by means of a little  clamp, or by
means of  a sounding-board of light, compact and sonorous wood, the sense
of hearing may also be made to aid  materially the diagnosis.  In several
instances  I have caused the click of a Sound against a stone in the bladder
to be heard by a medical class of five hundred students, through the interven-
tion of the sounding-board attached to the Sound after it is introduced into
the bladder.
  On the  part of the patient, there are also certain circumstances which are
favorable  to the establishment of a diagnosis by these means.   Thus the
bladder, at the time of sounding, should hold sufficient water to  keep its sides
moderately distended.  When, therefore, the patient has urinated a short
time previous to the visit of the surgeon, a silver catheter should be first in-
troduced,  and  about twelve ounces  of tepid water slowly injected, so as to
distend the  bladder, and prevent its  closing on  the  instrument.   If, after
sounding  with the bladder in this condition, a stone cannot be felt, the fluid
may be allowed to escape, or be voided by the patient, in order that the con-
traction of the bladder may bring the stone in contact with the instrument.
Small  calculi in  patients with  diseased prostate are also sometimes difficult
to detect, unless the finger is introduced into the rectum;  and the same
manoeuvre will often prove useful in other cases.  A change in the position
of the patient sometimes renders the presence of a stone apparent, which
could  not previously be felt, "by causing it  to touch the  sound; thus, after
lying on the back, a position  first on  one  side and  then on the  other, cau-
tiously taken, will often cause the instrument to touch the stone;  and, in two
instances,  Physick succeeded in thus detecting a calculus where other means
had failed, the patient being  placed in  one instance so nearly on his  head
that the fundus of the bladder became the most depending part.*
  The record of cases in which patients have been cut, without the operator
finding any stone, as well as the history of those whose bladders contained
large calculi, the presence of which had not been detected during life, are
sufficiently numerous to lead every  operator to  use the utmost caution in
sounding his patient.   Thus, a fibrous tumor, attached to the prostate gland
by a slender pellicle, is reported by Velpeauf to have been mistaken for
stone;  while  Desault, Cheselden, Cooper, and  Velpeau!  cite other cases
where  even large stones existed without being  recognized.   By a resort to
anaesthetics  many of the former sources of difficulty can now be removed,
so that one familiar with the changes of structure liable to be produced in
Dorsey's Surgery, vol. ii. p. 179.            f Mott's Velpeau, vol. iii. p. 888.
                     X Op. cit., vol. iii. p. 891. 
OPERATION OF  PERINEAL LITHOTOMY.
521
 the bladder by disease, can hardly fail, with proper care and repeated exam-
 inations, to satisfy himself fully of the actual condition of this viscus.
   In addition to the knowledge  gained, by sounding, of the presence of a
 stone, the operator should also learn the probable size, consistence, number,
 and position  of  the calculi, all of which will materially aid him in deciding
 upon the kind, as well as the steps of the operation, that  may be required
 for their removal.

                      \ 2.—Constitutional Treatment.

   The presence of the stone being in most instances the cause of much of
 the suffering  and general constitutional disturbance seen at this period of the
 complaint, it might be supposed  that its  prompt removal would afford the
 best chances  for a recovery;  but  experience  has firmly established the fact
 that the greatest success attends such operators as have first carefully attended
 to the preparation of their patients.
   To prepare a patient for  the  operation of lithotomy requires  a  correct
 judgment, and the combination of the highest medical with  the best surgical
 experience, as the means must vary in different cases; but in every instance
 the patient should be placed in as healthy a condition as possible.  He must,
 therefore, neither be too much depleted nor stimulated, while every secretion
 should be noted, in order to tell the proper condition of his whole system.
 As  a  general rule, it is beneficial to evacuate the bowels  thoroughly, but
 gently, before operating; to obtain perfect rest; to have the mind  free from
 anxiety, and  to place the  digestive and  thoracic viscera,  as well as the skin,
 in a good condition by means of alteratives, sedatives, and diaphoretics.  No
 better means  can be resorted to for  the  relief of the train of symptoms that
 have been termed a " fit of the stone " than the free use of alkaline and diluent
 drinks;  the hip-bath; anodyne suppositories or enemata, and the occasional
 inhalation of  ether.   I have in several instances afforded much relief simply
 by administering boluses of the following alkalies and diuretics:—

                    B.—Saponis  Hispan.,
                        Carb. sodae exsiccat., aa 5j;
                        01. juniperi,          gtt. Ix.
   M. Et ft. mass dein in pil. xxiv dividend.    S. One every four hours.

   In cases of gravel, the same  formula, by neutralizing the uric and lithic
 acid,  has caused  the evacuation  of such an  amount of sand as induced
 patients to think the stone was being dissolved.


                      \ 3.—Local  Preparatory Means.

   The local preparatory measures required in lithotomy refer both to the
 part of the body to  be operated  on and to  the apartment selected for the
 performance of the operation.
   The perineum  of a patient about to be cut for  stone should in all cases be
 perfectly cleansed and shaved, in order to avoid the irritation liable to be
 caused after the  operation by the adhesion of unhealthy discharges  to the
 hair of the part.  The rectum should  also  be thoroughly emptied by a
 laxative enema, and then put at rest by the use of an anodyne ; but the blad-
 der should be kept nearly full, either by inducing the patient to retain his
nrine, or if this cannot be done, or if the secretion is deficient, by previously
injecting tepid water as directed iu sounding.
  In selecting a room, it is important to have one that  is well  ventilated, 
522            PRINCIPLES AND PRACTICE  OF SURGERY.

and with a good light falling either from above or from one side; to have a
firm narrow table, and sufficient stands or tables for the reception  of instru-
ments, etc.
  After selecting the table, it should be covered by a mattress and pillows,
the end of the mattress being doubled under  and tied or  pinned  firmly to-
gether, so as to elevate and support the  hips.   Over this should be placed a
thick  blanket, and over this a sheet, the end of which should hang dowu to
the floor,  in order  to  receive the blood, urine, feces, etc.   The resort to a
shallow box or  pan of sawdust at the  foot of the table, aud placed just
beueath the end  of the sheet, will also aid  in preserving  the  cleanliness of
the apartment.
  In addition to such  instruments as may be required for  the  special  mode
of operating selected  by the surgeon,  there should also always be prepared
a large syringe  and catheter; a pitcher of barley-water  to wash out  such
fragments of the calculus as may be created in extracting the stone, together
with a little cup of  sweet oil, sponges, basins, water, towels, and  stimulants
should the occasion require them.
   Five assistants may be required  to aid  the  operator.   The first should
hold the staff and scrotum  of the patient, according to the directions fur-
nished by the surgeon.   Two others should place the patient's knee in their
axilla, while their forearms should be  passed  round  his leg, so that by bear-
ing their weight upon his pelvis  they may steady it  upon  the table, and, by
keeping his thighs separated, render the perineum tense.   The fourth should
stand  at  the patient's head and  shoulders, to administer the anaesthetic,
watch its effects, and furnish drink or  such  other attentions as the circum-
stances may call for; the fifth should remain in the room to wait upon all.
                           SECTION III.

                       THE LATERAL OPERATION.

  The division of the perineum upon the left side of the raphe, so as to open
the bladder through the left half of the prostate  gland, is  an operation of
considerable antiquity,  and by many regarded as the best mode of operating
where the stone is not  excessively large.   Although those selecting it have
from time to time deemed it advantageous to modify the various instruments
by which  the division  of the prostate was to be effected, there is but little
difference in the  other steps of the operation, and this  account  will  there-
fore be limited to the operation as practiced by Cheselden, Abernethy,  Cline,
and others, in Europe; by Physick, Dudley, Barton, McDowell, and others,
in the United States.


      §  1.—Instruments that may be wanted during the  Operation.

   In order to meet all the contingencies that may arise in the lateral method
of lithotomy, the surgeon should prepare  and place upon  a tray the follow-
ing articles, which are mostly shown in Plate LIIL, to wit: one large  and
deeply grooved staff, to pass into the bladder; one large round-bellied scal-
pel with which to incise the perineum;  one sharp-pointed  bistoury to open
the membranous part of the urethra, if the scapel is not sufficient; a gorget
or knife to incise the prostate; forceps of different sizes, with and without
fenestra;  a scoop; Earle's crushing forceps, or Heurteloup's lithontripteur • a
tenaculum;  Physick's forceps and needle, in case of wound of the internal 
         THE LATERAL OPERATION OF  PERINEAL LITHOTOMY.     523

pudic artery;  and ligatures, needles, and lint for arresting the hemorrhage,
or plugging the wound, if requisite.,
  Introduction  of the Staff.—The  patient being etherized, and placed as
before directed, the surgeon should oil and introduce a sound into the blad-
der to render the presence of the stone evident to his assistants, and, having
done so, withdraw the sound and introduce the staff;  or, the sounding may
be practiced the day before the operation, and verified simply by the staff at
the time of the operation.   The latter being then accurately adjusted in the
median  line of the body, the first assistant should hold it, while the patient's
hands and feet are  bandaged together, if the assistants are  not men of ex-
perience, but with the employment of anaesthetics and  with good assistants
this is  not necessary, though  it is much  the safest practice.   The patient
being now in position, with the perineum  fully exposed, the  surgeon should
feel for  the tuberosity of the ischium, the  bulb of the urethra, and the body
of the staff, so as to recognize these  points of reference, and, being  satisfied
with  the position of  the staff,  direct the assistant how to hold it.   On
this point there  is much difference of sentiment, such surgeons as prefer to
be guided in  their incisions solely by the  staff, liking it to bulge out in the
perineum and incline well toward the left aside;  while others, relying upon
their  anatomical  knowledge, prefer having its point kept accurately in the
bladder, with its concavity  close under the arch of the pubis, and its handle
turned a little to the right groin, so as merely to present its groove toward
the left  side of the raphe.  Of  the two methods,  I prefer the latter, relying
upon  the staff rather in cases of error  or deviations in incising a deep
perineum than for  the primary incisions.   In my opinion, any surgeon who
cannot  open  the membranous portion of  the urethra without the aid  of a
staff, is but badly qualified for the performance of the operation of lithotomy.
            \ 2.—Lateral Operation with the Cutting Gorget.

  The surgeon being conveniently seated on a moderately low stool or chair
without a back, or else kneeling on one knee, should commence the operation
by placing the first and second fingers  of his left hand upon the perineum
near the raphe, so as to steady the skin, and then holding the scalpel in his
right hand like a pen, puncture the skin and fat by a perpendicular  pressure,
at a point one line to the left side of the raphe, and immediately behind the
scrotum, that is, at one which corresponds with the lower side of the arch of
the pubis, or is  about one inch in  advance of the sphincter  ani muscle.
Commencing at this point, let him now, by  a  steady pressure, continue the
incision in a straight line to a spot corresponding nearly with the middle of
the fibres of the sphincter ani muscle, and about half way between it and the
tuber ischii, the  incision being about three and a half inches long in the
adult, and boldly made,  so as to divide the parts neatly,  while it should  be
of sufficient depth, especially in its middle, to reach the membranous part of
the urethra.  The beginning and end of this first incision need not, however,
be deeper than the skin and fat, while the greater depth of its middle should
be such as would  make a conical wound, the apex of which should be toward
the bladder, Plate LIV.  Fig. 1.  If the first incision is not deep enough in
its centre, two or three touches of the scalpel may be made, so as  to divide
the transversalis  and levator ani muscles with the lower edge of the trian-
gular ligament and expose  the membranous portion of the urethra, the
rectum being depressed and  pushed toward  the right side  by the  left  fore-
finger in the wound, while the scalpel continues  the  incisions.  Wheu the
membranous  portion of  the  urethra is so exposed that the groove of the 
PLATE
LIV.
                 LATERAL  OPERATION FOR LITHOTOMY.
   Fig. 1. A view of the position of the patient, surgeon, and assistants, as far
 as they could be shown upon one figure, in the lateral operation for stone.  1, 2.
 Hands  of the  first assistant holding the staff vertically,  and holding up the
 scrotum.  3. Left forefinger of the surgeon depressing the rectum  in the deep
 incision in the perineum.  4, 4, 5, 5. The hands  and arms  of the assistants*
 Their arms are, however, represented as placed upon the thighs of the patient
 instead of nearly parallel with his legs, as they ought to be; but this position
 was incompatible with  the view.  6. The appearance of the  incision in a deep
 perineum, immediately after puncturing the membranous portion of the urethra.
                                                             After Nature.
   Fig. 2.  Manner of holding and passing the knife into the groove of the staff
 when the bladder is opened by it instead of the gorget, its handle being gently
 depressed so as to  keep its  point in the groove  of the staff as it enters the
 bladder.  1. The staff.  2.  First position of the knife.   3.  Its final position in
 the neck of  the bladder.                                   After John Bell.
  Fig. 3.  The right forefinger passed into the bladder along the staff, so as to
 recognize the position of the stone before passing in the forceps.  1. The staff.
 2. Hand of the surgeon.                                   After John  Bell.
  Fig. 4. An outline to show the  manner of enlarging the  wound by means of
 the probe-pointed  bistoury.  1. The staff in position.  The  forefinger of the
 surgeon introduced into the opening in the neck of the bladder with its palmar
 surface  pressing against the  back of 3, a probe-pointed bistoury in the act of
 enlarging the incision in the prostate gland.                  After John Bell.
  Fig. 5. Outline representing the forceps as grasping one stone, while a second
 is represented below it.  1,  1. Improper line in which to attempt extraction, as
it exposes the neck of the bladder to contusion against the arch of the pubis.
2. Forceps seizing the stone.  3, 4. Proper direction of the forceps  in  the last
efforts for extraction of  the calculus.                        After John Bell.
  Fig. 6. A  view of the mode of retaining the 6tone in the  scoop during its
extraction by this  instrument.  1. The scoop.  2. The left  forefinger of  the
6ur8eon-                                                   After John BeU.
       (524) 
Plate 54.
 
 
          THE  LATERAL  OPERATION OF PERINEAL LITHOTOMY.     525

 staff may be readily felt, pass the left forefinger  into the wound, while the
 hand is in extreme pronation, so that the radial  edge of the finger may be
 turned downward, the ulnar side of its pulp and  the point of the nail being
 made to touch the staff, while its back presents to the left descending ramus
 of the pubis.  Then laying down the scalpel and taking up the sharp-pointed
 bistoury,  pass it flatwise, or with its back to the rectum, along the left fore-
 finger as  a director; carry its point to the bottom of the wound;  puncture
 the membranous portion of the urethra so as to enter the  groove  of the staff,
 as may be told  by the escape of  a little urine and the contact of the instru-
 ments; and then, cutting from behind forward,  lay bare the staff by  one
 stroke, from the prostate to the  bulb, when more urine will follow, and the
 staff will  be clearly felt and seen.  Then  promptly taking the gorget, dip its
 point into oil, place its beak in the groove of the staff;  stand up;  take the
 handle of the staff from the assistant; balance the two together, the edge of
 the blade being inclined downward and outward, and then by a steady move-
 ment press the gorget along the staff into the bladder.   As its cutting edge
 progresses, the  handle of the gorget should be made to  descend in front of
 the anus so as to keep the beak perpendicularly applied to the staff, and pre-
 vent its slipping, while the blade should be so conducted  as to pass nearly
 parallel to the ramus of the ischium.  As soon as the  prostate is incised, a
 gush of urine will follow,  and show that the bladder has been opened.  Then
 withdraw the gorget promptly, but leave  the staff  in the bladder; again pass
 in the  left forefinger; touch the stone with it, Plate  LIV. Fig. 3; direct the
 assistant  to withdraw the staff; and, taking the forceps in the right hand, with
 the thumb and fore or second finger thrust through  the rings in its handles,
 pass the  point of the forceps into the bas-fond  of the bladder along the left
 forefinger, with  the blades closed; touch the stone,  and endeavor to seize it
 in the  forceps, so that its longest diameter shall not be transverse to the
 wound; or if this cannot be readily done by the right hand alone,  take one
 handle  of the forceps in each hand, turn  the instrument flatwise, so that it
 may act as a scoop, and then, fishing about, get the stone into the grasp of
 the instrument.  After the stone is properly grasped by the forceps, with-
 draw the  left forefinger, slide it along the forceps to the  centre screw, and,
 by a gentle lateral and up-and-down movement, extract the calculus by such
 a moderate amount  of force as may be  necessary to dilate the wound,  but
 not bruise it, Plate LIV.  Fig. 5.
   One  calculus  being removed, introduce  the  right forefinger and feel for
 others,  or for fragments; then pass into the bladder, through the wound, a
 large catheter;  adapt to its free  end  the nozzle  of the syringe  containing
 barley-water, and wash out the clots of  blood, fragments, etc. that may be
 left behind; after which it only remains to arrest any severe hemorrhage that
 may show itself, and to dress the  wound in  the manner hereafter stated.
   Remarks on the Lateral Operation.—The section of the prostate gland,
 as accomplished by Physick's gorget, Plate  LIU. Fig.  4, is one  of great
 certainty  and cleanness, creating a wound which is admirably adapted  to
 healing, in consequence of the accuracy with which the two surfaces may be
 approximated.
   The advantages of the  ordinary gorget have been variously estimated at
 different periods, some surgeons  asserting that its operation  was too me-
 chanical, and its division of tissue a "stab in the  dark;"  while others have
 highly lauded it.  In the United States, the English cutting gorget was the
favorite instrument of Physick, who modified it  so that its blade could be
separated  from  the beak, and  thus  made to receive a perfect  edge—a
modification of great value, and one which really gave this instrument a new
character, making it a perfectly  firm and keen  knife.   The gorgets that 
520           PRINCIPLES AND PRACTICE  OF SURGERY.

have since been made in the United States have been mostly of this pattern,
and have been employed by Gibson, Rhea Barton, Randolph, and McDowell,
as well as by most  of  the lithotomists of  Philadelphia.  The venerable
Dudley, of Kentucky, whose  success as a lithotomist is so  widely known,
having operated  more  frequently with success than  any other  surgeon,
always employs the gorget, though he prefers that of Cline, of England.
  An examination of the objections that have been urged against the use of
the gorget shows that the faults charged upon  it are chiefly due to the old
English gorget, or that known as the gorget of Hawkins, as this cannot be
sharpened close to the beak, and,  in passing along the staff, is therefore apt
to leave a portion of the prostate uncut at the sides of the staff, in conse-
quence of which the  gorget is liable to be thrown out of the staff, and made
to cut toward the rectum.   Many of the instances  referred to by the oppo-
nents of the instrument are also rather examples  of the want of skill in the
operator than of defects in the instrument, as a good surgeon could hardly
fail to lithotomize a patient with any instrument.
   There are, however, many operators in the United  States who do not use
the gorget, preferring beaked knives, of various  kinds and shapes, most of
which are apparently favorites,  from personal peculiarities in operating.  In
many instances such knives are only modifications of a gorget, act in  the same
manner, but do not make so accurate an incision, and are liable to create an
opening in the pelvic fascia by leading the operator to incise the prostate to
too great an  extent laterally.   In a deep perineum it is always difficult to
judge of the position of the point of a knife, even when apparently directed
by the left forefinger; but with a staff held in the median line of the body, with
its curve close under the pubis,  and with the beak of a gorget well placed in
it, it is impossible to extend an  incision beyond the limits of the width of the
blade.   The  advantage and disadvantage of the gorget is, however, a sub-
ject which has engaged powerful advocates on both sides, and I shall therefore
dismiss it with the simple  statement of individual preference for the gorget
of Physick, though at the same time I should not  hesitate to cut for stone
with a staff and pocket bistoury, if nothing else could  be obtained, nor doubt
the possibility of any skillful surgeon operating neatly and properly  with any
instrument when a correct anatomical knowledge of the structure concerned
was made to  direct it.  The choice of  a knife is the least important part of
any operation, and the discussions spent on the shape of instruments would
be much more valuable if  more closely connected with the anatomy of the
region and less with  the mechanical ideas of the cutler.
    § 3.—Operation with the Single Lithotome Cache of Frere Cosme.

  The single lithotome cache or concealed lithotome of Frere Cosme resem-
bles that of Dupuytren, Plate Llli. Fig. 3, and has but one blade.  It is
introduced into the bladder by passing its beak into the staff, when the latter
has been  exposed as in the preceding  operation; when, carrying its point
into the bladder and then opening the blade by pressure against the handle,
the prostate and neck of the bladder are to be incised while the instrument
is being withdrawn in a perfectly horizontal direction.  If the handle of the
lithotome is too much elevated, the lower surface of the bladder will be ex-
posed to injury ; while, if it is much depressed, the incision will be too small.
If the blade is directed outward, the pudic artery may be wounded, and if
too much downward, the rectum* may  be opened.
* Malgaigne, Philadelphia edit. p. 505. 
        THE  BILATERAL  OPERATION OF PERINEAL  LITHOTOMY.     527

  Remarks.—In very many instances, I have operated upon the subject
with this instrument, as  well as with that of Dupuytren,  in  the  manner
usually d'rected by the French  surgeons, but have always  felt the uncer-
tainty of the extent of the incision thus effected.   The liability of the blade
to spring;  the difference  in the  resistance offered to its escape by different
perinei;  the  liability to too great expansion, etc., have satisfied me that it
cannot bear a comparison either with the gorget of  Physick or with what
has been termed the "beaked knife of Liston."  Its chief recommendation
appears to be the difficulty of wounding  the rectum.  Such  an  event would
certainly be a strong recommendation of the  instrument, if lithotomy was to
be performed by every individual, but cannot prove so to an accomplished
surgeon—and none but a good surgeon should attempt this  operation.


                            SECTION  IV.

                      THE BILATERAL OPERATION.

  In the Bilateral Operation of  Lithotomy, the bladder is opened by an in-
cision through each half of the prostate gland, and a  wound made, through
which a calculus may be extracted of somewhat larger dimensions than is  pos-
sible by the lateral section.   From having been revived and brought  into
notice, as well as modified by Dupuytren in 1824, it is  often spoken of as his
operation, though  Celsus, it is well  known, was also familiar with a similar
method.
  Operation  of Dupuytren.*—Instruments.—The instruments employed by
Dupuytren were:  1. A sound, which was lighter than the  ordinary sound,
sloped off at  the end of its grooves, and expanded for two inches in length,
at the point where it most curved, so that it might the  better distend the  ure-
thra.  2. A double-edged scalpel  fixed in a handle, and sharp on each edge for
about one-third of an inch  from its point.  3. A double lithotome, Plate LIIL
Fig. 3, the two blades of  which  opened in one handle, and were so acted on
by two levers as to separate in a curved direction, and divide each side of the
prostate in its oblique diameter.
  Operation.—The patient being placed as before directed, and the position
of the various points of reference accurately  recognized, Plate  LV. Figs. 1,
2, the staff should be introduced  and held in a perfectly perpeudicular direc-
tion, while the surgeon extends the integuments of the perineum with  the
fingers of his  left hand, and makes  a  semicircular incision with the double-
edged scalpel held in his right, commencing on the right side at a point half
way between  the tuberosity of the ischium and the anus, passing half an  inch
in front of the anus, and terminating on the left side of the perineum  at a
point corresponding with  the starting-point on the right, Plate  LV. Fig. 3.
By continued, but  rapid incisions, the superficial  fascia, anterior point of the
sphincter ani muscle, and the connective tissue  are divided, and the mem-
branous part of the urethra laid bare, wheu  the nail of the left index fiuger
enables the surgeon to feel the groove in the staff, which may then be exposed,
as before directed, by means of a bistoury.  The forefinger, during all  this
period, should be made to depress the rectum in  order to prevent its injury.
After opening the urethra for one-third  of  an inch,  use the left forefinger
nail as a guide to the lithotome cache, and introduce the instrument by hold-
ing it in the right hand with the thumb beueath and the two fingers above,  pre-
senting it to the staff, so that its convexity may look downward.  The con-
* Malgaigne's Operative Surgery, Philadelphia edit. p. 507. 
PLATE   LV.
 THE  OPERATION OF LITHOTOMY AS  PERFORMED IN THE  BILATERAL
        SECTION, WITH THE  LITHOTOME CACHE OF DUPUYTREN.

   Fig. 1.  Position of the patient, with lines drawn on the perineum to show the
 points of  reference and the direction of the incision.  The subject being in the
 position of lithotomy, the testicles and penis have been turned up, and the peri-
 neum divided into two equilateral triangles, the angles of which are made to
 touch the  bones around the perineum.  1.  Pubis.  2, 3. Tuber ischii. 4. Coccyx.
 2, 3, 5. Line of external incision.         From Froriep, but after Dupuytren.

   Fig. 2.  Dissection  of the same subject.  The fascia superficialis  has  been
 turned up from the edge of the incision, so as  to  show the accelerator urinse
 muscle and the transversus perinei arteries. The sphincter ani is seen below,
 and the divided fibres of part of the levator ani are shown in the figure.  1. The
 skin.  2.  Fascia superficialis.   3. Sphincter ani muscle.  4. Line of the median
 incision through the anterior fibres of the levator ani muscle.  5.  Accelerator
 urinae muscle.  6.  Perineal arteries.  7. Perineal fascia dissected up, and turned
 over the body of the penis.               From Froriep, but after Dupuytren.

   Fig. 3.  The External Incision in Bilateral Lithotomy.  1,2. The hands of the
 first assistant holding the staff vertically, and elevating the scrotum. 3. The left
 forefinger of the surgeon depressing the rectum.   4.  Right hand about termin-
 ating, 5, the incision.  The external incision should  be made from left to right,
 with its convexity forward, so as to form an arc of about 100°.
                                                After Bourgery and Jacob.

   Fig. 4. Section of the prostate with the  double lithotome cache upon a sub-
ject which  had been dissected, so as to show the incision, the anterior portions
of the sphincter and levator ani muscles having been removed.   1. Accelerator
urinae muscles.  2,3. Internal pudic  artery and nerve.  4. Transverse perineal
artery.  5.  Hand of the surgeon.   6. Levers which regulate the blades  of the
lithotome.                                      After Bourgery and Jacob.

  Fig. 5. Lateral section of the prostate as made by the single lithotome cache,
a portion of the sphincter and levator ani and anterior end of the anus being
removed in order to show the prostate gland.  1. Bulb of urethra.  2.  Membra-
nous portion of urethra.  3.  Prostate gland.  4, 5. Lithotome in position.  6.
Corpus cavernosum.  7. Symphysis pubis.  8. Vesiculae serainales.  9.  Rectum.
                                               After Bourgery and Jacob.
       (528) 
PI are bh.
 
 
        THE BILATERAL OPERATION OF PERINEAL LITHOTOMY.     529

tact of the two instruments being now recognized, the surgeon should take
the handle of the  sound in  his left hand, and, elevating it so as to place its
curve close under  the symphysis pubis, slide  the lithotome along its groove
into the bladder;  then,  withdrawing the staff, turn the lithotome so as to
present its concavity downward, or toward the anus, and, grasping the lever,
depress it to the handle of the instrument so as to unsheath the blades, with-
drawing the instrument progressively downward until it cuts  its way out,
Plate LV. Fig. 4.
   The left index  finger, being then introduced through the  wound into the
bladder, should examine the extent of the incisions, and if they are not suffi-
ciently large, direct a probe-pointed  bistoury so as to enlarge  them, Plate
LIV. Fig. 4.  But if they are large enough, the  forceps should  be intro-
duced, and the stone extracted as before directed.
   The width of Dupuytren's incision, when widest, was not more than two
inches, or one  inch  through each  lobe of  the prostate, so that the incision
did not pass the circumference of the gland, and therefore did not open the
reflection of  the pelvic fascia.
   Operation of Ogier, of Charleston.—A boy, thirteen years of age,  with a
large calculus, was operated  on as follows :   The rectum being emptied, and
a staff placed in the bladder, a semilunar incision was  made in the perineum
just under the bulb of the urethra, commencing about half way between the
anus and the tuberosity of the ischium on the right side, and terminating at
the same point on the left side, so as to divide the skin and  perineal fascia.
This being  rapidly increased in depth at its centre, the staff was soon felt
with the point of the scalpel, a small puncture made in the membranous  por-
tion of the urethra, and then Dupuytren's double lithotome being introduced
into the bladder, the staff was withdrawn, the lithotome turned with its con-
cavity downward and the neck of the bladder divided from  within outward
by expanding the  blades of the instrument so as  to  make  it cut as it was
drawn out.  The stone having been then seized with the forceps, was readily
extracted, though  it measured two and a half inches  in length, three and a
half in circumference, and weighed one ounce three drachms.
  Operation of R. D. Mussey, of Cincinnati.—With a rather narrow scalpel,
the superficial  crescentic  incision is made with its convexity anterior, so as
to expose the staff at the membranous portion of the urethra, Plate LV.
Fig. 3.  A straight, probe-pointed narrow bistoury being then passed along
the groove of the staff,  with its edge turned toward the left side until it
enters the bladder, the point of the  left index finger is  slid along the back of
the bistoury, and  made to press it  against the prostate so as to divide the
latter sufficiently to admit the point of the finger into  the bladder, when the
staff should be withdrawn and the prostate further divided, if necessary.  The
finger being then rotated, the palmar  surface  of its point should be made to
rest upon'the right side of the prostatic portion of the urethra,  the bistoury
be turned upon the finger to the opposite side, and  the right side  of the
prostate also divided as far as is necessary, the stone being afterward extracted
as usual.
  Operation of Fergusson, of England.—Under the impression  that a
straight line in the course of the raphe with  diverging slips  on  each  side of
the anus, (like a Y reversed a,) would permit more expansion of the  wound
than any other form of external incision, Fergusson employed it with satis-
faction in a case of lithotomy, after having tried it in the operation of lithec-
tasy, or extraction of a calculus by opening the membranous portion  of the
urethra  and dilating the neck of the bladder, as proposed by Willis.   Eve,
of Nashville, Tennessee, has  also recently adopted this incision in preference
to the semicircular cut of Dupuytren.
     vol. n.—34 
530           PRINCIPLES AND PRACTICE  OF SURGERY.

  Operation of Paul F. Eve, of Georgia.—The staff being introduced into
the bladder, a short incision is made directly in the raphe at the bulb of the
urethra, the direction being changed at a very oblique angle at the end of
about three-fourths of an  inch, in order to terminate at a point midway be-
tween the anus and the left tuber ischii.  With the edge of the knife  now
turned upward, penetrate  the  tissues, and commence the other leg of the A
at a point on the right side corresponding to the one just terminated on the
left.  This incision being deepened as the instrument ascends, arrives at the
middle of the perineum  with its edge turned directly upward, when  the
urethra is opened and the staff exposed, after which the operation is com-
pleted by the lithotome in the usual way.
  Remarks.—Of twenty-three cases  operated on by Eve  with the double
lithotome, four died,  three of which  were from the operation, two indirectly
and one  directly;  and seventeen were well in two  weeks  after  the opera-
tion.*
  Operation of J. F. May, of Washington.—The patient, being etherized,
was cut  as  in the operation of Dupuytren, and a  large stone  readily ex-
tracted.  Its longest diameter was two inches and  a fraction,  its shortest
diameter one and five-eighths of an inch, and its circumference five and  five-
eighths inches.
  Remarks.—Among American surgeons, the bilateral operation was first
performed by Ashmead, of Philadelphia, in 1832, and by Ogier, of Charles-
ton, in 1835, since which  there have  been many who have advocated  and
practiced it, among whom may be mentioned Stevens, Hoffman,  and Post,
of New York ;  Warren, of Boston ;  Mussey, of Cincinnati; May, of Wash-
ington ; Pancoast, of Philadelphia ;  Eve, of Nashville ; Pope, of St. Louis;
Dugas and  Campbell, of Georgia, with many others; though several of them
prefer the use either of a special instrument or of a probe-pointed bistoury
to the lithotome of Dupuytren.   My  own experience, as gained  upon  the
subject, corresponds entirely with this, as even with a lithotome, selected by
the  hands of Charriere, of Paris, I have found  the blades to  spring and yield
to such an extent as to interfere with the accuracy of the section.  The mode
of operating described by Mussey is, therefore, preferable  to that advised
by Dupuytren.
  As  the incision of Dupuytren permits a very free dilatation of the perineal
integuments, and also corresponds with the arch of the pubis through which
a large calculus must pass, I do not think there is auy material advantage
gained in the size of the  wound by the incision resorted  to by Fergusson
and Eve, while the central portion of it, except in very skillful hands, would
expose an operator to much greater risk of wounding the bulb of the urethra
than is the case  in  Dupuytren's operation.   A median  incision through
the  skin  aud perineal fascia, in the line of the raphe, will readily expose
the  bulb, though,  of course, a skillful  operator might expose  it  without
wounding it.
  The points of recommendation claimed for the bilateral  operation  over
either of the others, are a more direct and free access to the bladder without
injuring the vesical plexus of veins, as well as  less risk of dividing important
blood-vessels; but, on the other hand, the  rectum is more exposed in the
primary incisions, and perineal fistula, impotence, and a tendency to stric-
ture near the prostatic portion of the urethra  are said to be increased.  Sta-
tistics alone can settle a question of this kind, though at present it is gener-
ally admitted that in cases of very large calculi, or in a case attended by
anchylosis  of the  hip, as  in that reported  by Pope,  of  St. Louis, or in
* Report to Med. Association, 1852. 
         THE MEDIAN OPERATION OF  PERINEAL LITHOTOMY.      531

analogous  difficulties,  the  bilateral is  preferable to  the  lateral section.
The lateral incision is,  however, fully capable of removing a large stone, and
I have extracted one by this method that weighed two ounces and seventeen
grains, and was six inches in circumference.   The  increased  fondness  of
American surgeons for the bilateral rather than the lateral operation, seems,
however, to indicate that experience proves its special advantages, though
fashion occasionally regulates surgery to a certain extent as it does less im-
portant subjects.
                             SECTION V.

                        THE MEDIAN OPERATION.

   Lithotomy having at one period been the especial province of one family,
 or class of individuals, it is not surprising that various plans of accomplish-
 ing it should have been each highly lauded, and handed down as perfect from
 generation to generation.   Among all these methods, that in which the
 perineum  is incised in the median  line, and the stone  extracted by opening
 the urethra in the same direction—being the old operation of Sanctus Mari-
 anus, and hence  sometimes called the " Marian operation"—would at first
 sight appear to be the safest.   But this operation, though very ancient, has,
 in truth, but  little to recommend it, except in the case of small calculi, or for
 the removal of foreign  bodies, as  a broken catheter, etc., from the  bladder.
 It is now only referred to because some of its  steps may occasionally be
 found useful in extracting such fragments of calculi as lodge and become fixed
 in the urethra,  or for the removal of  such pebbles  as  are developed in the
 prostate gland, and because it has within  the last few years been revived, in
 a  modified form, by Allarton, of  England,  and spoken of as his  method.
 The  operation of Giovanni  di  Romanis, as published in  1520,  and  since
 repeatedly modified, is as follows:—
   Operation of Vacca Berlinghieri.—The patient being placed in the posi-
 tion for lithotomy, an incision is to  be made in the median line of the perineum
 from  the origin of the scrotum to the anterior border of the anus, so as to
 divide the skin, superficial fascia, and anterior fibres of the sphincter ani mus-
 cle, and lay bare the groove of a staff in the membranous  portion, without
 exposing the bulb.  The knife, or probe-pointed bistoury, being then passed
 along the  groove of the staff into the bladder, the prostate is to be divided
 to the extent of four or five lines in a direction  parallel with the median line.
   Allarton's Operation.—Placing the patient in the position for lithotomy,
 introduce  a deeply grooved convex staff into  the  bladder,  give it in charge
 of an assistant, and push the left forefinger into the rectum until it distinctly
feels the prostate gland.   Then with a long, sharp-pointed straight bistoury,
holding its edge toward the staff, puncture the perineum in the raphe, about
three lines in front of the anus, and push it toward the membranous portion
of the urethra, the forefinger in the rectum serving as a guide to prevent the
wounding of the  bowel.   On  puncturing the membranous portion of the
urethra, elevate the handle of the bistoury so as to cut the perineum upward
in  its median line, and freely lay bare the convexity of the staff.   Then,
passing a  ball probe along the staff into the bladder, withdraw the staff, and
gradually  pushing the left forefinger along the probe, dilate the  prostatic
portion of the urethra and neck of the bladder until the stone is felt;  upon
introducing the forceps, extract as before directed.
   Remarks___The advantages claimed for this operation are its safety, free-
dom from  hemorrhage, and its easy execution ; all which are admitted.  But 
532           PRINCIPLES AND PRACTICE  OF SURGERY.

experience has shown that it is specially adapted only to small calculi, and
it is doubtful  whether such cases would not  be better treated by means of
lithotripsy.  If the blade of a lithontriptic instrument or a catheter should
be broken off in the bladder, or if a piece of slate-pencil or a pipe-stem should
have been accidentally passed into the bladder, then the median operation, as
modified by Allarton, may be advantageously resorted to.
                           \ 1.—Lithectasy.

  The term Lithectasy has been employed to designate the modification of
the median operation recently revived by Willis, of England.*  In the oper-
ation of Romanis or Marianus, as advocated by  Marceaux, or the major
apparatus—so called from the number of instruments employed iu its per-
formance—the membranous portion of the urethra was opened by an incision
made near  to, but on the side of, the raphe;  after which a probe was passed
along the staff into the  bladder, and then two conductors being passed along
the probe, the prostate gland and  neck of the bladder were forcibly dilated,
or,  perhaps, torn.  As  modified by Willis, this operation  now consists in
opening the membranous portion of the urethra by an incision in the line of
the raphe above the anus.   After  thus opeuing the urethra, a sponge-tent, a
piece of compressed sponge, a dried  piece of carrot-root,  as suggested  by
Guerin, of Bordeaux, or some similar dilator, is introduced, and the opening
expanded, in twenty-four  hours, sufficiently to admit the entrance of  such
forceps as will remove a small calculus.
  Remarks.—This operation has  but little to recommend it.  The dilating
process is  slow and apt to be a serious  source of irritation to the patient.
Owing to the difficulty of accurately deciding on the size of a calculus, there
is also the risk of having an opening which will not permit the stone to pass
until the wound is further enlarged by the  knife.   It will,  therefore, be but
seldom adopted by any surgeon who is familiar with the performance of the
ordinary lateral operation.
                    \ 2.—Recto-Vesical Lithotomy.

  The idea of opening the Bladder through the Rectum was suggested as
early as the sixteenth century, but appears to have fallen into disrepute until
revived by Sanson, of  Paris, in  1816.  His  method of operating was  as
follows:—
  Sanson's Operation, f—The patient being placed in the position for lithot-
omy, introduce a staff with a large curve into the bladder, and have it held
perpendicularly by an assistant.   Then  passing  the  left forefinger into the
rectum, pass  in on the finger a  sharp-pointed  bistoury, and, cutting from
behind forward, divide the sphincter ani  muscle and the  lower anterior por-
tion of the rectum so as to expose the  prostate gland.   On passing the fore-
finger into the wound behind the gland,  feel the staff through the parietes of
the rectum and bladder, and, puncturing the tissues, open the groove of the
staff about one inch, when a gush of urine will follow, the prostate remaining
uudivided.
  Remarks.—This operation  was modified by  Sleigh so as to divide  the
portion of the  bladder bounded  laterally  by the  vasa deferentia  and  the
vesiculae seminales—above by the cul-de-sac, or reflected portion of the peri-
* Willis on Stone.    f Cooper's Surgical Dictionary, by Reese.  N. Y., 1851. 
            THE SUPRA-PUBIC OPERATION  FOR  LITHOTOMY.        533

toneum, and below or anteriorly, by the prostate gland and the union of the
seminal tubes, without incising the sphiucter ani muscle.
  Except in the case of an immense calculus which  projected into the rectum,
this operation can hardly be regarded as justifiable, the high operation, or
that above the pubis,  being preferable, if the stone cannot be crushed.   In
the few instances reported, death has frequently supervened, rectal  fistulas
have followed, the feces have passed into the bladder, and the patients, after
escaping  peritonitis and the  evils of fistulas, have  been unable to retain the
urine in the bladder,  owing to the division of  the  muscle of  the vesical tri-
angle.  The operation has been so long regarded as obsolete, that it is diffi-
cult to understand how any surgeon should at the present day feel justified
in repeating it in opposition to the well-known experience of Scarpa, Du-
puytren, and other European  surgeons, who soon expressed their dissatis-
faction at the result of  the cases operated on.   It is only now mentioned to
caution any who may be tempted, by its apparent novelty, against its  repe-
tition.


                             SECTION VI.

                    OF THE SUPRA-PUBIC OPERATION.

   As  the  process of peritoneum which  lines  the  abdominal muscles is re-
flected from above  the pubis to the superior and  posterior portions of the
bladder, there is  a space left anteriorly through which it is possible to open
the bladder without incising  the peritoneum, and it is at this point that the
extraction of calculi by the  supra-pubic or hypogastric operation has been
occasionally  practiced;  though the majority of operators  have  preferred
incising the perineum.
   Operation of Sir Everard Home.—An incision being made  four inches
long, between the pyramidales muscle in the direction of the linea alba, the
tissues were divided down to the tendon, which was then  pierced  close to the
pubes, and divided by a probe-pointed bistoury to  the extent of three inches,
a portion of the origin of the  pyramidales being detached so as to increase
the size of the  opening near the  pubes.   The forefinger being  now passed
in toward the pelvis,  the fundus of the bladder was recognized, and a  silver
catheter, open at both ends, being carried into the urethra, its point could be
felt pressing upon the fundus of the bladder.   A stylet, which had been con-
cealed in  the catheter, being then forced  through  the coats of the bladder,
was followed by  the end of the catheter, and the stylet being withdrawn, the
puncture  in the  bladder was enlarged sufficiently to admit  two fingers, by
means of the  probe-pointed bistoury.   The stone being now felt by one fin-
ger, while the superior fundus of the bladder was held up by the other, a pair
of forceps, with a net attached, should be passed down into the bladder, and
the stone directed into  it and retained there by the finger till extracted.  A
slip of linen being then introduced into the bladder, one end  was allowed to
hang out of the wound, and the edges of the latter closed by adhesive plas-
ter, a catheter being kept in the urethra in order to draw off the urine.
   Remarks.—This operation, which was assigned to Franco, in  1561, and
afterward practiced by Rousset in 1581, has seldom been deemed advisable
by surgeons,  except for the removal of very large  calculi, or in consequence
of a diseased  prostate.
   In the United  States, it was first performed by Gibson, of Philadelphia,
but it has since been  repeated  by Carpenter, Van Valzah,  and  George
M'Clellan, of Pennsylvania.*  In  a case reported  by Wm.  D.  Johnson, of
* Gibson, vol. ii. p. 260.  Gross, p. 500. 
534            PRINCIPLES AND PRACTICE OF  SURGERY.
Georgia, the lateral operation was first performed, and then the supra-pubic,
in consequence of the great size of the calculus, its weight being nearly six
ounces, its longitudinal circumference seven inches, and its lateral circum-
ference five inches and three-quarters.*  The chief recommendation  of the
high operation appears to be the safety arising from the absence of hemor-
rhage;  but  this is more  than counterbalanced  by the risks of peritonitis,
urinary infiltration, and abscesses,  and it should only be resorted to in cases
of very large calculi that cannot be crushed by instruments introduced into
the bladder through the lateral or bilateral incision ; cases that can seldom
be presented to a skillful operator.

                   I 1.—The  Quadrilateral  Operation.

   Vidal du  Cassis having suggested the incision of the prostate in several
directions, like the radii of a circle, so as to admit of the  greater distention
of the opening, his mode of operating has been designated as the quadri-
lateral operation.   Except in the very rare instances of enormous calculi,
such incisions  must, however, be unnecessary, and, when required, could be
easily added to any of the other plans of operating, though  originally sug-
gested iu connection with  the  bilateral operation.
                           SECTION VII.

              GENERAL REMARKS ON PERINEAL LITHOTOMY.

  In  the consideration  of the  different  methods  of performing  perineal
lithotomy, little has been said in reference  to  the  mode of extracting the
stone; in relation to the accidents likely to occur during the operation; or
in respect to the dressing and after-treatment, all of which demand special
consideration.

                     \ 1.—Extraction of the Stone.

  In extracting a calculus, after the bladder has been opened by either the
lateral or bilateral methods, much care and skill are necessary, this part of the
operation being, in many instances, the most difficult and tedious step of the
proceeding.   The wound may apparently be free, and  the primary incisions
rapidly aud neatly made, with every appearance of  a  speedy termination to
the  operation; and yet the mere extraction  of the stone through the wound
will occupy more  time than would suffice  for several incisions.   In order
promptly to accomplish the removal of the stone, the operator should, there-
fore, first endeavor to learn  its position and mode of presentation, and in this
he may be materially assisted by recalling the shape of the  bladder, its rela-
tions to surrounding parts,  and the tendency of the stone to gravitate to the
most depending point. Most calculi, especially when single, lie at the posterior
inferior part or the bas-fond of the bladder, in consequence of their weight,
or because the contraction of the muscular coat forces them  to occupy such a
position as is most favorable to the escape of the urine by the urethra, pre-
senting, therefore, their longest diameter longitudinally, and  their flattened
side downward.   In order  to  seize a stone thus placed, the curved forceps
should be introduced, so  that the convexity  of their blades may correspond
* Southern Med. and Surg. Journ., vol. vii. p. 393, 1851. 
             GENERAL REMARKS ON PERINEAL LITHOTOMY.         535

 with the posterior angle of the wound, their handles being at the same time
 elevated sufficiently to place their points in the lowest portion of the bladder,
 Plate LIV. Fig. 5.  When the  thickness of the perineum  permits  it, the
 left index finger should also be made to depress the  posterior angle  of the
 wound, especially in the bladder, and serve  as a guide for the forceps; but
 as in a large deep adult perineum this is sometimes impossible, the operator
 will be compelled to rely upon the knowledge gained in his previous  exam-
 inations for the probable position of the calculus.  After touching the stone
 with the points of  the forceps, the  rings of the latter  should be seized be-
 tween the thumb and fingers of each hand, the blades cautiously expanded,
 and then by a half turn to the left, made  to scoop up or seize the calculus as
 it is forced  into the grasp  of the instrument by its own weight, or  by the
 contractions of the bladder.  If, however, this should  not be the case, the
 operator may gently expand and close the blades of the instrument,  giving
 them at the same time  a gentle lateral  and  up-and-down motion, so as to
 sweep the bladder by their smooth  and  external surfaces, until the stone is
 brought within their  grasp.   When seized,  the  left  forefinger should be
 slipped along the blades, so as to feel if the  short diameter  of  the stone is
 parallel with the transverse diameter of the  wound, and being  satisfied of
 this, the calculus, if large, may be extracted by pulling it gently  but steadily
 toward the operator, it being at the same time moved laterally, as well as
 up and down, in order to favor the dilatation of the  wound.   The  use of
 Barton's forceps—Plate LIIL Fig.  9—will materially facilitate  the extrac-
 tion of the  stone, as the fenestra diminish  the space occupied by the thick-
 ness of the  instrument;  but if the calculus  is of the ordinary size, and the
 incisions sufficiently large, little difficulty will be experienced  from the latter
 source.  In many instances, the incision in the prostate has not been suffi-
 ciently large, or the inferior angle of the wound or the opening  in the skin
 is too narrow ;  and when this is the case, much may be done  by  persevering
 and gradual dilatation of the part,  or by enlarging the angle of the wound
 with the bistoury.  When the size  of the stone forbids all hope of its ex-
 traction entire, then it should be crushed by Earle's forceps, Plate  LIIL
 Fig. 14, or by Heurteloup's lithontripteur, and extracted piecemeal, the frag-
 ments being removed by washing out the bladder with barley-water.
   The Scoop is an instrument that may prove serviceable  in cases  where
 the size of the  stone forbids the  hope of introducing  the  additional  thick-
 ness of the forceps, or in cases of numerous calculi, or in that of fragments
 of  a calculus.   Or it may be  resorted to for the removal of  such calculous
 concretions as are occasionally found upon parts of the bladder, and  which
 require to be peeled off.   Wheuever the attempt  is made to remove  a cal-
 culus by the scoop alone, the point of the forefinger of one hand should  be
 placed against  the stone to steady it in the hollow of the instrument,  Plate
 LIV. Fig. 6.
   After removing a calculus by any instrument, the finger should be  again
 introduced into the bladder,  and carefully passed around it in order  to
 ascertain whether some particles have not been left.   Shouldany be found,
 it will be better to wash them out by freely injecting  barley-water than  to
 attempt  to  seize them with forceps, or  to  remove them  with  the scoop.
 The injection will also prove useful by removing clots from the part.
  If the stone should be encysted, or adherent, the steps to be pursued will
depend mainly upon the manner in which it is  attached, and on the  judg-
ment of the operator.   Sometimes the attachment is owing to folds of the
bladder being introduced  into asperities in  the calculus, and these may be
often overcome  by passing  the finger gently round, and hooking out the
stone; or a  process from the stone may have entered a dilated ureter, or be 
536
PRINCIPLES AND  PRACTICE OF SURGERY.
placed in an abnormal pouch in the bladder.   To relieve either of these lat-
ter attachments, it is  usually necessary to exercise judicious traction upon
the main portion of the stone ; though  the process  of the mucous membrane
may require to be ruptured with the finger, or, if it is a simple band, to be
divided by the knife, in order to free it;  but the necessity for the latter is
very rare, aud it should never be resorted to until every other means have
failed.

               \ 2.—Accidents  connected with Lithotomy.

   An  accident that occasionally complicates the  operation of lithotomy,
even in careful hands, is hemorrhage, though, under ordinary circumstances,
this is not sufficiently severe to demand active treatment.  A wound of the
rectum  may happen, but it can generally only be regarded  as evidence of
the incompetency of the operator.
   Hemorrhage may arise from several points connected with the incisions in
lithotomy : 1st, it may come from the perineal arteries; 2d, from the vesical
plexus of veins; and, 3d, from the internal pudic ; the latter being, however,
much less frequently wounded than an inexperienced surgeon might suppose,
as it lies too near the ascending ramus of the ischium to be in the way of
any ordinary incision.   When, however, the hemorrhage from any point is
sufficient to demand treatment,  it may  be arrested either by the application
of the ligature or by pressure.
   I.  Ligature in Hemorrhage.—The ligation of the smaller perineal arte-
ries does not differ in any respect from  the ligation of other vessels, the open
vessel being seized with a  tenaculum,  and then tied with the silk ligature.
But if by any accident—and it is rare—the main trunk of the internal pudic
artery be divided, the hemorrhage will be more troublesome, though it may
be promptly controlled simply  by compressing the artery with  the  finger
against the ramus of the ischium until  a  ligature can be thrown  around  it.
To accomplish  the latter, few  instruments  will be found more serviceable
than  that  resorted to by Physick under similar circumstances,  and hence
named Physick's forceps and needle, Plate  III. Fig. 5.  The needle being
passed beneath  the trunk of the artery,  the ligature is carried around the
vessel, and made to compress it by inclosing a portion of the flesh near the
vessel. *
   II. Plugging in Hemorrhage.—From the varicose condition of the vesi-
cal plexus, especially in old men, a general hemorrhage or oozing  is some-
times seen from the wound, without  its being possible  for the  surgeon to
detect any point suitable for a ligature.   Under these circumstances, com-
pression is the only alternative, and may be  readily accomplished  by passing
a large catheter into the bladder through the wound, and then packing the
latter full of lint or charpie, the escape of  the  urine through  the catheter
 preventing  distention of the wound in the  neck of the  bladder, while the
 lint at its sides favors the formation  of the clots which tend  to close the
 vessels.  After the lapse of three  days, or when  there is evidence of sup-
 puration in the wound, this lint should be carefully withdrawn, lest it inter-
 fere with the cicatrization.
   III. Wound of the Rectum.—From want of attention to  the entire
 evacuation  of the bowel before  the operation, or from the  great dilatation
 of the  prominent pouch or enlargement  geuerally noted near the middle of
 the  gut, or from the surgeon wandering from the staff  in the prosecution of
 his incisions, the rectum  has been perforated on its anterior surface, and
* Dorsey's Surgery, vol. ii. p. 190. 
            AFTER-TREATMENT IN  PERINEAL LITHOTOMY.         537

the after-treatment of the case complicated with the production of a rectal
fistula.   Although such a fistula is a source of annoyance, adds an unneces-
sary risk to the chances of the patient, and is, I think, positive proof of the
want of skill in the operator, its evils  have been over-estimated by some wri-
ters, as, unless the wound is large, it is usually readily amenable to treatment.
In the simple case of a small puncture of the gut, which is detected  at the time
or soon after the operation, the best mode of obviating it is to evacuate the
contents of the bowel, give a large anodyne enema to keep the parts at perfect
rest, and then, by means of the catheter passed into the bladder through the
wound, prevent urinary infiltration of the surrounding  structures.   In more
extended injuries, the entire division of the sphincter ani muscle, as in rectal
fistula, together with the free use of  anodynes, by  allowing the gut to col-
lapse,  will  favor  the  union of the incision.  But even where a rec|p-vesical
fistula has  resulted, cauterization and perfect rest have often sufficed to heal
it.   In two instances, where I have  seen  this accident occur in the  oper-
ations of rapid surgeons, little  or no treatment was requisite, the patients
recovering without being aware of the  occurrence.
                           SECTION  VIII.

              AFTER-TREATMENT  IN  PERINEAL LITHOTOMY.

  The importance of a judicious after-treatment in every operation has been,
perhaps, sufficiently insisted on in  the previous pages, yet the knowledge of
a case in which  an inexperienced  operator, after  succeeding  in extracting
a calculus by lithotomy, felt  compelled to seek  directions respecting the
proper steps of the after-treatment, induces me to give it in this operation
such extra attention as my limits will permit.


                          § 1.—Putting  to Bed.

  After the completion of the  operation,  including the arrest of hemorrhage,
the first point to decide upon will be the dressing.  In most instances nothing
is required  except rest,  as the wound is intended to  heal by granulation.
According to some surgeons,  certain  advantages  are to be  obtained  from
tying the patient's knees together, and keeping him upon his left side,  so as
to favor the union of the edges of the wound, and the escape of the  urine
without infiltration of the surrounding parts.   Others, again, place a  large
catheter in the bladder by passing it through the wound, fastening it in position
by a strip of adhesive plaster,  which is attached to the perineum, so that the
catheter, by leading the urine off to a saucer, may keep the patient dry.  But
the use of this catheter is liable to the serious objection that it prevents union
by the first intention of the neck of the bladder, this union having been the
fortunate result  in two of  Physick's operations.*  When the catheter  is re-
tained in this way more than a  few days, it is also very apt to lead to the estab-
lishment of  perineal fistula.   For many years, I have  been accustomed to
have patients removed directly from the operating table to the bed without
any dressing, the  bed being kept dry by the  'strict attention of the nurse,
and  the  removal of the  cloths placed beneath the wound as soon  as they
were wet.   I would therefore  urge the advantages of preparing the bed and
patient as follows:  Place a piece of oil-cloth upon a  good elastic hair mat-
* Dorsey's Surgery, vol. ii. p. 191. 
PLATE  LVI.
 INSTRUMENTS EMPLOYED IN  THE OPERATIONS OF LITHOTOMY  AND
                             LITHOTRIPSY.

  Fig. 1. The Sound employed in detecting the presence of a stone in the blad-
der of the male.  1. Its smooth handle.  2.  A curve of a medium size.
                                                          Kolbe's pattern.

  Fig. 2. Staff employed in operating for lithotomy on the female.
                                                          Kolbe's pattern.

  Figs.  3, 4, 5, 6. Staves of different sizes  and curves, so as to be adapted  to
the urethra of different patients in the ordinary lateral operation for lithotomy.
The handles should be broad and well serrated, so as to furnish a firm hold, and
preveut the groove slipping or turning from  the position in which it is wished  to
be held  during the perineal incisions.                        Kolbe's pattern.


  Fig. 7. Jacobson's instrument for crushing a calculus in the bladder.   1. The
articulated loop which holds and crushes the stone when it is  caught  in the
grasp of the instrument.   2.  The screw which closes and expands the loop.
                                                          Kolbe's pattern.

   Fig. 8.  Heurteloup's Lithontripteur.   1.  The female blade.   2. The male
blade.  3. The vice in which the  screw works in  crushing the  stone.   4. The
screw.                                                     Kolbe's pattern.
  Fig. 9. A Litholabe for extracting fragments of a calculus  or  pebbles  from
the neck of the bladder.                                     Kolbe's pattern.
  Fig. 10. Leroy  d'Etiolles's Articulated Scoop for the  removal of  fragments
which lodge in the urethra.                                  Kolbe's pattern.
(538) 
HU!—IU-
™5>
Fi£.5.
Kg.lC
M_
99999999999� 
 
             AFTER-TREATMENT IN PERINEAL  LITHOTOMY.         539

tress at a point  corresponding with  the  patient's hips; place over this the
ordinary sheet;  and place upon this, transversely, the end of another sheet
folded in four lengthwise, so that as soon as one part is wet by the urine, it
may be drawn away and a dry part substituted. The position of the patient
"upon  the  left  side, with the knees drawn up,"  has long been a standing
rule, and so religiously  observed  by some that I  have seen the great tro-
chanter and crest of the ileum almost ready to come through the skin from
the continued pressure,  the patient being compelled  to  use large doses of
opiates in order to  obtain sleep.  In numerous cases in which I have oper-
ated, I have never paid much attention to the position of the patient after
the first twenty-four hours, as the lymph effused upon the edges of the wound
during this  period was generally sufficient to prevent smarting from  the
urine passing over it, while as soon as any amount of urine collected in the
bladder, the patient invariably turned himself  so as to favor its evacuation.


                     \ 2.—Treatment of the Wound.

   The urine escaping from the wound by the  lowest angle, occasionally in-
duces  some little cutaneous irritation, which, if it becomes an  annoyance,
should  be obviated  by  anointing the part with mild  cerate.   After two or
four days the lips of the wound usually become tumid, and present signs of
inflammation.  In  most instances, this is  only indicative of the efforts  of
nature  to close  the perineum, and should not, therefore,  be interfered with
unless excessive, when  warm, moist cloths, frequently changed, will suffice
for its  regulation.   If  calculous matter forms around  or in the wound, it
should  be washed away with a stream of water from a syringe, or  loosened
by the action of a weak solution of hydrochloric acid.
   The bowels also  should  be kept at perfect rest by anodyne enemata until
the fourth day after the operation, when the administration of a mild laxa-
tive,  as rhubarb or  citrate of magnesia, will be  serviceable.   If,  on  the
escape  of urine through the penis, the perineal  wound  does not  heal,  a
catheter may be placed  in the urethra, and the union of the wound  facili-
tated by the use of  caustic or by means of pressure.


                    I \ 3.—Constitutional Treatment.

   As a general rule, the  constitutional treatment after  the operation for
lithotomy should be antiphlogistic, though  strict attention should also be
given to  the previous habits of the patient.  If  the  patient is an  old man,
good diet, or even stimulants, will frequently be demanded, and tardy heal-
ing of the wound will sometimes be prevented by such an increase  of diet.
   But among the most  important of the  steps connected with the  constitu-
tional  after-treatment of lithotomy is the removal, if possible, of  the cal-
culous diathesis, as  it is not sufficient for the cure of the patient  that  the
surgeon  should have removed the stone; a change in the character of the
nrine must also be induced.  It is therefore advisable, in every case, to test
the urine, both before and after the operation, by litmus  paper, the micro-
scope, or  similar means, until its peculiar characters are known, and then
to obviate the unhealthy  action of  the  kidneys by acids, alkalies, diet, or
other appropriate means of treatment. 
540           PRINCIPLES AND  PRACTICE  OF SURGERY.
                             SECTION IX.

   GENERAL  ESTIMATE OP THE VALUE OF THE DIFFERENT METHODS OF
                       OPERATING FOR  LITHOTOMY.

   After what has been said in the  preceding sections, of the special ad-
vantages of  the different modes of operating, there is but little that is new
to offer in a  general estimate of the whole of them; and yet such a summary
is not without its  value.
   Statistics of the Lateral Operation.—The statistics of lithotomy, though
presenting the result of a large number of cases, do not  offer a perfectly re-
liable account, because, in many instances, nothing is said of the peculiarities
of the case, the age of the patient, or other incidents which must exert a very
important influence upon an opinion.  Yet, as such statistics have a certain
value, and  are at present the only data upon which  an inexperienced surgeon
could form even an approach to an estimate of the risks to which a patient
is exposed by the operation, they are presented as  obtained from the sources
mentioned.
                                                      Cases.        Deaths.
      Dudley, of Kentucky*............................................ 207         6
      Pennsylvania Hospital, Philadelphia*.....................   83        10
      Gardner, of Kentuckyf..........................................   15         1
      Davis, of Ohiof....................................................   72         6
      Eve, of Georgiaf...................................................    2         1
      Bush, of Kentuckyf..............................................    5         0
      Gibson, of Philadelphia^.......................................   50         6
      Mettauer,  of Virginia^...........................................   73         2
      John  C. Warren, of Boston?....................................   30         2
      Henry H.  Smith, of Philadelphia.............................   13         0
      March,  of Albanyg................................................    7         0

                                                      557        34
      Smith, of Bristol, England, reports for Great Britain... 354        79

   The mortality in Great Britain, after the  operation, including children, is
about 1 in 4.  The mortality in the United States, including children, is about
1  in 15.   Showing that the operation  of lithotomy has  been nearly four
times as successful in the United States as in Great Britain.
   Statistics of the  Bilateral Operation.—After examining  the various
tables, and separating these from the cases specially mentioned as operated
on by the bilateral section, the following result has been  obtained:—
                                                  Cases.       Deaths.
      Paul F. Eve, of Georgia||.................................   25    .     4  specified.ff
      Spencer, of Virginia||......................................   16          2     "
      Mussey, of Cincinnati*7....................................   18          0     "
      Hotel-Dieu**..................................................   26          0     "
      Dupuytren*...................................................   70          6     "
      Warren, of Boston*.........................................    3          o     <<

                                                  158         12
   Or a  mortality  of about 8 per cent.

        * Trans. Am. Med. Assoc., vol. iv. p. 273, 1851.      f Ibid., p. 274.
        X Gross on  Urinary Diseases, p. 470.
        \ Trans. Am. Med. Assoc., vol. i. p.  161.
        I! Ibid., vol. iv. p. 274, 1851, and again in a report, April, 1852.
        «: Ibid., vol. ii. p. 226, 1849.
      ** Velpeau,  Op. Surg., by Mott, vol. iii. p. 918.
      ft Of these,  one died directly from the operation. 
VALUE  OF THE DIFFERENT METHODS OF LITHOTOMY.     541
  In the twenty-five cases operated on by Eve, two were females, and in no
case did he know either of a fistula in perineo or of a stone having ensued
upon the operation.
  In a recent notice of the result of  lithotomy in the London hospitals,
the statistics are as follows:—
  Lithotomy.—Of 186 cases operated on in the metropolitan hospitals, 146
recovered and 40 died.
  Ages.—137 were under 20, of whom 123 recovered and 14 died; 49 were
adults, of whom 23 recovered and 26 died.
   Causes of Death.—Benal diseases, 14; hemorrhage, 4; pyemia, 4; peri-
tonitis, 4; shock of operation, 2; extravasation of  urine, 2; abscesses about
the bladder, 2; wounds of fundus of bladder by the knife, 2; exhaustion, 1;
convulsions, 1;  cystitis, 1; bronchitis, 1.*
   Of 152 cases in the Glasgow Boyal Infirmary, there were 19 deaths:—
	Cases. ........................... 50	Deaths. 3
«< 10 " ............................	........................... 34	2
" 15 •' ............................	....................... 11	1
" 20 " ............................	........................... 14	5
« 30 " ............................	........................... 15	5
" 50 » ............................	........................... 14	0
Over 50 " ...........................	........................... 14	3
                                                    152         19

  Proportion of deaths to cases in patients under fifteen years,  1 to 15 83;
over fifteen years, 1 to 4384.   Proportion in  whole number of cases,  1 to
6*913.  Of these,  52 cases were operated on by  Buchanan's  rectangular
method, with 5 deaths, or 1 to lOl.f
  Of 175 cases operated on in the provincial hospitals, 22 died.
  Causes of Death.—Peritonitis, 6;  abscesses about the bladder, 4; hemor-
rhage, 3; pyemia, 2; shock  of operation, 2; renal diseases, 2; extravasation
of urine, 2; exhaustion, 2;  broncho-pneumonia, 1.   Of the  175 cases, there
were, under five years old, 41 cases, and 5 died; between five and ten years
old, 55 cases, and 1 died.
  Stone in Females.—Twenty-four cases, 16 metropolitan and 8 provincial.
Of 24 cases, 2 died;  both these deaths were cases of adults.J
  Statistics of Supra-pubic  Lithotomy. — A brief account of the cases
operated on shows that this operation has obtained a sufficiently large suc-
cess to justify its repetition where other means are not admissible.  Out of
twenty-five cases which I have collected, from various sources, twenty-one
have been cured and four died, thus  presenting a mortality of about one in
five.
  Great allowance must, however, be made for the results as shown in all
these tables.   In several instances, the deaths have not  been specified; in
others, the surgeon has relied  upon his recollection, and supposed that he
has operated on about fifty cases with a moderate number of deaths; and in
the statistics furnished under the head of the lateral operation, it is not
always certain that the lateral  method was the one employed.   I have, how-
ever, examined the statements closely, and endeavored to obtain a correct
result, and my conclusion is that the only point that can be depended on in
the above tables is, that out of 715  cases, 541 were cut by the lateral, 149
cases by the bilateral, and 25 cases by the hypogastric operation, thus show-
ing a decided preference among surgeons in favor of the lateral operation.
* Med. Times and Gaz.     f Glasgow Med. Journ.     J Med. Times and Gaz. 
CHAPTER  V.
     LITHOTRIPSY, OR CRUSHING  OF STONE IN  THE BLADDER.


  The removal of a calculus from the bladder by the  introduction of crush-
ing instruments capable of reducing its particles to such a size as would pass
out by the urethra, is an operation of great antiquity, having been spoken
of by Ammonias about 110 B.C.,* though it appears to have  been lost sight
of, until again  brought forward through the  efforts  of  Civiale, of  Paris,
about 1822.   Like most other novel  operations, the progress of lithotripsy
was  at first retarded  by the  great number of instruments supposed  to be
necessary  for its  performance.   Enlightened by the  experience of the dis-
tinguished European surgeons who seconded  Civiale's efforts, and simplified
the method very considerably, the operation has now  been brought to such
perfection that any surgeon  can accomplish it, if a sufficiently  dextrous
manipulator; gentleness, a delicate sense of touch, and a light  hand, aided by
a good crushing instrument, being the points most essential  to  its perform-
ance at the present period.
  In the  United States the operation of lithotripsy has been practiced to a
considerable extent, by the employment of Heurteloup's instrument as well
as with that of Jacobson.
  The first operation  was performed by Depeyre, of New York, in  1830;
the second by Alban G. Smith, then of Kentucky, in  1831;  and soon after-
ward by Randolph,  of Philadelphia;  Spencer, of  Virginia  ; Uttery,  of
Rhode Island; Gibson, of Philadelphia; N. R.  Smith, of Baltimore;  and
subsequently by many others.  To Randolph, of Philadelphia, the American
profession are, however, chiefly indebted for the early and progressive  cul-
tivation of lithotripsy in this country ; his name being extensively known  in
connection with his labors on this  subject.   Few  surgeons in the United
States have repeated the operation  more frequently than he did  upon pa-
tients of  all ages, and few have  been more distinguished in this department
of surgery, either for  the beauty of their manipulation,  or for the success
which  attended their operations.  In every case he was remarkable for the
care he exercised  in the preparation  of his patients, as well as for the brevity
of "the sittings."
  Without entering into the general  history of the progress of the operation,
or spending time  in the description of the multifarious instruments hereto-
fore devised aud  employed, this account will be limited to the  operation  as
performed with the " lithontripteur," or "stone-crusher," of Heurteloup, this
being the instrument now most frequently resorted to.
    * Smith's Diet. Greek and Roman Antiquities, art. Chirurgir.
(542; 
OPERATION OF LITHOTRIPSY.
543
                             SECTION I.

         PRELIMINARY TREATMENT  NECESSARY  IN  LITHOTRIPSY.

  As the principal danger in the operation  of  lithotripsy arises from the
production of crystals, it is of the utmost importance that every means be
employed  to prevent it.  The preliminary treatment  will therefore  often
be the chief  source of success, and  it should be  pursued according to the
following  plan : After  giving  attention to the condition of each organ,
special efforts should be made to remove the irritability of the bladder by
the free use  of the warm hip-bath,  by anodyne enemata, and especially by
the use of alkalies, as they, by depositing on and equalizing the surface of a
rough stone, often counteract one great source of irritation.   When  these
constitutional remedies have  induced a less irritable condition, a local pre-
paratory treatment should be commenced, especially the frequent introduc-
tion of bougies, so as to dilate the urethra gradually, and accustom the  parts
to the passage of an instrument.  By perseverance in the daily use of a
bougie for about eight days—allowing it to remain in the bladder for a half
hour or hour, according to the irritation it causes, care being always taken
to remove it if the patient complains  much of pain—and gradually augment-
ing its size, the urethra may be prepared to receive the largest lithontriptic
instrument not only without pain, but without much irritation.   The  prep-
aration of a narrow bed or table of a convenient height, some tepid water, a
little  oil, and a good instrument, complete the preliminary measures.
  The selection of the lithontripteur is a matter of the greatest consequence,
and unless the instrument is of the finest  temper and finish, it should never be
used.  I have been accustomed to test these qualities by crushing  a moderate-
sized tamarind stone in the instrument before attempting to break a calculus.
The danger from an  imperfect instrument is, however, not in its breaking,
so much  as  in  its  bending or spreading at the point, so as to prevent its
retraction.    In two  instances, iu the hands of Geo. M'Clellan,  of Philadel-
phia,  the male blade of Heurteloup's instrument was broken short off in the
bladder, and  yet subsequently voided with the urine and sand ; but when,
from want of temper, the female blade is  expanded, or either blade is twisted
or bent, the withdrawal of the instrument may become impossible  without a
serious laceration of the neck of the  bladder and urethra.
                             SECTION II.

                      OPERATION OF  LITHOTRIPSY.

  Having  in former years aided in carrying out the  plan of treatment di-
rected by Randolph, of  Philadelphia,  who was  eminently accomplished  as
an operator in this  department of surgery, I have selected his method as
that which may be advantageously followed;  not that it presents anything
peculiar, but because it is sanctioned by the experience of one of the earliest
and most frequent operators in the United States, and has since  been con-
firmed by me in numerous operations on my own patients.
  Operation of Randolph.—The patient, after a careful preliminary treat-
ment, being placed upon his back on a narrow table, covered with blankets,
and with a pillow  under  the  hips, bring the latter to the end of  the  table,
elevate the head and shoulders slightly by pillows, and support the feet on 
PLATE   LVII.
   OPERATIONS FOR THE REMOVAL OF STONE FROM THE BLADDER.

  Fig. 1.  Hypogastric  Operation for  Lithotomy.  An incision having  been
made in the linea alba, and the  bladder opened, the  left forefinger of the sur-
geon is seen holding up the  superior angle of the wound.   While an assistant
separates the left side by a blunt hook, the right hand of the surgeon elevates
the calculus from the bas-fond of the bladder by means of  the scoop.  1.  Left
hand of the surgeon.  2. His right hand elevating the stone.
                                               After Bourgery and Jacob,

  Fig. 2. The scoop which thus supports the stone, and prevents its again fall-
ing into the bladder, being now held by an assistant, the surgeon seizes it in the
forceps with both  hands, and is seen in the act of extracting it.  1, 1. Hands
of the surgeon.  2. Assistant  holding the  stone near the wound, so that the
forceps can readily seize it.                      After Bourgery and Jacob.

  Fig. 3. A view  of the Operation of Lithotripsy.  A section  of the  parts
around the pelvis shows the position of the patient, and the manner in which
the stone is seized  and held by the lithontripteur of Heurteloup.
                                               After Bourgery and Jacob.

  Fig. 4. Another  view of the same operation, showing the position of the frag-
ments in the bladder and the mode of seizing them, after  the stone has been
crushed two or three times.                      After Bourgery and Jacob.

  Fig. 5. Extraction of a fragment of a calculus from the prostatic portion of
the urethra by means of the articulated scoop of Leroy d'Etiolles.  The instru-
ment is introduced  as a straight sound, gradually passed behind the fragment,
and then its end made to turn up at a right angle with its stem by means of a
screw concealed in  its shaft.  1. Handle of the  instrument.   2. Its  articulated
point.  3.  Fragment as held by it.  4. Prostate gland.
                                               After Bourgery and Jacob.
       (544) 
Fig
 
 
OPERATION OF  LITHOTRIPSY.                  545
chairs, so that the knees may be wide apart.  If the  urine  has now been
retained, the lithontripteur may be immediately passed into the bladder in the
same  manner  as the catheter, and with quite as  much ease  by  a practiced
hand ;  but if the urine has escaped, a silver catheter should be first passed,
and tepid water injected into the bladder until it is partially distended, when
the lithontripteur being gently introduced, its blades may be cautiously ex-
panded and carried from before backward, or from right to left, or from
behind forward,  or from left to right, according to the position of the stone,
the manipulation of a few seconds usually enabling the operator  to catch it,
Plate LVII. Fig. 3, though sometimes it apparently falls into the grasp of
the instrument as  soon as the latter is expanded  in the bladder, and before
the instrument is carried to any extent laterally.   After seizing the stone,
and moving it a little in the bladder so as to be sure that no portion of the
mucous coat is included in the grasp of the instrument, close the blades  by
turning  the screw with the hand, and thus break the stone; after which
another part may be seized  and broken.   If the  patient does not complain,
it may now be  seized a third time,  Plate LVII. Fig. 4, after which the
instrument should be gently tapped and  moved about, in order to free it of
the fragments, when the blades should be perfectly  closed,  and  the  instru-
ment withdrawn from the urethra.  The " sitting " may sometimes last only
about five minutes, but seldom over twenty, even  when it causes  the patient
no pain.
   After-Treatment.—The patient, if comfortable, should now be kept on a
light diet; but, if in pain, employ a hip-bath, with an enema of sixty drops
of laudanum in a little thin starch, or a dose of Dover's powder, when if, after
the lapse of from three to five days, no constitutional or local irritation for-
bids it, the operation may be repeated.
   After crushing a stone, it sometimes  happens  that  a fragment, in being
voided, lodges and becomes fixed in the urethra, and this is usually the most
troublesome part  of the after-treatment.  If arrested near the neck of the
bladder, the better plan is  to push it  back into the  bladder by means of a
sound ; but when it is near  the fossa navicularis, it may become necessary to
dilate the orifice^of the urethra, aud remove the  fragment, if possible, with
fine forceps.   Should it, however, be further back, an effort may be made to
draw it out by means of Leroy's scoop,  Plate LVI. Fig. 10; or, if fast in
the spongy portion of the  urethra, by cutting down and extracting it through
the opening, Plate LI. Fig 5.
   Remarks___In operating for lithotripsy, much  will depend on the manual
skill of the operator, as well as on his accurate knowledge  of the anatomy
of the structure operated on.   In order to obtain the  first,  the young sur-
geon will find it  very useful  to practice  upon stones introduced into  the
bladder of a subject, or to place them  in a moderately soft buckskin bag, lay
the latter  upon a pillow, aud then with closed eyes endeavor to catch  the
stone without inclosing also a portion of the buckskin.   But although  the
operation of lithotripsy may thus be  made to appear  an apparently simple
one, it is only so when practice has rendered the operator dextrous.  In
the hands of Civiale  and Randolph, I have seen a patient continue in con-
versation with a smile upon his face  during the whole sitting, while other
operators  have  given rise  to the most intense suffering  by their heavy,
clumsy, and thick-fisted manipulations.   Since the introduction of anaesthetic
agents, it has been thought that all pain from the operation could be avoided,
and yet  the dangers not increased ;  and  such,  I think, is  truly the  case ;
because, when the bladder is  freely distended by the  water previously in-
jected, and  the  surgeon is  a practiced  operator, the use of the anaesthetic
will not only prevent any suffering, but facilitate the operation by preventing
     vol. ii.—35 
r>46
PRINCIPLES AND  PRACTICE OF SURGERY.
straining.  To such a surgeon the sense of touch, and that mental percep-
tion which enables him to know by his fingers exactly where the point of the
instrument is in the bladder, will prevent any injury to the coats of the latter.
But, under other circumstances, and  in  the hands of those who can only
imagine  what they are  doing, the use  of anaesthetics will be attended by
much danger, as the cries of the patient will be the  only proof that can be
offered of the coats of the badder being injured ; in other words, anaesthetics
will  facilitate the operation of lithotripsy in most instances, though  it may
also  lead to most  serious accidents.   In the  primary operations of  young
surgeons, it will certainly be safer for them to omit it.
                            SECTION  III.

           CASES ADAPTED TO  THE OPERATION OP LITHOTRIPSY.

   The claims of lithotripsy and its advantages over the operation of lithot-
omy is a subject that has engaged considerable attention at different periods
since the early efforts of Civiale, and been discussed with a fervor that has
shown the  strength of individual predilection rather than the  real merit of
the question.   It is sufficient evidence of the prejudice that has  sometimes
been  exhibited in the  expression of opinions  on  this  subject,  to know that
very  few surgeons, who  prided themselves on their  dexterity as lithoto-
mists, have ever  practiced or  advocated  lithotripsy;  while some  of those
who excelled in lithotripsy, as warmly designated lithotomy "as a barbarous
operation," etc.
   Such a  result  being very frequently the consequence of  the enthusiasm
and reaction observed in all new movements, it will answer  my present pur-
pose merely to allude to  it, as a caution to the young reader against allow-
ing himself to be  influenced by the authority of  any name, no matter how
high it may stand  in surgical  repute, and induce  him to pursue  the more
judicious and eclectic system of selecting for his patient either lithotomy  or
lithotripsy, in accordance with the  following general ideas:—
   1st. A sound condition of the urethra and bladder, as well as a good con-
stitution, is essential to the success of lithotripsy.
   2d.  Very soft and phosphatic stones are the best for lithotripsy.
   3d.  Hard and  rough calculi the  best for lithotomy; because even,  if
crushed, the fragments will prove a source of irritation both to the bladder
and urethra.
   4th. Lithotomy will do better than lithotripsy in emaciated,  nervous, and
dyspeptic patients; though these,  of course, are not promising cases for any
operation.
   5th. Lithotripsy is applicable especially to the young  and middle-aged—
the diseases of the prostate, and the condition of the bladder consequent on
it, rendering the success of the operation doubtful, as  a general rule, in old
age.
   6th. Lithotomy, if judiciously performed, will afford  a better chance  of
success than lithotripsy, in cases attended by symptoms  of vesical catarrh, etc.
   But in every case of lithotripsy, let  it be remembered that the preliminary
and  after-treatment are  quite  as  important in the result as the operation
itself.  Rigors and fever,  retention  of urine, and cystitis, are among the
results of lithotripsy in many instances, and a high degree of skill is neces-
sary to protect the patient from the effects of this condition of the system.
Both the preliminary and  after-treatment are so essential to the success of 
LITHOLIBY.
547
the operation that it is difficult to decide  between them ;  but, if there is a
difference, I should assign the greater value  to the preliminary treatment.
To operate  for lithotripsy without the most careful preparation of the pa-
tient's general health, is  certainly indicative either of ignorance or of the
indifference  of the operator to the result of the operation.
                             SECTION IV.

                               LITHOLIBY.

   Litholiby—XtOo':, stone, OXtfiw, to crush—is the term recently adopted by
 Denamiel, of France, to express an operation in which a stone is crushed as
 it lies in the  vesical triangle, by means of an instrument introduced into the
 bladder on one side, and the forefinger in the rectum on the other, a sound
 in the bhidder serving as a point of support.  As he  expresses  great  con-
 fidence in the disintegrating qualities of alkaline fluids, he makes their ad-
 ministration  precede  the operation.   As the distance from the perineum to
 the neck of the bladder is usually two and a quarter inches, though it may
 vary from one to four, the prostate and neck of  the  bladder are  so slightly
 separated  from the rectum that any  hard body in the bladder may readily
 be felt by  a finger in the rectum.   He therefore operates as follows:—
   Denamiel's Operation.—The bladder being moderately distended, place
 the patient in the horizontal posture upon the edge of a firm bed, the thighs
 being separated and raised, and the feet resting on chairs;  then, introducing
 the left fore and middle finger into the rectum, feel the stone, and, having
 found  its  position, pass in  a curved sound grooved on  its convexity, so that
 it may readily hold  the stone,  and, pressing the stone firmly against  the
 souud  by means of the fingers in the rectum, crush it thoroughly by directing
 the pressure  to the right  and left.   If the calculus is very soft, Denamiel
 states  it may thus be  readily crushed; but if it is hard, several sittings, and
 the free use of alkaline fluids to favor its disintegration, will be required.
 Warm water should also be freely injected into the bladder after each attempt
 at crushing, in order  to remove the particles.*
  Remarks.—Of this operation I have no  personal knowledge, nor am I
 aware  that it has ever been repeated either in Europe or the United States;
 without further  data  I should  mistrust  it: 1st,  because  it is well known
that the supposed disintegration of calculi by the use of alkalies  is only the
saturation of the acid  constituents of the urine, which are then voided in the
state of gravel, but which  do not include any portions of  a former stone;
and 2d, because any  compression that could be attempted upon a stone of
even moderate firmness would necessarily bruise both the blader and rectum.
* Med. News, p. 147.  From Lond. Med. Times, 1853. 
CHAPTER  VI.
DISORDERS OF, AND OPERATIONS ON, THE FEMALE GENITO-URINARY
                              ORGANS.


                             SECTION I.

             SURGICAL ANATOMY  OP THE  FEMALE PERINEUM.

  The Female Perineum embraces a region that has been variously described
by authors, some including in its boundaries most of the external organs of
generation, and carrying it, as in the male, from the  pubis to the coccyx;
while others  define it as the  portion between the anus  and vagina.   For
surgical purposes,  the former is the most  useful, though the changes pro-
duced in delivery are chiefly limited to the latter.   Without entering  upon
all the details of this structure, it may suffice,  at present, to allude briefly to
such portions as are concerned in surgical operations.
  The surgical relations  of the Vulva require no other  reference than the
mention of the fact that the areolar tissue is here freely developed,  and that
cysts, abscesses, or wounds of this part should be treated with reference to
the liability of this structure to liquid infiltrations.
  The Clitoris, formed chiefly of an erectile structure like the corpus caver-
nosum of the male, arises by two  branches from the ramus  of the ischium
and pubis, and has a small prepuce formed by the extension of the mem-
brane covering the nymphae.   Occasionally the clitoris gives  rise to such
irritation as may demand  its removal.
  Below the  clitoris, and  within the nymphae, there is found a triangular
smooth  surface, about three-fourths of an inch long,  called the Vestibule.
This surface terminates inferiorly, or posteriorly, in the orifice of the urethra,
and is one of the points in which lithotomy is performed.
  The female Urethra is  from twelve to fifteen lines long, and pursues a
direction which passes in a line from below upward aud from before back-
ward.   Its vesical  extremity  is the largest,  and its  vulvular orifice the
smallest, representing in this arrangement a cone, the base of which is toward
the bladder;  hence, small calculi escape readily, and simple dilatation of the
orifice facilitates the passage of those of a large size.   At the orifice may be
found a marked rising, or tubercle, which is an approach to the bulb of the
urethra as seen in man, and serves as a guide to the  finger of the surgeon
when introducing the female catheter.   Near its commencement, the urethra
is close to the vagina, but as it ascends it becomes separated from it by  a
triangular space corresponding with the  vestibule, which is occupied by  a
very loose cellular  tissue.
  Below the  urethra is the orifice of the ATagina, which, in virgins, is often
closed by the membranous expansion known as the Hymen.  Most frequently
this membrane is  thin, delicate, and readily  lacerated, though sometimes
when dense and  imperforate, or thickened by inflammation, it demands the
       (548) 
ECZEMA  OF THE VULVA.
549
use of the bistoury, in order to permit the  escape of the menstrual fluid, or
sexual intercourse.
  The vesico-vaginal septum is  sufficiently extended, reaching even as far
as the boundaries of the anterior face of the  vagina, and  creating  rather a
vesico-uterine than  a vesico-vaginal septum.
  Between the vagina and the rectum, for a distance of fifteen lines above
the anus, is a condensed areolar and adipose tissue, uniting the two canals,
and constituting the recto-vaginal septum, and  above this the peritoneum
descends so as to form  the recto-vaginal pouch.   Below  the  recto-vaginal
septum, or in the perineum  proper' of some anatomists,  there is found the
skin, anterior extremity of the sphincter ani muscle, the perineal fascia,  and
the posterior portion of the  sphincter vagina?  muscle, together with a con-
nective tissue which is remarkable for  its laxity and the  number of blood-
vessels which run to it.
  The muscles of the female perineum are very much the same  as those
found in the male, but they are  usually less developed, with the occasional
exception of the sphincter vaginae.   The  levator ani  is  also separated in
front by an interval which is occupied by the vagina and neck of the bladder.
  The blood-vessels and nerves  do  not differ  materially from the arrange-
ment  found in man, being chiefly branches of the pudic  artery and sciatic
or sacral nerves.
  In studying  the  layers of the  vulva from before backward, there may be
noted: 1, the mucous membrane; 2, a vascular  and connective tissue con-
taining the roots of the  clitoris, covered by the erector clitoridis muscle, and
having the  anterior extremities  of  the sphincter vaginae muscle  upon its
sides;  3, the triangular  ligament traversed by the urethra, and containing
the transversalis perinei  artery;  4,  the dorsal  veins of the clitoris and the
plexus which surrounds the neck  of the bladder;  lastly, the inferior and an-
terior portion  of the bladder, through which the  incisions are   made in
lithotomy,  as practiced in the female.
                             SECTION  II.

                  DISORDERS OP THE EXTERNAL ORGANS.

   The External Organs of the Female being covered by skin and  mucous
membrane, and  presenting a large  number of sebaceous  and mucous folli-
cles, are liable to  inflammation from various causes, which shows itself as
eczema, abrasion,  ulceration, and tumors, from  obstruction of the ducts of
the follicles.

                       § 1.—Eczema of the Vulva.

   When eczema  or herpes is developed in  the Vulva, the itching is often
intolerable, while the serous discharge and excoriation are exceedingly annoy-
ing.  The general  principles applicable to the treatment of eczema, wherever
developed, are all that  is necessary for the relief of the affection in this
organ;  such as the application of heat and moisture by means of the con-
stant use of  cloths saturated  with warm mucilage, and covered with oiled
silk,  until the heat and redness is  diminished, after which  cloths wet with
a weak  solution of the acetate of lead should be applied.  Should the ex-
ternal irritation  be due to a vaginal discharge, the latter should be promptly
treated, the  patient's digestion being carefully attended to.   Anodyne and
alkaline washes, as a solution of borax and morphia, are very useful. 
                       PLATE   LVIII.
  INSTRUMENTS EMPLOYED IN OPERATIONS UPON THE  VAGINA AND
                                RECTUM.
  Fig. 1. Lever Speculum  of Marion Sims,  for elevating the posterior lace
of the vagina.  1.  Surface which is applied to the posterior face of the vagina.
                                                           Kolbe's pattern.
  Fie. 2. Sims's Smaller Speculum for elevating the anterior end of the vagina.
                                                           Kolbe's pattern.
  Fiff. 3. Sims's Knife, for freshening the edges of a vesico-vaginal fistula.
    b                                                      Kolbe's pattern.
  Fig. 4. Sims's Needle, for iuserting the sutures in a vesico-vaginal fistula.
                                                           Kolbe's pattern.
  Fig. 5. Sims's Crotchet, for sustaining the traction made in drawing upon the
threads.                                                    Kolbe's pattern.
  Fig. 6. Sims's Hook, for seizing the edge of the fistula, or the loop of a suture.
                                                           Koibd's pattern.
  Fig. 7. Small  Blunt  Hook, to support the  edge of  the fistula when being
transfixed by the needle.                                    Kolbe's pattern.
  Fig. 8. A Fork to sustain the  traction made in tightening the wire  ligatures.
                                                           Kolbe's pattern.
  Fig. 9. Forceps  for seizing the wires aud  fastening the shot in closing the
sutures.                                                     Kolbe's pattern.
  Fig. 10. Sims's Female Self-Retaining Silver Catheter, as employed  in vesico-
vaginal fistula?.                                              Kolbe's pattern.
  Fig. 11. Ordiuary Female  Catheter of Silver.                  "       "
  Fig. 12. Meigs's Shield for the vulva in incurable vesico-vagiual fistula?.
                                                           Kolbe's pattei-n.
  Fig. 13. Bivalve Speculum Vagina?.                          "
  Fig. 14. Univalve Speculum.  1. Handle.   2. Vaginal portion.
                                                           Kolbe's pattern.
  Fig. 15. Fenestrated Speculum, open on the side, and applicable either to the
vagina or rectum.   1. The feuestrum.                        Kolbe's pattern.
  Fig. 16. Ordiuary Rectum Speculum for dilating the anus.      "
  Fig. IT. Disk Pessary for  prolapsus uteri.                     "       "
  Fig. 18. Physick's or Meigs's Ball Pessary—silver gilt.
  Fig. 19. Hodge's Curved Pessary.            "    "
  Fig. 20. Chase's Vaginal Syringe.   1. Shield to close the vulva and assist in
retaining the injection.                                      Kolbe's pattern.
  Fig. 21. Double  Canula for ligating uterine polypi.             "      "
  Fig. 22. A Rectum Bougie.                                   "      *<
  Fig. 23. A " Porte Meche" for inserting lint in fistula in ano.     "
  Fig. 24. Gibson's Stylet for puncturing the rectum in incomplete fistula.
                                                           Kolbe's pattern.
  Fig. 25. Spring to carry the ligature after the puncture is made.
                                                           KoU>&8 pattern.
       (550) 
Plate 58.
 
 
HYPERTROPHY OF  THE  CLITORIS.
551
                      \ 2.—Occlusion of the Vulva.

  Various evils result from the continuance of inflammation in the external
organs of the female ;  thus in the young child adhesion of the adjacent sur-
faces may close the fissure of the vulva, interrupt the escape of the urine, or
ultimately create an obstacle to sexual union.   It is, therefore, important to
prevent or relieve it promptly, by dusting the excoriated parts freely with
finely powdered  starch, or by keeping a  slip of cloth, wet with mucilage,
constantly between the labia.   In  infants, when the labia are partially ad-
herent, it is  only necessary to slip a stiff  probe beneath the new adhesions
and lacerate  them;  or, if they are of a firmer character, to incise them care-
fully in  the  median  line by means  of a director and bistoury.  Ointments
are objectionable  applications in these  disorders, as  they are liable to be
decomposed  by the heat of the parts, and become a source of irritation.
         \ 3.—Inflammation of the Hymen and Enlarged Follicles.

   Occasionally the surgeon will be consulted  in reference to a vulva irrita-
tion, accompanied by the presence of small pink  grain-like bodies that are
found in connection with the Hymen.   In two cases that I have  seen, these
bodies appeared to be formed of the obstructed mucous follicles of the hymen
and orifice of the vagina, and to require the free use of dry astringent powders,
as tannic acid, or equal parts of sulphate of zinc and powdered gum-arabic
dusted over the inferior edge of the hymen with a camel's-hair pencil.
   Similar growths, or Warts of the Epithelial Tissue, are also met with in
the adult female, being due to continuous irritation. These warts vary in size
from a mustard seed to that of a mulberry, and are simply a hypertrophy of
the follicles, and are not always  venereal, yielding, like warts on the  penis, to
excision  with the scissors and the application  of astringents, or to the use of
chromic acid, as before directed.*  When  deprived of the epithelial covering,
these bodies often become exceedingly sensitive, and a  source of great incon-
venience.  Bathing in lead-water, leading to a deposit of the carbonate of
lead on  the surface, diminishes their sensibility,  after which chromic acid
may be applied to a few spots at a time.
   The sensitive tumors, near the female urethra, described by some writers,
I  have never recognized.   Inflamed caruncula?  rayrtiformes  I have occa-
sionally met with, and,  when the anterior horns of the hymen  run  well up,
they may remain and form these sensitive bodies,  the  origin of which it is
not easy  otherwise to explain.   Excision  and  cauterization is said to be the
best treatment.   Ulcers of these parts,  of a non-syphilitic or carcinomatous
character, are rare, and amenable to general laws.   Condylomata of this
region present nothing peculiar, and have been before described.  Abscesses
of the labia should be promptly  evacuated,  and cystic tumors  treated, as
elsewhere directed, by extirpation.
                    g 4.—Hypertrophy of the Clitoris.

  Enlargement of the Clitoris of a marked character may be a simple hyper-
trophy, or the result of a malignant growth, analogous to cancer or Epithe-
lioma of the Penis.   If the latter, much benefit will be derived from the use
* Vol. i. p. 316. 
552
PRINCIPLES AND  PRACTICE OF SURGERY.
of the  dried sulphate of zinc.  Wheu the  simple  hypertrophied condition
causes  serious  evil,  its amputation may be accomplished  by making an
elliptical incision  around the base of the clitoris, holding the portion to be
amputated in a ligature  or pair of forceps, and carefully ligating the arteries
of the  clitoris  as  the incisions progress, the retractions of the vessels often
creating profuse hemorrhage, and in some  instances requiring the applica-
tion of the  persulphate of iron or the actual cautery.  Hemorrhage,  in am-
putation of even a moderately enlarged clitoris, will demand attention.


                      § 5.—Polypi of the Urethra.

   Polypi of the Female Urethra are  generally pedunculated, and may be
removed by the ligature, like polypi elsewhere.

                           \ 6.—Catheterism.

   In the introduction of the Female Catheter, the course and length of the
urethra should be remembered, especially if a tumor or displaced womb exists
at the  same time.
   Operation___Place the patient either upon the side or back with the knees
drawn  up, and then, without uncovering  her, pass the forefinger of the left
hand, slightly flexed, to the posterior commissure of the  vulva, separate the
labia with the knuckle, pass the pulp of the finger to the anterior or superior
margin of the orifice of the  vagina, feel for the urethral  tubercle, and, pass-
ing the catheter along this finger as a director, carry it  gently upward and
backward so as to present its concavity under the arch of the pubis.   As
soon as the  point  enters the bladder, close the end of the  instrument with
the finger, and  apply a small bowl to receive the  urine.   In withdrawing the
catheter, the end  should also be closed with the finger, to prevent the urine
soiling the bed, the motion  by which  the instrument was introduced being
reversed.

                       § 7.—Imperforate Hymen.

   When the Hymen is thickened by inflammation,  or is imperforate,  and
causes inconvenience by retention of the menses, puncture it with a bistoury
or thumb-lancet, and make a crucial incision, to prevent union of the  wound
from the collapse of the membrane.  Extreme  sensibility of the Hymen is
sometimes the result of  inflammation developed either by its partial rupture
or by  extension of inflammation from the adjacent surface.   Cold anodyne
and astringent applications generally relieve it.  But a puncture, under these
circumstances,  will sometimes  create quite a free  bleeding, which  is only
arrested by  the shriveling of the membrane.
                     \ 8.—Occlusion of the Vagina.

  Occlusion or Imperforation of the Vagina may result either from con-
genital defect or from inflammation developed by injuries, or from extended
vaginitis, though most frequently the cause is a mechanical injury, or it is the
effect of a protracted labor.  When obliterated, the aid of the surgeon must
be sought in order to restore the function of the canal, and give exit to the
menstrual fluid or permit sexual intercourse.  As such cases necessarily vary
much, it is impossible to  lay down any precise plan of proceeding, and the 
OCCLUSION  OF THE VAGINA.
553
operator should, therefore, be mainly guided by his anatomical knowledge of
the part, and by the contractions that are well known to follow the formation
of cicatricial tissue.
   When imperforation of the vagina is perfect  and congenital,  an accurate
diagnosis of the existence of a womb should first prove the necessity for the
operation, as, until this can be settled, no treatment ought to be attempted.
But should the evidence of the presence of this organ  be  satisfactory, the
dissection maybe prosecuted by placing the woman in the position for lithot-
omy, introducing  a catheter  into the bladder,  a  finger  or bougie into the
rectum, and then cautiously incising the intermediate portions of the line of
the natural curve of the vagina, until the uterus  is  reached, or until the depth
of the incisions excites a fear of penetrating the peritoneum at the point of
its reflection from the  bladder.  Subsequently, the  parts should be prevented
from adhering by the use of emollient dressings and bougies. An instructive
case of this operation has been reported by Meigs, of Philadelphia.*
   Operation of Randolph, of Philadelphia.—The operator being seated in
front of the patient, and the latter placed upon  her back, with the knees
drawn up, a strong metallic staff, slightly curved, was introduced into the
bladder, and held by the assistant.   Then, while the left  index finger was
kept in the rectum, the tissue between the urethra and rectum was dissected
very nearly up to the substance of the womb itself by horizontal  strokes of
the bistoury.   Not  being able to find the  os uteri, the operation was now
suspended,  a silver-gilt bougie, four  inches  long, and as  thick as the thumb,
directed to  be constantly employed to preserve the newly-formed canal, and
the patient seut home.   Three months subsequently, after constantly wearing
the bougie, the lady returned to the city, suffering from  uterine distention,
when the vagina was found to be covered with a smooth surface resembling
a  mucous membrane, and a tumor could be distinctly felt through the upper
end of the canal.  On  puncturing this with  a trocar and canula, a viscid sub-
stance was evacuated, the patient relieved, and the  menstrual  fluid subse-
quently  found to  escape by the vagina    The  latter,  however, contracted
until nothing was left but a sinuous opening sufficient for the menstrual fluid.
   In operating for  the  relief of occlusion  of the vagina, special attention
should be given to the previous history of the case, and if the defect has  been
the result of inflammation developed by injuries to the part creating an atresia
or contraction of the canal rather than its perfect obliteration, the tendency
of inodular structure to contract should be stated to the  patient before com-
mencing any treatment.  Great disappointment has ensued in two cases, that
I  have seen in consultation,  from the return of the constriction, after the
vagina  had been incised and dilated to its full  extent, and  this  contraction
supervened in one case notwithstanding the efforts of a vigorous husband to
prevent it.  Mott, of New York,-f and Ewart, of Charleston,! have also re-
ported cases in which the contraction returned, notwithstanding every means
was  employed to  prevent  it.  When  the  diseased tissue is extensive and
near the vulva, it is  better to attempt the introduction of a  slip  of skin  from
the vulva, by a plastic operation, or  obtain  the  alterative effects of  the fre-
quent and light applications of the nitrate of silver, than resort to the dissect-
ing or incising operation just  described.   Though the  latter may succeed
sometimes, it will not invariably do so.
* Pract. of Med., 2d edit. p. 383.        f N. Y Med. Times, vol ii. p  1, 1832.
         X Charleston Med. and Surg. Journal, vol. viii. p. 81, 1853. 
                          PLATE  LIX.

     OPERATIONS UPON  THE FEMALE GENITO-URINARY ORGANS.

  Fig. 1. Operation of Celsus for closing a recent laceration  of the Perineum,
as modified  by Dieffenbach.  After uniting the sides  of the  laceration  by the
application of  the quilled suture, two lateral incisions  are made so as to  relieve
the tension  of the perineum.   1. Quilled suture.  2, 2.  Lateral  incisions of
Dieffenbach.                                    After Bourgery and  Jacob.

  Fig.  2. Roux's Operation for the cure of a Recto-Vaginal Fistula, which was
situated behind the recto-vaginal septum.  A quadrangular flap has  been de-
tached from the posterior  parietes of the vagina,  drawn  forward,  and  then
attached to the freshened edges of the integuments,  near the  fourchette.   1, 1.
Fingers of assistants.  2. The needle-holder.      After Bourgery and  Jacob.

  Fig. 3. Enlarged  drawing of the same, showing the position of  the sutures
and the line of union.  Two  stitches of the interrupted suture are placed on
each side as  well as front.                        After Bourgery and  Jacob.

  Fig. 4. Suture of a Longitudinal Recto-Vaginal Fistula.  1. The hand of an
assistant dilatiug the vagina with a bivalve speculum, so us to fully expose the
fistula.  2. The hand of the surgeon in the act of forming the suture after the
edges of the fistula have been freshened either by caustic or the knife.
                                               After Bourgery and  Jacob.

  Fig. 5. Deyber's Operation  for the cure of a Transverse Vesico-Vaginal Fis-
tula.   1,1. Fingers of the assistants exposing the parts.  2.  The stylet,  which,
being introduced through the urethra, is about to pass the thread through the
posterior lip of  the fistula.  3. The  forceps seizing it.  The suture  at the
opposite angle is seen as applied, but it is not tied  until  all the threads are
placed.                                        After Bourgery and  Jacob.
(554) 
'pi
Fie .4
 
 
LACERATION OF  THE  PERINEUM.                555
                             SECTION  III.

                     LACERATION  OF THE PERINEUM.

   Laceration of the Perineum may result from mechanical injury, as falls
 upon legs of  stools, etc., or, as in one case under my care, from the blow of
 the horn of a pet deer.  But the most common cause is parturition, the tear
 being the result either of inattention or inability on the part of the accoucheur
 to support the perineum, especially in a first labor, or in consequence of the
 improper application of the forceps.  When caused by parturition,  this con-
 dition may present three varieties: 1st. Simple laceration of the  skin from
 the fourchette more or  less  toward  the anus.  2d. Division of the areolar
 tissue, superficial perineal fascia, and fibres of the constrictor vaginae muscle.
 3d. Laceration of  the  recto-vaginal septum, with some division of the con-
 strictor vaginas muscle as well as of the sphincter ani muscle—the laceration
 of this muscle being the most  serious form.  In the first and second varie-
 ties, the prompt apposition of the edges, by simply keeping the limbs closed
 for a few days, will often suffice for a cure.  But if not noticed until the edges
 of the laceration have cicatrized without union, the patient will be disposed
 to prolapse of the  vagina and  uterus, and  to an enlargement of the vaginal
 orifice that impairs sexual intercourse and causes other  serious inconveni-
 ence.  In the third variety, the evils are more  marked, consisting in an in-
 ability to control the  rectum,  in consequence of which gas and feces  con-
 stantly escape;  in  the  persistence  of  a  serous  diarrhoea; in procidentia
 uteri; and in an excoriation of the adjacent surfaces, which render the un-
 fortunate female disgusting to  herself or a burden to her  friends.
   Diagnosis.—Laceration of the perineum, if looked for, is easily recognized;
 but unfortunately it is not  noticed until too late to hope for union by the
 simple process of nature, except in the first and simplest variety.   When a
 patient, within a day or  more of labor, complains that "she suffers from the
 piles," a careful examination of the anus and perineum should be made, the
 orifice of the  vagina being temporarily plugged with a sponge to arrest the
 lochia?.
.  Prognosis.—The prognosis will vary with the extent of the injury.  Simple
 closing of the limbs, and keeping them so for three days,  will often cure the
 first variety, while  an  operation by suture or suture and freshening of the
 edges with divison of the sphincter ani muscle will be required for the second
 and third varieties.  In  the latter,  though  the cure is frequent, the result is
 somewhat uncertain.   The evils of an unhealed laceration have been before
 stated.
   Treatment—The treatment  of the second  variety consists in thoroughly
cleansing the edges of the rent, if seen promptly, or in freshening them if seen
later, and approximating them  by  the silver and quilled  suture, the bowels
being kept at  perfect rest for five or six  days.  The third variety being the
most common and serious, constitutes the usual class  of cases requiring the
operation for lacerated perineum. This may be performed in various methods,
as hereafter stated, each being  applied to special cases.   In all cases,  how-
ever, the general rules laid  down  by Dieffenbach, of Berlin, should be ob-
served :—
   1. To  thoroughly prepare the patient for the operation by emptying the
bowels, shaving the parts, etc.
   2. To  operate as soon as possible after the occurrence of  the injury, even
when the parts are tumid from the labor.   Baker Brown, of London,  has, 
556            PRINCIPLES AND  PRACTICE OF  SURGERY.
however, advocated* with great reason a departure from this rule, when the
patient is not seen on the first or second  day after delivery, deeming it best
in all other cases not to operate until after the third month, as the parts will
then better bear the denuding of the edges, and be sufficiently strong to sus-
tain the suture.
   3. To employ three or five twisted or quilled sutures, commencing at the
anus and ending at the fourchette, closing first the torn angle of the sphincter
ani.
   4. To administer enough opium to keep the patient quiet and the bowels
at rest, the urine being regularly drawn off by the catheter.
   DiefFenbach's  Operation.—The parts being prepared, and  the  patient
placed in the position for lithotomy, in a good light, raise the edges of the
fissure by forceps, and freshen them by excising the indurated  portion with
curved scissors or a bistoury.  The side of the rectum being now united by
a fine single  point of  the  interrupted suture, deeply introduced, close the
middle of the fissure, and, applying four stitches of the quilled suture, at equal
distances, approximate the parts accurately; as the  loss of  substance puts
the united  parts  upon the  stretch,  make two  lateral incisions, half  an inch
on each  side  of the posterior margin of the external  labia?, Plate  LIX.
Fig. 1, which will soon relieve the tension of the line of the fissure, and, by
filling up with  granulations, prevent future traction on the cicatrix until it
becomes firm.   The sutures being allowed to remain till loosened, care is to
be taken to keep the bowels in a soluble condition by employing daily injec-
tions after the seventh day.
   Mettauer, of Virginia.f  in the case of a lady, thirty years of age, who suf-
fered a laceration of the perineum during parturition six months previously,
from which  there resulted  " a complete  disunion  of the  recto-vaginal wall
from the verge of the  anus three inches up the rectum, terminating  superi-
orly in an obtuse angle, the rectum being contracted upon itself so as to ren-
der its several teguments a mere band of the width of five-eighths of an inch,
while the retaining power of the  sphincter ani was destroyed," operated as
follows:—
   Operation.—The patient being placed in the position for lithotomy, with
the knees held wide apart,  denudation of the margin of the fissure to the ex-
tent of three-fourths of an  inch was accomplished by the aid of hooks, scis-
sors, and scalpels, according to circumstances.  The bleeding being arrested,
leaden ligatures were introduced in succession from within out, and from the
angle to the verge of the fissure, at the distance of one-fourth of an inch apart,
by means of curved needles threaded with silk, to the loop of which a leaden
wire was attached.  Physick's needle proved very useful in introducing these
threads, and, as the leaden  ligatures were successively tightened by twisting
them sufficiently to bring the abraded surfaces in contact, their ends were cut
off.  Twelve ligatures were required to close the breach, and these being sub-
sequently tightened, the margins of the wound were cauterized with the nitrate
of silver.  The patient was then kept perfectly quiet in bed,  with the knees
tied together; the bowels were not moved for four days, and then the matter
did not escape through the  fissure.  The ligatures were removed in six weeks,
and  the union was perfect.   In this case the metallic suture was employed!
many years before Sims suggested its more general application.
   Plastic Operation  of Horner,  of  Philadelphia.^—In this  patient the
laceration was complete from the  vulva to the anus, the parts were cica-
* On Surgical Diseases of Women, Philada. edit., p. 38.
f Am. Journ. of Med.  Sciences, vol. xiii. p. 118, 1833.
X Ibid., vol. xx. p. 329, 1850. 
LACERATION OF  THE  PERINEUM.
557
trized over an inch deep, and but one fissure was apparent from near the os
coccygis to the clitoris; there was a constant tendency to diarrhoea, and much
of the fecal matter passed  through  the rim a vulvae.
  Operation.—A previous operation by freshening the edges and the use of
sutures having failed, the  patient submitted to the following operation fif-
teen months after the first:—
  After being thoroughly etherized, two flaps were made from the perineum
adjacent to  the vulva, one on the right and the other on the left side, twisted
on their bases, crossed between the rectum and vulva, and fastened by sutures,
so that the right flap formed the upper  part of the rectum, and the  free side
of the left the lower part of the vagina;  stitches of the interrupted suture
along the rectum and along the vagina closing each of these cavities by the
approximation of their raw surfaces.   For ten days  there was no fecal dis-
charge,  but at this time the union, though  not perfect, kept the septum in
position, and ultimately benefited, though it did not cure, the deficiency.  I
have recently seen this lady—the recto-vaginal septum is tolerably good, but
the action of the  sphincter ani is  imperfect.  As in her present state she
can  render  herself comfortable, and retain  feces and flatus, except in occa-
sional attacks of diarrhoea, and as she suffered seriously in  previous opera-
tions from erysipelas, etc.,  I advised her to  remain content  with  her condi-
tion, and run no further risk of her life.
  Baker Brown, of London, who has been  remarkably successful in the re-
sults of  his  operations, in the worst form  of laceration, lays  much stress* on
the division of the sphincter ani muscle, and operates  as follows:  After pre-
viously preparing the patient, by cathartics, etc., he selects a scalpel, probe-
pointed  straight bistoury, long  dissecting  forceps, three large  needles for
the deep quilled suture, and small ones for the superficial interrupted suture,
two pieces of quill, or bougie tenaculum.    Instead of the silk ligature, the
metallic thread, as originally used in 1833 by Mettauer, of Virginia,  and
before described, will be better.
  Brown's Method.—After etherization, place the patient in the position for
lithotomy, shave the parts thoroughly, and let one assistant render tense the
sides of  the fissure.  Then make a clean incision, about one inch  external
to the side of the fissure, throughout its  entire length, and deep enough to
reflect inward the mucous membrane, and lay bare the whole surface of the
laceration on one side.  Then do the same on the other side, connecting the
two  incisions and paring  away any intermediate portion of  the  mucous
membrane, over the recto-vaginal septum.   When the fissure is thus thor-
oughly denuded of every portion of  raucous membrane, the left forefinger
should  be introduced wittiin the margin  of the anus.  Then pass  along  it
the probe-poiuted bistoury, and cutting firmly outward and backward, from
withiu the rectum, divide thoroughly all the fibres of the sphincter ani muscle
and  the  subcutaneous areolar tissue, each  side of the coccyx, and about a
quarter of an  inch in advance of its point,  cutting to the extent of an  inch
or two,  external to the anal orifice, thus destroying all muscular traction by
freeing the sphincter ani from its origin in the coccyx  The degree of relaxa-
tion  thus sought for must  be regulated by the extent and character of the
laceration, it being remembered that the freer the iticision in this  line the
greater  will  be the relaxation.
  The thighs being now somewhat approximated, the sutures should be  thus
placed:  Having a strong needle carrying a double thread—as directed for
the  quilled suture—seize the denuded tissues on the  left  side,  between the
left forefinger and thumb, and plunge the needle, with the right hand, through
* Brown, op. cit. 
558
PRINCIPLES AND  PRACTICE OF SURGERY.
 the skin and subjacent tissues, introducing it one inch external to the pared
 edge, and carrying its point deep downward and inward, until it reappears on
 the inner edge of this side of the denuded surface.  Introducing it at the cor-
 responding margin of the opposite denuded side, make it traverse the tissues
 on the right side, in a direction upward and outward, until it escapes at a
 point  one  inch  distant from  the external margin  of this side.   The first
 suture being placed near to the rectum, introduce, in a similar manner, two
 others at  equal distances, one above the  other, and inclosing  the  quills
 secure the ligature firmly on them, so as accurately to approximate the deep
 denuded tissues.  Then, passing the right forefinger into the  vagina and
 the left  into the rectum,  ascertain  that  these  deep  parts  are  completely
 joined, and, withdrawing the fingers, close the  skin  only on the line of the
 raphe  by three or four points  of the  interrupted metallic snture, and, cleans-
 ing the parts carefully by a sponge, apply the water-dressing, retaining it in
 position by a T-bandage.
   After-Treatment.—Place the patient  on her left side  in bed, with the
 limbs closed, and flexed on the abdomen; give two grains of opium at  once,
 and one grain  every four or six  hours subsequently.  Ice to  be sucked,
 arrow-root or beef tea for the first twenty hours, and, if  no fever supervene,
 give a generous diet after the second day.
   It is important that  the catheter should be regularly employed  thus:
 Pass it from behind the buttocks between the thighs, and keep the end closed
 by the thumb, as  it prevents  the  urine dropping on the  wound.  On the
 eighth or ninth day, if all goes well, the patient may,  on her hands and knees,
 be allowed to pass her water.  The deep quilled sutures  may be removed
 on the fifth or sixth day, and the external interrupted sutures a day or two
 later, taking care, in the removal of  each,  not to separate the thighs.   The
 opium  should be persevered in for two or three weeks, so as preserve consti-
 pation, the bowels  being opened for the first time  only  when the adhesion
 seems firm, a dose of oil being given  at night, a tepid injection in the morn-
 ing, and the perineum supported when the first hardened feces escape.
   When, from any cause, adhesion is not complete throughout, the applica-
 tion of the nitrate of silver or the actual cautery may be necessary.*
   In the cases in which I have practiced this operation of Brown's, I  have
 employed coarse metallic threads for the deep, and  finer for the  superficial
 sutures, introducing a Sims' catheter, and  leaving it  in the bladder__points
 which will be found useful as modifications of the original operation, as there
is no necessity to remove the metallic threads before the tenth day, or  even
later, as the irritation they create is trifling.   The division of the sphincter
ani muscle, as proposed and practiced by Brown, is of great consequence to
a successful result.
* Brown, op. cit. 
CHAPTER  VII.
                 OPERATIONS FOR  VAGINAL FISTULJ5.

   From the relative position of the female bladder, urethra, and rectum to
 the vagina, it occasionally happens that sloughing or ulceration of the inter-
 mediate tissues produces a direct communication between these parts, through
 which either urine or feces escape into the vagina.   Such openings are  usu-
 ally designated as vaginal fistulae, and may be either vesico-vaginal, utero-
 vaginal,  or recto-vaginal,  according to the viscus into which they open.


                             SECTION I.

                        VESICO-VAGINAL  FISTULA.

   Pathology.—In Vesico-vaginal Fistula there exists an opening of greater
 or less extent between some portion of the vagina and the urethra or bladder,
 or both, which varies greatly in character and depth under different circum-
 stances.   Most frequently this opening is the result of sloughing, consequent
 either upon the long-continued pressure of these parts against the pubis by
 the child's head in parturition, or of the inflammation or laceration induced
 by the improper  use  of instruments,  or from the presence of foreign bodies
 in the bladder or vagina.
   When  any of  these causes impairs the vitality of the part, the portion
 affected is liable to separate or slough out, and leave an ulcerated opening
 with irregular edges, which, by the deposit of lymph in the efforts of nature
 to repair the loss, become thickened and indurated.  From the loose character
 of the attachment of the mucous coat of the bladder, and the efforts at strain-
 ing, a fold or two of the latter is also often  forced  into the vagina at the
 edges of the ulcer. Tedious labor and neglect of the condition of the bladder
 being the most common cause, the fistula will be found at some point either
 of the bas-fond or neck of the bladder, or at the posterior two-thirds of the
 urethra.   When  the  result  of labor,  the opening  is most commonly trans-
 verse, the size of  it being diminished by the os uteri being drawn downward
 and forward, so as to relax  the anterior wall of  the vagina.  But when the
 fistula has been excited by the action of  instruments, it is more  frequently
longitudinal.
  The evils resulting from the existence of a vesico-vaginal fistula, as well
as the difficulties  of the cure, will depend in a great measure on the diameter
and position of the opening; these evils and difficulties being  greater in pro-
portion to the proximity of the fistula to the bas-fond of the bladder, and
least when it is in or near the anterior portion of the urethra.
  The treatment  of a vesico-vaginal fistula may be either palliative or cura-
tive, but the latter was so rare in a perfect degree that Velpeau and others
formerly asserted that,  "among all the cases related of cures, there were
                                                          (559) 
560            PRINCIPLES AND  PRACTICE OF  SURGERY.
but a very small number that were entirely free from doubt."*  Subsequently
he modified his statement by making it especially applicable  to  those in
which the bas-fond  of the bladder was involved.   The experience of Hay-
ward, Mettauer, Sims, Bozeman, and others, especially in the United States,
has, however, frequently proved that these fistula? are perfectly amenable to
treatment.   The complaint  may, therefore, be treated either  by the pallia-
tive or the radical plan  of proceeding.
                       \ 1.—Palliative Treatment.

  Without spending time in referring to the treatment of these fistula? by
means of sponges and  plugs  introduced into the vagina, they being at best
but imperfect means of preserving cleanliness and preventing excoriation, I
shall at once call attention to a simple contrivance and bandage suggested,
I think, by Meigs, of Philadelphia.   This instrument—which explains  itself,
Plate LVII I.  Fig. 12—resembles somewhat an oyster-shell, fits accurately
to the vulva, and is held in its place by the attachment of a T-bandage,  while
a caoutchouc bottle, which is  fastened on an opening at the lower end of the
shield, is then  attached around the thigh, and receives the urinary secretion.
In  old and incurable cases, such a shield,  made of silver and gilt, with the
urinal attached,  will be found of great service, and add much to the comfort
of the patient.
  When the fistula is comparatively recent,  even though very large, the
patient may be  much  benefited by the frequent application of the nitrate
of silver to the  edges of the ulcer, so as  to favor the formation of granu-
lation, while in recent cases,  and in those limited  to the urethra, the use
of the catheter, and of highly astringent  injections into the  vagina,   with
perseverance in  such  a position—lying on the  stomach—as will favor the
escape of the urine through the upper half of the urethra, combined with the
use of nitrate  of silver, will often- diminish very materially the fistulous ori-
fice.

              \ 2.—Operations for Vesico-Vaginal Fistulae.

  The difficulties attending the closure of a vesico-vaginal fistula by freshening
its edges, and  approximating them by various kinds of sutures, have led sur-
geons to suggest the use of different instruments, and to recommend various
modes of operating.   To recapitulate all these would be as tiresome  as it
would be useless, and this account will  therefore be limited to a few  which
have been selected from among the cases reported  by such surgeons in the
United States as have paid special attention to the subject.
  Operation of  Hay ward, of Boston, f—At  the close of a series of cases
reported by this surgeon, the following account of the operation is given:—
  Operation.—The patient being placed  as for lithotomy, and thoroughly
etherized, but not tied,  a large-sized  bougie made of whalebone and highly
polished should  be introduced through the urethra to the very fundus  of the
bladder, so as to depress it toward the vagina by elevating the end of the
bougie toward the pubis.   After bringing the edges of the fistula fully into
view, the callous portion should then be excised either with the curved scis-
sors or knife,  or both, the edges being held by means of a double hook, while
the vaginal covering is dissected from the  mucous coat of the bladder  to the
distance of two or three lines.
* Velpeau'a Op. Surg., by Mott, vol. iii. p. 858.
f Cases of Vesico-vaginal Fistula, by George Hay ward, M.D
Boston, 1851. 
OPERATIONS FOR  VESICO-VAGINAL FISTULA.
561
   A short needle, with  an eye near the point, and made to  fit on a long
handle, being then passed  through the outer covering of one side of the
fistula, should be seized by the forceps and withdrawn from the handle, then
drawn through the lips of the wound, fitted again to the handle, and passed
through the opposite side in  the  same manner.   As many stitches as are
necessary being thus taken, one thread of each should  be cut off, and the
other left to show when the ligature has separated from the bladder. A large-
sized female catheter being now secured in the bladder by a T-bandage, the
patient should be laid on her side, with the shoulders raised so as to facilitate
the escape of the urine, and the instrument removed every twenty-four hours,
in order to prevent its clogging.   After three days it may  be removed  alto-
gether; but the urine should be drawn off every three hours for ten or twelve
days more, so as to prevent any strain on the bladder.  The diet should con-
sist entirely of liquid, mucilaginous food, until the ligatures separate, and the
bowels—which should always be freely evacuated prior to the operation—be
kept at rest for some days, as little effort  as is possible being also made by
the patient to empty the bladder.
   Remarks.—Out of nine cases operated on in this manner by Hay ward,
three succeeded perfectly, five  were relieved, and the others not benefited.
I have also performed a similar operation on one occasion, with much relief
to the patient.
   Operation of the Author.*—In  a case of vesico-vaginal fistula, in which
the opening was about the size of a Spanish  quarter-dollar piece, and situ-
ated at the neck of the bladder, extending backward toward the orifice of
the ureters,  and forward to within  one inch of the  external opening of the
urethra, occupying nearly the position of the vesical triangle, I  succeeded in
effecting  a  cure  by means of  the  ordinary hare-lip  operation—performed
January 7th,  1848.
   "A piece of soft pine wood, about the  size of the forefinger, convex on
one  side and  flattened on the other, was first  passed into the urethra, with
its flat side next to the vagina, and carried back into the bladder,  so as to
depress the edge of the fistula.  Upon this I cut off the  posterior lip of the
opening, partly by a vertical-bladed knife  made for  the occasion, and resem-
bling somewhat an ordinary hoe, and partly by a long-bladed  scalpel.   By
elevating the handle of the stick in the urethra, the anterior lip  of the fistula
was also readily depressed and its  edges pared off, the paring  being freely
continued into the angles of the fistula.   Four long hare-lip pins, slightly
bent, and fastened into an acupuncturation needle-holder, were now passed,
one after the other, through the anterior lip of the fistula from below upward,
aijd then through the posterior  lip from above downward, not transfixing the
mucous coat, and the pin, of course, not entering the urethra.  Four figure
of 8 ligatures thrown around the pins, on  the vaginal side, now closed the
fistulous opening so  perfectly that a fine probe could not  be made to pass it,
except at a spot between the two central pins."  A catheter was introduced
as usual.  Seven days subsequently, the pins were removed, when it was found
that  the wound had united, except at the centre, where a gap was left which
ultimately closed under the use of  the nitrate of silver.
  Operation of  Mettauer, of Virginia, f—A  fistula about the  central  part
of the vesical  triangle, of the size of a Spanish dollar, and nearly circular,
which had existed six months,  and was the result of sloughing, was treated
as follows:—
          * Medical Examiner, vol. v. N. S. p. 155, 1849.
          f Am. Journ. Med. Sciences, vol. xiv. N. S. p. 107.
vol. ii.—36 
                           PLATE  LX.

      OPERATIONS ON THE  FEMALE GENITO-URINARY ORGANS.

  Fig. 1. Jobert's Operation for Elytroplasty,  or closure of a vesico-vaginal
fistula, by means of a flap taken from the integuments of the labium raajus, and
twisted upon its base round to the orifice of the fistula, where it is retained by
sutures.                                        After Bourgery and Jacob.

  Fig. 2. Freshening the edges of a vesico-vaginal fistula while they are secured
in 1, the  forceps of Fabri.  One  blade of  the forceps, being furnished with a
plate of  wood, is passed into the bladder  through the urethra, and serves as a
point of support for the other blade, which has a fenestrum capable of contain-
ing and approximating the lips  of the fistula.      After Bourgery and Jacob.

  Fig. 3. Velpeau's Operation of Anaplasty for the  cure of a recto-vaginal fis-
tula, the flap being taken from the side of the vulva  and attached to  the fresh-
ened edges of the fistula.                        After Bourgery and Jacob.

  Fig. 4. Ligation of a large  Uterine Polypus.  The orifice of the vagina being
kept open by the fingers of the assistant, the polypus has been  seized with 1,
Museux's hooks, and drawn down to the os externum by another assistant. The
surgeon  having then thrown a ligature around the pedicle of the tumor by means
of the two ligature bearers 2, 3, has drawn the ligature 4 through the knot-tier
5, and is about to strangulate it.                 After Bourgery and Jacob.
(562) 

ssssksN^

,*.>*
 
 
OPERATIONS FOR  VESICO-VAGINAL  FISTULA.          563
   Operation.—After  a preparatory constitutional treatment, the woman
was placed and confined as  in the operation for lithotomy, and the vagina
dilated by two broad spatula? pressed against its opposite sides, the edges of
the fistula being denuded by seizing them with delicate hooks, and trimming
them with keen scissors, curved  flatwise.   A straight needle, thirteen  lines
long, being then armed with a silk ligature, doubled so as to  form a noose
fully six inches long at one of its free ends, the bent extremity of a leaden
wire of small size was  fastened to it, and then by forceps and a porte-needle
introduced through the edges of the ulcer, so as to form the  first stitch of
the leaden suture, the ends of the leaden thread being loosely twisted, so as
not  to  pucker the  edges of the  fistula.  Eight distinct  sutures  being  thus
formed and loosely twisted, were progressively tightened  until the opening
was perfectly closed, when the ends of the leaden wires were brought out at
the vulva, and  the  soft  parts protected by investing  them with oiled silk,
after which a catheter  was fastened in the bladder.   The wires being tight-
ened on  the third, and again  on the seventh day, the bowels were not moved
until the eighth, and on the thirteenth day the sutures were removed, "per-
fect union having taken place throughout the entire line of contact."   The
use of the catheter  was,  however, persevered in for four  weeks  for fear of
vesical efforts,  and the  patient  subsequently had  two children without  a
return of the accident.
   Operation of Sims,  of New York City.—Operation.*—Having prepared
the instruments figured in  Plate LVIII. Figs. 1 to 10, and given  every at-
tention to  the general condition of the patient, the  operation should  be
conducted in the following manner:—
   Position of the Patient.—In order to obtain a correct view of the vagina,
place the patient upon her knees, on a table two and a half by four feet, and
have the nates elevated,  while the head and shoulders are depressed.   The
knees should also be separated six or eight inches, the thighs placed at about
a right angle with the  table,  and the clothing so loosely arranged  as not to
compress the abdomen.  An  assistant on each  side should then  lay a hand
in the fold between the glutei muscles and the thigh, the ends of the fingers
reaching to the labia majora, and by simultaneously  pulling the  nates upward
and outward open the os externum.  The pelvic and abdominal viscera being
thus made  to  gravitate toward the epigastrium, the presence of the atmos-
phere will suffice  to distend the  vagina to its utmost limits, thus freely ex-
posing the  os tinea? and  the fistula.  To facilitate the view of  the operator,
the assistant on the right side of the  patient should now also elevate the
perineum and recto-vaginal  septum by means of the lever speculum, Plate
LVIII.  Fig. 1, a smaller speculum—Plate LVIII. Fig. 2—being  used  to
press the urethra downward against the  symphysis pubis when circumstances
demand it.   In most cases a good northern light on a clear day will suffice
for the display of the canal;  but if more is requiste, a looking-glass should
be so arranged as to throw the rays of the sun upon the part.   The orifice
of the fistula being now  distinctly seen,  the next step in the operation is  to
freshen its edges.
  To Freshen the  Edges of the Fistulous Opening.—A delicately curved
tenaculum—Plate LVIII. Fig. 6—being inserted into the margin of the fistula,
a sharp-pointed knife—Plate LVIII. Fig.  3—is made to shave off the edge
of the opening to the extent of a quarter or third of an inch, so as to denude
the part  thoroughly on the vaginal surface, but without removing any of the
lining membrane of the bladder, unless it project so  much into the vagina as
to obstruct the operation, which is rarely the case.
* Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 59, 1852. 
564
PRINCIPLES AND  PRACTICE OF SURGERY.
   When the fistula is small, there is abundance of tissue, and there need be
no fear about removing the parts freely, the success of the operation depend-
ing much upon the perfection of the freshened edges.  During the scarifica-
tion, there  is  always  some  hemorrhage, which may  be readily removed by
little probangs of sponge, one assistant attending solely to the preservation
of the cleanliness of the orifice.
  The Suture.—The object of all the sutures  being  to unite the freshened
edges of the fistula, the interrupted, quilled, and twisted of ordinary wounds
have been employed.  From its peculiar methods of action, Sims designated
his as the "clamp suture."  It is composed of fine annealed silver-wire, about
the size of  a horse-hair,  which is fastened  to  cross-bars after the manner of
the quilled suture.   The bars may be made of silver or lead, either solid or
tubular, highly polished  and without  any asperities, particularly at their ex-
tremities. Acting as clamps, the embraced parts swell up and overlap them,
while they produce sufficient ulceration of the vagina to permit their becoming
imbedded, and  sometimes so hidden  from view that  they will often remain
nntil surrounded by granulations.  This suture may  be  left untouched for
six or ten days, or longer, and  has never  ulcerated  out.  If removed too
soon, the cicatrix may yield, and judgment must, therefore, direct the proper
period for the removal of the clamps.
  Placing  the Sutures and Closing the Fistula.—With a long needle, Plate
LVIII. Fig. 4, armed with silk thread, a puncture is made in the middle of
the scarified edge of the fistula, about half an inch anterior  to its  border,
the needle carried deeply into the vesical septum, but without transfixing it,
brought out just at the edge of the  mucous membrane of the bladder, carried
across  the  opening, entered  at  the opposite  side at a point  corresponding
with its anterior direction, and  brought out on  the  vaginal  surface, about
half an inch  beyond the  scarified edge, but  without touching the vesical
mucous membrane, when the first thread is placed in position.  The passage
of the  needle through the  anterior edge is sufficiently easy;  but the loose
and yielding nature of the posterior margin renders some support necessary
before it can be made to appear on the vaginal surface.  To accomplish  this,
a blunt hook—Plate LVIII. Fig. 7—should be placed flatwise at the point
of exit of the needle, so as to make a fixed point for  it, when it will readily
pass, after which the small tenaculum—Plate  LVIII. Fig. 6—may be made
to hook up and draw out the ligature from the side of the needle, when the
latter may  be withdrawn, and the  other ligatures passed in like  manner.
To prevent the cutting  and pain which  would  ensue  upon drawing the
thread upon the posterior edge of the fistula,  a crescent-shaped fork—Plate
LVIII. Fig. 5—should be passed in, and  made to serve as a pulley for the
thread.
  The three threads being thus placed, the most difficult  part of the oper-
ation is finished, and it  only remains  to substitute the  wires  and apply the
clamps, which  is readily  accomplished as follows :—
  To apply the Wires  and Clamps.—Take  a piece of the wire, twelve or
eighteen inches long, make a small  crook at one end, and, fastening it to one
end of the  silk thread, draw the wire through the edges of  the fistula, and
bring its ends  out of the vagina.  Then do  the  same with the remaining
wires, and having made small oblong  openings in the  bars, either of silver or
lead, at distances corresponding with that between the points of the suture,
fasten the distal ends of  the  wire to  one bar, either by twisting it round it'
or by passing  it through a  perforated shot, and  then  bending it  over the
former.  This  being done, pull upon  the proximal ends of the wires, or  that
nearest to  the orifice of the vagina,  and draw the bar up  into  the vagina 
              OPERATIONS FOR VESICO-VAGINAL FISTULA.          565

above  the fistula, or between  its upper margin  and the os tinea?, using a
fork—Plate LVIII. Fig. 8—broad enough to serve as a pulley for all the
wires while being drawn into position.   Now pass the proximal ends of the
wires through the  other bar,  push it into the vagina till it is placed iu front
of, and parallel with, the anterior edge of the fistula, and then using the fork
to press up the clamp, draw firmly on the wires until the denuded edges  of
the fistula are so  closely in contact that an ordinary probe would not pass
between them, when the following simple contrivance will suffice to hold the
clamps in position and fasten the wires: Slide  a perforated shot over the
free  end of each wire, push it up to the clamp, and then firmly compress-
ing it  on the wire by means of forceps, Plate LVIII. Fig. 9, the shot will
be made to serve as a knot to the wire and prevent its being drawn through
the clamp.   The  ends of the wires being then cut off about one-fourth  or
one-eighth of an inch from the shot, and bent over, they will be effectually
prevented from slipping.
   The whole operation, which usually occupies twenty or thirty minutes, or,
under any circumstances, an hour, being now completed, the patient should
be put to bed, and a self-retaining catheter—Plate LVIII. Fig. 10—applied
to keep the bladder empty; an anodyne administered, the bowels kept at rest
as long as possible, being usually ten or fifteen days after the operation, and
the whole followed  by  a careful after-treatment.   The sutures should  be
examined on the third or fourth day, again  on the sixth or seventh, and, if
not doing mischief, (exciting too much inflammation or  ulceration,) not
removed until the  ninth or tenth day.
   Removal of the Clamps.—Clip off the flattened shot, and elevate the an-
terior clamp from its bed by a blunt hook, when the posterior clamp may  be
hooked up with the wires attached, pushed backward into the vagina, disen-
gaged  entirely, and then  lifted out with forceps.  The patient should then
remain in bed, and use  the catheter for several days to prevent any strain
upon the new cicatrix.
   Operation of D. Hayes Agnew, of Philadelphia.—The edges of the fis-
tula, which was transverse through the trigone vesica?, and exceeded an inch
in its greatest diameter, " were  seized  with  a pair of  rat-toothed forceps,
placed upon the stretch,  and, with a straight sharp-pointed bistoury, pared  in
their whole extent.   Seven needles, slightly curved at the point, each armed
with a silver  suture, were carried  successively, by means of Gemrig's needle-
holder, through the edges of the wound down to,  but not beyond, the vesical
mucous membrane."
  " These sutures  being brought out of  the  vagina, and carefully separated
from each other, the two ends of each were  passed through a perforated
disk of metal, as used and figured  by Sims, which being carried down  to
the wound, and traction made on the wires, approximated  the  edges very
completely.   Perforated shot were next  run down each suture, and clamped
by means of a long pair of strong-bladed forceps."*
  Operation of Bozeman by the "Button Suture."—Urethro  and vesico-
vaginal fistula? have  also been treated by N. Bozeman,  of Alabama, who,  in
an extended paper.f strongly recommends the " button suture," in which the
clamp  is formed of a disk of lead  shaped somewhat like  a button, which
approximates the freshened surfaces when applied to  the metallic threads  in
very much the same manner that a button closes a vest or coat.  Various
* Medical and Surgical Reporter, vol. i. N. S. No. 20, p. 339, 1859.
f North American Med.-Chirurg. Review, July and November, 1857. 
566
PRINCIPLES AND  PRACTICE OF  SURGERY.
 surgeons, as Gaston, of South Carolina, Wood, of Cincinnati, Baker Brown
 and Spencer Wells, of Great Britain, have  employed  it with satisfaction.
 Bozeman reports twenty-one cases of simple and complicated fistula  cured
 by  his method, fifteen  being cured by the first operation, a success that is
 highly satisfactory.
  Remarks.—Although vesico-vaginal  fistula cannot be regarded as a com-
 mon complaint, it is unfortunately too  often  met with, and every means of
 affording relief will, therefore, be readily seized by a patient thus dreadfully
 afflicted.  There is, however, a great difference  in the utility of the means
 that have been  proposed', and to estimate the value of each of these  is  by no
 means easy, when so much must depend  upon the position, size, and duration
 of  the fistula, as well as upon the mechanical skill of the operator.   The
 space for manipulation is necessarily small, and  yet the  neat and accurate
 apposition of the parts is essential to success;  the selection of any one plan
 of  treatment must, therefore, be left to  individual judgment and  delicacy of
 manipulation.   In three cases,  I have obtained relief from different methods
 of  treatment.   In a small fistula, in the posterior edge of the urethra, cau-
 terization closed the opening.  In a larger orifice, at the anterior end  of the
 vesical triangle, the twisted  suture and hare-lip pins  induced the union of
 more than two-thirds of the  original fistulous opening.   In a third, who had
 an  opening  at the neck of the bladder,  the interrupted suture, carefully  ap-
 plied, afforded but partial relief.  The great point to be observed in  all is to
 support the edges during the adhesive process, prevent traction in  the trans-
 verse line of the vagina, and keep the bladder empty, and this, it is now  be-
 lieved, can be easily accomplished solely by metallic threads, without the neces-
 sity of any "clamps," or "buttons."  Experience has also greatly simplified the
 instruments  first suggested, so that the operation may at present be well per-
 formed simply by freshening the  edges  of the fistula—introducing  metallic
 sutures, and closing the wound, either by twisting the metallic threads  so as to
 knot them, or by sliding a perforated shot upon them, and compressing it so as
 to retain  the loop of the  suture iu its position.   In the incurable  cases,  the
 vulva shield and bottle — Plate  LVIII. Fig. 12 — will be found to furnish
 much comfort, both mentally and physically.   In  some cases plastic  surgery
 has been  brought to bear upon the treatment of this complaint,  and the  open-
ing successfully  closed by sliding a flap from the adjacent parts.  Jobert  ad-
vises the  performance of  a plastic operation, which he terms " Elytroplasty,"
while Velpeau recommends "Anaplasty."  As these operations are figured in
Plate LX. Figs. 1, 3, a detailed account of them is here unnecessary.
                            SECTION II.

                        VESICO-UTERINE FISTULA.

  In a treatise by Jobert,* on the treatment of vaginal fistula, attention has
been especially called to the existence of a rare form of fistula, in which a
communication exists between the bladder and uterus above the insertion of
the vagina, in consequence of which the urine escapes into the vagina through
the os uteri.  This complaint is stated by Jobert to arise from the long-con-
tinued  pressure of the child's head, especially in a deformed pelvis, or from
* Des Fistules Vesico-Uterines, etc., par A. J. Jobert, (de Lamballe ) Paris, 18">2, 
RECTO-VAGINAL  FISTULA.
567
the unskillful use of instruments, or  the  injury resulting from craniotomy.
To relieve this, Jobert advises the lateral division of the neck of the uterus,
by means of  a pair of long blunt-pointed scissors, so as to gain a good view
of the fistula, after which he proceeds to treat it by turning up the anterior
flap of the neck of the  uterus, freshening the edges of the fistula and uniting
them ; or by applying the flap as  a plug, by a  plastic  operation, the details
of which I am compelled to omit,  as the rarity  of the disease would not jus-
tify the space that it would require in a work of the general character of the
present treatise.
  Vesico-TTtero-Vaginal Fistula is another form of the complaint to which
Jobert has alluded, which is also very rare, and which is to be treated on the
principles just stated.
                            SECTION III.

                        RECTO-VAGINAL FISTULA.

   Pathology.—In recto-vaginal fistula?, a communication is established be-
tween the rectum and vagina by an opening which is in the  anterior wall of
the rectum, and  the posterior of the vagina.  The aperture may be of various
sizes, and either congenital or the  result of such injury as induces sloughing
or the formation of an abscess.   Congenital fistula? of this  kind, or an arti-
ficial anus opening  into  the vagina, is comparatively rare, though I have
seen one in the  case of a child six months old, it being in this case compli-
cated with a deficiency of the lower portion of the rectum,  the gut opening
into the vagina nearly a half inch above the os externum, and the anus being
deficient.   The  occurrence of cholera infantum  preventing any attempt at
relief, the child  returned to its home in the country, and  has not since been
heard of.   Recto-vaginal fistula? are frequent, the result of laceration of the
vagina and the  subsequent inflammation consequent on the improper use of
instruments during delivery ; they are also generally longitudinal, and give
exit to fecal matter and flatus through the  vagina as  well  as  the rectum.
Position and rest,  coupled with a natural tendency in the orifice  to close, are
often sufficient to effect a cure, and yet it occasionally happens that consider-
able skill and attention will be required in order to heal them.   As the
various means referred to in the treatment of the vesico-vaginal fistula? are
equally and more readily applicable to this class, the operative methods need
not be so fully detailed as in the preceding variety of fistula?.
   Operation of Barton, of Philadelphia.*—A young lady, after  suffering
from an abscess, which was discharged, was left laboring under a fistula for
four years, which resisted the ordinary treatment by tents, setons, and caus-
tics.  This fistula commenced about three-fourths of an inch within the right
labium, and passed by a very irregular course up the pelvis, inclining to the
rectum, into which  it opened at about three and a half to four inches from its
inferior aperture in the vagina, giving exit to fluids and  flatus  through the
genitals.
  As the sinus could not be  included in a seton, and ulcerated  through, or
laid open without destroying the perineum, it became necessary to adapt an
operation to  the case.
  Operation.—The  sinus having  been dilated  for a few days  by a  tent, a
seton was introduced into the fistula per vaginam, by  means of  an  eyed

             * Am. Journ. Med. Sciences, vol. i. N. S. p. 305,  1840. 
568           PRINCIPLES AND PRACTICE OF SURGERY.

probe, thence passed through its whole extent, till  it entered the rectum by
its  orifice in that  canal, whence it was  brought down to, and  out  at  the
anus, the two ends being loosely tied merely for security.  After a few days
the loop was undone, and the end of the seton which came out of the  vagina
was passed  through the eye of a  probe previously  bent at its other end.
This  probe  being  then inserted into the vaginal orifice of the  fistula,  was
carried about an inch and a half up the sinus, and its point directed toward
the periueum, just exterior to the  sphincter  ani muscle, where a small  but
deep incision was made, the probe pushed through, and the end of the seton
brought out and tied to the rectal end of the ligature, thus including in the
loop the parts between the outer surface of the sphincter ani muscle and the
rectum, the seton being subsequently twisted and drawn tighter and tighter,
until it cut its way out, as in the ordinary operation  for fistula in ano with
the ligature.  So  soon  as the new channel thus formed had  attained  a
larger size than that entering the vagina, the discharges deserted the latter,
and it healed up.   It then only remained  to treat the  seton  in the same
manner as in fistula in ano, till it ulcerated out, when the parts healed,  and
the lady recovered perfectly.   Four years  subsequently she was free from
the complaint.
  R.  D. Mussey, of  Cincinnati, has also reported a case  of recto-vaginal
fistula, in which  he accomplished a cure by using the "clamp  sutnre" of
Sims, as referred to in  the section on vesico-vaginal fistula?.
  Roux's Operation for Entero-vaginal Fistula.—" In  a case where  the
ilium terminated in  the vagina, Roux opened the  abnormal parietes, sepa-
rated from the vagina the portion of the  intestine that terminated in  it,  and
tried to invaginate  it into the inferior end  by means of a suture.   The patient
dying afterward, the autopsy showed that, instead of invaginating the por-
tion of the ilium in the  inferior end of the large intestine, it had been inverted
to its superior end."
  Velpeau's Operation by Anaplasty.—A lady, after undergoing an opera-
tion for the  closure of a recto-vaginal fistula by means of the suture, was left
with a perforation  in the lower part of the recto-vaginal partition, above the
front of the suture.  To close this,  a flap two inches long, and eight or ten
lines wide at its  base, was cut from the tissues about the left labium majus,
and a thread being affixed to its upper extremity, it was drawn from  the
vagina  into the  fistula in the rectum, so as  to be fastened near the anus,
Plate LX. Fig. 3.   Two-thirds of its  extent, however, mortified, and as it
adhered only on one of its sides, the fistula was diminished but one-third of
its size.  Velpeau, nevertheless, thinks that  in more  tractable  patients,  and
by taking every possible precaution not to weaken the vitality of the flap, such
an  operation will offer  some prospect of success.
                            SECTION IV.

                   STONE IN THE FEMALE BLADDER.

  As the symptoms and pathology of calculus in the female resemble closely
those already described in connection with calculus  in  the male, it  is  un-
necessary here to do more than describe the means of treatment, and men-
tion  the fact  that a diagnosis of stone  in the female  bladder can alone be
made by introducing a sound into that viscus, and touching it.   In numerous 
LITHECTASY IN THE  FEMALE.
569
instances a displaced  uterus, polypi in the  urethra, etc. have presented the
rational symptoms of stone  when the latter did not exist.
  The great dilatability of the female urethra favoring the escape of pebbles
of considerable size, the  existence of urinary calculus is much more rare in
the woman than it is in the  man, though it is occasionally seen.   Before the
revival of lithotripsy, the treatment  of such cases was usually accomplished
by dilating the urethra, or by opening the bladder at various points, as in
the operation of lithotomy  in man.   Lithotomy  in the female is, however,
often followed by incontinence of urine'and by other evils which do not so
frequently ensue in  males; and, as most calculi can be  removed by crushing,
and the easy dilatation of the female urethra  especially fits it for this oper-
ation, as well as for  the passage of large fragments, I do not regard the
operation of lithotomy as justifiable in women, except in cases of extremely
large calculi.
   When a  calculus is so large that it nearly fills the bladder, Lithotomy
may be best performed through the vagina.
                        \ 1.—Vaginal Lithotomy.

  Ordinary Operation-—With the patient etherized, and in the position for
lithotomy, pass a straight grooved staff into the bladder, with the groove
turned to the vagina, and depress its point until it can be felt in the vagina.
With a sharp-pointed bistoury puncture the vagina and bladder  at a point
fifteen lines from the anterior or vulvar orifice of the urethra, and entering
the groove of the staff, cut cleanly backward in the groove, through the in-
ferior fundus of the  bladder, for about one inch ;  pass the forefinger of the
left hand promptly into the bladder, and introduce the forceps upon it, with-
drawing the stone by cautious movements in the line of the inferior pelvic
strait;  or, if the calculus  is too large to be  grasped  by the forceps, intro-
duce a lithotriptic instrument, and, crushing it to pieces, wash and scoop out
the fragments.   After cleansing the  bladder  thoroughly, unite the edges of
the wound by a few stitches of the interrupted metallic suture, as in closing
a vaginal fistula, and  introducing Sims' catheter, treat the case as a vesico-
vaginal fistula.   Should a fistula result, treat it as before directed.
  The advantage of  this method  over lithotomy, as  usually performed by
incising the urethra,  or by the high operation,  is its  comparative freedom
from danger, and the subsequent ability of the  patient to retain her urine;
incontinence often supervening when the urethra has been incised.
                     \ 2.—Lithectasy in the Female.

  Lithectasy in  the female will often  enable  the  surgeon to remove  small
calculi without much difficulty.  When the calculus is small, the ordinary
polypus  forceps  may be  passed  closed  into  the  bladder, opened, and  the
pebble pushed toward them until  seized  by a  forefinger  in  the  vagina,
pressing  the  bas-fond of the bladder upward and forward.   Having seized
the pebble in its long diameter, withdraw the forceps very  slowly, moving
the forceps up and down, as well as laterally, so as gradually to dilate  the
urethra as the pebble is drawn out.   Dilatation of the female urethra may
also be accomplished by introducing a  small piece of compressed  sponge, 
570
PRINCIPLES  AND  PRACTICE OF  SURGERY.
with a ligature attached, and allowing it to remain in the canal two or three
hours.   As the female urethra is capable of slow dilatation till it will admit
the forefinger, the judgment of the operator must direct the size of the  tent
to be introduced.   When the urethra is thus dilated, the expulsive force of
the bladder will often expel a pebble; if  not, forceps must be employed. If
dilatation of  the urethra is too long or  forcibly practiced, incontinence of
urine is apt to follow, from paralysis of the sphincter vesica? muscle.
                     I 3.—Lithotripsy in the Female.

  Although Lithotripsy,  when  properly practiced,  is  a simple operation
upon  the  male, the performance of  lithotripsy in the  female is even  more
readily accomplished, the urethra of the latter being  shorter and much  more
distensible, and the bladder so near to  the vagina that the introduction of
the forefinger into this canal will sometimes enable the  operator to push the
stone into the grasp of the instrument if he  is otherwise unable to catch it.
There is,  however, caution  required ;  lest,  from the escape  of  urine, the
coats of the bladder be grasped in  the instrument.   The  position of the
patient, and the other details, are very much the same  as  those  described
in a previous chapter; but there is less trouble in the after-treatment, owing
to the facility with which  women can void large fragments  by the urethra.
It may be incidentally mentioned that this operation  does not require expo-
sure of the patient's person. 
CHAPTER  VIII.
                     DISORDERS  OF THE UTERUS.

   The progress of uterine  pathology, and the increased attention given by
 surgeons to these disorders during the  last thirty years—though Hunter
 wrote on them iu 1770— render these complaints an important subject of
 study as well as a  frequent object of attention.  "When," says Bennett,*
 "general therapeutical treatment  fails to give relief, resort must be  had
 simultaneously to  more energetic  means, such  as surgery resorts to in the
 treatment of chronic local inflammatory disease in other parts, as the throat,
 anus, a truth so generally admitted  that in Europe the prominent authorities
 on these disorders embrace the names of such surgeons as Lisfranc, Velpeau,
 and Jobert."
   It is to such uterine disorders as specially demand surgical measures as an
 important part of their treatment that attention will now be given, though
 here, as in many other  disorders, it is impossible to separate surgery from
 the other duties of the  practice of medicine.
   As the disorders of the external and internal os uteri, with the neck  and
 body of the uterus, can be recognized only by the touch and sight, the healthy
 appearances and feeling of the organ must be first briefly attended to.
   By the sense of Touch we learn the position  of the uterus, its density  and
 sensibility, the presence of tumors,  etc.  By Sight we learn the color of the
 organ, its hypertrophied or atrophied condition, the existence of inflamma-
 tion and its results, the  presence of ulceration, maligant deposits, etc., points
 mainly decided by comparison with its healthy  condition.
   In the healthy and normal condition, the usual position of the uterus is in
 the median line of the pelvis, in the  axis of the superior strait, with the fundus
 inclining upward and forward, and  the neck and os  inclining downward  and
 backward, the fundus deviating so  as to bring the os into the  axis of the
 vagina  while the patient stands.   When  she  lies  down the fundus  tends
 backward and the os slightly forward from this line.  As the rectum descends
 on  the left side of the sacrum, and  often  contains feces,  it is not unusual in
 either position of the patient to find the fundus inclined to the right and the
 neck to the  left groin.
   The Virgin Os is a  small circular  opening, the anterior edge or lip of which
 is  usually fuller and  thicker than the posterior.  In the mother the os is
 usually a transverse slit. In health  the virgin os is a dimple that will barely
 receive the pulp of the forefinger; in the  mother it is rather deeper, and  will
 permit the tip of the  finger to enter it.  When the finger can enter one-half
 of an inch, there is an abnormal condition.   The length of the cavity of the
uterus in the normal state, from the external os, is about two and a half inches,
that of the neck being about  one and a quarter, and that of the body the same.
 Simpson's sound—made of  flexible metal—will usually pass through the os
uteri externum to the  os internum without difficulty, but will not, in the normal
state, pass through the  internal os  without some slight force.  In disease it
* Diseases of the Uterus.
(5T1) 
572            PRINCIPLES AND  PRACTICE OF  SURGERY.
passes more readily.  In health, and in the normal position of the uterus, the
sound will follow the normal line of the organ just stated; in retroversion, ante-
version, retroflexion or anteflexion, or lateral displacement, it surely indicates
the direction of the uterus by following the line of its cavity.  As this sound
is graduated by inches, it is easy to tell by the touch how far it penetrates the
organ.  Great gentleness must be employed in manipulating with it in any ex-
amination, lest the internal uterine membrane be lacerated and inflammation
developed.  In establishing the patulous condition of the os and cervix uteri,
the position of the body and fundus, and the presence of tumors, this sound is a
great addition to the means of diagnosis.  If it cannot be had, a bougie may
be employed instead. When the  sound is passed into the cavity of the healthy
uterus,  the sensibility  corresponds with that of  the healthy vagina—com-
plaints of soreness,  pain, etc., when the sound is in the cavity of the uterus,
may, therefore, be regarded as indicative of a morbid condition.   In employ-
ing the sound, place the patient on her back, pass the left forefinger to the
os uteri, and glide  the  sound on it as a  director.  When the instrument is
within the uterus, the latter can  be carried in any direction, and, with the left
hand  on  the abdomen, the uterus and sound  may be felt anteriorly, the pres-
ence of  tumors noted, etc., without the patient suffering  acutely, if gentle-
ness is observed.
  Various forms of specula vagina? are figured in Plate LVIII.   In using
any of them, it is best to place the patient on her back, with her hips near the
edge of the bed,  and cover her entire person with  a sheet.  Then recognizing
by the touch the  position of the os uteri, place the left forefinger in the vagina
so as  to depress the fourchette, separate the labia  with the second forefinger,
and, with the speculum well anointed, pass it along the finger as a guide, and
carefully and slowly introduce it by a slight rotary and lateral movement from
before backward  in the axis of the vagina. As soon  as the instrument enters
within the sphincter vagina? muscle, withdraw the left forefinger and fold the
sheet carefully around the instrument, so  as to cover  entirely the patient and
leave the right hand of the operator and the instrument uncovered.   Then
gradually passing the speculum  in the axis of the vagina and of the pelvic
straits, examine the condition of  the vagina as its  folds  pass before the point
of the speculum, varying the position of the instrument  until the  os is  placed
fairly in  its field.  The best speculum for constant use is one of glass coated
with quicksilver  and covered with  cloth and  gutta-percha, as suggested by
Fergusson, of London.  The varnished instrument, so generally sold in the
United States in imitation of this, is worthless, being liable to break and to
have rough edges. The valved or metallic instruments are useful, but not so
easily manipulated and  kept clean,  while the folds of a relaxed vagina falling
into the fissure  between the blades of a bivalve instrument are liable  to  ob-
struct the view.
  In health the vagina and uterus are of a moist  pink color—being lightest
in virgins.  Inflammation changes the shades of this pink to a bright scarlet
or deep  purple.   Such an amount of mucus or  pus as will accumulate as
the instrument enters, is  abnormal.   In  health  there is no apparent dis-
charge from the os uteri, the lips  are also smooth and not sensitive, the vagina
is moist, but not bathed  in fluid.  The healthy vaginal mucus, if freely  secreted,
is white, creamy, aud fluid, is acid in its reaction, reddening blue  turmeric
paper, and, when examined by the microscope, exhibits, as Donne, of Paris,
has shown, an epidermal epithelium.   The uterine mucus  is more viscid and
tenacious and alkaline  in  its  reactions, restoring  the blue color to red tur-
meric paper.   The  variations in position, with the results of inflammatory
action in these organs,  may be recognized by a comparison with the healthy
condition, and will be separately presented. 
DISPLACEMENTS  OF THE UTERUS.
573
                             SECTION I.

                    DISPLACEMENTS OF  THE UTERUS.

  The uterus may be displaced by descending into the vagina until the os
rests on the perineum—Prolapsus—or till it escapes through the vulva—Pro-
cidentia—or the fundus may fall into the hollow of the sacrum, while the os
rises toward the pelvis—Retroversion—or the fundus fall toward the pelvis
and the os to the sacrum—Anteversicn.  The body may also be bent back-
ward while the neck retains its median position—Retroflexion—or it may fall
forward—Anteflexion.  These displacements being unnatural, and the result
either  of mechanical causes, as blows, falls, straining, etc., or the consequence
of chronic inflammation, induration and hypertrophy, or of such congestion
as increases  the bulk and weight of the organ, have been studied with great
accuracy, in view of their influence on the patient's health.  Surgeons, how-
ever, have differed in their views of the results and causes of displacement,
Velpeau,  Malgaigne, Huguier, and others regarding uterine displacement as
the consequence of mechanical forces, and the cause of the  suffering inflam-
mation, and change of tissue  often noticed in connection with displacement;
while Dubois, Caseau, and other obstetricians think that the inflammation,
hypertrophy, etc. preceded and caused the displacement.   With  such oppo-
site opinions there has been suggested varied and diverse plans of treatment,
surgeons generally advocating a mechanical support or resistance to the dis-
placed organ;  phycicians regarding the cure of the inflammation and the
reduction of  hypertrophy  of  tissue as sufficient in most instances, without  a
mechanical treatment.  As  in many other questions, the advocates of each
side have probably erred, displacement when present, and however caused,
demanding  support by artificial means,  like pessaries; while,  as the dis-
placement either causes or supervenes on functional disturbance, a constitu-
tional  and local alterative and antiphlogistic treatment will also be required.
In  England, Bennett is generally opposed to their  use, West rather advo-
cates it, and Baker Brown is  opposed to it.  In the United States there are
many who advocate the use of pessaries. That their use has been much abused
cannot be doubted ; that their entire neglect has led to evil is equally correct.
That if long worn they weaken and dilate the vagina, and remove  a natural
support, creating, sometimes, ulceration of the neck by pressure,  is also true.
But it must  be admitted that chronic inflammation of certain parts is greatly
aided by  rest in  a good position, while, by a judiciously applied  pressure,
hypertrophy is diminished, or such a stimulus exercised as  facilitates a res-
toration of the normal nutritive action of the affected tissue.   Hence I can-
not doubt, that  when  with a displaced uterus we also have induration or
hypertrophy  of the os and neck, with elongation, increased mucous secretion,
pain and the other symptoms of chronic  metritis, the application of a well-
selected pessary is useful, and cannot augment the evil, especially if combined
with internal medicines and local alteratives.   On the other hand, when we
have simply displacement of the organ with but trifling symptoms  of engorge-
ment, increased mucous discharge, abrasion of the epithelium of  the raucous
membrane of the os and  neck, I think the  use of a pessary injurious as  a
general rule,  to which we  may occasionally find exceptions.   In a large num-
ber of cases  of uterine displacement in virgins, the use of a pessary, by over-
coming the normally contracted  condition of the vagina, is liable greatly to
increase  the  evil.   In married women, where the relaxed  condition of the
canal and the recurring force of coitus is liable to augment a displacement, 
574
PRINCIPLES  AND  PRACTICE OF SURGERY.
the employment of a pessary is often most useful.   The selection of an exclu-
sive plan of treatment is here, as in other  disorders, therefore  very apt  to
result in evil.
  The forms of the pessary  have varied considerably—the  circular disk,
globe, and horseshoe pessary are those most employed in the United States.
The intra-uterine or stem pessary of Simpson, with the caoutchouc bottle, etc.,
have comparatively few advocates in the United States.   In the  first named,
the perineum is the  basis of support, the anterior  or posterior  portion of the
neck the part sustained.  As the distance  between these points varies in dif-
ferent cases, the length and width of the pessary  resorted to must also vary.
Usually a pessary that moves freely in the vagina is too small, and oue that
creates a sense  of distention and pressure too large.  When, after its intro-
duction, there is a sense of bracing and increased strength, with no annoy-
ance from the bladder or rectum within six hours after its  application, the
instrument has been well selected and judiciously placed.  The various modi-
fications of the disk pessary are the best, Plate LVIII. Figs.  17,  18,  19,
being easy to introduce  and withdraw, and not  interfering materially with
marital  rights, this being often a serious ethical question.
  Operation.—To introduce a pessary, place the  patient on her back or left
side, depress the fourchette with  the forefinger, and, gently pressing the pes-
sary backward and upward, slip it inside the sphincter vagina? muscle in the
line of the axis of the vagina.  In marked prolapsus and retroversion, place
the upper edge of the pessary behind the neck of the uterus in the vaginal cul-
de-sac.   In  marked anteversion, when seen, it may perhaps be necessary  to
place it, for a few hours, anterior to the os, provided it does not irritate the
bladder.   Usually carrying the os and neck  forward, by placing the  pessary
behind them, answers all that is required even in  anteversion;  as the fundus
will then fall in the  opposite direction.  While the pessary is  in  place, cold
injections into the vagina of soap and water or a m:ld astringent should  be
daily practiced.   When the pessary is finally removed, rest in bed for a few
days aud astringent washes will be useful,  and prevent the feeling sometimes
induced by the removal  of the  instrument, a sensation  analogous  to that
caused by the removal of a splint that has  been worn for some time in the
case of a fractured  bone.  Metallic pessaries are  generally preferable  to
glass, which might  be  accidentally broken, and are not so liable to become
offensive as the instruments made of or covered with gutta-percha and caout-
chouc, unless these articles are vulcanized.
  In removing a pessary, reverse the manipulation, hooking it down with
the point  of the forefinger, withdrawing it through the orifice of the vagina
on the axis of the canal.   With  a very considerable experience in the use  of
pessaries as an  adjuvant to other plans of treatment in the disorders of the
womb,  I  have  seldom, if ever,  seen  inflammation, ulceration, or irritation
caused by one  well  selected and  fitted to  the condition, and  I have had
patients to wear them as long as three years without professional  attendance;
daily vaginal injections being carefully practiced.   Where a large and long
instrument has been employed,  or one with too long a curve in the horse-
shoe variety, so as to press very forcibly on  the  neck of  the uterus, I have
occasionally seen the instrument a source of inflammation.   But this is only
evidence of the defects of the practitioner,  and not of the instrument.  When
carefully fitted  to the length and width of the vagina, a pessary will often
prove a valuable  adjuvant to other measures in the treatment of these dis-
orders, and especially when the displacement is due to  a hypertrophy of the
organ.
  The various forms of abdominal supporters for  the relief of displacements
of the uterus are undeserving of mention, as anatomically  incorrect in priuci- 
POLYPI OF THE UTERUS.
575
pie.   The perineal supports in procidentia and  marked prolapsus are  often
useful, either alone or as additions to vaginal supports  or pessaries.   If an
artificial uterine support is deemed essential, or even an  auxiliary to the case,
as it often is, the best  in ray experience is the disk pessary, or some  of its
modifications.  That which I have most frequently employed is known  in the
United States as Hodge's pessary, Plate LVIII. Fig.  19, being sanctioned
and largely employed in the extended experience  of ray colleague, the Pro-
fessor of Obstetrics in the University of Pennsylvania.
  When the  displacement of the uterus amounts to marked  procidentia, and
when its duration has  created such relaxation of the  vagina and perineal
muscles as renders the treatment by a pessary or perineal bandage imperfect,
the operation  of Episoraphy  has  been  practiced, and  may be  thus per-
formed :—
  Ordinary  Operation of Episoraphy.—Dilating the  vagina,  either by
Sims' speculum, Plate LVIII. Figs. 1, 2, or a bivalve,  dissect carefully two
or more longitudinal strips of raucous membrane from the vagina.  After the
hemorrhage has ceased, unite the adjacent raw edges by a few stitches of the
interrupted metallic suture until union occurs, which will usually require from
four to  nine  days.  As the lower portion of the vagina is thus  made to
cicatrize longitudinally, the contracted canal offers usually an insuperable
obstacle to the  escape of the uterus.
  Geddes, of Charleston, in bad procidentia uteri obliterated the vaginal ori-
fice, by paring the skin from the margin of the labia and stitching the  fresh-
ened surfaces together, leaving an orifice for the escape of the menses, etc.,
when demanded.
                            SECTION II.

                       PUNCTURE OF THE UTERUS.

  Puncture of the Neck of the Uterus is an operation that may be required
by various circumstances, but is  mainly demanded in cases where, from me-
chanical causes, such a degree of inflammation has beeu excited as has led to
the closure of the os uteri.  Occasionally the obliteration of the mouth of the
uterus is  congenital,  but in many instances it is simply closed by an adven-
titious membrane.  The restoration of its patulous condition, or the for-
mation of a new orifice, must therefore be regulated by the peculiarity of each
case.
  Puncture of the uterus may be accomplished by means of a sound, pushed
steadily into  its cavity if  the obstruction is slight and the orifice otherwise
normal; though, in  more  difficult cases,  the use of  the speculum, with a
guarded bistoury, Plate LXI. Figs. 3, 4, 5, or the trocar and canula, will be
requisite.   Under any circumstances, when the  perforation is made, care
should be taken to preserve  the continuance of the opening by the use of
bougies or sponge-tents.


                            SECTION  III.

                        POLYPI OF  THE  UTERUS.

  Polypi of the Womb, like those found elsewhere, present us with a peculiar
class of tumors, whose characteristics are  mainly dependent on the mucous
membrane  to which  they are attached, the specific peculiarities of which 
576
PRINCIPLES AND  PRACTICE OF SURGERY.
 have been already described.*  When developed in the womb, polypi maybe
 removed by very much the same means as were detailed as applicable to them
 when seated in the nostril, the chief difference being due either to the struc-
 ture of the part, or to the great size  sometimes attained by polypi in this
 organ.   In some  cases, uterine polypi have attained a very great size, an
 instance of  which is  reportedf  by O'Keefe, of Georgia,  in a  case which
 occurred  in  the practice  of King, of  Alabama, where the tumor  after
 removal weighed three pounds.  H. H. Campbell, of the  same State,  also
 reports a case, in which the tumor was the size of a child's head.  When  ute-
 rine polypi attain this size, it may be necessary  to act upon them piecemeal,
 and so to modify the operations practiced on  the same class of tumors in the
 nostril, as to permit their more ready extirpation.   Repeated punctures, so
 as to evacuate the blood from the mass, with the long-continued use of astrin-
 gents, or the formation of sloughs by the application of the actual cautery,
 may all, therefore, be made to precede the entire removal of these tumors by
 the ligature  or  knife.   The strangulation of uterine polypi by the ligature
 being, however,  the safest as well as the  most common method of removing
 these tumors from the  womb, especially when they are  pedunculated, it  will
 be  taken  as illustrating the principal operation demanded for  their cure,
 though it is liable to the serious  objection  of causing irritation  by the  dis-
 charge from the tumor while it is sloughing,  as well as of inducing a tardy
 removal of the tumor.   For these  reasons many prefer excision, disregarding
 the hemorrhage.
   I. Ligature.—By means of the double canula, a loop of a wire  ligature
 may be drawn tight enough to  strangulate  the tumor in the following man-
 ner :—
  Operation.—Place the patient on her back, with the knees drawn up;
 introduce the speculum so as fully to  dilate the vagina; and, recognizing
 the position of the os uteri, pass the canula—Plate LVIII. Fig.  21__and
 loop of the ligature over the polypus to the mouth  of the uterus by means of
 a probe, so as to place the  loop  as high up as possible.  Then, while  an
 assistant retains  the loop in  position by means of the probe, draw upon the
 wire so as to strangulate the tumor and leave it to slough off, tightening the
 ligature, from day to day, by means of the  screw of the instrument.
  Another mode of strangulating uterine  polypi  is shown in Plate LX.
 Fig. 4.   Should the hemorrhage  resulting from any mode  of operating be
 profuse, it  may be checked by the application of the  tampon or the use of
 astringents.
  Excision of Polypi  may be accomplished  by  seizing them with forceps,
 and removing them  either with the bistoury or scissors.
  In a large fibrous polypus of long standing in  a patient under the care of
 H. L. Hodge, of Philadelphia,  I succeeded in excising the  mass by intro-
ducing the finger  into the  womb, passing  a  bistoury along  it, incising  the
substance  of the tumor, and scooping it out piecemeal by the finger and
instruments;  the mass  removed filling a good-sized soap-dish of a  toilet
table.  The cure was perfect.   The dilatability of the os uteri, in many cases
of fibrous polypi, especially when the patient is  near the termination of  the
menstrual period, renders it quite  possible to enucleate tumors under similar
circumstances, the  mass of it yielding to pressure as  soon as the  mucous
covering is opened.
* See Operations on the Nostrils, vol. i. p. 343.
f Report of Committee on Surgery to Med. Society of Georgi; 
AMPUTATION OF THE NECK OF  THE  UTERUS.
577
                             SECTION  IV.

                AMPUTATION OF THE NECK OF THE UTERUS.

    Excision or Amputation of the Neck of the Uterus has been frequently
 performed for the relief of carcinomatous affections of this part, and though
 similar in its results to the operations for cancer seated elsewhere, and only
 furnishing temporary relief, yet in some cases even this may become a matter
 of consequence, and the surgeon may therefore desire to perform the opera-
 tion, though not anticipating the accomplishment of a cure.
    Operation of Lisfranc___The woman being placed in the position for
 lithotomy, before a good  light, the vagina should be dilated by a bivalve
 speculum, the diseased neck of the uterus  seized  by Museux's long hooked
 forceps, or  by a pair  of tumor forceps, Plate  I.  Fig. 19, with handles ten
 inches long, and steady traction made upon them, until the uterus is forcibly
 prolapsed and brought near .to the orifice  of the vagina, when its neck may
 be excised either by a  probe-pointed bistoury or by a pair of scissors curved
 on the flat, as was done  by Dupuytren.  The hemorrhage, which  is often
 very profuse, should be checked by plugging the vagina.
   Amputation of a Uterus.—" Sims, of New  York, has recently amputated
 an entire uterus with  the  Ecraseur of  Chassaignac.  The case was one of
 procidentia, in which the uterus had been  for a long time  entirely inverted,
 and could not be forced back into the pelvis.  No hemorrhage followed,
 excepting from a vessel connected with one of the broad ligaments, which
 was afterward ligated.  The patient rapidly recovered."*
   Chassaignac's Operation for Excision  of the Neck of the Uterus.f—
 Place the patient on  the  edge of a bed, in the position for lithotomy, aud
 introduce a bivalve speculum, depressing  it well  posteriorly.   Then seize
 and implant  firmly, as high np the neck of the  uterus as possible, double
 hooks, or the forceps  of Museux,  and  draw the uterus  sufficiently toward
 the orifice of the vagina to  permit the application of the loop of the ecraseur.
 Then slowly constricting the chain of the  ecraseur, the entire neck will be
 amputated without the loss of " a single drop of blood."
   Remarks.—Having repeatedly witnessed Lisfranc's operations, I am satis-
 fied that the excision of the neck of the uterus by cutting instruments, when
 once performed, will prove  so serious and troublesome that its repetition will
 be attempted with great unwillingness by any surgeon.   The most dangerous
 hemorrhage supervened in all the cases that  I witnessed, and in several (about
 four) Lisfranc was compelled to defer the operation. Nor has his success been
 such as would induce any one who is familiar  with the true results of operations
 for cancer, to rely upon the permanency of the relief which it can afford.  Ex-
 cision of the neck of the uterus has, however, been performed in the United
 States by Jameson, of Baltimore,  in  1824; Strachn, of Virginia, in 1829;
 Warren, Sr., of Boston, in the same year; N. J. McL. Moore, of New Hamp-
 shire, in 1847; Atlee, of Philadelphia, in 1848; Eve,  of Georgia, in 1850;
 Usher Parsons, of Rhode Island, in 1852; and Ogier, of Charleston, also in
 1852; but as the results of these operations have not been tabulated, it is diffi-
cult to estimate their success. In thirty-six cases, Lisfranc was much troubled
by the hemorrhage; J two of his patients died of peritonitis, two under can-

         * Cincinnati Lancet and Observer, Feb., 1860.
         f Chassaignac,  op. cit.,  p. 283.                  J Malgaigne.
    vol.  n.—37 
578
PRINCIPLES AND PRACTICE  OF SURGERY.
cer of the spleen or liver, and eleven sunk under more or less speedy relapses.
If, then, it is desired to get rid of a cervix  uteri, I should prefer attempting
it by the application of the ecraseur, as above described.


                            SECTION  V.

                     EXTIRPATION OF THE WOMB.

  The complete Extirpation of the Uterus has been accomplished by Essell-
man, of Nashville, by  means of the ligature  applied on the inverted uterus,
while this organ has also been excised by Paul F. Eve, of Georgia.
  Complete Extirpation of the Uterus by Ligature, after Chronic Inver-
sion of the Organ, by John M. Essellman, of Nashville.—A lady, thirty-
two years of age, had labored under inversion of the uterus for several years,
in consequence of the  manipulation of  an  old woman.   Various symptoms
inducing the belief in the existence of a polypus, a ligature of saddler's silk,
well waxed, was applied around the tumor and tied tight, causing great pain
and prostration  for the first four or five hours, her pulse sinking to a mere
thread.   Reaction ensuing, she rested well the first night; and the ligature
was tightened each morning for  eighteen days, at  which time the tumor
came away, proving, to the surprise of all who saw it,  to be the uterus in-
stead of a polypus.*   The patient did not leave her bed for months after the
operation, "but was finally restored to  perfect health."
  Operation of Eve, of Georgia.f—A negro woman, twenty-eight years of
age, married, but never pregnant, had been laboring for  a long period under
a malignant tumor of  the uterus, to cure which she consented to excision of
a part, or the whole of the womb.
  Operation.—The bowels and bladder having been thoroughly evacuated,
the patient was put fully under the influence of chloroform, the tumor drawn
down to the os  externum by forceps, and then the mass  carefully excised
from above downward, or  in an antero-posterior direction, by the  knife, it
being suspected at the time that the uterus was involved.  One artery bled
quite vigorously, but it was tied, and the hemorrhage arrested by a solution
of the sulphate of zinc.  There was no protrusion of the bowels, or any severe
symptoms; a rigid diet and the horizontal  position were maintained for ten
days, and the opening  into the peritoneum was closed  by agglutination and
adhesion.
  The  uterus, with the Fallopian  tubes and broad and round ligaments,
could be distinctly seen in the mass.
                            SECTION VI.

             EXTIRPATION OF THE OVARY,  OR OVARIOTOMY.

  When the  ovary has  been the  seat of such changes as have induced a
degeneration  of structure, and especially when it has resulted in the forma-
tion of a cyst or other tumor, it has been proposed, within the last century,
to remove the entire mass by means of an incision through  the abdominal
parietes.  Such an operation is not as difficult as it is dangerous from its
subsequent effects, and the prognosis should, therefore, be well considered
before the operation is attempted.
* Amer. Journ. Med. Sciences, vol. vii. N. S. p. 254, 1844.
t Ibid., vol. xx. N. S. p. 399, 1850. 
             EXTIRPATION  OF THE OVARY, OR  OVARIOTOMY.        579

   Ovariotomy may be accomplished by an incision into the abdominal pari-
 etes, of sufficient extent to permit the escape of the mass.   As the diagnosis
 is not easy, and the size of the tumor varies considerably under different cir-
 cumstances, two operations  have been described, and have been designated as
 the  great  and lesser operation, the distinction being chiefly owing to the
 length of the external wound.
   In  the  Minor, or exploratory operation, or that  proposed by William
 Hunter, the incision  should  be  about two  inches long, and  the ovarium
 tapped, or the condition of the part, and especially the extent of the adhesions,
 learned  by introducing the finger  through the small wound.   The  Major
 operation  lays open the  abdomen  from the umbilicus, or even beyond it, to
 within an inch and a half or two inches of the pubis, so as make the cut from
 eighteen to twenty-four inches long.   The minor  operation is palliative, or
 intended to assist the diagnosis, while the major is for the removal of the
 mass.

                       § 1.—The Msyor Operation.

   Operation of McDowell, of Kentucky.*—In December, 1809, a patient,
 with an enlarged ovarium,  was operated  on as follows:  Being placed on a
 table of the ordinary height, and all the dress  removed that could impede
 the operation, an  incision was made iu the abdomen, parallel with the line
 of the rectus abdominis muscle, but about three inches from it on the left
 side, and extended from the margin of the ribs to the pubis.f  On opening
 the abdomen, its parietes were found to be a good deal contused from the
 tumor having rested on the  pommel of a saddle, on which  the  patient had
 traveled.   The tumor, after being fully exposed, being found to  be too large
 to be removed entire, a strong ligature  was placed around  the  Fallopian
 tube near  to the uterus, and the tumor cut open, Plate LXI. Fig. 1, when
 it was proved to consist of the ovarium and fimbriated extremity of the Fal-
 lopian tube.   About fifteen pounds of a dirty,  gelatinous-looking substance
 being  evacuated, the Fallopian tube was divided, and the sac, which weighed
 seven  pounds and a half, extracted.
   As soon as the external incision was made, the intestines fell out on the
 table,  and  could not be replaced during the operation, which lasted twenty-
 five  minutes.  The patient was, therefore, placed on the left side, so as to
 permit the blood to escape,  after which the intestines were replaced, and the
 wound closed by the interrupted suture, the ligature around the Fallopian
 tube being left  out of its lower  angle.   Between  every two stitches there
 was  placed a strip of adhesive plaster, which aided the union, and  after
 applying the usual dressings,  the patient was put to bed, kept on a strict
 regimen, and in twenty-five days returned to her home, which was sixty miles
 off.  The patient was a  Mrs. Crawford, of  Kentucky, and subsequently of
 Indiana, wh  re she died in 1841—thirty years after  the operation—in the
 79th year  of her age, having  enjoyed excellent  health up to the period of
 her death.   She  had no children after the operation. J  Of ten cases oper-
 ated on by McDowell, eight were cured.
  Operation of Atlee, of Philadelphia.§—Preparatory Measures.—The
diagnosis being carefully established, the bowels and bladder should be evac-
uated,  the room warmed to  the temperature of 80° Fahr., the finger-nails
of the operator and his assistants trimmed close, and  the following instru-
* Eclec. Repert. and Analyt. Review, vol. vii. p. 242, 1817.
f Ibid., vol. ix. p. 547.
X Gross, History of  Kentucky Surg., p. 8.
g Am. Journ. Med. Sciences, vol. viii.  N. S. p. 51. 
                           PLATE  LXI.

       OPERATIONS ON THE  FEMALE GENITO-URINARY ORGANS.

  Fig. 1. McDowell's Operation for Ovariotomy.  An incision  has been made
through the linea alba, the abdomen opened, and a ligature passed around the
pedicle of the tumor, near to its  uterine extremity.  The hands of the assistants
are seen retaining the tumor in position, while the surgeon, grasping the section
of the broad ligament of the uterus, is about to divide it with the scalpel, beyond
the ligature, so as to avoid unnecessary hemorrhage.  1, 1. Hands of the as-
sistants.  2, 2. Those of the operator.            After Bourgery and Jacob.

  Fig. 2. Extirpation of the Uterus by means of the Ligature, in a case of pro-
cidentia uteri.  The uterus and the vagina having been prolapsed beyond the
vulva, and the viscera which had been invaginated  in  the  utero-vaginal pouch
having been reduced, an assistant  kneels below the  operator, and  seizes the
vagina and uterus between bis thumbs and fingers, 1,1, in order to prevent their
escape, while the surgeon passes a needle,  with a double ligature, vertically
through the vagina, ties the right half, and is about to tie that on the  left, the
ends of which are seen pendent.                 After Bourgery and Jacob.

  Figs. 3,4. Uterotomy, or incision of the neck of the uterus, either by a  straight
or curved bistoury, in order to enlarge the os uteri and facilitate the extraction
of a polypus.                                   After Bourgery and Jacob.

  Fig. 5. Section of the abdominal parietes, in  order to show the operation of
puncturing the os uteri, when it is requisite to evacuate the menstrual secretion.
1. Left hand of  the  surgeon, as placed  upon the  hypogastrium, in order to
steady the uterus.  2. The  right hand of the surgeon, holding  the trocar, and
directing its point upon the right forefinger, which is curved so as to carry it to
the position of the os uteri.                      After Bourgery and Jacob.
       (580) 
 
 
            EXTIRPATION  OF THE OVARY, OR  OVARIOTOMY.         581

ments placed upon a tray, to wit:  two good and large scalpels for the ab-
dominal incision, one probe-pointed bistoury, one director, one tenaculum,
two dissecting forceps, one  pair of dressing forceps, together with ligatures,
sponges, towels, brandy, etc., a narrow table being also well covered and
placed in a good light, with two chairs to receive the patient's feet.
  Operation.—The patient,  clothed in an ordinary nightgown,  rolled up
around the waist, being placed upon her back upon the table, with her hips
near the end, and covered  by a sheet, applied like a diaper, her feet are to
be supported by two  chairs, her limbs covered with another sheet, and her
head and shoulders moderately raised.  The surgeon should then place him-
self upon the patient's right ride, and commencing an  incision immediately
below the umbilicus, carry it boldly through the  skin and subcutaneous tis-
sues to the sheath of  the recti muscles, extending the incision in the median
line to within one inch of the symphysis pubis.  A small incision being then
made through the linea alba, the peritoneum  is to be cautiously cut and opened
to the  extent of the external wound by means of the probe-pointed bistoury.
   The hand being now introduced into the abdominal cavity, the connections
of the tumor should  be examined,  and an effort made to tilt it out, when, if
the abdominal opening is too small, the incision  may be continued  below to
the pubis, and above  to three inches beyond the umbilicus, passing around
the latter  on its left side.  The tumor being then  turned out on the side
opposite to its pedicle, the  latter was found, in the case operated on, to con-
sist of a broad  ligamentous sheath  five or six inches broad, extending from
the left hypochondrium into the pelvis; had the sigmoid flexure of the colon
incorporated in it; was highly vascular, one vein as large as a goose-quill,
extending  along its  attachments," and sending out ramifications which were
much  gorged with blood.   This pedicle consisted of a double fold of peri-
toneum, arose from the broad ligament of the uterus, had a triangular form,
and  its lower edge, which  ran from the uterus to the left side of the pelvis,
was several inches long,  while the  upper, which  ran from the tumor to the
uplifted sigmoid flexure, was one inch long. The Fallopian tube, which was
also very much elongated and somewhat attenuated, was stretched up to the
top of the  tumor.
   A surgeon's needle, armed with  a  single strand of saddler's silk, being
waxed, was now passed so  as to include an  inch  of the lower border of the
pedicle, and firmly tied, after which this part of the pedicle was divided near
the tumor, exposing  some  of the large veins upon its  surface, which broke
as sopn as they were deprived of their peritoneal  coat, and gave rise to most
of the  hemorrhage that was seen.  A second ligature of double-stranded silk
was then introduced  about an inch above the first, made to embrace several
veins, and being then firmly tied, the remainder of the pedicle was tied with
another ligature, and  then severed, when the whole tumor was removed.  The
blood which flowed into the  pelvis did not  exceed six ounces, and was care-
fully removed by soft and  warm  sponges.   The ends  of the pedicle  being
then examined, and no oozing noticed, the  four  ligatures were brought out
at the lower end of the wound, and the latter closed by  nine hare-lip sutures
and intervening adhesive strips, covered  by patent lint and a soft compress,
and the whole secured by a broad towel,  which extended from the thorax to
the trochanters.  The operation occupied about  an hour; peritonitis super-
vened,  and death ensued on the fifth day.
   Statistics of the Operation.—The formation of tables showing the results
of the  operation of ovariotomy has, fortunately for the  profession, been well
attended to; but the question of its success up to this period is not definitely
settled.  The following table, expressive  of the opinions  of  Simpson, of
Edinburgh, shows the present position of the question:— 
682            PRINCIPLES  AND PRACTICE  OF SURGERY.
SIMPSON'S  VIEWS ON OVARIOTOMY.*
             OBJECTIONS.
  1.  It is a dangerous operation.

  2.  The operation is as fatal now  as it
was at tir-t;  does not diminish in fatality
with the progress of medicine.
  3.  The disease  is liable to  return  after
the operation.

  4.  The condition of the patient is not
improved.
              ANSWERS.
  1.  But  not  more so than other capital
operations, as (imputation at hip, etc.
  2.  This idea is erroneous; the per cent.
of mortality is diminishing, us shown by
the statistics of Atlee and Clay.
  3.  It is really very seldom that it does
so, much less  frequently than is  the ca:-e
for very many other operations.
  4.  It is improved in  very many cases:
and,  if not in  all, this is also true of many
other surgical operations.
Mortality after Ovariotomy, and after various other Capital Operations.^
Reporter.	Nature of operation.	Cases.	Deaths. 120 59 32 29 35
Fock........		292 179 44 93 72	
Atlee........			
	,i		
Clay......... Peacock...			
Cooper and		G22	296
Various	Ligation of innominata		
surgeons..		14	14
		40	18
Inman and Phillips.... Cox..........	Ligation of other large	370 24	123
	Amputation at hip-joint		
			18
Malgaigne. Malgaigne.	" of limbs.......	852 200 276	332 122 101
Fenwick ....	d <«	4937	1565
Proportion of deaths.
41 in 100, or 1 in 2f
33 in 100, or over 1 in 3.
7:] in 100, or 1 in If.
31 in 100, or 1 in 3J.
49 in 100, or 1 in 2.

47 in 100, or 1 in 2TL.

All those operated on have
  died.
45 in 100, or nearly 1 in 2 ^.

33 in 100, or 1 in 3.

75 in 100, or 1 in 1J.
33 in 100. or over 1 in 3.
61 in 100, or 1 in 13.
36-6 in 100, or 1 in "2^.
32 in 100, or 1 in 3-X.
                 I 3
   The candid inquirer after truth may also realize the position of this ques-
tion by laying aside all  preconceived  opinions, and examining it under the
following or similar heads:—
   1.  Are such tumors proper subjects for an operation ?
   2.  Is  their removal attended by  any extraordinary difficulty or danger
during or after the  operation ?
   I.  Are Ovarian Tumors proper subjects for an Operation?—In investi-
gating the merits of ovariotomy, this question stands  prominently  forward,
and must mainly regulate an opinion of the value of the operation.
   To show the sentiments of a few experienced surgeons, I cite the following
opinions:—
   Yelpeau^ says: "The diseases which require ovariotomy are, if left to the
  * From a Clinical Lecture, Medical Times  and Gazette, (see Maryland and Virginia
Medical Journal, May, 1860.)                                             6
  f From a Clinical Lecture  of Simpson, of Edinburgh, Medical  Times and Gazette
(see Maryland and Virginia Medical Journal, May, 1860.)                         '
  X Velpeau, Operat. Surgery, by Mott and Townsend, vol. iii. pp. 538, 539. 
            EXTIRPATION OF THE OVARY, OR OVARIOTOMY.         583

resources of nature, almost always  fatal; but, though incurable, they do not
generally cause death until after a  long-protracted period, which lasts,  as a
medium, five or six years."  Under certain conditions, such as the medium
size and mobility of the tumor, he deems them proper subjects for the oper-
ation.
   Churchill* thinks "there are cases in which this operation would be justi-
fiable on the grounds that the disease  is incurable by medical means;  that
the patient will ultimately die from constitutional disturbance  after suffering
more or less inconvenience;  and that tapping in ovarian dropsy is attended
with great danger."
   Colombat,f  who seems to  be least decided in his views, says:  "Without
wishing to proscribe the operation, it ought not to be resorted to,  except as
an extreme resource."
   CheliusJ thinks, "unless the disease causes great annoyance, no  operation
is allowable; but puncture only affords a short relief, as the fluid re-collects
so much the quicker the oftener it is evacuated."
   Blundell§ says: "We may be justified in operating, provided  it be the
wish of the patient."   But he  also says:|| "All  the operations  upon the
ovaries are worthy of consideration; for, if one can be made to cure an un-
happy individual, who would otherwise fall a victim to disease, it will be an
invaluable good to the fairest and least offending part of our species."
   From an examination of these opinions—and  they are certainly those of
great  professional  worth,  and might  be  readily augmented,  did  my space
permit—we are, I think, justified in concluding that the majority of ovarian
tumors cannot be controlled by medicine; that  their natural course is to
terminate fatally in about  five years;  that tapping  them is attended  with
considerable danger; and  that, when they create  great distress  to the pa-
tient, and the latter is fully informed of the probability of failure and the
chance of death, such tumors may, as a forlorn hope, be regarded as occa-
sionally proper subjects for an operation.
   II.  Is the Removal of  an Ovarian Tumor attended  by any extraordi-
nary difficulty or danger during or after the Operation?—In attempting
to decide this portion of the question, little more than a general opinion can
be given, as individual cases  will often be found in this disease, as  in others,
in which peculiar difficulties must  be overcome.    As a general rule, the
dangers attending  the  removal  of ovarian tumors  are  mainly due to the
error of diagnosis, it being almost impossible to foretell the condition of the
attachments of the  tumors;  and yet,  though many such instances are on
record, there are a number of cases in which the diagnosis was correct  and
the operation successful.
   Thus, "out of 81  cases  collected  by B. Phillips, in 1844, in which ovari-
otomy was attempted, no  tumor was found  in 5, and in 6 others it was not
ovarian;" and "in 15 of the 81 cases it was irapossible to remove the tumor
after the abdomen was  opened,  owing to the  adhesions,"^ though of these
9 recovered.   Of the 81 cases, 49 recovered  and  32 died.   Of 61 in whom
the tumor was extracted, 35 recovered and 26 died.
* Notes on Ovariotomy, quoted from Meigs's Colombat, p. 418.
f Diseases of Females, Meigs's translation, p. 432.
X Clielius's Surgery, by South, vol. iii. p. 212.
| Diseases of Women, p. 118,  quoted from Churchill, Phila. edit. p. 304.
|f Churchill, p 305.
lj Druitt's Operat. Surgery, Phila. edit. p. 422, 1848. 
PLATE  LXII.
      OPERATIONS UPON THE UTERUS THROUGH THE ABDOMEN.

  Fig. 1. Langenbeck's Operation for Extirpation of the Uterus.  An incision
having been  made through the linea alba, the  hands, 1,1, of two assistants
elongate  the  angles  of the wound, and retain the intestines in the abdomen,
while the surgeon, after applying a ligature to the broad ligaments of each side,
seizes the womb with 2, his left hand, and is about to extirpate it  above the
vagina with the knife, 3, in his right haud.
                                              After Bourgery and Jacob.

  Fig. 2.  A view of the Cesarean Operation. The incision having been carried
from just below the umbilicus to a little above the pubis, the abdominal parietes
and the peritoneum have been divided in the line of the linea alba, the  uterus
opened, and while 1, the left hand of the surgeon, separates the right lip of the
abdominal wound, the right hand, 2, has seized  the head of the foetus, which
presented in this instance, and is  about to deliver the child.
                                               After Bourgery and Jacob.
(584) 
fio 1
 
 
ON  THE  CESAREAN OPERATION.
585
                            SECTION VII.

                     ON THE CESAREAN OPERATION.

  The term Caesarean  Operation  has,  from  a  very early period,  been
assigned to  that in which the parietes of the womb were incised through the
walls of  the abdomen, in order to permit the removal of the child  in this
manner when the pelvis was too small or  deformed to allow of its delivery
per vias naturales.  Few of the operations proposed for the benefit of man-
kind present the surgeon with as many scruples  in regard to the course to be
pursued  as this; and he may well hesitate before deciding upon an operation
which, though it may offer a prospect of saving the life of the infant, exposes
the mother to almost certain death.   As the preservation of  the life of the
child is also by no means certain, the surgeon, when thus called upon, should
endeavor to weigh correctly the value of each life to society, and, if satisfied
of the greater value of that of the mother, remove the child  piecemeal
through the vagina.  In Paris, as stated by Velpeau,* every woman died
on whom it was performed  during forty years, and in Great Britain there
had  been no well-attested cure, as reported by S. Cooper.   Out of 424 others
reported by other surgeons, as occurring elsewhere, 210 died, making the
chances  of success  about one out of two, supposing all the  accounts to  be
accurate, but yet  presenting a fearful odds when it is remembered that the
delivery may be accomplished without risking  the life of the mother more
than in many instrumental deliveries.   In the United  States, the operation
has  been performed in a few instances with  nearly similar want of success,
though it was attended by a most fortunate termination in the patient oper-
ated on  by  Gibson, of Philadelphia,f and on whom it was performed twice,
thus proving successful in two different pregnancies.  Jeter,  of Georgia, in
1852 also  operated successfully on a patient thirty years old,!  and Byrd
Page and  Neill, of Philadelphia,  have each successfully accomplished the
same thing.
  Preparatory Measures.—The operation having been decided  on, there
should be prepared one or two good large scalpels, one sharp and one probe-
pointed  bistoury,  dissecting forceps, dressing  forceps,  a director,  scissors,
hare-lip  pins, ligatures, a syringe, catheter, brandy, ammonia, sponges, adhe-
sive  strips, spread  cerate, compresses, and bandages.   The abdomen should
also  be entirely free from hair, and the rectum and bladder thoroughly evacu-
ated.  The arrangement of the bed or table, as directed in  lithotripsy, will
usually be useful in this operation.
  Ordinary Operation.—The patient  being etherized, so as to tranquilize
the bowels,  two assistants should compress  the abdomen with their hands,
so as to steady the  uterus, and prevent its  variation  from the abdominal
parietes.  The surgeon then,  with a large scalpel,  should incise the  integu-
ments in the line  of the linea alba from just below the umbilicus to within
about one inch of  the pubis,  not passing too near the latter, in consequence
of the position of the bladder, and passing on the left of the umbilicus, if he
extends the incision upward,  in order to avoid the anastomosis between the
epigastric and umbilical veins.  The abdominal parietes being thus divided,
the peritoneum should be punctured, the left  forefinger introduced as a direc-

  * Op. Surg., loc. cit.
  f Am. Journ. Med. Sciences, vol. xvi. 1835, and vol. xxii. 1838.
  X Transact. Med. Society of Georgia.  Report on Surgery, in the Southern  Journal
of Med., vol.  viii. p. 744. 
586
PRINCIPLES AND PRACTICE OF SURGERY.
tor, and the membrane slit up with the probe-pointed bistoury, to the extent
of the outer incision.   The uterus, being now fully exposed, should be cau-
tiously incised, layer by layer, until the membranes around the foetus are ex-
posed, when an assistant should rupture them, if possible, per vaginam ; but
if not, the sides of the abdomen should be closely pressed against the womb,
and the  liquor aranii discharged through the wound. Two assistants should
now hook up the uterus with their fingers  at the  angles of the wound, in
order to prevent its variation from the  external incision, and the surgeon
then extract the child according to its  position, Plate LXII. Fig. 2;  the
membranes and placenta being  subsequently  removed  per vaginam,  or
through the wound, according to circumstances.
  The parts being now thoroughly cleansed, and any clots  that may have
collected washed  out through the vagina,  by means  of the syringe  and
catheter, the bleeding vessels may be  ligated, if the uterine contraction is
not sufficient to arrest the  flow of blood.   A strip of linen  should then  be
placed in the pubic angle of the abdominal wound, and the sides of the latter
united by the hare-lip suture and strips, the uterine contractions diminishing
and closing the opening in that organ.  Spread cerate, a compress, and a
body-bandage  complete the dressing,  when opiates may be administered,
and an appropriate after-treatment directed, in  order to combat peritoneal
inflammation.
                         CHAPTER  IX.

  DISORDERS OF, AND  OPERATIONS PRACTICED ON, THE RECTUM.


                            SECTION  I.

                  SURGICAL ANATOMY OF  THE RECTUM.

  Arising at the inferior and left side of the fifth lumbar vertebra, the rec-
tum descends obliquely downward to the centre of the sacrum, and following
thence the middle line of the bones,  it terminates  near the  point of  the
coccyx, in the anus.   Although nearly cylindrical in its entire  length, the
rectum yet presents a considerable dilatation or pouch near its lower end.
  The rectum has the  same number of coats as the other intestines, but its
inferior  third is not covered by the peritoneum.  In  man, it corresponds
with the position of the bas-fond of the bladder, vesicular seminales, prostate
gland, and membranous portion  of the urethra, to  all of  which it  is very
loosely attached  by its anterior face; but in the  female, it  adheres  directly
and closely to the posterior face of the vagina.*
  The peritoneum stops about two inches from the end of the rectum in
woman, but it is from two to three inches above the anus in man.t
  The muscular coat of the rectum, like that  of the other intestines, is com-
posed of circular and  longitudinal  fibres; but  when  the  latter reach  the
lower margin of the anus, they do not terminate,  but turn under it between
the  internal and external sphincters,  and  then  ascend in contact  with  the
* Diet, de Med., tome xxvii. p. 271.                   + Malgaigne. 
DISORDERS OF THE  ANUS.
587
mucous coat, or the submucous cellular tissue, into which  they are finally
inserted.  This connection exerts considerable influence on the mucous coat
in hemorrhoids, as well as in prolapsus ani.
   The mucous coat at the  lower end of the rectum is thrown into longi-
tudinal folds—columns—at the  lower  end of which are  numerous small
pouches of from  two to four lines in  depth, which point upward, and are
occasionally the seat of a disease—encysted rectum—which is characterized
by intense itching.*
   The arteries of the rectum are known  as the hemorrhoidal, and are  suffi-
ciently large and  numerous, about an inch and a half from the anus, to cause
troublesome hemorrhage.   When diseased, the  flow of blood from them is
apt to be profuse, even when they are  divided near the anus.
   The hemorrhoidal veins are very numerous, and form, at  the lower part
of the gut between the mucous and muscular coat, the hemorrhoidal plexus,
which anastomoses freely with the adjacent veins, all of which  are without
valves.   The thinness of the mucous coat over these veins gives to internal
hemorrhoids the  very smooth, shining, and bluish or purple tint which  is
characteristic of this complaint
   On the exterior face of the rectum, the hemorrhoidal plexus is applied to
the internal sphincter muscle, and  branches of it pass through the  muscle in
bo many directions  that its fibres are sometimes, and especially in  bad cases
of hemorrhoids, so intermixed with enlarged veins as to  appear like an  erec-
tile tissue, f
   The orifice of the rectum (anus) is closed by a sphincter muscle, which is
under the control of the will;  the contraction of which  has an effect in pro-
ducing the folds or wrinkles  found  in the skin about the anus, while its relax-
ation permits, in certain  diseased conditions, the eversion of the mucous
coat, together with the blood-vessels and nerves.  Even in the ordinary evac-
uation of the bowel, the loose adhesion of the mucous to the adjacent tissues
permits the formation of a circular pad which is formed  of the inverted por-
tion of the gut, and favors the escape of the  fecal contents by  forcing the
matter to free itself from the surface of the bowel, while the  skin of the part
is thus  protected from contact with the discharges, when  of the ordinary
solidity.   Certain diseased  conditions change this action, as will  be again
referred to under the operations for fissure  and prolapsus ani.
                             SECTION  II.

                        DISORDERS  OP THE  ANUS.

   The skin covering the margin of the Anus is liable, like the skin of other
portions of the  body, to the development of inflammatory action,  which is
here aggravated both by the friction of the cheek of one buttock against the
other, as well as by the constant passage of the feces  over it.  In  addition
to the ordinary results of inflammation of the skin, as congestion, suppura-
tion, and  ulceration, the integuments of  the  anus are especially liable to a
form of vesicular disease that  constitutes  a  true eczema—is the source of
great annoyance to the patient, and  is not unfrequently regarded as due  to
disease within the rectum, instead of being, as it frequently is, purely an ex-
ternal disorder of this region, though perhaps first  excited by irritating dis-
charges from the rectum.
* Horner's Anat., vol. ii. p. 47, 9th edit. 1851.
j- Diet, de M6d., tome xxvii. p. 274. 
588
PRINCIPLES AND  PRACTICE OF  SURGERY.
                       \ 1.—Eczema of the Anus.

  Symptoms.—Eczema of the anus, like the eczema of other regions, is seen
either as an acute, or, more frequently, as a chronic disorder.  When acute,
it is preceded by a constant sense of burning and itching, which the patient
assigns to the chafing of the parts, and the continued itching of which usually
continues to be one of the most annoying features of the disorder.   A close
examination will now show the edge of the fold of the buttock, as well as
the margin of the anus, to  be red, hot, moist, and abraded of cuticle, while at
other points, minute vesicles, filled with serum, will be seen scattered around,
as in the ordinary form of  acute eczema of other parts.  As the fluid escapes
by the rupture of these vesicles, it may be either clear, like serum, or slightly
yellowish in its tint, staining  the linen of the patient, and forming on the
skin around the anus, when it dries, the thin white or yellowish scales which
are characteristic of eczema; or, if the affection is chronic, it will leave the
parts  of  a dark-reddish color, with a  slight  crust on  them, like that often
noted on the  legs, in connection with ulcers, and known as  Chronic Eczema
Rubrum.  Not unfrequently this irritation is also found upon  the thighs and
Bcrotum of the male, and on the pudendum and perineum of the female, being
often  the result, in these  cases, of the extension of the disorder from the
anus.
  Etiology.—Eczema of the  anus may be developed by any cause that will
induce congestion and superficial inflammation  of the skin;  thus, it is fre-
quently the result and attendant of hemorrhoidal tumors, the capillary con-
gestion created by the enlarged rectal veins, as well as the ichorous matter
which flows from such tumors  as are  ulcerated,  creating precisely the same
condition of the skin about the anus that is seen on the legs, and  has already
been alluded to as one of the sequela? of leg ulcers.   Fissure of  the anus,
fistula in ano, prolapsus ani, etc. may also give rise to  this disorder, though
the irritation thus caused is not unfrequently regarded  merely as a symptom
of rectal disease, and treated  accordingly, while it may be a distinct com-
plaint.
  Diagnosis.—The presence of one or more vesicles in the neighborhood of
the anus, with the  characteristic itching and burning of eczema as seen else-
where, usually suffice to render the diagnosis  easy, when the parts are care-
fully examined by placing the patient on his back before a good light,  and
then elevating and opening his thighs, so as  to  see clearly the  entire peri-
neum.   When the examination is made from behind simply by opening the
cheek of the buttocks, the  folds of the skin, and the hair, found in the adult,
often conceal the characteristic vesicles.
  Patients.—Adults, both male and female, who are fleshy, constipated, and
subject to hemorrhoids or fistula, are  those  mostly affected, though such as
are thin and of the tuberculous diathesis also suffer from the complaint.
  Prognosis.—The  prognosis of eczema of the anus will  depend upon the
cause of the  irritation.  Usually, the patient can be readily relieved of the
complaint when it is acute ; but unless the hemorrhoidal congestion can  also
be removed, or when the  disease is  chronic, the prognosis as  regards the
cure should be guarded, the disorder being occasionally very difficult to re-
move, unless the functions of the rectum can also be restored to their normal
condition.
  Treatment.—When this external irritation of the anus is the result of con-
stipation, or of a varicose condition of the hemorrhoidal veins, or of external
piles, the administration of an active mercurial purge is always beneficial,
the bowels being subsequently kept in a soluble condition by the administra- 
DISORDERS OF THE  RECTUM.
589
tion of sulphur and magnesia, so as to correct acidity, after which the chief
reliance must be placed on local remedies.  These local  applications should
be regulated by the extent and character of the inflammation.  If the eczema
is  acute, and accompanied  by much burning and a free serous discharge,
nothing will afford greater relief than frequent bathing with lead-water, or
the application of pieces of lint wet with the same, the lint being retained by
the use of a T-bandage ;  but when the disease is more chronic in its charac-
ter, and presents a dry, scaly appearance, with intolerable itching, the  warm
water-dressing—that is, lint saturated  with  warm water, and covered by a
piece of oiled silk—will prove most soothing; or the patient may steam the
part  by sitting over a vessel of hot water.   Poultices  of all kinds are ob-
jectionable, owing to their adhering to the hair, so that they become a source
of irritation ; while, if  the  latter  is shaved  off, the  suffering of  the patient
will be increased in  a day or two  by the friction on the short  ends as the
hairs grow again.  Much relief from the itching may also be obtained from
the following ointment:—
                   R.—Hydrarg. sulphuret.flavus, grs.  xv;
                       Aconitiae, grs. ij ;
                       Pulv. camphorae, grs. v;
                       Axungiae, ^j. M.
         S.  Anoint the parts thoroughly, and  rub it well in with a soft rag.

   The dry, scaly condition  may also be benefited after steaming by anoint-
ing the part with the following ointment:—
                         R.—Pulv. camphorae,
                             Sodae carb. aa grs. x;
                            Glycerin, sj;
                            Axungiae, Ijj.  M.

   In the more chronic cases, especially if accompanied by a serous discharge,
the following is often very useful:—
                       R.—Hydrarg. chlorid. mit. sjiss;
                           Pulv. plumbi acetat. grs. x;
                           Axungiae, Sj;j.  M.
                       S. Anoint the parts twice daily.

   Should  external or internal hemorrhoids  exist at the same  time, these
should be appropriately treated, though even  then the means above directed
will prove  highly useful.
                             SECTION III.

                       DISORDERS OF THE  RECTUM.

   The Disorders of the Rectum requiring operative treatment are so numer-
ous, and its structure so important, as to have engaged a large portion of the
time of those surgeons who have devoted themselves specially to their study,
and were  they at present  to receive  the detailed consideration that might
be expected, would occupy the remainder of my space.  A condensed descrip-
tion must therefore suffice.
   The aid of the surgeon  may be  required in this region for the  removal of
foreign bodies; for encysted rectum ; fissure of the anus; imperforate anus;
prolapsus ani; fistula in ano ;  hemorrhoids ;  stricture of the rectum j and
extirpation of the lower portion of the bowel for cancer. 
590            PRINCIPLES AND  PRACTICE OF  SURGERY.
                    \ 1.—Removal of Foreign Bodies.

  The Removal of Foreign Substances from the bowels may be accomplished
by the finger, handle of a teaspoon, scoop, forceps, or  other similar instru-
ment, according to the circumstances of the case.   In the removal of articles
which have sharp points  or cutting edges, it will be found advantageous to
dilate the anus by means  of a speculum ani, so as to protect the mucous coat,
unless the size of the object should forbid it.  In a  case reported by Ruschen-
berger, of the U. S. Navy,* where a glass goblet, three and a half inches high,
with a brim two and five-eighths inches, and a base one and seven-eighths
inches, was introduced into the rectum of a  Chinaman, the whole was re-
moved by Parker, of Canton, by crushing it with  strong forceps, protecting
the parts with folds of cloth, and removing the  smaller fragments with  a
teaspoon ;  and a similar treatment would be requisite for the removal of all
fragile articles.
                        \ 2.—Encysted Rectum.

   In 1792, Physick, of Philadelphia, called the attention of the  profession
to a condition of the rectum in patients who had been previously thought to
labor under neuralgia of the anus, or a series of symptoms which some re-
garded as an imaginary complaint, and which had then been generally over-
looked by surgical writers.\  This condition is characterized by the follow-
ing symptoms:  " Sometimes the patient experiences  little or no  uneasiness
between the stools; at others, he has a sensation of discomfort, as if a worm
or insect were in the canal; or it produces an intense itching which is often
sufficient to prevent sleep; and there is occasional pain after a stool, though
this  is uncomplicated with  spasm of the sphincters.  The touch shows no
tumor or other disease of the gut; no pus is present, except when the disease
is complicated ; but an examination made by passing a hooked probe a short
distance within the anus, and withdrawing it, will demonstrate the existence
of a little pouch or cyst, which is  so  exquisitely sensitive to  the  point of
the probe as to cause acute suffering."
  These pouches were subsequently minutely examined by Horner, and their
anatomical relations  strictly defined,J so that now they are  usually regarded
as a normal portion of the gut, which only demands interference when it be-
comes the subject of diseased action.  To relieve the symptoms above detailed,
Physick proposed the excision of the affected cyst.
  Operation  of Physick, of Philadelphia.—Bend the point of a probe on
itself for about half an inch, so  as  to form  a hook, pass  it into the anus,
and  by  a movement backward  and forward, and with the point close to
the side of the gut, draw down the membranous  portion or wall of  the sac,
and snip it off with the scissors, so as to lay the pouch completely  open.  As
the irritation is liable to be reproduced, a repetition of the operation may
be called for.   Injections of cold  water and attention to the fecal evacuation
will subsequently facilitate the cure.
  The necessity for  this  operation  is now  doubted by those  who  regard
these pouches as the natural receptacle of the mucus, which, by lubricating
the orifice of the rectum, facilitates the voiding of the feces.
*• Am. Encyclop. of Med. and Surg., article Anus, by Reynell Coates M D
f Am. Journ. of Med. Sciences, vol. xvii. N. S. p. 410.  1849.
X Special Anat. and Histology, vol. ii. p. 147, ninth edition. 
FISSURE OF THE ANUS.—IMPERFORATE  ANUS.         591
                        § 3.—Fissure of the Anus.

  Fissure of the Anus is the  term employed to designate a long, narrow,
linear ulceration of the verge of the anus, which sometimes extends from the
sphincter ani to the folds of  the skin on the margin of the anus, and is in-
variably attended by extreme pain  on defecation, intense  burning subse-
quently, and by spasm  of the  sphincter ani, a characteristic  sign that has
been much insisted  on since the time of Boyer.  When something more than
a palliative treatment by anodynes, and similar means of producing relaxa-
tion of  the  sphincters is demanded, a cure may be accomplished by lightly
cauterizing the  surface, until the  ulcer is healed, or by paralyzing the ex-
ternal sphincter by  a transverse division of  its  fibres.  This may be accom-
plished  either by dividing the muscle from the inside  of the gut outward, or
by a subcutaneous incision, or by lacerating the ulcerated edges by dilating
the anus, either by introducing  the fingers or tents, or  an anal  speculum, as
advised by Maisonneuve.
  Operation of Dilatation—-The operation of dilatation is performed by in-
troducing the index  finger of  each  hand into the anus, and then forcibly
dilating the contracted muscle first antero-posteriorly, and then transversely.
The relief afforded  by this simple means is sometimes almost instantaneous,
and the operation is well worthy of trial before resorting to a division  of the
fibres of the muscle.   But if it fail to cure, then the application of the knife
may be  practiced as follows:—
  Operation of Boyer.—Place the  patient on the side, introduce the left
forefinger, well greased, into  the gut, and  pass a very narrow probe-pointed
bistoury flatwise  along  the finger as a director.   The cutting  edge of the
bistoury being then directed to  the right or  left side, according to the direc-
tion of  the fissure, cut through the raucous membrane, and the fibres of the
sphincter, dividing all the tissues at a single cut.*  In the subcutaneous in-
cision,  the point of a very narrow, sharp-pointed bistoury is to be passed
beneath the mucous coat near the fissure, and the  fibres of the muscle divided
by cutting outward.   Theu, turning the bistoury flatwise, withdraw it at the
point of entrance.
  Copeland, of England,f asserts that the incision of the raucous and areo-
lar coat is sufficient, without dividing the fibres of the muscle.
                         \ 4.—Imperforate Anus.

   The term Imperforate Anus designates those malformations in which the
natural outlet of the rectum is closed either by a membrane, by a contraction
of the anus, or by a congenital deficiency of the rectum, the gut terminating
in a cul-de-sac at  a distance which varies from a half inch to three inches.
Its relief is to be accomplished  by dividing the obstruction, as in the follow-
ing plan :—
   Operation.—Puncture the membrane or the integument  at the proper
point, for the anus, either with a trocar, abscess lancet, or bistoury, and dilate
the opening by means of a tent.   Should contraction of the orifice supervene,
as is frequently the case,  make a crucial incision in the part, or dissect out a
portion of the integuments.
  Although the operation for imperforate anus is one which does not present
* American Encyclop. of Med. and Surg., loc. cit.
f Lond. Med. Gazette, vol. xvi. 
                          PLATE  LXIII.

               OPERATIONS PRACTICED ON THE RECTUM.

   Fig. 1. Removal of hemorrhoids by means of the ligature.  On the right
 side is seen the double canula and wire ligature of Physick, and on the-left the
 application of the double silk ligature.  1, 2.  Two ends of the  ligature  passed
 through the piles, and intended to strangulate one-half of the tumor.  3, 4. The
 other ends of the ligature about to surround the opposite half.  5. The wire liga-
 ture as applied.                                             After Nature.

   Fig. 2. Horner's Operation for the removal  of hemorrhoids.   The patient
 being placed on the side to be operated on, the hand of one assistant draws up
 the buttock of the opposite  side. A ligature  being  then passed  through the
 largest pile and tied in a loop, the thread is held by another assistant, or by the
 surgeon.  A short  tenaculum transfixing the base  of the pile  now draws the
 tumor off from the buttock, while  the surgeon makes an incision around the ex-
 ternal side of its base, so as to free it from its connection with the skin.  The
 loop of a wire ligature being then  thrown around the pile, so that one side of the
 loop lies in the  incision, while the  other is applied on the mucous surface of the
 tumor, the latter is perfectly strangulaled without the integuments being involved
 in the ligature.  1, 2. Hands of  assistant.  3. Ligature passed through the
 tumor to prevent its retraction within the rectum.  4. Tenaculum raising it from
 the side of the anus.  5.  Double canula and wire ligature.       After Nature.

  Fig. 3.  Operation for Imperforate  Anus, and extirpation of a  small flap.
 1. Forceps.   2. Scissors.                        After Bernard and Huette.

  Fig. 4. Dupuytren's Operation for  Prolapsus Ani.  1.  Forceps.   2. Scissors
 excising a fold of the skin at the verge of the anus.
                                               After Bernard and Huette.
  Fig. 5. Ricord's Operation for Prolapsus Ani.  1, 2. Ligatures passed through
the mucous coat so as to elevate the portion to be excised. 3. Curved scissors.
                                               After Bernard and Huette.
       (592) 
Fly. 1.
Fio.2.
^s^^ 
 
PROLAPSUS  ANI.
593
any very great  difficulties in its  performance, it is as well that the surgeon
should be reminded that there is no immediate haste necessary in performing
it, and that its  execution will be easier in proportion as the delay gives time
for the accumulation of feces in the rectum so as to cause a protrusion of the
end of the bowel and the formation of a tumor.  In  one case, reported in
the Provincial Medical and Surgical Journal, (March,  1851,) a child with
imperforate anus lived for 102 days without any evacuation, and during this
time never vomited;  and though such an instance is a rare one, it yet suffices
as a nexample of the tolerance of infants under these circumstances.
   In  four cases which  have  come  under my observation, I have operated at
periods which  varied from forty-eight hours to  five days, and lost only one
patient.   Three of them were males, and one a female.


                          \ 5.—Prolapsus Ani.

   As the mucous coat of the rectum is very movable upon its muscular coat
through the intervention of the areolar coat, it facilitates the  escape of the
feces  from the  anus by protruding slightly over the edge of  the  sphincter
ani muscle, as is well seen, though in a greater degree than in  man, in the
defecation of the horse.  When thus protruded, the action of the levator ani
muscle again draws  it within  the  sphincter, which, closing firmly, retains it
within its folds.
   But when the sphincter ani becomes very  much relaxed, or the levator ani
loses its power, or the  connective tissue becomes infiltrated with serum, the
protrusion of the mucous coat becomes more marked and permanent, or the
bowel  itself becomes invaginated  and forms a tumor  at the anus, which is
known as prolapsus ani, or as "falling of the body," or sometimes is spoken
of as "the body coming down."

                                  Fig. 438.
A front view of the Appearance of the Parts in Prolapsus Ani, showing the Circular and Concentric character
                     of the Folds of the protruded Mucous Coat.

  Etiology.—The  causes creating  this condition in adults may be either
those that tend to relax and weaken the attachments of the rectal mucous mem-
brane, or such irritation as creates straining, and forces  the  bowel outward,
     vol.  ii.—38 
594            PRINCIPLES AND PRACTICE  OF SURGERY.
or it may be due to the extension of irritation from the bladder or adjacent
parts—or to inflammation, as after the tenesmus of dysentery.  The various
causes in childreu may be constant crying, long straining at stool, obstinate
diarrhoea, dysentery, and stone in  the bladder; while  in the  adult it also
often ensues on constipation, on hemorrhoids, on the use of aloetic purges,
or on the constant use of purgative enemata;  the relaxation of the anus is
also created in men by the free use of tobacco.
  Symptoms.—After an effort at stool, a tumor is found at the anus, which
is soft, pinkish, corrugated, and evidently covered by a mucous membrane
which  shows evidences of congestion if firmly constricted by the sphincter
ani muscle, becoming darker and more purplish in  its color, and inflamed,
hot, and  painful, if not  soon replaced.   When of long standing, the  pro-
lapsed portion becomes hard, firm,  and resisting from the effusion of lymph
into the  submucous areolar tissue, which renders it difficult to replace the
part; but when recent, the tumor will often disappear within the rectum by
its own contraction, or may be readily replaced by the gentle pressure of the
fingers.  When a chronic, thickened and constricted tumor becomes more or
less permanent in  its position, and is congested, indurated, and difficult to
reduce, and is  also violently constricted at the anus, it may inflame, suppu-
rate, ulcerate,  or slough off, as is sometimes seen in the chronic  tumors of
old people  in  almshouses and  hospitals where the prolapsus has  been long
neglected.
  Patients.—Prolapsus ani is met  with at both extremes of life, being often
seen in children under three  years, and also frequently developed in adults
over sixty years of age.
  Diagnosis.—Prolapsus ani may  be told from hemorrhoids or piles by the
fact that the tumor in prolapsus is  usually a mass  formed of continuous and
concentric circular folds  around the anus, and presents a villous-like surface,
while hemorrhoids are more or less distinct tumors, resembling in size and
color the intestine of a chicken if distended with indigo water and tied every
half inch or two inches in length.   Hemorrhoids also do not create as  bulky
a tumor  as prolapsus ani, are  much more painful, and bleed more freely,
and while the  tumor of prolapsus is returnable  into  the  rectum in  mass,
hemorrhoids require to  be replaced one  after another.   Prolapsus ani is
common in young children, but hemorrhoids are not seen except in the adult.
The forefinger will also readily pass through the  sphincter ani  muscle with-
out causing pain in prolapsus, as the anus is relaxed, while it is contracted
and quite painful in hemorrhoids.  Condylomatous tumors can be told from
prolapsus ani  by the  history of the case, and  by the symptoms which  have
been already detailed in connection with the chapter on Syphilis.
  Prognosis—The prognosis of a recent prolapse of the rectum is favorable,
but in the chronic tumors of aged adults it should be guarded; for, though the
protrusion may be returned, the sphincter ani muscle is usually so much re-
laxed that it is difficult,  and sometimes impossible, to prevent the reproduc-
tion of the tumor at the next effort at defecation.
  Treatment.—The indications in the treatment are: 1, to reduce the pro-
lapsed rectum promptly ; 2, to retain it within the sphincter ani; 3, to remove
the cause of the disorder.
  The reduction of the prolapsed portion of the rectum may usually be ac-
complished  by placing the patient  in the  horizontal position, and anointing
the entire tumor, as well as the fore or the first two fingers of the surgeon's
hand with olive oil or lard; then,  pressing upon the centre of the tumor,
carry a fold  of it np  into the rectum within  the sphincter  ani mnscle with
the fingers of one hand, and pushing up another fold with the  other fingers, 
PROLAPSUS  ANI.
595
retain the first until the second is nearly within the sphincter, continuing the
manipulation till the entire tumor is restored, when a piece of spread cerate
should be placed over the anus, and held there for a few hours by a compress
and T-bandage.  The prolapsus of children does not usually demand so much
manipulation, and,  when once returned, does not require  the employment of
a  compress, as  it will remain  reduced until the next effort at defecation.
Much may be done, both in adults  and children, to prevent the recurrence
of prolapsus by requiring them in defecating to sit on a seat which is inclined
at an angle of 45°  to the horizon, so as to throw the weight of the intestines
upon the abdominal parietes, and prevent the action of the muscles frora com-
pressing the  rectum in a perpendicular line.   The seat upon which they sit
in defecating  should also have a very small and narrow  opening,  not more
than four or  six  inches wide for an adult, so as  to support the cheek of the
buttock, and thus aid in  the lateral compression of the anus at the moment
of defecation.   If the prolapsus is due to constipation, laxatives should be
constantly employed, while if it is due to the tenesmus of dysentery, injec-
tions of laudanum will prove useful, ascarides and worms in the bowels being
removed by an  appropriate treatment.  The retention  of the bowel after
its reduction  may generally be accomplished simply by the use of a compress,
or  a  pad attached to a  vertical spring, which is fastened to a band around
the pelvis, such  an  instrument being made by the cutlers, for the bad cases
occasionally met with in old people.  Sometimes  it may become  necessary
to employ, for a few days, a rectal pessary, so as to give the mucous mem-
brane an artificial support, especially if the sphincter ani is  much relaxed.
Should the tumor  be very much congested  and inflamed, it will be best to
keep it constantly bathed with cold water for a few hours previous to attempt-
ing its reduction, or it may even require  the local abstraction of blood  by
leeches around the  base of the tumor.
   In some cases benefit will be derived  frora injections of the infusion of
rhatany, or weak solutions of the tinctura ferri chloridi, in the proportion of
twenty drops or  half a drachm to the ounce of water, the strength being regu-
lated by its stimulation, which should never be sufficient to cause pain.  The
decoction of  white  oak bark, or an ointment of  ten grains of tannic acid to
the half ounce of lard, a portion of which is to be placed within the anus,
is  also often highly serviceable.
   When the sphincter ani and the verge of the anus are  very much relaxed,
an operation may be demanded, while the tumor may  require the removal of
a strip of the mucous membrane, or the application of caustic, or a ligature,
for its radical cure  in the chronic prolapsus of adults.
   Operation of  Dupuytren.—With the patient  in the position just recom-
mended for the restoration of the bowel, pick up with a pair of forceps one
of the radiated folds of the skin on the verge of the anus, and cut it off  by
means of  scissors curved on  the sides, prolonging the cut about one-fourth
of an inch into the mucous coat of the gut.
   After this one, two or more similar folds may be excised, and the wounds
left to cicatrize.
  Velpeau,*  instead of this,  prefers union by the second intention, and after
excising a fold, introduces a little  lint  into each wound,  in order  to insure
suppuration and  favor the subsequent contraction of the cicatrix.  The cure,
in  either plan, being dependent on the contraction of the parts thus induced,
the surgeon should  be cautious in regard to the amount excised, lest he pro-
* Mott's Operat. Surgery, vol. iii. p. 1106. 
596
PRINCIPLES AND  PRACTICE OF  SURGERY.
duce such  a  diminution  of the anus  as  will interfere with  the  subsequent
efforts at defecation.
  Operation  of Robert.—Excision of a Portion of the Sphincter Ani.—
Remove, either by scissors or the  scalpel, a transverse portion of the sphinc-
ter ani muscle, and unite  the wound by a twisted suture.
  Operation  of Cheselden.—Cauterization.—Apply caustic potash length-
wise upon one or more points of the mucous coat, favor the suppuration, and
await the cicatrization.   The French surgeons sometimes  prefer the actual
cautery, or strong nitric acid similarly applied.
  Excision or Amputation of the Tumor.—In very bad  irreducible cases,
the adhesions of the  adjacent portions of the tumor prevent its reduction;
suppuration and sometimes hemorrhage ensue, and the aged patient is ex-
hausted by the discharge and suffering.  Under these circumstances, the
removal of the tumor by  excision  or ligature  has been practiced, and  may
possibly, though rarely, be again demanded.
  Operation  of Ricord.—Pass a  needle  and ligature  through the  mucous
coat alone, near the base  of the tumor, so as to retain it in position, and ex-
cise  it by a circular cut either with the scissors or bistoury, arresting the
hemorrhage by ligating each vessel as cut.   Then removing the retaining
ligature, guard against secondary hemorrhage,  and obviate excessive  con-
traction by the use of bougies.
  Remarks.—In the operations just  quoted, little difficulty will be found
in their performance, but much judgment will be requisite in deciding upon
their necessity.   In young patients such operations will seldom be required,
as these cases usually yield to the treatment before described without any other
operation.  If the prolapsus is so marked and obstinate as to require the adop-
tion  of  an  operation, that of Cheselden  should  be  first tried, and  then, if
requisite, resort may be had to the operation of Dupuytren.   In excising
the  folds as there directed, four generally suffice,  one  being in front, another
behind,  and two others laterally, as directed  by him ;  the amount included
in the forceps, and excised, being  regulated by the degree of relaxation  of
the anus.

                     \ 6.—Hemorrhoids, or Piles.

  Pathology. — Hemorrhoids — «</*«,  blood,  and ptm, to  flow — consist  of
tumors seated at or near  the verge of the anus, which, when ulcerated, are
liable to bleed at each effort at defecation.   Although this complaint has been
long known to the profession, there is  yet a diversity of sentiment in regard
to its pathology.  By some writers, hemorrhoids are described as a varicose
condition of the anal veins, (Jobert;) or as tumors resulting from a laceration
of the veins and the effusion of blood into the adjacent submucous or subcu-
taneous areolar tissue, (Ribes;) or as  preternatural  cysts, which are some-
times distended with blood and very much swollen, while at others they are
more empty and flaccid.   These different views, as thus expressed by distin-
guished surgeons, can only be reconciled on the supposition that a condition
of parts similar  to each  of those  described may accompany every case of
hemorrhoids at some  period of its  course.  On  this supposition, and with a
knowledge  of the minute anatomy  of the anus  and rectum, it appears  an easy
matter to harmonize these varied conditions, and explain the true pathology
of the complaint.  Thus the mucous membrane, at the verge of the anus,  being
continuous  with the skin, and having beneath it a fine anastomosis of  veins
without valves, which veins are seated in a connective tissue, and directly con-
tinuous with  those of the mesentery, may be  ruptured and create precisely 
HEMORRHOIDS, OR PILES.
597
 such a condition of parts as has been described by Ribes; while in the dis-
 tended  condition we may yet refer the whole complaint to a varicose condi-
 tion of  the veins of  the  anus, and especially of the hemorrhoidal plexus, as
 stated by Jobert.  Thus constipation, straining, and all the usual causes of
 hemorrhoids may first  induce fullness of these vessels, then serous or lymphy
 infiltration of the connective tissue in which the distended veins freely anasto-
 mose, while their rupture will readily lead to effusion of blood, and the for-
 mation  of a  cyst covered by mucous membrane or skin,  according as the
 vessel is above or on the line of the external sphincter ani.  If, then, absorp-
 tion of  the more liquid parts of such a cyst were to ensue, it would certainly
 create a semi-solid or mulberry-like  tumor, such as is described by Ribes,
 while the inflammation and ulceration of either the raucous or cutaneous sur-
 face of  the tumor might give  rise to a hemorrhage the  amount of which
 would depend on the size of the vein opening into it.  If,  then, it is wished
 to define the pathological characters of an external pile, I should say it is a
 tumor covered by the skin  or mucous membrane on the verge  of the  anus,
 which tumor is due either to a laceration of the hemorrhoidal veins, and the
 escape of blood into the  subcutaneous connective tissue, or to a varicose con-
 dition of the vessels.  The first tumor, when excised, will not bleed, but simply
 give vent to  a clot, or perhaps present the appearance of the  semi-erectile
 tissue, before referred  to.   In connection with the varicose condition of the
 veins, we may also find such an  enlargement of the arterial capillaries as  is
 usually  due to inflammatory action under any circumstances.
   An internal blind pile being, on the contrary, a varicose enlargement of
 one  or  more branches of the same veins higher up the  rectum, will conse-
 quently be a tumor covered by the mucous coat of  the part, which mucous
 covering is liable to become elongated by  infiltration of  its submucous con-
 nective tissue;  while  if it  inflames, ulcerates, and  opens a vessel, it would
 give rise to  a hemorrhage  that would be  most marked when the efforts at
 defecation create congestion.   Such  a tumor will, therefore, require  to be
 treated  with an especial regard  to this inflammation,  as well as with reference
 to the hemorrhage likely to follow the opening of veins without valves, or of
 small arteries so situated as not to be readily seen.
   Etiology. — The  local causes of hemorrhoids may be anything that will
 create engorgement and distention of the hemorrhoidal veins, as  straining
 from constipation, pregnancy,  constant  sitting on  warm  cushions, or the
 excessive use of tobacco, which, relaxing the anal muscles, favors congestion
 of the part, in a plethoric habit; or the congestion created by irregular men-
 struation may act as a  predisposing cause.
  Patients.—Hemorrhoids are seldom if ever seen in those younger than
 eighteen years of age, being generally met with in the prime of life, though
 they are not unfrequently found in those as old as sixty-five years.  They may
 attack either sex, and  especially those who lead  sedentary lives, or are dys-
 peptic.
  Symptoms.—As hemorrhoidal tumors are due to  vascular changes in the
 rectum,  which induce inflammatory and neuralgic irritation, the earliest symp-
 tom of their  presence  is  a sense of fullness aud irritation, or soreness about
 the anus, which is especially marked for an hour or more after an evacuation.
 Soon these symptoms  become more distinct, creating the sensation of a for-
 eign body being in the rectum, and giving rise to a feeling of dissatisfaction,
 or a repeated desire to  stool, the pain extending toward the sacrum and
spine, or toward the bladder and down the thighs, from the nervous connec-
tions of the part.   The feces are now sometimes streaked with blood, or the
paper is tinted, or about a teaspoonful of blood escapes toward the end of 
598
PRINCIPLES  AND PRACTICE  OF SURGERY.
the stool;  itching is also developed near the anus, this being often due to
eczema, while the parts are constantly moist, and the linen soiled with pus
or blood.   The  escape of blood usually gives temporary relief, but, if often
repeated, creates evidences of anaemia.  At the next  stool the tumors may be
more  engorged,  and  the patient will recognize their  presence with the finger.
If they continue to be constricted  by the  sphincter ani, or any irritation in-
creases the afflux of blood to them, they will then be more tumid, hot, and pain-
ful, and, if now inspected, will  be found  to be violet colored, smooth, shining,
and exquisitely painful to the touch.  As the irritation continues, the sphinc-
ter ani participates in it, and contracts spasmodically, causing the patient to
scream violently with the shooting character of the pain, while defecation
creates horrible torture, the tumor then becoming much blacker and larger,
and terminating sometimes—if left unreduced — in ulceration of the part
after a day or two.   Sometimes, on the contrary, the spasm passes off, and
the tumor  is  then less engorged, until, after forty-eight  hours, it is  quite
flaccid, and the patient  may be comparatively comfortable, or only suffer at
the periods of defecation.  The constricted condition, with  the irritation and
intense suffering just described, is usually said to be due to  a fit of the piles.
The long continuance of hemorrhoids  usually causes  great disorder of the
digestive, circulatory, and nervous functions, the patient being liable to dys-
pepsia, flatulence, colic, and a sense of constriction, or sinking about the um-
bilicus, while he is troubled with palpitation of the heart, a quick, irritable
pulse, dyspnoea,  and  the other symptoms of anaemia.  Not unfrequently his
entire  moral character  is changed, becoming  cross, peevish,  irritable, and
irascible, quarreling with every one, and not unfrequently resorting to the use
of alcoholic drinks or opium to deaden his sensibilities.
  Diagnosis.—The knotted character of the tumors; their position on the
side, and not  in the centre of the anus; their violet color; their bleeding,
etc., generally render the diagnosis of hemorrhoids easy.
  Prognosis.—The prognosis of this disorder is decidedly favorable, unless
complicated with bad prolapsus ani, in an old  and broken-down  patient,
when  it should be guarded ; but I regard every case of hemorrhoids, not thus
complicated, as susceptible of being cured, with safety to the patient, if care-
fully operated on.
  Treatment—The treatment of hemorrhoids maybe either palliative or
radical.  The palliative  consists in administering, every day,  before the pa-
tient goes to stool, an injection of  a full pint of cold flaxseed mucilage, or of
cold water, though the first is  preferable.  Then the parts, after defecation,
should be well bathed in cold water, the bowels kept free by mild purgatives,
and some of the balsams or terebinthinates  be  occasionally administered.
The following is a  remedy which  will often prove serviceable, especially
when the tumors are  ulcerated, and bleed, as it acts directly on the mucous
membrane:—
                      R.—Pulv. resinse, 3J;
                          Bals copaibae, f^ss;
                          Mel despumat. Jivss  M.
  S. A tea or dessert-spoonful at bedtime, each night, till the bowels become free and
the irritation is relieved.

  Comfort  will  also be obtained from  the  use of anodyne and astringent
ointments.
                      R.—Pulv. acidi tnnnici, grs. x;
                          Pulv. plumbi acetat. grs. v;
                          Ext. aconitum nap. gss;
                          Axungiie, ^ss.  M.
                      S. Anoint the part thoroughly. 
                       HEMORRHOIDS, OR PILES.                   599
                                                             r
  When the tumors are external, attention should also be given to the exist-
ence of eczema of the anus, which should be treated as before directed.
  Radical Treatment of Hemorrhoids.—The radical treatment of hemor-
rhoids consists in destroying the tumors in patches, by the use of nitric acid
or other caustics, and in their entire removal by the wire ligature, or by the
ecraseur.  In the ancient method of treating hemorrhoidal tumors, when they
were removed by excision, frightful hemorrhages sometimes supervened; the
accounts of which have created so much alarm in the  minds of patients that
many continue to suffer for  years from  hemorrhoids, rather than—as they
suppose they must—risk their lives by an operation.   It  becomes, therefore,
the duty of every medical man to  disabuse them on this point, and to assure
them that, by the operations now  performed, they can not only be safely re-
lieved, but radically cured.  Out of more than eighty patients that have been
operated  on, to my  knowledge—many of  whom have been in my own prac-
tice—but one has died from Horner's operation, as hereafter described; while
in but one has it been necessary to  operate on the second side, after the tumor
had been  removed by a previous operation on the other.
  I. Application of Nitric Acid—Strong nitric acid, when applied for the
relief of hemorrhoids, as suggested* by Houston, of Dublin, in 1848, and
also by Cusack,  is  especially applicable  to  those  cases in which  there  is
hemorrhage, with marked ulceration  and thickening of the mucous coat
over the pile.   It proves useful by its caustic effects inducing sloughing and
subsequently the  cicatrization of the ulcer.  It also changes the action of a
chronic swelling, or induration of tissue,  so as to cause the effused lymph
to serve the purposes of healthy organization, instead of  creating a  diseased
enlargement in the connective tissue around the veins.
  In applying it, the piles may either be protruded,  or  else the rectum be
dilated by means of a glass speculum with an opening in its side, the open-
ing being turned to the tumor.    Then, with  a piece  of soft wood or a hair
pencil dipped in a little of the strong acid, touch the tumors  in a longitu-
dinal direction, so  as to destroy entirely the vitality of the part  touched,
without  permitting  the  acid  to  spread to the adjacent parts.  In order
to  do this, but a few  drops of  the acid  should  be  put on the brush  or
swab, and the adjacent parts being  painted with  sweet oil, the  cauterized
portion should be washed with the  same immediately after the application
of the acid.
  The advantages claimed for this  treatment, by Houston, are safety from
hemorrhage, and contraction of the vessels and  tissues  consequent on the
separation of the slough.  The objection to its use is the continuance of severe
pain, when  the cauterization is not  sufficient  to kill  the part,  or when any
portion of the acid escapes on to  the skin, at the verge of the anus.
  Thweatt, of Virginia,  has successfully treated hemorrhoids by this means,
and so have several other surgeons in the United States.   Cooke, of England,
has also relatedf six cases of hemorrhoids cured under the use of the nitric
acid, by applying a dossil of lint dipped in the acid to the pile, and pressing it
there for fifteen or twenty minutes; during this time the pain is severe, though
the cure is rapid; an abscess close to the  sphincter muscle  also followed in
one case, but ultimately got well.   Severe dysuria has  frequently supervened,
and the ulcer left by the separation of the slough requires after-treatment on
general principles.
  II. The Ligature.—The hemorrhoidal tumor may  be strangulated either
* Dublin Med. Journ., March, 1843, p. 94, et seq.;  also Sept. 1844.
f London Med. Times aud Gazette, April, 1853. 
600
PRINCIPLES AND PRACTICE  OF SURGERY.
 by threads passed through its base, and then tied so as to surround it, or by
 encircling it with a wire ligature drawn tight by means of a double canula,
 (Physick,) or by throwing a simple loop of silk over it, so as to constrict its
 base, Plate  LXIII. Fig. 1.
   These methods of  applying  the ligature are  often  followed  by serious
 symptoms, aud its employment is  better effected  by the  plan of Horner,
 hereafter described.
   III. Excision.—The removal of hemorrhoidal tumors by excision may be
 effected by seizing them in toothed forceps, and removing them with scissors
 curved on the side, (Dupuytren,) or by passing a ligature through the tumor,
 and excising it with a bistoury.
   As illustrative of the dangers  sometimes created  by excision,  I cite the
 following unpublished case left in  manuscript by the late W. E. Horner, of
 Philadelphia:—
   Excision of Hemorrhoids, free hemorrhage.—"The Hon. Mr. B.,  mem-
 ber of Congress from  Ohio, has had hemorrhoids for  several  years.  He has
 lost but little blood frora thera.  By forcing he brings down three of a purple
 color, and about half the size of an ordinary fig.
   "He appears to be  about  forty-five years of age, short, but muscular and
 powerful, aud of  great energy of  character.
   " Operated on by T. Harris as follows:  the tumors being  forced down, a
 ligature  in the case of each  one was passed longitudinally through its base
 with a needle.  This ligature being then drawn  up slightly, the tumor was
 excised at its base with a pair of strong scissors.  A flat fold of the skin, at
 the margin of the anus, was also excised.
   "Operation done at 11^ a.m., and  borne with remarkable fortitude.  At
 a quarter past twelve  profuse bleeding and alarming  faintness  having  come
 on, lint dipped in creosote was introduced into rectum.  This not answer-
 ing, about 3U of creosote mixed into a ball with wheat flour  was introduced
 by means of a speculum.  But  little blood was discharged externally, but,
 from the extreme prostration, attended with faintness and  vomiting, urgent
 thirst and general uneasiness, apprehensions were  excited that an internal
 bleeding might be taking place in  the colon.
   "About 3£ p.m. faintness still alarming, with some  slight external flow of
 blood; on  introducing a speculum, the suppository  of flour and  creosote
 came away.  The rectum was then packed with lint imbued with the creosote.
  " About 8£ p.m. discharged the  lint, aud with it about a pound  of coagu-
 lated blood.
  "His condition being the same  up to 10£ p.m., a teaspoonful of laudanum
 was given by the mouth.
  "He took, in  the afternoon,  some  doses of the  acetate of lead,  but his
 stomach was too irritable to  retain it.
  "In the morning some brandy and water was given; also neutral mixture.
  "There was no very active external hemorrhage after the first day, but
 the extrerae pallidness of his face  and  the prostration indicated that it had
 occurred, to a large extent, into the colon.
  " In five or six days afterward, his bowels being opened by an  injection,
 an immense quantity of dark grumous blood came off, showing that great
 internal hemorrhage had occurred  while he was in the fainting condition.
  "In about four weeks he left the city, cured."
  IV.  Incision at the Base of the Pile, followed by Ligature.__The objec-
tion to the  use of the wire ligature, as usually applied, is the extreme pain
induced by the constriction of the  nerves of the skin, as  well as the suffering
and delay consequent upon the sloughing of the tumor.  The  following plan 
                       HEMORRHOIDS, OR PILES.                   601

has, therefore,  been suggested, in order to obviate suffering, and  effect a
speedy, safe, and permanent cure :—
  Operation of Horner, of Philadelphia.*—Calm the irritability of the
rectum  by cold water injections, employing  them  several  days before the
operation.  Then, at the time of the operation, empty the rectum, direct the
patient to force  out the tumors by straining in a squatting position  over
a vessel of hot  water, and place him in bed on the side corresponding to the
tumors after they are protruded.
  Now, after a thorough etherization, pass a large needle  and  strong silk
ligature transversely through the upper part  of the largest tumor,  and, re-
moving the needle, form a loop by tying together the ends of the ligature,
directing  it to be held by an assistant, so as to prevent the retraction of the
hemorrhoids within the rectum,  Plate  LXIII.  Fig.  2.   A strong awl, or
slightly curved tenaculum, being next made to transfix the base of the same
tumor in a line transverse to the ligature, the  assistant should hold this with
his other  hand so as to pry or elevate the  mucous coat  from the subjacent
parts, when  the  surgeon should make a semicircular incision around the
base  of the tumor of a sufficient depth to detach the anal plexus of veins
from  the  sphincter muscle, cutting into the skin and  not upon the  mucous
lining of  the bowel, keeping sufficiently  close to  the margin of the  anus
to prevent a fold of integument  being left upon  its edge, as this is apt to
swell, inflame, and become exceedingly painfull The awl and  ligature being
then  passed through the loop of a wire ligature, the latter should be carried
around the base of  the tumor, so as to occupy the line of the incision on one
side,  and  the mucous covering of the tumor on the other.  The wire being
drawn perfectly tight, or until the tumor becomes  dark brown or black, its
end should be  fastened upon the canula, and the venous plexus will be per-
fectly constricted through the mucous coat of the rectum on  the inner face
of the tumor, and through the connective  tissue of the gut on its outer side.
If the tumor remains large and very tumid,  after being constricted by the
ligature, puncture it with a lancet or bistoury,  and permit its blood to escape;
after  which a piece of cerate should be temporarily placed between the tumor
and the incision in the skin of  the margin  of  the anus, to  guard against
adhesions of the  tumor, and an anodyne  enema  given,  the thread  ligature
being left  in the hemorrhoid for four and twenty hours, when  it may be
used  to elevate the  tumor  while it  is snipped off with a  pair of  scissors,
the wire loop being  thus freed from its  position without creating  any loss
of blood.
  The Ecraseur.—The suggestion, in 1855,  by Chassaignac, of Paris, of a
means of  slowly strangulating any tumor until the ligature cut or lacerated
through the mass by means  of  a chain drawn tight  in a shaft by a screw
—the instrument being called the Ecraseur,  or crusher—has attracted con-
siderable attention,  and was received at first with marked favor.  A calmer
investigation, aided by experience, has, however, tended to excite in the minds
of many great doubts of its utility, while its application by the author to the
removal of mammary glands, legs, etc. has created the distrust often caused
by blind enthusiasm. To hemorrhoids it was, however, supposed that the ecra-
seur would be specially applicable, and well adapted for their removal with-
out risk of heraorrhage or other evil result.  Experience, even as stated by
Chassaignac in his treatise on " l'Ecrasement Lineaire," has, however, shown
that heraorrhage does occasionally supervene, that contraction of the anus is
sometimes so marked as to render it desirable promptly to open the wound
* Am. Journ. of Med. Sciences, vol. iv. N. S. p. 358. 
602            PRINCIPLES AND  PRACTICE OF SURGERY.
left by the ecraseur, and introduce a meche ;  while, in some instances,* the
belly  has become  enormously distended by flatus, owing  to the adhesions
of the side of the  anus, the dilatation of which exposed to hemorrhage, and
necessitated  the use of the meche  to  prevent the growing together of the
adjacent portions of the orifice of the bowel.
  Although as a matter of history, and  to enable others to judge for them-
selves of the advantages of this so-called new operation, I cite it, it is with
no wish  to recommend or approve of its repetition.  With the safety and
benefits of ligation by the use of threads, or by the application of a wire
ligature or the sloughing of the tumors by nitric acid, well  established, there
is no good reason for substituting a plan that requires a resort to an expen-
sive instrument  as an  addition to strangulation by a ligature previously
applied to pediculate the  mass; it  being well established that the ecraseur
cannot be made to act on tumors with broad bases.  Chassaignac's operation
is as follows:—
Fig. 439.
H. S-C3ALO.
 Fig. 439.—Two varieties of the Ecraseur of Chassaignac, showing how the loop of the chain is tightened
         so as to excise by slow pressure whatever is included in its grasp. (After Kolbe.)

  Operation of Chassaignac by the Ecraseur.—In order to  form a pedicle
for the tumor, the forefinger of the operator, with a large loop of a ligature
on the knuckle, should be introduced into the rectum, with the last phalanx
curved so as to hook out toward the exterior of the anus the hemorrhoidal
tumor, without bringing it entirely out of the gut.  The loop of this ligature,
being then pushed  by an assistant over the convex side of the forefinger as
far as possible to  the base of the pile, is then to be drawn tight  (Fig  440)
around the tumors.^
  The loop of an Ecraseur being  now made to surround the hemorrhoids
close  above the  ligature, is to be  slowly tightened, about one link of the
chain being drawn within the shaft every half minute, so as to give time for
* Op. cit, pp. 89 and 102. 
HEMORRHOIDS, OR  PILES.                         603
the formation of a  coagulum  in the veins of the hemorrhoids;  the excision
by the ecraseur occupying from twelve to  fifteen minutes.*

                                        Fig. 440.
  Fig. 440.—A view of the Preliminary Steps necessary in the removal of Hemorrhoids by the Ecraseur.  1.
The hand of an  assistant supporting the buttocks as the patient lies on his right side with the left thigh
strongly flexed on the pelvis.  2. The left forefinger.  5. The right forefinger of the operator in the act of
passing the loop of a ligature, 3,4, around the hemorrhoids, in order to pediculate the tumor for the ecraseur.
(After Chassaignac.)
                                        Fig. 441.
  Fig. 441.—A view of the Application of the Ecraseur in the Removal of Hemorrhoids.  The hemorrhoids
being internal, have been drawn down and held by a book.  1. Hand of an assistant supporting the buttock.
2. The hemorrhoidal tumor, with some prolapse of the mucous membrane. 3. The ligature applied to pedic-
ulate the tumor.  4. The hand of an assistant holding it.  5. The ecraseur embracing the tumors in its loop.
6. The multiplied hook. (After Chassaignac.)
* Traitement par l'Ecrasement Lineaire, par M. E. Chassaignac, p. 64.   Faris,  1856. 
                          PLATE  LXIV.
                  OPERATIONS FOR FISTULA  IN ANO.
  Fig. 1. A Section of the  Rectum and Anus, in order to show the relations of
the parts in a Blind Fistula.  1.  Rectal orifice of the fistula.  2. Its position in
the fat abont the anus.  3.  The gut.  4. The anus.  5. The structure immedi-
ately around the auus.                          After Bernard and Huette.

  Fig. 2. A similar section to show the relations of an Incomplete Fistula.  1.
Orifice of the fistula iu the buttock.  2. Its termination.  3.  Rectum.  4.  Anus.
5.  Surrounding parts.                           After Bernard and Huette.

  Fig. 3. Section showing the relations of a Complete Fistula.  1. Rectal orifice.
2.  External opening.   3. Rectum.  4.  Anus.  5.  Surrounding structures.
                                               After Bernard and Huette.

  Fig. 4. Operation for Fistula in Ano  by the Knife.  The patient being placed
upon  the affected side, the parts can  thus be laid open without exposing the
surgeon to the chance of injuring his own finger, as has often  happened by the
sudden  motion of the patient when placed upon his  hands and knees.  1. The
hand of an assistant supporting the buttock.  2. The left forefinger of the surgeon
passed into  the rectum to touch the point of the bistoury.  3. His right hand
introducing the bistoury through the anal orifice of the fistula, in order to  divide
the parts from above downward as he withdraws both hands.  4. The fistulous
opening.                                                    After Nature.

  Fig. 5. Section  to show the Operation of Probing a Fistula.   1. Rectal
orifice of the fistula.  2.  Its anal orifice.  3. The rectum.   4. A probe passed
along the fistula until its point touches the forefinger in the rectum.
                                                After Bernard and Huette.
  Fig. 6. Division of a-Superficial Anal Fistula by the Bistoury, as passed along
a Director.   1.  The rectal orifice of fistula.  2.  Its anal opening. 3. The gut.
4,  5. The director.   6. The bistoury passing along  it.  7.  The  portion  of the
integuments near the anus, which is  to be laid open.  The  drawing represents
the patient in  the position of Fig. 4.              After Bernard and Huette.

  Fig. 7. The Operation for Fistula in  Ano by means of the Ligature.  1. The
rectal orifice.   2. The anal opening.   3. The rectum.  4, 4. The ligature in
situ.   5. The tissue to be divided.                After Bernard and Huette.
        (604) 
L'late 64.
Fig. I.
 
 
FISTULA IN  ANO.
605
  Remarks.—The dangers that have been incurred in the excision of piles,
and the suffering consequent on the ordinary method  of applying the  liga-
ture, are facts that every experienced  surgeon must have frequently noted.
When, therefore,  it is necessary to select  a mode of operating, I would
recommend that proposed by Horner, as it is  one the success of  which I
have well tested.  In but one case has it been necessary to repeat the oper-
ation, while many, and some even of the very worst hemorrhoids that I have
ever encountered,  have been cured in about  two weeks, some patients being
able to sit up in bed in seven days; and  daily experience only tends to increase
my confidence in  it.   It is, however, of great consequence that the tumor
should not be excised and the ligature removed until the  strangulation has
entirely interrupted  the circulation of the part, lest hemorrhage be induced
subsequently.   In one patient, within the  last two years,  free hemorrhage
supervened several hours after the removal of the ligature, in consequence of
the vomiting induced  by the  use of the anaesthetic.   Though arrested by
ligating the vessels,  severe diarrhoea followed, and the patient died  on the
fourth day.

                          § 7.—Fistula in Ano.

  Pathology.—When, from any cause, an  abscess is developed about the
anus, it may discharge itself  by one or more small orifices,  either externally
upon the buttocks, internally  into  the  gut,  or by both surfaces.  From the
constant action of the sphincter and levator ani muscles, the approximation
of the sides of this abscess and their union is prevented, the  parietes of the
cavity become callous,  the orifice becomes small, contracted,  and indurated,
and the  condition known as Fistula in Ano is induced.   To facilitate the
adhesion of these  parts, by exciting  proper inflammatory action, and bring
the sides of the  abscess in contact, so that they may be kept at perfect rest,
is the object of the operations performed  for the relief of this complaint.
To accomplish this, two principal means are resorted to: 1.  The ligature. 2.
Incision.
  The Ligature.—The application of  a ligature to a fistula,  so as to induce
the division of the sphincter muscle by ulceration and the formation of healthy
granulations, may be effected in various ways; and by the use of the follow-
ing instruments of Gibson, it is rendered a simple and not very painful oper-
ation.
  Operation of  Gibson.*—A silver canula, five inches long and an eighth
of an inch wide, slightly curved, so as to convey a watch-spring ten inches
long, with a bulb at one end  and an eye at the other,  and with a steel stylet,
Plate LVIII. Figs.  24, 25, being  first prepared, the  surgeon should gently
probe the course of  the fistula, and if  it is  incomplete, pass in the canula,
with its  stylet  retracted, passing  the  left forefinger  into  the rectum, and
pressing the point of the canula against the side of the gut, where it is sup-
ported by  the finger; then push forward the stylet, puncture the wall of the
rectum, withdraw  the stylet, and pass  the canula through the opening thus
made, until it touches the finger in the rectum. On passing the watch-spring,
armed with a ligature, into the canula, carry the spring into the  cavity of
the gut,  and bring  one end  out of the anus;  when,  the canula and watch-
spring being removed,  the other end of the ligature will be  left  coming out
of the fistulous  orifice, Plate  LXIV. Fig.  7.  The  two  ends being now
loosely tied, the  patient may walk about until the ligature ulcerates out and
* Institutes of Surg., vol. ii. p. 164. 
606
PRINCIPLES AND  PRACTICE OP  SURGERY.
escapes, as during this  time the formation of granulations will generally
have removed the complaint.
  .Operation by the Knife.—Empty the bowels, and place the patient upon
the side next to the fistula;  pass the left index finger into the rectum; pass
the bistoury into the fistula;  bring its point to touch the finger, and, with-
drawing the two, lay open the gut and the cavity of the abscess by dividing
the levator  ani longitudinally, and the sphincters transversely.  Then keep
the anal orifice of the  fistula moderately open by introducing charpie  or lint
until it heals from its  upper  end  by the formation of new granulations, Plate
LXIV. Fig. 4.
  Remarks.—Among the various methods of operating for fistula  in  ano
recommended by surgeons at various periods, there is no difference  in the
indications to be accomplished, though individual peculiarity has suggested
a variety of instruments.  Of all these, but one demands special notice, and
that is the sheath bistoury of Wheatley and Physick.  This  instrument re-
sembles the  ordinary sharp-pointed bistoury, but has a sheath attached upon
the blade, which  covers its cutting edge as well as its point, but may be
shifted at pleasure.   This sheath saves  the patient the  pain likely to be
created by passing the sharp edge and point against the sides of the  fistula
in introducing the instrument, a  matter of some moment where etherization
is not practiced.  The position of the patient upon the side, with the limb
of the sound side flexed and that of the affected side extended, Plate LXIV.
Fig. 4, as pursued by  the French surgeons, is also better than that upon the
hands and knees,  or leaning  over a table or bed.  In the latter position, the
pain caused by the incision is apt to force  the patient away from the sur-
geon,  in consequence  of which the forefinger of the operator is liable to
injury.  Such a position is also incompatible with etherization, which, in an
operation upon an inflamed and sensitive part, is essential to the comfort of
the  patient.   Where time is not an object, or in tuberculous patients, the
ligature is  best  adapted to  the cure; but incision  is the most prompt  and
certain.
  When the surrounding parts and the edges of a fistula are indurated, the
French surgeons are accustomed to pare them  off, and leave the wide wound
thus made to heal by granulations.  But, in  the majority of cases, such a pro-
ceeding only increases the suffering of the patient, and delays the cure.  In
very callous cases, a slight paring of the edges of the incision  may expedite
the  treatment;  but, in most  instances, nature is capable of removing the in-
duration.
  For many years, surgeons  have entertained the  opinion that in pulmonary
tuberculosis the existence of a fistula in ano should  be sedulously cherished,
as it was thought to  exercise a  beneficial effect  upon this disorder.   This
opinion has, however,  been gradually yielding  to  more correct views of the
origin and progress of pulmonary tubercles, and the beneficial revulsive in-
fluence of  anal fistula  is now justly doubted.
  In the number of the Buffalo Med. Journal for February, 1858,  P. H.
Strong has ably  argued against the correctness of this opinion, and con-
tends  that the  proper object  for therapeutics, in tuberculous patients with
fistula, is to  remedy  the dyscrasy  on which it depends, and not to attempt to
eliminate the material by a continuous suppuration, as in fistula.  The better
plan of treating fistula in ano, in  tuberculous patients, is to favor the prompt
healing of the fistula  by the use of the ligature, and improve the  general
health of the patient by tonics and chalybeates. 
STRICTURE  OF THE RECTUM.
607
                      \ 8.—Stricture of the Rectum.

  Stricture of the Rectum is  often alluded to as a disease existing  inde-
pendently of other disorders, though most frequently it is due to the growth
of the carcinomatous deposits just alluded to.  An induration may, however,
be caused by the syphilitic disorder of the bowel, which is due to unnatural
intercourse, as is sometimes seen  in  Europe,  or it may be created by a true
tuberculous deposit in the cellular tissue, or in the adjacent glands, which, by
forming tumors, may press upon and obstruct the calibre of the bowel.  Very
often, however, the stricture of the rectum, which  is supposed to exist,  con-
sists merely of the spasmodic contraction of the sphincter ani muscle  that
has been already described  in  connection  with  the  subject of fissure of the
anus.
  Symptoms.—The  symptoms of stricture show themselves chiefly in the
obstruction of the course of the feces, in disordered  digestion, in hemor-
rhoids, and in the development of fistula in ano.
  Treatment.—The treatment is chiefly palliative, consisting in the dilatation
of the anus by the cautious use of bougies, and in attention to the digestion,
while the pain is relieved by the free use of anodynes. 
608
PRINCIPLES AND  PRACTICE  OF  SURGERY.
AMERICAN PAPERS ON THE DISORDERS OF, AND  OPERATIONS ON, THE
                GENITO-URINARY ORGANS  AND RECTUM.
    OPERATIONS ON THE PENIS.

New Method of performing the Operation
  of Phymosis,  by George  Bu*he,  M.D.
  New York.—New York Medtco-Chirurgi-
  cal Bulletin,  vol. i.  p 224.         1832.
Induration and Enlargement of the Penis,
  with a  new Mode of Amputating that
  Organ, by Thos. L.  Ogier, M.D. Charles-
  ton.—-Am. Journ. Med. Sciences, vol  xviii.
  p. 382.                          1836.
On Amputation  of the Penis,  by John P.
  Mettauer, M.D.  Virginia.—Boston Med.
  and Surg. Journ., vol. xvii.  p. 197.  1837.
A Case of Imperforate Prepuce, by D. J.
  C.Cain, M.D.  Charleston.—Am. Journ.
  Med. Sciences,  vol.  xiii.  N.  S.  p.  521,
  1847; also  Southern Journ. of Med.  and
  Pharm., Jan.                    1817.
Malformation of the  Genito-Urinary Ap-
  paratus, by L. A. Dugas, M.D. Georgia.
  —Southern Med. and Surg. Journal, vol.
  v. N. S. p. 193.                  1849.
Amputation of  the   Penis  for Cancer,
  (healed readily, but disease  reappeared
  at Pubis in  seven  months.)  by Wm. E.
  Horner, M.D.  Philadelphia — Med. Ex-
  aminer, vol. vii. N.  S. p.  99.       1851.
Report of a Case of  Phymosis,  (operated
  on by  Ricord's Operation and  Serres-
  fines instead of Suture,)  by Juriah Har-
  ris*, M.D. Augusta, Ga.—Southern Med.
  and Surg. Journ., vol. viii.  p. 21.   1852.
Gangrene  of the  Penis, supervening  upon
  an Attack of Typhoid Fever in a Patient
  suffering at  the  time with Gonorrhoea,
  by T. G. Richardson,  M D.   New Or-
  leans.—New Orleans Medical  and  Surg.
  Journ., vol. xvi. p.  679.           1859.
   ON DISORDERS OF  THE MALE
              URETHRA.

Fistula in Perineo, attended with consider-
  able loss of substance, cured by Lunar
  Caustic, by Wm. E. Horner, M.D.  Phila-
  delphia.—Phila. Journ. of Med and Phys.
  Sciences, vol. ix p. 141.         1824.
On the Treatment of Strictures of the Ure-
  thra by a Perineal Incision, with Cases,
  by Horatio G. Jameson,  M.D.  Baltimore.
  (First operation in 1820.) — Am. Med.
  Recorder,  vol. vii.  p. 251.         1824.
Description  of an  Instrument  (with a
  Plate)  for dividing  Strictures of  the
   Urethra, by  E. R. Chew, M.D.  Louisi-
   ana — North American Med. and  Surg.
   Journ., vol. v. p. 341.             1828.
 Practical Observations on Stricture of the
   Urethra, by H. G. Jameson, M.D.   Bal-
   timore.—Am. Med. Recorder, vol. xii. p.
   329.                             1828.
 Case of Stricture of the  Urethra, (treated
   by a  Perineal Section,) by Horatio G.
   Jameson, M.D.   Baltimore.—Maryland
   Med. Recorder, vol. i. p. 177.       1829.
 Operations for Artificial Urethra, (success-
  ful,) by John C.  Warren, M.D.  Boston.
   —Boston Med. and Surg. Journ., vol. ii.
   p  321.                          1829.
 Treatment of Stricture of the Urethra by
   rapid  and  free Dilatation, by  Paul F.
   Eve,  M.D.   Georgia.—New  York Med.
   Times, vol. iv. p. 3Ul.             1832.
 On Hypospadias, with Cases, by  George
   Bushe,  M.D.  New  York.—New  York
   Medtco-Chirurgical Bulletin, vol. ii. p. 1.
                                  1832.
 Case of Stricture of the Urethra strongly
   simulating Lithiasis. by N.  H.  Smith,
   M.D.   Baltimore.—North  American Ar-
  chives Med. and Surg.  Sciences, vol. i p.
  185.                             1835.
Complete Suppression  of Urine  from ob-
  literation of the  Membranous portion of
  the Urethra,  Puncture of  the  Bladder
  above the Pubis, Perineum opened and
  a new Urethra formed, (cured.) by E.
  Geddings, M.D.   Baltimore.—-4m. Ar-
  chives Med. and Surg. Sciences, vol. i. p.
  31.                              1835.
A Case of Stricture of the Urethra, cured by
  Bougies of the Bark of  the Slippery Elm
  Tree,  by Wm. Waters, M.D. Maryland.
  —Am. Journ. Med. Sciences, vol xxv. p.
  321.                             1839.
 Practical Observations on those Malforma-
   tions  of  the  Male Urethra and Penis,
  termed  Hypospadias and  Epispadias,
  with  an  anomalous  Case,  by John P.
   Mettauer, M.D.  Virginia.—Am. Journ.
  Med. Sciences, vol. iv.  N. S. p.  43.  1K42.
Employment of Gutta-Percha in the treat-
  ment  of Strictures, by Henry J. Bige-
  low, M.D.  Boston.— Boston Medical and
  Surg.  Journ , vol. xl. p. 9.        1849.
Case of Impermeable Stricture of the Ure-
  thra, (operated on through the Perineum;
  died on the nineteenth  day, having suf-
  fered from Hemorrhage,) with the sug-
  gestion of a new  shaped Catheter, by J. 
PAPERS  ON  THE  GENITO-URINARY  ORGANS  AND  RECTUM.    609
    A. Wragg, M.D. Savannah,G&.—Charles-
    Med. Journ., vol. viii. p. 799.      1852.
  Cure of a Laceration of the Urethra, by J.
    Gautier, M.D.  Alabama.—Am.  Journ.
    Med. Sciences, vol.  xxviii. N.  S. p. 413.
                                    1854.
  Perineal Section for Stricture of the Ure-
    thra, by F.  D. Lente, M.D.  New York.
    —Am. Journ. Med. Sciences, vol.  xxix.
    N. S. p.  574.                     1855.
  Remarks on Strictures of the  Urethra, by
    L. A. Dugas,  M.D.  Georgia.—Southern
 *  Med. and Surg. Journ., vol. xi. N. S.  p.
    645.                             1855.
  An  Easy  Mode of Constructing  Bougies,
    by P. H. Cabell, M.D.   Alabama.— Am.
    Journ. Med. Sciences, vol. xxxii. N. S.  p.
    578.                            1856.
  Perineal Section for Impermeable  Stric-
    ture, with  complete Recovery, by J. J.
    Chisolm,  M.D.   Charleston,   S.  C. —
    Charleston Med. Journ., vol.  xii. p. 301.
                                   1857.
 Case of an  Anomalous Sac or Pouch, con-
   nected with  the membranous portion of
   the Urethra, by C. E Isaacs, M.D.  New
   York.—New York Journ. of Med., vol. v.
   3d S. p. 9.     v                  1858.
 Stricture of the Urethra, treated by Syme's
   Operation of Perineal Section,  by W. S.
   Halsey, M.D.  Philadelphia.—American
   Journ. Med. Sciences, vol. xxxvi.  N. S. p.
   72.                             1858.
 Constitutional  Effects Produced  by  Sub-
   stances introduced into  the Urethra, by
   J.  L. Crawcour,  M.D.   New Orleans.—
   Am. Journ. Med. Sciences, vol. xxxvi. N.
   S.  p. 290.                        1858.
 History of Compressed Sponge for the Treat-
   ment of Strictures of the Urethra, Rec-
   tum, etc., also Morbid Growths and other
   Affections, by J. P. Batchelder,  M.D.
   New York.—New  York  Journal of Med-
  icine, vol. vi.  3d S. p. 301.        1859.
Diseases of the  Prostate Gland, by Valen-
  tine Mott, M.D.   New York.—Southern
  Med. and Surg. Journ., vol. xv. N. S. p.
  24.                              1859.
 OPERATIONS ON  THE TESTICLE AND
                  CORD.

 New Operation (Ligation of the Arteries)
   for Circocele, cured, by H. G. Jameson,
   M.D.   Baltimore.—Am. Med. Recorder,
   vol. viii. p. 271.                 1825.
 Operation for a  Tumor of  the Scrotum,
   (Omental  Hernia, cured,) by Jno. C.
   Warren,  M.D.  Boston. — Boston Med.
   and Surg. Journ., vol. i. p.  237.    18^8.
Case of Sarcocele successfully treated by
   tying the Spermatic Artery, by Horatio
   G.  Jameson,  M.D.  Baltimore.—Mary-
   land Med. Recorder, vol. ii.  p. 607.  1831.
Extirpation of the Testes and Penis affected
      vol. ii.—39
    with Cancerous  Disease, by J. C. Hall,
    M.D.   Washington.—Am. Journ. Med.
    Sciences, vol. x. p. 395.           1832.
  Extirpation of the Testis ; death from Phle-
    bitis, by Nathan R. Smith, M.D.   Balti-
    more.— North American Archives Med.
    and Surg. Sciences, vol. ii. p. 77.   1835.
  On  Tubercles of the  Testis, (Castration,
    etc.,) by Henry  H.  Smith, M.D.  Phil-
    adelphia.—Med. Examiner, vol. iii. p. 360.
                                    1840.
  Varicocele, and Extirpation  of the Testis,
    by F. H.  Hamilton,  M.D.  Rochester.
    —Boston Med. and Surg. Journ., vol. xxv.
    p- 153.                          1841.
  Treatment of Diseases of the Testicle, by
    Compression, in November, 1803,  by P.
    S. Physick, M.D.  Reported by Edward
    Hartshorne, M.D.  Philadelphia.—Am.
    Journ. Med. Sciences, vol.  iii.  N.  S. p.
    258.                             1842.
 Practical  Observations  on  the  Radical
    Treatment of Varicocele,  by John Wat-
    son, M.D.  New York.— Am. Journ. Med.
    Sciences, vol. x. N. S. p. 316.       1845.
 New  Operation  (Incision  and  Ligation)
    for the Radical Cure of Varicocele, per-
    formed  successfully  eight  times, by S.
    D. Gross, M.D.  Louisville.—Am. Journ.
    Med. Sciences,   vol.  xvi. N. S. p. 327.
                                    1848.
 Castration  of  an Enlarged and  Irritable
    Testis, by M. G. Delaney, M.D.  U. S. N.
   —Am.  Journ. Med. Sciences, vol. xvi. N.
   S. p. 292.                        1848.
 Extirpation of the Left Testicle, (etherized,
   cured.)  by  W.  E. Horner,  M.D.   Phil-
   adelphia.—Med. Examiner, vol. vii.  N. S.
   P- 33.                           1851.
 Extirpation of the Testis, (by  Jobert's Op-
   eration,  bi-valve flap, semi-circular in-
   cision, convex downward, so as to in-
   sure the  subsequent  escape of pus,) by
   Charles  Bell Gibson, M.D.   Richmond,
   Virginia. — Stethoscope,  vol. i.  p.  145.
                                   1851.'
 Ligation of the Spermatic Artery for the
   Cure of  Varicocele, by Horace  Nelson,
   M.D.  Plattsburg,  N. Y.— Boston  Med.
   and Surg. Journ., vol. xliv. p. 334.  1851.
 Removal of Diseased Testes,  (cured,) by
   R. McSherry, M. D. U. S. N.—Am. Journ.
   Med. Sciences, vol. xxii. p. 119.    1851.
 Case of Congenital Cystic Sarcoma of the
   Left Testicle, (extending from near the
   left  inguinal ring to near the knee,)
   cured by  excision, by D. Gilbert,  M.D.
   Philadelphia.—Philadelphia  Med. Exam-
  iner, vol. ix. N. S. p. 154.        1853.
Accidental  Castration,  by  L.  A.  Dugas,
   M.D. Georgia.—Southern Med. and Surg.
  Journ., vol.  ix. N. S.  p. 209.     1853!
Varicocele and its Treatment, by J.  Har-
  riss, M.D.  Augusta, Georgia.—South.
  Med. and Surg.  Journ.,  vol.  x. N. S. p.
  205-                             1854! 
610            PRINCIPLES  AND  PRACTICE OF SURGERY.
 Varicocele successfully treated, by Juriah
   Harriss, M.D.  Georgia. — Amer. Journ.
   Me I. Sciences,  vol. xxviii.  N. S.  p. 284.
                                  1854.
 New  Instrument for producing  Compres-
   sion in Orchitis,  by T. L. Ogier, M.D.
   Charleston, S. C. — Charleston  Medical
   Journal, vol. ix. p. 788.          1^54.
 Case  of  the  Entire Scrotum and  Integu-
   ments of the Penis, with one Testicle and
   Cord attached, torn off,  recovery, with
   Sexual Powers, by Robert  W.  Gibbes,
   Jr . M.D.  Columbia, S. C.—Charleston
   Med Journ., vol.  x. p. 154.       1855.
 Castration. Recovery, followed by Phthisis
   Pwlmonalis, by Wm. T.  Taylor, M.D.
   Philadelphia.—Am. Journ. Med. Sciences,
   vol. xxx N S. p. 85.             1855.
 Elephantiasis of the Scrotum and Buttock,
   Operation.  Death, Autopsy, by N. Boze-
   man.   M.D.   Alabama. — New  Orleans
   Med. and Surg. Journ.,  vol. xi.  p. 433.
                                  1855.
 Testicle  containing  Hair, Removal, by J.
   C. Nott,  M.D.   Mobile, Alabama.—Am.
   Journ.  Med. Sciences, vol. xxx. N. S. p.
   77.                             1855.
 Varicocele cured by Retrenchment of the
   Scrotum,  by  Samuel  B.  Richardson,
   M.D.   Louisville,  Kentucky.—Southern
   Med. and Surg. Journ.,  vol. xii. N. S. p.
   371.                            1856.
Description of the Valve at the Termination
   of the Right Spermatic Vein in the Vena
   Cava, with Remarks on its Relations to
   Varicocele, by John II. Brinton, M D.
   Philadelphia.—Am. Journ. Med. Sciences,
   vol. xxxii.  N. S. p. 111.          1856.
Extirpation of Tubercular  Testicles, with
   a Description of the Pathology and His-
   tory of a very interesting  Specimen, by
   J. J. Chisolm,  M.D.  Charleston, S. C.
   —Charleston Med. Journ., vol. xii. p. 614.
                                  1857.
Case  of  Hsematocele, by J. H.  Packard,
   M.D.   Philadelphia.—Am. Journ. Med.
   Sci., vol. xxxvi. N. S. p. 81.      1858.
           ON  HYDROCELE.

Hydrocele  treated by Injection, by David
  Hosack,  M.D.  New York.— N. Y. Med.
  Repository, vol. i. p. 419.         1797.
Observations on Hydrocele, by B. Winslow
  Dudley. M.D.  Lexington.—Transylva-
  nia Journ. of Med., vol. i  p. 268.  i828.
Case of Congenital Hydrocele, tapped by
  Dr. McComb, with  Remarks by George
  Bushe,  M.D.   New York.—New  York
  Medico-Chirurgical Bulletin, vol. i. p. 21.
                                  1832.
On  Hydrocele,  by George Hay ward, M.D.
  Boston —Boston Med. and Surg.  Journ.,
  vol. xix.  p. 154.                 1839.
Case of Sudden Formation of Hydrocele,
   unconnected with inflammation of Tu-
   nica  Vaginalis,  (operation — cure,) by
   Henry II. Smith, M.D.  Philadelphia.—
   Am.  Journ.  of Med.  Sciences, vol.  xiii.
   N. S. p. 85.  '                    1847.
Large Hydrocele, (53 ounces,) cured by in-
  jection and seton, by Henry H. Smith,
   M.D.  Philadelphia.—Medical Examiner,
   vol. vii. N. S. p. 175.              1851.
Radical Treatment of Hydrocele by Lunar
   Caustic, applied to the Internal Surface
   of the Tunica Vaginalis, by W. Parker,
   M.D.  New York.—N. Y. Journ. of Med.,
   vol. xii. N. S. p.  51.              1854.
Hydrocele successfully treated by Incisions
   and  introducing  a Tent-cloth, by  Bed-
   ford Brown, M.D.  Salem, Fauquier Co.,
   Va.—Am. Journ. Med. Sciences, vol. xxx.
  N. S. p. 268.                     1855.
Hydrocele permanently cured by Injection
  of Iodine and a  Seton combined, by  Isaac
  Lefever, M.D.  Perry  Co.,  Pa.—Amer.
  Journ. Med. Sciences,  vol.  xxx. N.  S. p.
  406.                             1855.
Radical Cure of Hydrocele without Injec-
  tions,  by  A.  S.   Hudson, M.D.   Am.
  Journ. Med. Sciences, vol. xxix. N.  S. p.
  269.                             1855.
Two Cases of Hydrocele, by Juriah Harriss,
   M.D.   Augusta, Ga.—Southern Med. and
  Surg. Journ., vol.  xi. N. S. p. 400.  1855.
Hydrocele of the  Tunica Vaginalis, by G.
  Fries, M.D.   Cincinnati.— Western Lan-
  cet, vol. xviii. p 81.              1857.
Bilobular Hydrocele, Operation, Cure,  by
   A. Mercier, M.D.   New Orleans.—New
   Orleans Med. and Surg.  Journ., vol. xv.
  p. 194.                          1858.
Two cases of Chronic Hydrocele radically
  cured, in fourteen days, by Excision of
  the Tunica Vaginalis Testis, by Henry
  H. Smith,  M.D., of Philadelphia.   Re-
  ported by J. J.  Woodward, M.D.  Phila-
  delphia.—Am. Journ.  Med. Sciences, vol.
  xxxv. N. S. p. 344.              1858.
  OPERATIONS ON THE  BLADDER.

Preternatural Retention of Urine in conse-
  quence of external injury, Bladder tap-
  ped  above the Pubes, cured,  by James
  Thacher,  M.D.  Plymouth.— Med. Com-
  munications  and Dissertations of  Mass.
  Med. Society, vol. i. p. 35.          1790.
Observations on  Retention  of  Urine, by
  Samuel Anan, M.D.  Baltimore.— Mary-
  land Med.  Recorder, vol. i.  p. 72.    1829.
Laceration of the  Urethra from a fall on
  the perineum, retention of urine, (Blad-
  der punctured above the  Pubes,) died,
  by Thomas F. Betton, M.D., of Philadel-
  phia, (with Observations by Isaac Hays,
  M.D.)— Am. Journ. Med. Sciences, vol.
  xix.  p. 389.                      1836<
Paracentesis of the  Bladder, through  the 
PAPERS  ON  THE  GENITO-URINARY  ORGANS AND RECTUM.   611
  Perineum, by N. R. Smith, M.D.   Balti-
  more.—Am. Journ.  Med.  Sciences,  vol.
  xxiii. p. 63.                     1839.
Closure of the Urethra from  an Injury of
  the Perineum,  Urine discharged by an
  Artificial Opening above the Pubes, the
  Natural Passage restored by an Opera-
  tion, by Gurdon  Buck,  Jr., M.D.  New
  York.—Am. Journ.  Med.  Sciences,  vol.
  viii. N. S. p. 544, 1844; also N. Y. Journ.
  of Med., Sept.                    1844.
Puncture of the Bladder above the Pubes,
  (cured,) by Otis F. Manson, M.D.  North
  Carolina.—Stethoscope,  vol. i.  p. 324,
  1851; and  West. Lancet, vol. xii. p. 409.
                                  1851.
Case of Puncture of the Bladder through
  the Symphysis Pubis,  by  D. Leasure,
  M.D.  New Castle, Pa.—Am. Journ Med.
  Sciences, vol. xxvii. N. S. p. 403.   1854.
Puncture of the Bladder through the Sym-
  physis Pubis,  by Dr. Brander.—Am.
  Journ. Med. Sci., vol. xxviii. N. S. p. 575.
                                  1854.
Spontaneous  Rupture of the Bladder,  Ex-
  travasation of Urine, Operation,  Recov-
  ery, by A. V. Williams, M.D. New York.
  —Am. Journ.   Med.  Sciences,  vol. xxix.
  N. S. p. 566.                     1855.
            ON  LITHOTOMY.

 Account of the  Successful Application of
   Cold Water to the  Lumbar Region in
   cases of Calculus, by John Willday, in a
   Letter to Benjamin Rush, M.D., 1788.—
   Trans. Phil. College of Physicians, vol. i.
   p. 76.                            1793.
 An Inaugural Dissertation on Stone in the
   Bladder, (recommending the Use of the
   Bistoury and Staff, with a Drawing,) by
   Henry U. Onderdonk, M.D.  New York.
   —Am. Med. and Philosoph. Register, vol.
   i. p. 394.                        1811.
 Extra-Uterine Foetus, incrusted with  Cal-
   culous Matter, extracted by the Opera-
   tion of Lithotomy, by Joseph  Bossuet,
   M.D.  Hingham,  Mass.—New  England
   Journ. of Med. and Surg., vol. vi. p. 135.
                                   1817.
 Lithotomy  Forceps, (made with  a fenes-
   trum, so as to permit the  grasping of a
   large calculus without the  extreme sep-
   aration of the handles of the instrument,)
   by John  Rhea Barton, M.D.  Philadel-
   phia.—Philada.  Journ.  Med. and Phys.
   Sciences,  vol. viii. p.  147.         1824.
Extraction of a Calculus from the Female
   Bladder  by Dilatation of  the  Urethra,
   by  Robert Hamilton, M.D.—Am. Med.
   Record , vol. xi. p. 115.           1827.
Two  Cases of Lithotomy,  (Lateral Opera-
  tion, both cured,) by  Lunsford  Pitts
  Yandell, M.D.  Lexington.—Transylvania
  Journ.  of Med., vol. i. p. 431.     1828.
 Description of a Remarkable Urinary Cal-
   culus, by R. D.  Mussey,  M.D—New
   Hampshire.—Am. Journ. Med. Sci., vol.
   iv. p. 333.                       1829.
 Case of Lithotomy, (Lateral Operation,)
   cured, by Hugh  H. Toland, M.D. South
   Carolina.—Transylvania Journ. Med.,vol.
   iii. p. 139.                       1830.
 Cases of  Lithotomy, (Lateral  Operation,
   cured,) in which the Stones were de-
   pendent on the  presence of a spicula of
   bone in the bladder, by Geo.  W. Camp-
   bell,  M.D.  Tennessee. — Transylvania
   Journ. Med., vol. iii. p.  211.       1830.
 Case of Chief-Justice Marshall;  Operation
   of Lithotomy ; more  than one thousand
   small Calculi extracted  by  Philip  S.
   Physick,  M.D.   Philadelphia.—Amer.
   Journal Medical  Sciences, vol. ix. p. 537.
                                   1831.
 Case of Stone, in which the Fundus of the
   Bladder was  coated  with  Calculous In-
   crustations, successfully operated on by
   Lithotomy, by Amasa Trowbridge, M.D.
   Watertown, New  York.—Am.  Journ.
   Med. Sciences, vol. xi. p.  27.        1832.
 On  the Bi-lateral  Operation for  Stone,
   (with Drawings  of Instruments  recom-
   mended for this Operation,) by  George
   Bushe, M.D.   New York.— N. Y.  Medico-
   Chirurgical Bulletin, vol. i. p. 1.    1832.
 Lithotomy  and Extraction of a Calculus
   measuring nearly twelve inches in cir-
   cumference, and weighing  upwards  of
   seventeen  ounces  avoirdupois,  (death,
   fifth day,) by Valentine Mott,  M.D.  N.
   York.—Am. Journ.  Med.  Set., vol. xiv.
   p. 530.                           1834.
 Supplementary Observations on Lithotomy,
   with a  description of the Instruments
   employed, etc.,  by N.  R.  Smith,  M D.
   Baltimore.—Baltimore Med. and Surgical
   Journal, vol. ii. p. 13.             1834.
 Case of Lithotomy in  which the  healing
   process  was interrupted by the super-
   vention  of an Eruptive Disease, by Jno.
   P.  Mettauer,  M.D.   Virginia.—Boston
   Med. and Surg. Journ., vol. xii. p. 283.
                                  1835.
 Statistical Account of the Cases of Urinary
   Calculi treated in the Pennsylvania Hos-
   pital, from May, 1756, to May, 1835, by
   Reynell  Coates,  M.D.    Philadelphia.
   (Sixty-one cases; fifty-two males; seven
   died.)—Am. Journ.  Med.  Sciences,  vol.
   xvii. p. 97.                      1835.
Case of Lithotomy,  Calculi of unusual size,
   (about eight ounces, cured,) by Nathan
   R. Smith, M.D.  Baltimore. (This case
  was the twenty-third operated on, with
  complete success, by Dr. Smith.)—North
  Am. Archives Med.  and Surg. Sci., vol.  i.
  p. 177.                          1835.
Lithotomy, Secondary Hemorrhage on the
  sixth and eighth days,  Pleuritis on the
  twelfth,  Cerebral Irritation on the six- 
612             PRINCIPLES  AND  PRACTICE  OF  SURGERY.
    teenth, and death on the twentieth day,
    by Nathan R. Smith, M D.  Baltimore.—
    North Am. Archives Med. and Surg. Sci.,
    vol. i. p. 233.                   1835.
 Observations on the Operation of Lithoto-
    my, illustrated by cases from the prac-
    tice of B.  W. Dudley, M.D.   Reported
    by J. M. Bush, M.D.  Lexington.—Am.
    Journ.  Med.  Sciences, vol.  xxi. p. 535,
    1837; also, Transylv. Journ. of Mid , vol.
    x. p  478.                       1837.
 Case  of  Urinary Calculus  in a Girl, suc-
    cessfully removed by Lithotomy, by T. D.
    Miitter, M.D. Philadelphia.—Am. Journ.
    Med. Sciences.vol. xxi. p. 260.     1837.
 Lectures on Lithotomy, with an Account
    of the Bi-lateral Operation, by Alexan-
    der H. Stevens, M. D. New York.— N. Y.
    Journ. Med, vol. xi. p. 104.       1838.
 Remarks on the Propriety and best man-
    ner of  breaking and  extracting  large
    Calculi  in the Lateral Operation, by J.
    C Nott, M.D. Mobile.—Am. Journ. Med.
   Sciences, vol. iv. N. S. p. 328.      1842.
 Lithotomy,  Bi-lateral  Operation,  with
   cases, by Paul F. Eve, M.D. Georgia.—
   Am. Journ. Medical Sciences, vol. vii. N. S.
   p. 504.                          1844.
 On the Bi-lateral Operation for Lithotomy,
   and on Lithotrity in the Female, by Jno.
   C.  Warren, M.D.  Boston.—Am. Journ.
   Med. Sciences, vol. viii. N. S. p. 293.  1844.
 On a new Form of Director and Gorget, by
   John P. Mettauer, M.D. Virginia. (With
   a Drawing )—Med. Examiner, vol. i. N. S.
   p. 648.                         1845.
 Lithotomy and Lithotrity, (with an Account
   of B. W. Dudley's Operations,) by J. M.
   Bush, M.D.    Lexington, Kentucky.—
   Am.  Journ. Med. Sciences, vol. xi. N. S.
   p. 545, 1846;  also, Western Lancet, Jan-
   uary.                           1846.
 Bi-lateral Operation in Lithotomy, by R.
   D.  Mussey,  M.D.   Cincinnati.—Amer.
   Journal Medical Sciences, vol. xi. N.  S. p.
   264.                            1846.
 Case of Lithotomy in the Female, with Re-
   marks,  by A.  Baker, Jr., M.D.   Che-
   nango County, New York.—Transactions
   of Med. Soc. State of New York, vol. vi.
   p. 133.                          1846.
 Extraordinary  Case of Urinary  Calculi,
   two hundred  and twenty-eight in num-
   ber, by John  Kelly, M.D.   New York.
   —Am. Journ. Med. Sciences, vol. xiii. N. S.
   p. 246.                          1847.
Lithotomy in a Child two years and eleven
   monthsold, Patient under the influence of
   Chloroform, (cured,)  by  Frank  H. Ham-
   ilton,  M.D.   Buffalo. — Buffalo  Med.
  Journ., vol. iv. p. 735.            1849.
Lithotomy  in an Adult under the influ-
   ence of Chloroform, (death in two weeks
  from Purulent Absorption,) by Frank
  H.  Hamilton,  M.D.   Buffalo.— Buffalo
  Med. Journ., vol. iv. 736.        1849.
  Lithotomy (Bi-lateral Operation) in a Boy
    ten years old, Calculus weighing 3*xv ;
    attacked  with  Dysentery  ninth  day,
    (died,) by Paul F. Eve, M.D.   Georgia.
    —Southern Med.  and Surg.  Journ., vol.
    v. p. 596.                        1849.
  Case of Lithotomy  in a Child, (four  years
    years old, cut by  the Bi-lateral Section,)
    Anaesthesia,  (Ether,)  died  forty-five
    hours after the Operation, by James R.
    Wood, M.D.   New  York. — New  York
    Journal of Medicine, vol. ii. N.  S. p. 326.
                                    1849.
  Lithotomy, one  hundred and seventeen Cal-
    culi, weighing  four  and a half ounces,
    successfully  removed, by Paul  F. Eve,
    M.D.   Georgia.—Am. Journ. Med. Sci.,
   vol. xvii. N. S. p. 539,1849; also, Southern
   Med and Surg. Journ., March.     1849.
 Results of fifteen Operations  for Lithotomy,
   by P.  C. Spencer, M.D.   Petersburg.—
   Am Journ. Med.  Sciences,  vol.  xx.  N. S.
   p. 103.                          1850.
 Stone in the Bladder,'weighing eight ounces,
   unpleasant Anchylosis of the  Hip, suc-
   cessful Bi-lateral  Operation, by Charles
   A. Pope,  M.D.  St.  Louis.—St. Louis
   Med. and Surg.  Journ., vol vii. N.  S. p.
   298.                             1850.
 Calculus  in  a Child seven  years  of age,
   (weight of Calculus  one  ounce, length
   one inch  and seven-tenths, greatest cir-
   cumference   four  inches   and  seven-
   tenths,) Lithotomy, Recovery,  by F. M.
   Robertson, M.D.  Charleston.—Charles-
   ton Med. Journal,  vol  vi. p 50.    1851.
 Lithotomy, (Calculus of Phosphate of Am-
   monia and Magnesia, weight two ounces
   and seventeen  grains,) Recovery, by
   Henry H. Smith,  M.D.  Philadelphia.—
   Med. Examiner, vol. vii. N. S. p. 235.
                                   1851.
 A Case of Double Lithotomy, (died in eighty-
   three hours ;  first lateral  incision, then
   high operation,  owing to the size of the
   Calculus;  weight nearly six   ounces,
   length three  inches,  longitudinal cir-
   cumference seven inches, width  two
   inches,  lateral  circumference  five  and
   three-fourth inches.) by Wm.  J. John-
   son, M.D.    Fort  Gaines,  Georgia.—
   Southern Med.  and  Surg. Journ., vol. vii.
   P- 727.                          1851.
 Lithotomy, (Bi-lateral  Operation, cured,)
   by Henry F. Campbell, M.D.  Augusta,
   Georgia. — Southern   Med.  and Surg.
  Journ., vol. vii. p.  393.          1851.
Removal of  an ounce and a half of Calcu-
   lous Matter from the Bladder by Lithot-
   omy, (Bilateral  Section, three  Stones,)
  by Henry F. Campbell, M.D.  Augusta,
   Georgia. — Southern  Medical and Surg.
  Journ., vol. vii. p.  459.           1851.
Two Cases of Lithotomy, (cured; Chloro-
  form ; Lateral Operation by N. R. Smith's
  Beaked Knife,)  by Carter P. Johnson, 
PAPERS  ON  THE  GENITO-URINARY  ORGANS AND RECTUM.    613
   M.D.  Richmond.—Stethoscope, vol. i. p.
   656.                             1851.
 Lithotomy successfully performed on a Boy
   aged seven, (Chloroformized and Bi-lat-
   eral Section,) by William Nephew King,
   M.D.  Roswell, Georgia.—Southern Med.
   and Surg. Journ., vol. vii. p. 663.  1851.
 Lithotomy,  Bi-lateral  Operation with  the
   Double Lithotome of Dupuytren, (cured,)
   by John Fred. May, M.D.  Washington.
   —Am.  Journ. Med.  Sciences, vol.  xxiii.
   N. S. p. 407.                     1852.
 Lithotomy in  a Female  four years old,
   (died,) by John Fred. May, M.D.  Wash-
   ington.—Am. Journ. Med.  Sciences, vol.
   xxiii. N. S. p. 411.               1852.
 Report of twenty-five  Cases  of Urinary
   Calculus, in twenty-three of which  the
   Bilateral Operation was performed, by
   Paul F.  Eve,  M.D.   Nashville.— Am.
   Journ. Med. Sciences, vol. xxiv. N. S.  p.
   41.                              1852.
 Operations for the removal of Calculi  in
   the Urethra, by D. W. Hammond, M.D.
   Georgia. — Southern  Med.  and   Surg.
   Journ , vol. viii. p. 654.           1852.
 Summary of twenty-five Cases of Urinary
   Calculi, in twenty-three of which the Bi-
   lateral Operation was performed, (twen-
   ty-one recovered,) by Paul F. Eve, M.D.
   Nashville.—N.  Y. Journal  of Medicine,
   vol. ix. N. S. p. 292, 1852, from Nashville
   Jf>urn.  Med.                     1852.
 Operation of  Lithotomy, (cured,  Lateral
   Incision.) by Alden  March, M.D.   Al-
   bany.— Western Lancet, vol.  xiii. p. 660.
                                   1852.
 Lithotomy in  a Child  eight years of age,
   successful under etherization, by Henry
   H. Smith,  M.D.   Philadelphia.— Med.
   Examiner, vol. viii. N. S. p.  224.   1852.
 Lithotomy, (successful;  Lateral Operation;
   Beaked Knife; two Stones, each an ounce
   and a half,)  by Richard L. Howard, M.D.
   Columbus, Ohio.—Ohio Med. and Surg.
   Journ., vol. iv. p. 290.            1852.
 Two Cases of  Lithotomy, (Lateral Opera-
   tion,  cured.)  by Richard  L. Howard,
   M.D. Columbus, Ohio.—Ohio Med. and
   Surg. Journal, vol. iv. p. 371.      1852.
 Three Cases of Foreign Bodies introduced
   into the Bladder, which were removed
   by the Operation of Lithotomy, reported
   by Amasa  Trowbridge, M.D.  Water-
   town,  N.  Y.—New  York Med. Gazette,
   vol. iv. p. 289.                   1853.
 Case of Lithotomy, (Chloroform ; Calculus
   five ounces ; died on the nineteenth day,)
   by M. L. Leider, M.D.  Ohio.— Western
   Lancet, vol.  xiv. p. 666.           1853.
 Cases of Lithotomy, (three, operated on by
   the Bi-lateral method and Chloroform;
   two  cured,  one  died,) by L. A. Dugas,
   M.D.  Augusta, Georgia.—Southern Med.
  and Surg. Journ., vol. ix. p.  82.    1853.
Stone in the Bladder, Lithotrity, Cystitis,
  etc.; Lithotomy, successful, by Wm. H.
  Van Buren, M.D.  New York.—N.  Y.
  Med. Times, vol. ii. p. 369.        1853.
Three Cases of Lithotomy, with Remarks,
  by L. A. Dugas, M D.  Georgia.—South-
  ern Med. and Surg. Journ., vol. ix. N. S.
  p. 82.                           1853.
Three  Cases of Lithotomy in Infants, by
  T. Wood,  M.D.— West. Lancet, vol.  xv.
  p. 73.                           1854.
Results of  Twenty-four  Operations  for
  Lithotomy,  by  P. C.  Spencer.  M.D.
  Petersburg, Va.—Am. Journ. Med. Sci-
  ences, vol. xxix. N. S. p. 577.      1855.
High Operation  for Stone in the Female,
  by W. Parker, M.D. New  York.—A7". Y.
  Journ.  of Med., vol. xiv.  N. S. p. 252.
                                  1855.
Two Cases of Stone in the Bladder, Lith-
  otomy, by Wm. H. Gardner, M.D. Wood-
  sonville, Ky.— Wester n Journ. of Med. and
  Surg., vol. iii.  N.  S. p. 341.       1855.
Remarks on the various Operations for re-
  moving Calculi from the Bladder of the
  Female, with a New Method, by G. C. E.
  Weber, M.D.  New York —Southern Med.
  and Surg.  Journ., vol.  xii.  N.  S. p. 735.
                                  1856.
Stone in the Bladder, Operation, Recovery,
  by D. S.  Brandon,  M.D.  Thomasville,
  Ga.—Southern Med. and Surg. Journ.,
  vol. xii. N. S.  p. 678.             1856.
Three Cases of Lithotomy, by L. A. Dugas,
  M. D. Georgia.—Southern Med. and Surg.
  Journ., vol. xii. N. S. p. 267.      1856.
Analysis of  123 Urinary Calculi in Warren
  Museum of Boston, by James C. White,
  M.D. Massachusetts.—New York Journ.
  of Med., vol. i. 3d S. p. 570.       1856.
Remarks on  the various Operations for the
  removal of Calculi from the Female Blad-
  der,  with  a  New Method, by G. C.  E.
  Weber, M.D.  New York.—N. Y. Journ.
  of Med., vol. i. 3d S. p. 53.       1856.
Cases of Lithotomy, by L.  A. Dugas, M.D.
  Georgia.—South. Med. and Surg. Journ.,
  vol. xii. N. S.  p. 267.             1856.
Gutta-Percha Bougie broken in the Blad-
  der, Lithotomy for Removal, Recovery,
  by It. T. Maxwell, M.D.  San Francisco,
  Cal. — Am. Journ.  Med.  Sciences, vol.
  xxxiii.  N.  S. p. 67.               1857.
Cystotomy  for  "Bar-like Ridge"  at  the
  Neck of the Bladder, treated at the Com-
  mercial Hospital of  Cincinnati.   Re-
  ported  by S. Sharp, M.D.  Cincinnati.
  — Western Lancet,  vol. xviii.  p.  271.
                                  1857.
Removal  of  a large Urethro-Vesical Cal-
  culus,  by A. Reeves  Jackson,  M.D.
  Stroudsburg,  Pa.—Am. Journ.  Med. Sci-
  ences, vol.  xxxvi. N. S. p. 87.      1858.
Results of  Twenty-eight  Operations  for
  Stone in the Bladder, by P. C. Spencer,
  M.D.—Am.  Journ.  Med.  Sciences, voL
  xxxvi. N.  S. p. 578.              1858. 
614
PRINCIPLES AND PRACTICE OF SURGERY.
       Remarkable Vesical Calculus formed on
         Wax, by J. C. Nott, M.D.  Lou3iana.—
         New Orleans Med. and Surg. Journ., vol.
         xv. p.  191.                      1858.
       Epicystotomy, with a Report of a Case suc-
         cessfully performed under most unfavor-
'        able circumstances, by E. Noeggerath,
         M.D.  New York.—New York Journ. of
         Med., vol. iv. 3d. S. p.  9.         1858.
          ON LITHOTRIPSY'.

Lithotripsy successfully performed, by L.
  Depeyre, M.D.  New York.  (October,
  1830. First successful Case in the United j
  States.)—North American Med. and Surg.
  Journal, vol. xi.  p. 492.           1831.
Successful Lithotrity, by Alban G. Smith,
  M.D.  Danville, Ky.—North Am. Med.
  and Surg. Journ., vol. xii. p. 256. 1831.
Lithotrity, successfully performed by P. S.
  Spencer.  M.D.   Virginia.—Am. Journ.
  Med. Sciences, vol. xii. p. 551.     1833.
Lithotripsy, successfully performed in six
  Cases, by J. Randolph, M.D.   Philadel-
  phia.—Am. Journ. Med. Sci., vol. xv. p.
  13.                             1834.
Removal of'Calculi from the Urethra, by
  means of a  Wire Loop attached lo a Sil-
  ver Bougie, by A. Leander Uttery, M.D.
  Providence.—Boston Medical and Surgical
  Journ., vol. xii. p.  237.           1835.
Case of  Urinary Calculus,  in which J.
  Randolph, M.D., successfully performed
  Lithotripsy.  Reported  by  Isaac Hays,
  M.D.  Philadelphia.—Am.  Journ. Med.
  Sci., vol. xvii. p. 258.            1835.
Sketch of Lithotripsy, with Cases, by Wil-
  liam Gibson, M.D.   Philadelphia.—Am.
  Journ. Med. Sciences, vol.  xviii. p. 338.
                                  1836.
Seven  additional Cases of Stone in the
  Bladder,  successfully treated by  Litho-
  tripsy, by J. Randolph, M.D.  Philadel-
  phia.—Am. Journ. Med. Sciences, vol. xix
  p. 52.                           1836.
Report of four additional Cases of Stone
  in the Bladder,  successfully treated by
  Lithotripsy, by J. Randolph, M.D.  Phila-
  delphia.—Am. Journ. Med. Sciences, vol.
  xxi. p. 13.                       1837.
Report of Cases of Lithotripsy, by N. R.
  Smith, M.D.  Baltimore.—Am. Journ.
  Med. Sciences, vol. xxi. p. 25.      1837.
Cases of Lithotrity performed  by J. Ran-
  dolph, M.D. Reported by 4. E. Stocker,
  M.D.  Philadelphia.—Am. Journ. Med.
  Sciences, vol. xii. N. S. p. 263.     1846.
Four Cases of Lithotripsy, performed  by
  J. Randolph, M.D.   (Two on  Children,
  aged  four years.)   Reported by J.  M.
  Wallace,  M.D.   Philadelphia.—Medical
  Examiner, vol. v. N. S. p. 288.    1849.
Lithotrity and Lithotomy, with the Use of
  Ether  in these Operations, by J.  Mason
  Warren. M.D.  Boston.—Amer. Journal
  M,d. Sci.,  vol. xviii.  N. S. p. 47.   1849.
Two Cases of Lithotripsy, by the late Geo.
  M'Clellan, M.D.,  in one of which the
  male  blade  of Heurteloup's  instrument
  broke  in  the  Bladder,  and was subse-
  quently passed by the Urethra. Reported
  by J. H. B. M'Clellan, M.D.  Philadel-
  phia.—Med. Examiner, vol. v.  N. S. p.
  513.                             1849.
Removal of  three inches of a Gum-elastic
  Cathether by means of Heurteloup's in-
  strument,  by J. H. Dillson, M.D.  Pitts-
  burg.—Am. Journ. Med. Sciences, vol. xx.
  N. S.  p. 268.                     18'jO.
Lithotripsy, successfully performed by Wm.
  E. Horner, M.D.   Philadelphia —Medi-
  cal Examiner, vol. vii. N. S. p. 97. 1*51.
Reply to strictures on a Case of Lithotrity,
  contained in the  April  number of the
  Western Journal of  Medicine and Sur-
  gery,  by L. A. Dugas, M.D.  Georgia.—
  Southern Med.  and  Surg. Journ.,  vol. vii.
  N. S.  p. 686.                     1851.
Case of Urinary  Calculus, attended  with
  peculiar circumstances and  treated by
  Lithotrity, by L. A. Dugas, M.D.   Ga.—
  Southern Med. and Surg. Journal, vol. vii.
  N. S. p. 207.                     1851.
Lithotripsy  in the Female, (cured,) by J.
  Deane, M.D. Greenfield, Mass.—Boston
  Med.  and  Surg. Journ., vol. xlvi. p 20.
                                   1852.
Report  on  Lithotrity  and Lithotomy, by
  L. A. Dugas, M.D.  Ga.—Southern Med.
  and Surg. Journal, vol. x.  N. S.  p. 719.
                                   1851.
Report on the Relative Value of Lithotrity
  and  Lithotomy, by L. A.  Dugas, M.D.
  Ga.—New York Journal of Medicine, vol.
  xiv. N. S. p. 154.                 1855.
Lithotrity in the  Female, by  L.  A. Dugas,
  M.D.   Ga.—Southern Medical and Surg.
  Journ., vol.  xii. N. S. p.  212.      1856.
Lithotrity, by C. S.  Fenner,  M.D.   Mem-
  phis, Tenn.—New  Orleans Med. and Surg.
  Journ., vol.  xiii. p. 448.           1857.
High Operation for Stone, performed upon
  an Original  Plan, with Essential Modifi-
  cations and  Improvements, by H. Stuart
  Hewit,  M.D.   New Y'ork.—New  York
  Journal of Medicine, vol. vi. 3d S. p. 217.
                                   1859.
  OPERATIONS  ON  THE EXTERNAL
     ORGANS OF THE  FEMALE.

Case of Imperforate Hymen, (patient, mar-
  ried  for two years before the operation
  relieved  her,) by J.  W. Horton, M.D.
  Maryland.—Maryland Medical Recorder,
  vol.  i. p. 408.                     1829.
Case of Fistulous Communication between
  the  Vagina,  Bladder, and Rectum,  by 
PAPERS  ON  THE  GENITO-URINARY  ORGANS  AND RECTUM.   615
  Charles Byrne, M.D., U. S. Army.— Am.
  Journ. Med. Sci., vol. vi. p. 70.    1830.
Observations on the Sanguineous Tumors of
  the Vagina, by Hugh  H.  Toland, M.D.
  South Carolina.—Transylvania Journ. of
  Med, vol. vii. p. 204.  *         1834.
Fungus Hoematodes, (in Recto-Vaginal Sep-
  tum; extirpation; cure?) by N. R. Smith,
  M.D.  Baltimore.—Amer. Archives Med.
  and Surg. Sci., vol. i. p. 37.       1835.
Case of Medullary Sarcoma of the Labia,
  etc., by A. B. Shipman, M.D. N. York.
  —Am. Journ. Med. Sciences,  vol. v. N. S.
  p. 368.                         1843.
A Case of Imperforate Hymen,  by  William
  Shultice,  M.D.  Virginia.—Am. Journ.
  Med. Sci., vol.  vii. N. S. p. 243.    1844.
Case  of Imperforate  Hymen, by John G.
  Melcalf, M.D.  Mass.—Am. Journ. Med.
  Sciences, vol. xii. N. S. p.  139.    1846.
Vaginal  Hysterotomy and subsequent De-
  livery  with the  Forceps, with safety to
  both Mother  and Child, by G.  S. Bed-
  ford, M.D  New York.—Amer.  Journal
  Med. Sci., vol.  xv. N. S. p. 348.    1848.
A previous Successful Case of the same.—
  N.  Y. Journal of Med , March.    1843.
Vaginal Hysterotomy, (successful  to  Mo-
  ther.) by John. H. Griffin, M.D. Virginia.
  — Amer. Journ. Med. Sciences, vol. xvii.
  N. S. p. 94.                     1849.
On  Occlusion of the Vagina, (operation by
  incision  and dilatation, relieved,) by H.
  J.  Holmes, M.D.   Mississippi.— Ohio
  Mid. and  Surg. Journ., vol. ii.  p.  540.
                                  1850.
Occlusion of the Vulva,  operation by  F.
  Cooley, M.D.  Lexington, Mo.—St Louis
  Med. and Surg. Journ., vol.  xiv. p.  239.
                                  1856.
OPERATIONS ON THE FEMALE PERI-
                 NEUM.

Parturient Laceration of the Recto-Vagi-
  nal  Septum, successfully  treated with
  Metallic Ligatures, by John P. Mettauer,
  M.D.  Virginia.—Am. Journ. Med. Sci-
  ences, vol. xiii.  p. 113.            1833.
Extirpation of the Os Coccygis for Neural-
  gia,  by J. C. Nott, M.D.  Mobile.— Am.
  Journ. Medical  Sciences, vol. viii. N. S. p.
  544.                            1844.
Hints on the Treatment of Lacerated Peri-
  neum, by Wm. E. Horner,  M.D. Phil-
  adelphia.—Am. Journ.Med. Sciences, vol.
  xx. N. S. p.  329.                1850.
Operation for Laceration of the Perineum,
  by F. M. Robertson, M.D.   Charleston.
  —Am. Journ. Med.  Sciences, vol. xxviii
  N. S. p. 404.                    1854.
Laceration of the Perineum and Sphincter
  Ani  during Parturition, cured by Di-
  vision of the Sphincter and  Subsequent
  Closure of the Perineum  by Sutures, by
  Willard Parker, M. D.  New York.—Am.
  Journ. Med. Sciences, vol. xxix. N. S. p.
  274.                            1855.
Complete Rupture of the Perineum, involv-
  ing the Sphincter Ani Muscle and Two
  Inches of the  Recto-Vaginal Septum;
  Successful  Operation  by  a  Combined
  Method,  by  Chas A.  Pope,  M D.  St.
  Louis.—St. Louis Med. and Surg. Journal,
  vol. xvii. p. 193.                 1859.
   OPERATIONS ON THE VAGINA.

Non-Existenee of the Vagina remedied by
  an Operation, by John C. Warren, M.D.
  Boston.—Am. Journ. Med. Sciences,  vol.
  xiii.  p. 79.                       1833.
Case of Vesico-Vaginal Fistula,successfully
  treated by an Operation, by George Hay-
  ward, M.D.   Boston.—Am. Journ. Med.
  Sciences, vol. xxiv. p. 283.         1839.
Recto-Vaginal Fistula, (cured,) by J. Rhea
  Barton, M.D.  Philadelphia.—American
  Journ. Med. Sciences, vol.  i. N. S. p. 305.
                                  1840.
On Vesico-Vaginal  Fistula, by  John P.
  Mettauer, M.D.  Virginia.—Am. Journ.
  Med.  Sciences, vol. xiv.  N.  S.  p.  117.
                                  1847.
Vesico-Vaginal Fistula,  treated by the or-
  dinary  Hare-lip Operation, (relieved,)
  by Henry H. Smith, M.D.  Philadelphia.
  —Medical Examiner, vol. v. N. S. p.  155.
                                  1849.
Case of Imperforate Vagina and  Malform-
  ation of the  Superior Portion,  Oper-
  ation,  (cure,)  by A. B. Shipman, M.D.
  Indiana.—Am. Journ. Med. Sciences, vol.
  xviii p. 401.                    1849.
Case of Procidentia Uteri—Successful Op-
  eration, (diminishing  the orifice of the
  Vagina,) by  J.  R. Wood, M.D.  New
  York.—New  York  Med. Times,  vol. i. p.
  41.                             1851.
Cases  of Vesico-Vaginal Fistula,  treated
  by an Operation, by  George Hayward,
  M.D.  Boston.—Boston Med. and Surg.
  Journ., vol. xliv. p. 209.          1851.
Three  Cases of Occlusion of the Vagina,
  accompanied by retention of the Cata-
  menia, relieved by an operation, by J.
  Mason  Warren,  M.D.   Boston. — Am.
  Journ. Med. Sciences,  vol. xxii. N. S. p.
  13.                             1851.
Occlusion of the  Vagina — Operation —
  Death, (in three days, from  Peritonitis,
  though the Peritoneum was not opened,)
  by Jno. O. Stone.  New York.—New York
  Journal of Medicine, vol. vi. N. S. p. 289.
                                  1851.
Case of Vesico-Vaginal Fistula, (cured by
  an Operation,) by Jos. Pancoast, M.D.
  Reported by C. D. Meigs, M.D.  Philadel-
  phia.—Medical Examiner, vol. vii. N. S,
  p. 650.                          1851. 
616
PRINCIPLES AND PRACTICE OF SURGERY.
 Case of Constricted Vagina and Occlusion
   of the  Os Uteri, (punctured; died,) by
   LaurenceTurnbull, M.D.  Philadelphia.
   —Mtd.  Examiner, vol. vii. N. S. p. 696.
                                   1851.
 Occlusion of the Vagina—Successful Oper-
   ation,  (Excision of Cicatrix.) followed
   by Conception and  Delivery, by P. C.
   Spencer, M.D.  Petersburg, Va.—Steth-
   oscope, vol. i. p. 209.              1851.
 On the Treatment of Vesico-Vaginal Fis-
   tula, by  J. Marion Sims,  M.D.   Ala-
   bama.—Am.  Journ.  Med. Sciences, vol.
   xxiii. p 59.                      1852.
 Almost Complete Occlusion of the Vagina,
   cured by an  Operation, by Geo. Hay-
   ward, M.D.  Boston.—Am.  Journ.  Med,
   Sciences, vol. xxiv. N. S. p. 350.    1852.
 Cases of Complete Occlusion of the Vagina,
   (one treated  by incision, etc., but con-
   tracting, notwithstanding every effort to
   prevent it,)  by  Valentine  Mott,  M.D
   New York.—New  York Med. Times, vol.
   ii. p. 1.                          1852.
 Three Cases of Occlusion  of  the Vagina,
   relieved by an Operation, by J. Mason
   Warren, M.D.  Boston.—Am. Journ. Med.
   Sciences, vol. xxv. N. S. p. 86.     1853.
 Recto-Vaginal Fistula, (cuted;  clamp su-
   ture,) by  R.  D. Mussey, M.D. Cincin-
   nati.—Ohio Med. and Surg. Journ., vol.
   vi.  p. 127.                        1853.
 Case  of Atresia Vaginae, by 0. H. Taylor,
   M.D.  Camden, N. J.—New Jersey Med.
   Reporter, vol. vi. p. 439.           1853.
Occlusion  of the Vagina—Conception, (Op-
   eration.) by T. L. Ogier, M.D.  Charles-
   ton.—Charleston Med.  Journ., vol. viii.
   p. 811.                           1853.
A  Case of Atresia Vaginae, (Operation un-
   successful, the parts contracting alter in
   cision, notwithstanding the employment
   of  dilatation,) by D.  E.  Ewart,  M.D.
   South Carolina. — Charleston Med. and
   Surg. Journ., vol. viii. p. 81.       1853.
A Case of  Congenital Occlusion of the Va-
   gina relieved  by an Operation, (punc-
   ture and  laceration,)  by Geo. L. Up-
   shur, M.D.   Norfolk, Va.—Med. Exam-
   iner, vol. ix. N. S. p. 523.          1853.
Vesico-Vaginal  Fistulae successfully treat-
  ed,  by N. Bozeman, M.D.—Amer. Journ.
   Med. Sciences,  vol. xxviii.  N. S. p. 283.
                                   1854.
Vesico-Vaginal  Fistula with Calculus, Re
   covery,  by B. W.  H  Mussey,   M.D.
   Ohio.—New York Journ.  of Med., vol.
   xiii. N. S. p. 150.                  1854.
Vesico-Vaginal  Fistula, Cure,  by Charles
   A. Pope, M.D.  St. Louis.—St. Louis Med.
   and Surg. Journ., vol. xii. p. 401.    1854.
Vesico Vaginal   Fistula of Seven  Years'
   Duration, cured in Thirteen Days, by J.
   Marion  Sims, M.D.  New York.—Am.
   Journ. Med. Sciences, vol. xxviii. N. S. p.
   283.                             1854.
 Vesico-Vaginal  Fistula  cured  by Sims'
   Operation,  by  A.  V. Williams, M.D.
   New  York.—Am. Journ. Med.  Sciences,
   vol. xxix. N. S. p. 578.           1855.
 Vesico-Vaginal  Fistula, by Gurdon Buck,
   M.D.   New York.—Am.  Journ., Med.
   Sciences, vol. xxix. N.  S. p. 282.   1855.
 Vesico-Vaginal Fistula successfully treat-
   ed, by Wm. C. Ashe, M.D.  Alabama.—
   New Orleans Med. and Surg. Journ., vol.
   xii. p. 8.                        1855.
 Contributions to Vesical Surgery,  (Vesico-
   vaginal Fistula?,) by J. P.  Mettauer,
   M.D.   Virginia—South. Med. and Surg.
   Journ., vol. xi. N. S. p. 417.      1855.
 Vesico-Vaginal  Fistulas, Button  Suture,
   Seven Successful Operations, by N. Boze-
   man,  M.D.  Montgomery,  Ala. — Am.
   Journ. Med. Sci., vol. xxxii. N. S. p. 578.
                                   1856.
 Vesico-Vaginal Fistula successfully treat-
   ed  after the Method of Sims, by T. C.
   Finnell,  M.D.   New  York.—New York
   Journ. of Med.,  vol. xvi.  N. S.  p. 352.
                                   1856.
 Vaginal  Hysterotomy twice successfully
   performed on the same Patient, by M. C.
   Hosbrouck, M.D.   Rockland Co., N.  Y.
   —N.  Y.  Journ. of Med.,  vol. xvi. N. S.
   p. 290.                           1856.
 Bozeman's Operation for Vesico-Vaginal
   Fistulse, by G. C. Blackman, M.D.  Cin-
   cinnati.— Western Lancet, vol.  xvii.  p.
   657.                             1856.
 Vesico-Vaginal Fistula,  by S. D. Thomas,
   M.D.   Pittsburg, Pa. — Western  Lancet,
   vol. xvii. p. 65.                   1856.
 Report  on Vesico-Vaginal Fistulae, by  P.
   M.  Kollock, M.D.  Savannah, Georgia.
   — Southern  Med. and Surg. Journ., vol.
   xiii. N.  S. p. 268.                 1857.
 Removal of an Encephaloid Tumor of the
   Vagina,  by C.  E. Isaacs, M.D.  New
   York.—N. Y. Journal of Medicine, vol. v.
   3d Series, p. 12.                  1858.
 Vesico-Vaginal  Fistula,  by C. S. Fenner,
   M.D.  Memphis, Tenn.—Am. Journ. Med.
  Sci., vol. xxxviii. N. S. p. 353.      1859.
Vesico-Vaginal Fistula cured by the But-
  ton Suture, by T. G. Richardson, M.D.
  New Orleans.—New  Orleans  Med. and
  Surg.  Journ., vol. xvi.  p. 881.      1859.
Vesico-Vaginal Fistula,  Complicated with
  Obliteration of the Urethra, and  almost
  perfect coarctation of  the Vagina; Per-
  fect Cure, by Chas. A. Pope,  M.D.  St.
  Louis.—St. Louis Med. and Surg. Journ.,
  vol. xvii. p. 196.                  1859. 
PAPERS  ON  THE  GENITO-URINARY  ORGANS AND RECTUM.   617
OPERATIONS ON THE UTERUS.
Occluded Os Tincae, Operation, (puncture
  by Trocar,) by A. Barclay, M.D.  New-
  burgh, New York.—American Lancet, vol.
  viii. p. 37.                       1853.
Extirpation of the entire Uterus  success-
  fully practiced,  by  E. Geddings, M.D.
  Charleston, S. C.—Am. Journ. Med. Sci.,
  vol. xxviii. N. S. p.  579.          1854.
Remarks on the  Use of Pessaries,  by L. A.
  Dugas, M.D.  Georgia.—Southern Med.
  and Surg. Journ., vol. x. N. S. p. 567.
                                  1854.
Utero-Abdominal Supporters, Braces, etc.,
  by L. A. Dugas, M.D.  Georgia.—South-
  ern Med.  and Surg. Journ.,  vol.  x. N. S.
  p. 61.                           1854.
Removal of the entire body of the Uterus
  by the large  Abdominal  Section, by E.
  R. Peaslee, M.D.  Maine.—Am. Journ.
  Med. Sci., vol. xxix. N. S.  p. 393.  1855.
Extirpation of the  Uterus, by G. Kimball,
  M.D.  Lowell, Mass.—Am. Journ. Med.
  Sciences, vol. xxx. N. S. p. 270.    1855.
Extirpation  of  the Uterus  for  Inversion,
  Recovery,byE. Geddings, M.D.  Charles-
  ton, S. C.—New  York Journ. of Medicine,
  vol. xiv. N. S. p. 157.            1855.
Rupture of  the  Uterus, Gastrotomy, Re-
  covery, by J. K. Mason, M.D.  Philadel-
  phia.—New York Journal  of Medicine,
  vol xiv. N. S. p. 157.            1855.
Removal of an Inverted Uterus, Recovery,
  by C. G. Putnam, M.D.  Boston.—Am.
  Journ. Med. Sciences, vol.  xxxii. N. S. p.
  572.                             1856.
Removal of a Tumor developed in the pos-
  terior wall of  the Uterus, by  F. Hinkle,
  M.D.   Lancaster Co., Pa.—Am. Journ.
  Med. Sciences,  vol. xxxii. N.  S. p. 359.
                                  1856.
Extirpation of the  Uterus and its Append-
  ages, Recovery, by John  M. Boyd, M.D.
  Knoxville, Tenn.—Am. Journ. Med. Sci.,
  vol. xxxiii. N. S. p.  572.          1857.
        ON POLYPUS UTERI.

Cases of Uterine Polypus treated by Liga-
  tures, by Thomas Chadbourn, M. D.  New
  York.—BostonMed. and Surg. Journ., vol.
  xxi. p. 289.                      1839.
Polypus Uteri, removed by Excision, by C.
  It. Oilman, M.D.  New York.—Am. Jour-
  nal Med. Sciences,  vol. ii.  N.  S. p. 519.
                                  1841.
Cases of Uterine Polypus, (new instrument
  for Ligature,) by  John  V. P. Quacken-
  bush, M.D.   Albany.—Am. Journ. Med.
  Sciences, vol. vii. N. S. p. 241.    1844.
Polypus and Inversion of the Uterus; Liga-
  ture, Excision of a large portion of the
  Uterus,  (recovery,)  by  A. L. Peirson,
  M.D. Salem, Mass.—Am. Journ.  Med.
  Sci., vol. xvii. p. 339.            1849.
Amputation of the Cervix Uteri for Scir-
  rhus, (died,)  by H. G. Jameson, M.D.
  Baltimore.—Am. Med.  Recorder, vol. vii.
  p. 543.                           1824.
Case of successful Excision of the Cervix
  Uteri in a Scirrhous State, by John B.
  Strachn,  M.D.  Virginia.—Am. Journ.
  Med. Sci., vol. v. p. 307.           1829.
Extirpation of a  Cancer of  the Uterus,
  (died sixth day,)  by John  C.  Warren,
  M.D.  Boston.—Am. Journ. Med. Sci.,
  vol. iv. p. 536.                   1829.
Uterine Tumor removed  by an Operation,
  (died,) by Moses  Hibbard, M.D.  New
  Hampshire.—Boston Med.  and Surgical
  Journ., vol. viii. p. 68.            1833.
Complete Extirpation of the  Uterus  by
  Ligature, after Chronic Inversion of the
  Organ, (successful,) by John M.  Essel-
  man, M.D. Nashville.—Am. Journ. Med.
  Sciences, vol. vii N. S.  p. 254.    1844.
Case of Extirpation of a Fibrous Tumor by
  the  large Peritoneal Section, by  W. L.
  Atlee. M.D. Pennsylvania.—Am. Journ.
  Med. Sciences, vol. viii. N. S. p. 539. 1844.
Case  of a  successful  Extirpation  of  a
  Fibrous Tumor from the surface  of the
  Uterus by the large Peritoneal Section, by
  Washington  L.  Atlee, M.D.  Philadel-
  phia.—Am. Journ. Med. Sciences, vol. ix.
  N. S. p. 309.                     1845.
Amputation of the Neck  of the Uterus, by
  N. J. McL. Moore, M.D.   New Hamp-
  shire.—Boston Med. and  Surg. Journ.,
  Dec. vol. xxxvii. p. 397.           1847.
Excision of the Cervix Uteri for Carcino-
  matous Disease, (died,) by Washington L.
  Atlee,  M.D.  Philadelphia.—Am. Journ.
  Med. Sciences, vol. xvi. N. S. p. 86.   1848.
A Sarcomatous Tumor, containing Hair and
  Stearine,  removed from the Womb,  by
  Gunning S. Bedford, M.D.   New York.—
  New York  Journ.  of  Medicine, vol. ii.
  N. S. p. 30.                     1849.
Case of Excision of the Uterus, (died three
  months after the operation,)  by Paul F.
  Eve, M.D.  Georgia.—Am.  Journ. Med.
  Sciences, vol. xx. N. S.  p. 395.     1850.
An  Eclectic Essay on the Non-Pediculated
  Fibro-Scirrhous Tumors of the Uterus,
  by Wm. C. Roberts, M.D.  New York.—
  N. Y. Journal of Medicine, vol. iii.  N. S.
  p. 330, 1849; also  Ibid., vol. iv. N. S. p.
  31.                             1850.
Amputation of  Uterus (successful)  after
  Partial  Inversion, by Usher Parsons,
  M.D.  Providence, Rhode Island.—Bos-
  ton Med. and Surg. Journal, vol. xliv. p.
  511.                            1852.
Removal  of a  Fibrous  Tumor from the
  Uterus, including  a portion of the Cer-
  vix Uteri, (cured,) by T. L. Ogier, M.D
  Charleston.—Charleston Med. Journ., vol.
  vii. p. 154.                      1852. 
618
PRINCIPLES AND  PRACTICE  OF  SURGERY.
Case  of  Polypus Uteri,  successfully re-
  moved  by Ligature, by S. B. Phillips,
  M.D.   New  York.—N  Y.  Journ.  Med.
  and Collat. Sciences, vol iv. N. S. p. 199.
                                  1850.
Case of Polypus of the Uterus, successfully
  removed," by S. B. Phillips. M.D.   New
  York.—New York Journ. Med., vol. iv.
  N. S. p. 348.                     1850.
Polypus Uteri, (cured by double Canula,)
  by Robert G. Jennings, M.D.  Virginia.
  —Stethoscope, vol. i. p. 491.       1851.
Polypus of the Uterus, (cured by the Liga-
  ture, with Gooch's  double Canula,) by
  A. Fattaway, M.D.  Georgia.—Southern
  Med. and Surg. Journ., vol. viii. p. 532.
                                  1852.
Case  of  Polypus Uteri, (successfully re-
  moved  with the double Canula and Lig-
  ature.)  by  John  P.  Mettauer,  M.D.
  Winchester, Va.—Stethoscope,  vol. ii. p.
  8.                              1852.
ON OVARIOTOMY AND GASTROTOMY.

Three Cases of Extirpation of the Ovarium,
  successfully performed, by Ephraim Mc-
  Dowell, M.D.   Kentucky, 1809.— Eclectic
  Repert. and Analyt. Review, vol. vii. p.
  242.                            1817.
[This  operation  was  the  first  of  the
  kind ever performed.   The operation of
  Houstoun,  of Scotland, in  1701, was
  merely the evacuation of  an  ovarian
  dropsy, there being no proof of the re-
  moval of the tumor, though his puncture
  was enlarged  to five inches.  L'Aumo-
  nier's  operation, generally  thought  to
  have been  the first,  was  also only the
  evacuation of an abscess of the ovary.—
  Gross's History of Kentucky Surgery..]
On Ovarian  Disease and  Abdominal Stea-
  toma,  by  Thomas  Henderson,  M.D.
  Georgetown, D. C.—Eclectic Repert., vol.
  viii. p. 545.                     1818.
Observations and  Cases  (two) of  removal
  of Ovaria,  by Ephraim McDowell, M.D.
  Danville,   Kentucky.—Eclectic  Repert.,
  vol. ix. p. 546.                  1819.
Case  of  Ovarian Tumor,  successfully re-
  moved by an  Incision  through the Ab-
  domen, by  Nathan Smith, M.D.  July 5,
  1820. Yale College.—Am. Med. Recorder,
  vol. v. p. 124.  '                 1822.
Case  of Extirpation of Ovarian Sacs for
  the  Cure of Hydrops Ovarii, (died,) by
  Joseph A. Gallup,  M.D.   Vermont.—
  New Eng. Journ. of Med. and Surg., vol.
  xiv. p. 358.                     1825.
Account of a Case of successful removal of
   a Diseased Ovarium, by Alban G. Smith,
   M.D. Danville, Kentucky.—North Amer.
   Med. and Surg. Journal, vol. i. p. 30.
                                  1826.
Case of Ovarian Tumor, successfully extir-
  pated, by David L. Rogers, M.D.  New
  V0rk.—A'. Y. Med. and Phys. Journ., vol.
  ii. N. S.  p 285, 1830;  also, Am. Journ.
  Med. Sciences, vol. v. p. 549.      1829.
Contributions to Ovarian Pathology, by E.
  Geddings. M.D.- Baltimore.—North Am.
  Archives  Med. and Surg. Journ., vol. i. p.
  111.                            1835.
Successful  Operation for  Ovarian Disease,
  Adhesion of the Wall of the Vagina, etc.,
  by R. D. Mussey, M.D.  Fairfield, New
  York.—Am. Journ. Med. Sciences, vol. xxi.
  p. 377.                          1837.
Case of successful Peritoneal Section  for
  the removal of two Diseased Ovaria, etc.,
  by  John  L. Atlee, M.D.   Lancaster —
  Am. Journ.  Med. Sciences, vol. vii. N. S.
  p. 44.                           1844.
Case of Congenital Tumor (of the Abdo-
  men) composed of numerous Cysts, by
  W.  L. Atlee, M.D.  Pennsylvania.—Am.
  Journ. Med. Sciences, vol. vii.  N.S. p.  84.
                                   1844.
Extirpation of a  Bi-locular  Ovarian Cyst
  by  the   large  Peritoneal  Section,  by
  W. L.  Atlee, M.D.  Lancaster.—Amer.
  Journ. Medical Sciences, vol.  viii. N. S.
  p. 43.                            1844.
Extra-Uterine Fcetation, Gastrotomy, suc-
  cessfully performed ten years after Con-
  ception,  by Alexander H.  Stevens, M.D.
  New York.—Am. Journ.  Med. Sciences,
  vol. xii.  N. S. p.  279, 1846; also,  New
  York Journal of Medicine, May.     1*46.
Case of Extra-Uterine Pregnancy, (cured
  by Gastrotomy,) by Edward Whinery,
  M.D. Iowa.—Am. Journ. Med. Sciences,
  vol. xi. N. S. p. 351.              1846,
Removal of an Extra-Uterine Foetus, fifteen
  years in cavity of Abdomen,  (through
  the Rectum,) and complete recovery, by
  Thomas  Yardley, M.D. Philadelphia.—
  Am. Journ. Med. Sciences,  vol. xi. N. S.
  p. 348.                           1846.
Extirpation of a  peculiar form of Uterine
  Tumor,  simulating Ovarian  Disease, by
  the large Peritoneal Section, (died,) by
  Samuel  Parkman, M.D.   Boston.—Am.
  Journ. Med. Sciences,  vol. xv. N. S. p.
  371.                             1848.
Extirpation of a Diseased Ovary, by Dan-
  iel Meeker, M.D. Indiana.—Boston Med.
  and Surg. Journ., vol.  xxxix. p. 116.
                                   1848.
Ovarium, successfully removed, by H. Mil-
  ler, M.D. Louisville.—Am. Journ. Med.
  Sciences, vol. xvi. N. S. p. 528.    1848.
Gastrotomy, (for  a  Uterine  Tumor which
  could not be removed,) recovery, by J.
  Deane, M.D.  Greenfield.—Am. Journal
  Medical  Sci., vol. xvii. N. S. p. 258, 1849;
  also, Boston Med. and Surg.  Journ.,  vol.
  xxxix. p. 221.                    1848.
Case of successful Extirpation of an Ova-
  rian Tumor by the large Peritoneal Sec- 
PAPERS  ON <THE  GENITO-URINARY  ORGANS  AND RECTUM.   619
   tion, by W. L. Atlee, M.D.  Philadelphia.
   —Am.  Journ.  Med. Sciences,  vol. xviii.
   N. S. p. 336.                     1849.
 Solid Ovarian Tumor, extending from the
   Pubis  to  the  Right  Hypochondrium,
   cured by Incision followed by Suppura-
   tion, by David Prince, M.D. St. Louis.—
   Am. Journ. Med. Sciences, vol. xx. N. S.
   p. 267.                          1850.
 Account of an Operation for the removal of
   an  Ovarian Tumor, by Alden March,
   M.D.   Albany.—Transact. New   York
   Med. Society, vol. viii. p. 201, 1850; also,
   New York Journ. of Medicine, vol. v. N. S.
   p. 140.                          1850.
 Fibrous Tumor of  the Left Ovarium suc-
   cessfully removed by the large Abdomi-
   nal Section, by William  H. Van Buren,
   M.D.   New  York.—Am.  Journ.  Med.
   Sciences, vol. xx. N. S. p. 272, 1850; also,
   N. Y. Journ. Med.. March.         1850.
 Two Cases of Ovariotomy, (with Statistics,)
   by  Washington L. Atlee, M.D.  Phila-
   delphia —Am. Journ. Med. Sciences, vol.
   xix. N. S. p. 318.                1850.
 Ovariotomy, three Cases, by P. J. Buckner,
   M.D.   Georgetown, Ohio.—Am. Journ.
   Med. Sciences, vol. xx.N. S.  p. 560, 1850;
   also, Ohio Med. and Surg. Journ., vol. iii.
   p. 1.                            1850.
 Ovarian Dropsy, removal of the Sac (large
   Section) and fatal termination, by A. H.
   Grimshaw, M.D.  Delaware.—Medical
   Examiner, vol. vi. N. S. p.  630.    1850.
 Gastrotomy successfully performed for Ex-
   tra-Uterine Conception, (right tubal,) by
   M Franklin Brown, M.D.  Hanibal, Mis-
   souri.—St. Louis Med. and Surg. Journ.,
   vol. vii. p. 205.                   1850.
 A Table  of all the  known Operations of
   Ovariotomy, comprising 222 Cases, etc.,
   by W.  L. Atlee, M.D.   Philadelphia.—
   Transact.  Am. Med. Association,  vol. iv.
                                   1851.
 Double Ovarian Dropsy, (both Ovaries suc-
   cessfully  removed by the large Perito-
   neal Section,)  by E. R.  Peaslee,  M.D.
   New York.
 [This  case,  it is believed, is unique; both
   ovaries being successfully removed at the
   same operation.  The catamenia appear-
   ed 72 hours after  operation;  they had
   been seen ten days before.]—Am. Journ.
   Med. Sci., vol. xxi. p. 371.          1851.
Case of Ovarian Dropsy, (Ovariotomy suc-
   cessfully performed,) by A. Dunlap, M.D.
   Ripley, Ohio.— Western  Lancet, vol.  xii.
   p. 355.                           1851.
Gastrotomy successfully performed  in a
  Case of Extra-Uterine Pregnancy, (pa-
  tient under chloroform, foetus in the right
  Fallopian tube, size of seven months,
  weight about five pounds,) by Drs. Brad-
  ley and Rogers,  Pineville, Alabama.—
   Western Lancet, vol. xii. p. 520,  1851,
  from New Orleans Medical and Surgical
  Journal.                        1851.
Ovarian Tumor removed, per vias natu-
  rales,  by Catheterism  of  the Fallopian
  Tubes,  by Samuel A. Cartwright, M.D.
  New Orleans.—Stethoscope, vol. i. p. 414,
  1851, from New  Orleans Med. and Surg.
  Journ.                          1851.
Attempted removal of an Ovarian Cyst by
  the  small  Abdominal  Section;  unsuc-
  cessful from the absence of a pedicle,
  (patient well, two months subsequently,)
  by S. Parkman,  M.D.  Boston.—Boston
  Med. and Surg. Journ., vol. xiv. p. 421.
                                  1851.
Ovariotomy, (large Section,  died,) by Jas.
  Deane.  M.D.  Massachusetts.—Boston
  Med. and Surg. Journ., vol. xliv. p. 474.
                                  1851.
Ovarian Dropsy cured by a  simple Opera-
  tion, adhesion of the sac to the abdomi-
  nal parietes being produced by external
  irritation;  the incision was made  near
  the linea semi-lunaris, the tumor tapped
  and  the canula  kept in  till a purulent
  discharge ensued; it was  then removed,
  and the fluid left to discharge naturally,)
  by John Douglass, M.D.  Chester Dis-
  trict, South Carolina.—Charleston  Med.
  Journ., vol.  vi. p. 669.            1851.
Ovariotomy successfully performed, (for a
  Multilocular Cyst.) by  Ezra P. Bennett,
  M.D.  Connecticut.—Am. Journ.  Med.
  Sciences, vol. xxiii. N. S. p. 282.   1852.
A very large  Mesenteric  Tumor, simulat-
  ing Ovarian disease, successfully extir-
  pated, by P. J. Buckner, M.D.  Cincin-
  nati.— Am.  Journ.  Med.  Sciences,  vol.
  xxiv. N. S.  p. 358.               1852.
Removal of an Ovarian Tumor by the large
  Abdominal  Section, death from  Perito-
  nitis, by Wm. H. Van Buren, M.D.  New
  York.—N.  Y. Journ. Med., vol. viii.  N.
  S. p. 212.                       1852.
Ovariotomy, (performed under Chloroform,
  died,)  by Ezra P. Bennett, M.D.  Dan-
  bury,  Conn. —N. Y. Journ. Med., vol.
  viii.  N. S. p. 288.                1852.
Ovariotomy, (death on the 14th day, of gen-
  eral  Dropsy,) by D.  D. Franklin, M.D.
  Tiffin, Ohio.—Eclectic  Med. Journ., vol.
  iv. p. 355.                       1852.
Case of Ovariotomy, (for first 18 days did
  well, then took cold, and died one month
  afterward of Peritonitis,) by Samuel D.
  Gross, M.D.   Louisville.— West. Journ.
  of Med. and Surg., vol. xi. 3d S. p. 39.
                                  1853.
Ovarian Tumor removed successfully, (large
  Section,) by D. McRuer,  M.D. Bangor,
  Me.—Boston Med. and Surg. Journ., vol.
  xlviii.  p. 74.                    1853.
Removal of an Ovarian  Tumor, (died of
  Hemorrhage 20£ hours after operation,)
  by G.  W. Bayless,  M.D.   Haslewood, 
620
PRINCIPLES AND  PRACTICE  OF  SURGERY.
   Mo.—St. Louis Med. and Surg.  Journ.,
   vol. xi. p. 204.                  1853.
Ovariotomy by  a  new method, (dividing
   the Peritoneum around the Pedicle before
   applying the ligature, cured.) by Rich-
   ard L. Howard, M.D.  Columbus, Ohio.
   — Ohio Med. and Surg. Journ , vol. v. p.
   211.                            1853.
Ovariotomy,  (adhesions,  died 17th  day
   after operation,) by Richard L. Howard,
   M.D.   Columbus, Ohio.—Ohio Med. and
   Surg. Journ., vol. v. p. 213.      1853.
Sudden Rupture of an Ovarian Tumor, Peri-
   tonitis, Recovery, by L. A. Dugas, M.D.
   Georgia.—South. Med. and Surg.  Journ.,
   vol. viii. N. S. p. 730.            1852.
Case of Ovariotomy, by A. Dunlap, M.D.
   Ripley, Ohio.—Am. Journ. Med. Sciences,
   vol. xxviii. N.  S. p. 407.          1854.
Case of Cystoid Tumor of the Ovary, suc-
   cessfully punctured through the Vagina,
   with Statistics, by J. Menninger, M.D.
   New York.—New York Journ. Med.,  vol.
   xiii. N. S. p. 75.                 1854.
Thirty Cases  of Ovariotomy,  by  W.  L.
   Atlee, M.D.  Philadelphia.—Am. Journ.
   Med. Sciences,  vol.  xxix. N.  S.  p. 387.
                                  1855.
Ovariotomy successfully performed, by T.
   F. Craig, M.D. Kentucky.—Am. Journ.
   Med. Sciences,  vol.  xxix.  N. S.  p. 281.
                                  1855.
Ovariotomy successfully performed, by A.
   Mercier, M.D.  New Orleans.—New Or-
   leans Med. and Surg. Journ., vol. xi  p.
   518.                            1855.
Gastrotomy successfully performed  for the
   removal of a Bar of Lead from the Sto-
   mach,  by John Bell,  M.D.  Wapella,
   Iowa.—Am. Journ.  Med.  Sciences,  vol.
   xxx. N. S. p. 272.                1855.
Gastrotomy for the removal of an Ovarian
   Tumor — error of diagnosis — peculiar
   condition of the Abdominal Parietes, pa-
   tient recovered, by Henry H. Smith, M.D.
   Philadelphia.—Philad.  Med.  Examiner,
   vol. xi. p. 1.                     1855.
Ovariotomy, (successful,)  by John G. T.
   Holston,  M.D.  Zanesville, Ohio.— West-
   ern Lancet, vol. xvi. p. 730.       1855.
Ovariotomy  successfully   performed,  by
   Ezra P. Bennett. M.D.  Danbury, Conn.
  —Am. Journ. Med. Sciences, vol. xxxi. N.
  S. p. 398.                       1856.
Ovariiin Tumor,  with Ascites,  (cured by
  the  large Abdominal Section, and Injec
  tions into the Cavity of the Peritoneum,)
  by E.  R. Peaslee, M.D.  New York.—
  Am. Journ. Med. Sci., vol. xxxi. N. S. p.
  49-                             1856.
Fatal  Hemorrhage from Tapping an Ova-
  rian Tumor,  by  E. R. Peaslee, M.D.
  New York.—Am. Journ. Med. Sciences,
  vol. xxxii. N. S. p. 574.           1856.
 Case of Ovariotomy, by George Fries, M.D.
   Cincinnati. — Western  Lancet, vol.  xvii.
   p. 721.            ,              1856.
 Case of Successful Ovariotomy, by H. N.
   Bennett, M.D. Bridgeport, Conn.—Am.
   Journ. Med. Sciences, vol. xxxiv. N.  S. p.
   357.                            1857.
 Rupture of the Uterus,  Gastrotomy  suc-
   cessfully performed, by John H.  Bayne,
   M.D.  Maryland.—Am. Journ. Med. Sci-
   ences, vol. xxxiii. N. S. p. 65.      1857.
 Ovariotomy,  (three cases,) Recovery,  by
   Nelson Winton. M.D.   Buffalo, N.  Y.—
   Am. Journ. Med. Sciences, vol. xxxiii. N.
   S. p. 574.                       1857.
 Three  Cases of Ovarian Tumor, success-
   fully treated with Iodine, by B. Rosmer,
   M.D.  Virginia.—Am.  Journ. Med.  Sci-
   ences, vol. xxxiii. N. S. p. 332.    1857.
 Extirpation of both Ovaries, by H. A.  Pot-
   ter,  M.D.  Geneva, N.  Y.—Am.  Journ.
   Med. Sciences, vol.  xxxiv. N. S. p.  555.
                                  1857.
 Gastrotomy,  (successful  Extirpation  of a
   Fibro-Cartilaginous Tumor,) by John B.
   Hays, M.D.    Missouri.—Am.  Journ.
   Med. Sciences, vol.  xxxiii. N. S. p.  322.
                                  1857.
 Ovariotomy, (successful,) by E. P. Bennett,
   M.D. Danbury, Conn.—Am. Journ. Med.
   Sci., vol. xxxiv. N.  S. p. 284.     1,857.
 Ovariotomy, (Pedicle  severed by the Ecra-
   seur,) by J. L. Atlee, M.D.  Lancaster,
   Pa.—Am. Journ. Med.  Sci., vol.  xxxvi.
   N. S. p 579.                    1858.
 Ovariotomy,  (successful,)  by Hazard  A.
   Potter. M.D.  Geneva, N. Y.—Am. Journ.
   Med.  Sciences, vol.  xxxvi. N. S. p.  571.
                                  1858.
 Two Successful Cases of Ovariotomy by
   the large Abdominal Section, by E.  R.
   Peaslee, M.D. New York.—Am.  Journ.
   Med.  Sciences, vol. xxxvi. N. S. p.  364.
                                  1858.
 Tapping in  Ovariotomy, Dropsy,  by  R.
   McDaniel,  M.D.   South   Carolina.—
   Southern Med. and Surg. Journ., vol.  xiv.
   N. S. p. 450.                    1858.
 Four Cases of Ovariotomy, by C. A. Pope,
   M.D.  St.  Louis.—St.  Louis Med.  and
  Surg. Journ., vol. xvii.  p. 19.     1859.
 Two Cases of an Encysted  Tumor  of the
  Ovary, treated successfully by Excision,
  by H. Miller, M.D. Louisville,  Ky.—
  Amer. Journ. Med.  Sciences,  vol. xxxvii.
  N. S. p. 318.                     1859.
Ovariotomy, by D. McRuer, M.D.  Bangor,
   ^e-—Amer. Journ.   Med.  Sciences,  vol.
  xxxviii. N. S. p. 287.            1859.
Ovariotomy,  by J. W.  Hamilton, M.D.
  Ohio.  Also  by  Charles A.  Pope, M.D.
  St. Louis, Mo.—American Journal Med.
  Sciences, vol.  xxxvii. N. S. pp. 577,  578.
                                  1859. 
PAPERS  ON  THE  GENITO-URINARY  ORGANS  AND  RECTUM.    621
    ON THE CESAREAN  OPERATION.

  Caesarean Operation, successfully perform-
    ed by  John L. Richmond, M.D.  Ohio.
    (Done  without assistance at 1 a.m., with
    instruments from a pocket-case.)—West.
    Journ.  of Med. and Phys. Sciences, vol. iii.
    P- 485.                         1830.
  Observations on the Caesarean Operation,
    (accompanied by an Account of the Op-
    eration of Wm. Gibson,  M.D.,) in which
    both Mother and Child  were preserved,
    by Joseph G. Nancrede, M.D.  Philadel-
    phia —Am.  Journ. Medical Sciences, vol.
    xvi. p.  343.                      1835.
  Case where the Caesarean Section was per-
    formed, with a fatal termination, by A.
    Brooke, M.D.—Am. Journ. Med. Sciences,
    vol. xviii.  p. 258.                1836.
  Account of a Case  in which the Caesarean
    Section, performed by W. Gibson, M.D.,
    was a second time successful in saving
    both Mother and Child,  by George Fox,
    M.D.—Am. Journ. Sled. Sci., vol. xxii.
    p. 13.                           1838.
  Caesarean Section  on a  Dwarf, by Cyrus
    Falconer, M.D.—Am. Journ. Medical Sci.,
    vol. vi.  N.  S. p. 264, 1843;  also Western
    Journal of Med. and Surg., May.   1843.
  Case of Caesarean Section,  (successful.) by
    Brodie  S.  Herndon, M.D.  Virginia.—
    Am. Journ. Med. Sciences, vol. xii. N. S.
    p. 386.                           1846.
  Caesarean Operation, (performed unsuccess-
    fully,) by A. B. Shipman, M.D.  Indiana.
    —Am.  Journal Med. Sciences, vol. xviii.
    N. S. p. 122.                     1849.
 Caesarean  Section successfully performed
    by Dr. Gorham. Louisiana.—Am. Journ.
   Med.  Sciences, vol.  xxiii. N. S. p. 283;
   from New Orleans Med. and Surg Journ.,
   Sept.                           1851.
 Caesarean Section, by Charles S. Mills, M.D.
   Virginia.—New Orleans Med. and Surg.
   Journ., vol. xiii. p. 206.          1856.
 Caesarean  Section, three times in the same
   patient,  by D  F.Owen, M.D. Charleston.
   Am. Journ. Med. Sci., vol. xxxi. N. S. p.
   567.                           •  1856.
 Rupture of the Uterus, Caesarean Section
   three  months  and six  days after, (re-
   covery,) by H. A.  Bizzell, M.D.  Clinton,
   N.  C.—Amer. Journ. Med. Sciences, vol.
   xxxi. N. S  p. 79.                1856.
 Caesarean  Section, (third time performed
   on  the same individual,) death,  by Wm.
   H.  Merriman, M.D. Ohtibuck, Co., Miss.
   —Charleston Medical Journ., vol. xi.  p.
   172.                             1856.

 ON AFFECTIONS  OF THE RECTUM.

Fistula in Ano in an Infant, eight  months
  old, cured by Incision, by Felix Pascalie,
  M.D.   New York.—Philadelphia Medical
  Museum,  vol. vi. p. 197.           1809.
  Stricture of the Rectum, successfully treated
    by an operation, by H. G. Jameson, M.D.
    Baltimore.—Am. Medical Recorder, vol.
    v.  p. 290.                        1822.
  Improved  Mode of Operating for Hemor-
    rhoids, by J. C. Rousseau, M.D.  Phila-
    delphia —Am. Medical Recorder, vol. ix.
    p.  288.                          1825.
  Fissure of the Rectum, attended with Con-
    striction of the Anus, cured by division
    of  the Sphincter Ani, by Alexander H.
    Stevens, M.D.—N. York Med.  and Phys.
    Journ., vol. iv. p. 242.            1825.
  Case  of Prolapsus Ani, in which the entire
    Rectum was successfully extirpated, by
    J.  W. Brite, M.D.   New  Castle,  Ken-
   lucky.—Am. Medical Recorder, vol. x. p.
    311.                            1826.
  Case  of Blind Hemorrhoids, cured by the
    Use of Setons, by Ransom M. Collins,
    M.D.  Louisiana.—Transylvania Medical
   Journal,  vol. ii. p.  139.           1829.
 Callous Stricture of the Rectum,  (died,) by
   Daniel King, M.D.  Charlestown, Rhode
   Island.—Boston Med. and Surg. Journal,
   vol. iii. p. 525.                  1830.
 Case of Prolapsus Recti, successfully treated
   by  Excision, by  J.  W.  Heustis, M.D.
   Alabama.—Am. Journ. Med. Sciences, vol.
   xi.  p. 411.                       1832.
 New Instrument for Fistula in Ano, by T.
   D. Mutter,  M.D.  Philadelphia.—Amer.
   Journ. Med. Sci., vol. xiv. p. 80.  1834.
 Remarks on the Pathology and Treatment
   of Hemorrhoidal Tumors, by N.  R. Smith,
   M.D.  Baltimore.—North Am. Archives,
   vol. ii. p. 10.                    1835.
 Prolapsus Ani, (cured by  Ligatures and
   Needles,)  by  George  Hay ward,  M.D.
   Boston.—Boston Med. and Surg. Journ.,
   vol.  xix. p.  156.                  1838.
 Remarks on the Treatment of Hemorrhoids,
   (suggesting  a new mode  of operating,)
   by Wm. E. Horner, M.D.  Philadelphia.
   Am. Journ. Med. Sciences, vol.  iv. N. S.
   p. 358.                          1842.
 On Strictures of the Rectum, by Thomas D.
   Mutter, M.D. Philada.— Medical Exam-
   iner, vol.  i.  N. S. p. 77.           1845.
 Description of a new Operation for Hemor-
   rhoids, by Amussat, translated by Henry
   Selden, M.D.  Virginia.—Amer. Journ.
   Med. Sciences, vol. xi. N. S. p. 346. 1846.
 Extraction of a Glass Goblet from  the Rec-
   tum, by W. S. W. Ruschenberger, M.D.,
   U.S.N.—Am Journ. Med. Sciences, vol.
   xvii. N. S. p. 409.                1849.
 Imperforate Anus, (operated on by trocar
   —child lived 18  months,) by J. H. York,
   M.D.  Boston.—Boston Med. and Surg.
  Journ., vol.  xiii. p. 273.          1850.
A Case of Imperforate Anus—operation__
  failure—remarks on the causes of failure,
  by John S. Mitchell, M.D.  Charleston.'
  —Charleston Med. Journal., vol. v. p. 752.
                                  1850! 
622
PRINCIPLES AND  PRACTICE  OF  SURGERY.
Large Hemorrhoids, operated  on by Hor-
  ner's plan, (cured.) by Henry H. Smith,
  M D.  Philadelphia.—Medical Examiner,
  vol. vii. N. S. p. 175.            1851.
Fatal Case of Tetanus following Ligature
  of Hemorrhoids, (ether, double ligature
  passed  through tumor  by needle.)  by
  James  Bolton, M D.   Virginia.—Stetho-
  scope, vol. i. p. 662.              1851.
Imperforate Anus, Operation, death, (rec-
  tum closed li  inch up by fleshy mass,)
  by  A.  Bryant  Clarke, M.D.   Holyoke,
  Mass.—Boston  Med. and Surg. Journ.,
  vol. xlvi. p. 100.                 1852
Imperforate Anus,  and other Malforma-
  tion, relieved  by an operation, by George
  Hay ward,  M.D.  Boston.—Am. Jorfrn.
  Med. Sci., vol. xxvi. N. S. p. 554.   1853.
  From  Virginia  Med.  and Surg. Journal,
  July.                           1853.
Hemorrhoids of 17 years' standing, cured,
  (by ligature and excision,) by John Mo-
  Call, M.D.  Utica.—A7:  Y. Journ. Med.,
  vol. xi. p. 350.                   1853.
Extensive Fistula, successfully treated by
  a new  method, by Horatio G. Jameson,
  Sen., M.D.  Philadelphia.—Am. Journ.
  Med. Sci., vol. xxviii. N. S. p.  129.  1854.
Ca3eof Perforation of the llectum, followed
  by  an  Extensive  Fecal  Abscess of the
  Nates,  by Lewis A. Sayre, M.D.   Belle-
  vue Hospital.—New York Journ. of Medi-
  cine, vol. xii.  N. S. p.  178.        1854.
Pathology and Treatment of Hemorrhoids,
  by  T. G. Richardson,  M.D.   Louisville,
  Ky.— Western Journal of Med. and Surg.,
  vol. ii.  N. S. p.  105.              1854.
 Extraordinary  Case of Prolapsus  of the
   Rectum, by  L.  A.  Dugas, M.D.   Geor-
   gia.—South.  Med. and Surg. Journ., vol.
   xi. N. S. p. 140.                 1855.
 Accidental Impalement, by B. F. Chapman,
   M D.—Am  Journ.  Medical Sciences, vol.
   xxx.  N. S. p. 550.                1855.
 Cauliflower Excrescence of the Anus, by J.
   11.  Freese, M.D.  Bloomington, 111.—St.
   Louis Med. and Surg. Journ., vol.  xiv. p.
 ,  242.                             1856.
 Ecraseur Lineaire of M.  Chassaignac, by
   A.George, M.D.  Baltimore, Md.—Am.
   Journ. Med.  Sciences, vol. xxxiii.  N. S.
   p. 52.                            1857.
 Death from a Tin Tumbler in the Rectum,
   by O. C. Gibbs, M.D.  Lake Co., Ohio.—
   Western Lancet, vol. xvii. p. 7.     1856.
 Imperforate Anus,  Descending colon ter-
   minating  in  the  bladder,  Operation
   through  the  perineum,  subsequently
   Amussat's operation  for artificial anus,
   by Daniel Ayres, M.D.  Brooklyn, N. Y.
   —New York  Journ. of  Medicine,  vol. ii.
   3d Series, p.  9.                   1857.
Removal of Hemorrhoids, with the  Ecra-
   seur,  by J. M. F. Gaston, M.D.  Colum-
   bia, S.C. — Charleston Med. Journ., vol.
   xiii. p. 472.                      1858.
Remarks on Imperforate  Anus, by James
   Jones, M.D.  Louisiana.—New Orleans
   Med.  and Surg. Journal, vol. xv. p. 98.
                                   1858.
Lecture on Hemorrhoidal  Affections, by L.
  A. Dugas, M.D.  Georgia.—South. Med.
   and Surg. Journal, vol. xiv. N. S. p. 219.
                                   1858. 
PAET   XVI.
DISORDERS  OF, AND OPERATIONS  ON, THE
                  EXTREMITIES.
             GENERAL OPERATIONS ON THE EXTREMITIES.

  The Upper and Lower Extremities, being composed of several tissues
which are analogous to those found in other regions of the  body, are liable
to many similar complaints, and sometimes require operations which are the
same in  principle as some of those already described; thus, the removal of
tumors, the relief of deformities arising from the cicatrices of burns, the liga-
tion of arteries, or the resection of bones, are very much the same in all parts
of the body, and must be regulated by the same general rules, the operations
on these  regions only differing in accordance with the anatomical relations of
the portion of the body in which  they are performed.  It will consequently
be unnecessary, in this portion of  the work, to do  more than describe such
modifications of these operations as  are required  by the position and  func-
tions of the extremities; and the reader is therefore referred to the preceding
pages for any operative directions  not specially required in connection with
this region.
  Two classes of operations are performed upon the extremities: one includ-
ing all those of a general kind required for the relief of the diseases of the
superficial tissues, as  the tendons  and blood-vessels;  the other referring to
such as are deeper seated, as the bones or the entire limb.
  The  class of operations of a general character which may be assigned to
the  first of these limits, and not previously described, embraces such as are
required  for the relief of deformities, as well as those due to disorders of the
blood-vessels aud nerves;  the second including such changes of structure as
are  usually the result  of injury, and necessitate amputation.
                         CHAPTER  I.

                             CLUB-FOOT.

  Among the most marked of the deformities seen in connection with the
more  superficial tissues  found in  the extremities, is Talipes, or Club-foot.
This is a very common complaint, and one  which, as it generally makes its
appearauce at birth, or in young children, causes great anxiety to the parents.
As a deformity, it  presents certain details applicable to the whole class not
                                                         (623) 
624           PRINCIPLES  AND PRACTICE OF SURGERY.
  only of club-feet, but of deformities in general; and a very slight examina-
  tion  of the subject will demonstrate that club-foot has many points in com-
  mon with  strabismus, with  spinal curvature, (muscular,) with certain forms
  of torticollis, with club-hand, and all other similar deformities. Before, then,
  we proceed to study the symptoms and treatment of the disorder in question,
  it is right that allusion should be made to some of the points connected with
  the action  of the muscles.
    As deformities from muscular  action are due to the general law that the
  two sides of the body are equal,  and that the muscles of each side have an
  equal amount of power—due allowance being made for the slight predomi-
  nance of those of the right  side over those  of the left, on account of their
  being more exercised—there are certain general principles applicable to their
  treatment which should be here alluded to.   For instance, it is well known
  that  where the muscles of one side are contracted, those of the opposite
  portion are usually lengthened;  and that while  those of one side are over-
  acting, those which oppose them must be acting with diminished power.   In
  all these cases, therefore, it will become the duty of the surgeon not only to
  overcome  this excessive  action  and weaken the power  of the  contracted
  muscles, but also to stimulate and  favor  the  contractile force of the elon-
  gated muscle,  while  he  hardens the skin  on points where pressure is to  be
  made, in order that it may be better borne if mechanical appliances are to
  be employed.
    Symptoms.—Club-foot is  a deformity in which there is more or less devia-
  tion in the  axis of the foot from the  natural line in one of several directions:
  thus the toes may be depressed, and the  heel elevated;  or the toes may  be
  turned inward or outward; or various modifications and combinations of these
  conditions may be present.
   Etiology.—The causes of club-foot are varied, and by no means thoroughly
 understood. By the older writers, the affection was ascribed  to various causes,
 all more or less absurd;  thus, it was supposed to be due to the  fact that,
 during pregnancy, the mother had seen something disagreeable, or suffered
 so as  to induce a contraction in the  toes of the foetus; and this absurdity is
 still popularly  believed in, as I was once told by a lady of high education,
 that a club-foot in her child, to  which  she called my attention, was caused
 by her having  stumped her toe when about the third month of pregnancy.
 By some it  has been ascribed to unnatural or irregular contractions of the
 uterus upon the foetus,  and  by  others to  the umbilical cord having ac-
 cidentally been  wound around the  limb;  and this latter  may  sometimes
 have been the active agent in producing the  deformity, though the general
 cause  applicable to  nearly every case  of congenital  club-foot is want of
 proper innervation; and the student who would truly understand  the path-
 ology of the disorder, must start with this idea.
   That so many infants with  club-foot also show more or less deviation in
 the spinal column, laterally, and even sometimes suffer from spina bifida, or
 hare-lip, would seem to  point out the fact that, in some cases, there is more
 than a mere local disorder.
   Varieties.—Five varieties of the complaint have been made by authors :—
   1. The first  and simplest is designated as Pes Equinus, because the in-
 dividual laboring under the  complaint, when he comes to walk, walks as a
 horse does, upon the end of the  phalanges, the heel being elevated and the
 toes depressed.   This variety, though  sometimes  existing alone  is  very
 generally more or less combined with those which will next be brought under
 consideration.
   2. The second variety is the reverse of pes equinus; as here we have  a
depression of the heel and an elevation of the toes, so that the patient stumps
along upon his heel, this being the variety  known  as Pes Calcaneus 
PES  EQUINUS.
625
  3. The third variety is one of the most common, and is that in which there
is a turning inward of the metatarsal bones and of the toes, as well as an
elevation of the heel;  and this form has received from writers the designa-
tion of Varus.
  4. The fourth variety is called Valgus; and here the toes  and the sup-
porting metatarsal bones are  turned  outward; this condition  is therefore
directly the reverse of varus, but, like it, generally combined with more or
less elevation of the heel.
  5. The last  variety is Pes  Plantaris, a deformity in which  there is a
doubling under of the toes beneath the sole of the foot, so that the individual
walks upon his instep, or upon some part of the upper portion of his foot
  That much may be done toward  remedying these various conditions by
mechanical  means, will readily be understood by any one who will reflect
upon the great changes produced  by pressure  and bandaging upon the foot
of the Chinese lady, and  it is therefore but reasonable to suppose that means
so potent in the production of deformity in the sound  limb cannot but be
useful, if judiciously applied, to the case  of one that is diseased.
SECTION  I.
PES EQUINUS.
Fig. 442.
  In taking up the special consideration of these different varieties of club-
foot, attention may first be given to Pes Equinus, as the contraction of the
gastrocnemius and soleus  muscles, or a certain  amount of pes equinus, not
unfrequently complicates varus and valgus.   In  order that the studeut may
understand  this or any  other  variety  of club-foot, a brief allusion  to  the
structure of the healthy foot will be useful.
  Anatomical Relations.—In the foot we have  the articulation of the bones
of the leg with the astragalus, the latter bone articulating below with the os
calcis,  and forward  with the scaphoides,  while
the os calcis, which  projects posteriorly and in-
feriorly, forms the heel, and gives an insertion to
the tendo-Achillis.   The  calcis articulates an-
teriorly with  the cuboid,  which supports  the
fourth  and  fifth  metatarsal  bones;  while  the
scaphoid  articulates  anteriorly with  the  three
cuneiform bones, which support the first, second,
and third  metatarsal bones.
  Any one  of the varieties of club-foot, after it
has existed for a short time, will cause displace-
ments of these bones of the tarsus, so that the
articulating surfaces will be much modified, or it
may even  go to  such  an  extent that the appro-
priate  articulating facets of the  bones will no
longer present  to each  other.   Besides  these
changes in  the  bones, the  modifications in the
action  of the muscles themselves require special
study.   Thus in pes equinus,  we have an over-
action  in  the gastrocnemius  and soleus, which
induces a shortening in these muscles that draws
up the heel by means of the  insertion of the
tendo-Achillis into the os calcis, Fig. 442.   The
antagonistic muscles, on the other hand, are lengthened. As a result, changes
    VOL. II.—40
Position of the Foot in Pes
  Equinus in the adult. 
626
PRINCIPLES  AND  PRACTICE OF  SURGERY.
 must necessarily be experienced in the limb, the tibia no longer resting upon
 the articulating surface of the astragalus, owing to the violent flexion of the
 foot, but being seated  upon this bone posteriorly to its usual  articulating
 face, or forming a new  articulating surface upon  the  os calcis itself.  Like
 displacements  also occur  in the relations to each  other  of  all the tarsal
 bones, as can be readily  understood. We have, then, in a case of pes equinus,
 first a deviation in the  normal contractility of the muscles concerned; then
 a deviation in the articular faces of the bones, which are no longer presented
 properly to each other; and next, various deviations in the ligaments of this
 part, these becoming irregularly  stretched,  in  order to  accommodate  the
 bones in their new position.  When all these facts are taken  into consider-
 ation, it will be understood that mechanical means for the treatment of such
 a deformity can only overcome it if used  patiently, and for a long time, it
 being absolutely essential to a cure that some treatment should be persevered
 in until the extended and relaxed ligaments and the  new facets of the bones
 have resumed their normal relations, a fact which should not be lost sight of
 in all cases of club-foot.
   Post-mortem Appearances.—A dissection of a case of pes equinus shows
 that, among the muscles, the gastrocnemius and soleus, with the plantaris
 and the plantar fascia,  the tibialis posticus, and  the  peronei muscles, and
 especially the peroneus  longus,  are all more or less contracted, their antago-
 nistic muscles being weakened,  relaxed, and extended.
   Treatment—The  treatment of pes equinus, as well as that of all the
 varieties of club-foot, will  depend  somewhat on the age of the patient  and
 the duration of the deformity.  In the infant, much may be accomplished by
 directing the nurse to  bend the foot daily in the opposite  direction  to that
 to which it inclines, until  the child is about six months old.   In the older
 child, or in the youth, more powerful means will be required, and some form
 of apparatus should therefore be promptly prepared.   When these  are ap-
 plied, the surgeon should either trust entirely to them, or combine the appa-
 ratus with  such operative measures as have for their object the  division of
 the contracted  tendon and the  subsequent  elongation of the effused and or-
 ganized lymph that unites its divided extremities.
  The mechanical means adapted to the treatment of simple pes  equinus
 may be resolved into  such  measures as will elevate the toes and  bring down
 the heel, and are usually designated as the club-foot shoe, or as the club-foot
 apparatus.   Of these there are a great variety, most of which are modifica-
 tions of the old shoe of Scarpa, though  the  progress of the mechanic arts has
 now furnished several specimens of a very neat and efficient mechanism.  The
 apparatus made by Kolbe will be again alluded to, Figs. 450,  451.
  In  preparing the patient  for wearing any of these, the surgeon  should
 harden the skin  by bathing it daily in strong oak-bark tea,  in order that the
 pressure necessary to effect  his object, and which must necessarily be kept up
 for some time, may not cause a troublesome ulceration in the foot.  Then  with
 a view of increasing the  efficacy of the mechanical measures,  and saving 'much
 valuable time—valuable because while the deformity exists the  bones are be-
coming more and more difficult to shift from their abnormal  position—it may
be advisable to practice  the division of the tendo-Achillis as the most power-
ful of those concerned in the  production of this deformity.   The  division of
this  tendon may be accomplished by a little  knife, which is designated as a
tenotome, and which is introduced  flat  beneath the skin between  it and  the
tendo-Achilhs, and then turned  so as to cause its edge to present toward the
tendon, when the foot being put upon the stretch, the tendon will be brought
up against the knife and divided, by forcibly extending the foot, the division
 of the tendon being recognized by an audible snap.   The  limb  being now 
PHALANGEAL VARIETY OF PES EQUINUS.            627
left at rest, the ordinary changes of subcutaneous wounds ensue, such as the
effusion of blood, the liquid portions of which are  shortly absorbed, after
which there is an effusion of lymph, which, becoming organized, unites the
two  cut  extremities of the  tendon.  This  new tissue, when first formed, is
elastic and extensible, and if at this period mechanical measures are applied,
the heel  may gradually be  brought down, and the deformity overcome in a
few days.  But the rationale of this plan of treatment should never be lost
sight of;  for if the surgeon ignorantly brings the heel down, by mechanical
means, immediately after the division of the  tendon, non-union may be the
result, or so much new structure may be formed, that the increased length of
the tendon will be  greater than is desirable to restore the  equipoise of the
limb, and the patient be lamed for  life, being thus rendered  unable to con-
tract his gastrocnemius muscle sufficiently to raise the heel from the ground.

                                Fig. 443.
View of a Foot after the Heel is brought down in Pes Equinus.
   The surgeon  should, therefore, delay about five  days after the operation
of tenotomy before mechanical  means are employed, and  only apply them
very gradually at first.   If the heel be brought down one line a day, in less
than two weeks  it will have descended an inch.   Gradual extension, there-
fore, is amply sufficient, and it is only by such pressure and patient persever-
ance that the cure can be accomplished.
   After the heel is thus brought to the ground, the patient, though well able
to walk, will generally present some deviation of the foot, if it is closely ex-
amined, Fig. 443.


                § 1.—Phalangeal  Variety of P#s Equinus.

  In connection with pes equinus, it is necessary  to allude  to what is called
the Phalangeal  variety of the complaint.   This is simply the variety of the
disease seen in children who have never walked, in whom the toes point di-
rectly downward, and is usually seen in children under twelve months of age.
In connection with this subject I would allude to one cause which sometimes
produces this variety in  children who had originally perfectly healthy feet, 
628           PRINCIPLES AND PRACTICE  OF SURGERY.

and that is the practice,  now fortunately going out of fashion, but recently
very popular, of amusing children by suspending them  in  the  apparatuses
popularly called  "baby jumpers."  In this the child was  suspended  frora
a hook  in the  ceiling, by a little contrivance which surrounded  the  body,
and was so  arranged that it  could barely touch  the floor  with its  toes.
Then the suspending cords being elastic, the least motion of the child pro-
duced a dancing up and  down, which seems  to  have delighted equally the
infant and the mother or nurse who had it in charge.   But in consequence
of the foot being kept constantly extended, and the heel elevated, more than
one instance has occurred, within my own  knowledge, in which a spasmodic
contraction of the muscles in the back of the leg took place, and a temporary
phalangeal pes  equinus was produced.
                            SECTION  II.

                         PES CALCANEUS.

  The second form of the complaint to which attention may next be  given
is precisely the  reverse of pes equinus.  Here the toes  go up and the heel
comes down, so that the patient walks exclusively upon his heel, producing the
                            deformity described as Pes Calcaneus, or that
          Fig. 444.           which is popularly called hooked-foot. Thisisa
                            comparatively rare form of deformity.  The os
                            calcis here sustains the weight of the body, and
                            the muscles on the back of the leg are preterna-
                            turally elongated, while those upon its front are
                            preternaturally contracted; the muscles whose
                            contractions  have  most effect in producing the
                            deformity being  the extensor communis,  the
                            extensor proprius  pollicis, and the  tibialis an-
                            ticus.   This  form  of the complaint  is  very
                            marked  in some instances, and is  sometimes
                            carried to such an extent that the anterior face
                            of the os calcis looks upward instead of for-
 a .ide new of the Right Foot in Pes   warj?-  In the8e cases> as in others, there are
     Calcaneus. (After Nature.)      modmcations of the articulating surfaces of the
                            os calcis and  of the bones connected with it, as
the os calcis no longer articulates in the normal manner with the cuboid, while
the bones of the tarsus  are  generally displaced.   Of course, there are also
changes in the ligaments of the part, caused  by the modified position of the
bones; thus, the ligaments upon the bottom  of  the foot will be found to be
elongated, while those on the dorsal surface will be shortened.
  Treatment—More may be done in the treatment of this complaint  by
prompt mechanical means  than in most of  the other varieties, as the form of
the foot enables the pressure  adapted to the treatment of pes calcaneus to be
so  readily borne that this form presents few difficulties if treated  at an early
period of life.  In order  to  bring  the foot  down, such measures as were
directed  for the relief of  fracture of the os calcis may be resorted to  or a
club-foot shoe applied, so  as to depress the toes and elevate the heel   '
 
VARUS.
629
                              SECTION  III.

                                   VARUS.

  In Varus, the toes and metatarsal  bones are  turned  inward, Fig. 445,
and  the heel is almost  always  elevated,  this variety  being usually compli-
cated with a certain amount of pes equinus.  The changes in the bones and
ligaments, in this form of  the  complaint, are very marked, and due often to
an arrest of development in the bones of the tarsus, this being conjoined not
unfrequently with a deficiency of calcareous matter in the bones  concerned,
so that they readily bend, a condition well illustrated  by a specimen iff the

         Fig. 445.                        Fig. 446.
  Fig. 445.—Outside view of Varus in the adult, the deformity not very marked. (After Miller.)
  Fig. 446.—View of the Imperfect Development and Displacement of the Bones in Varus. (After Miller.)

Wistar and Horner Museum of the University of Pennsylvania.   The prin-
cipal muscles contracted in this form of the complaint are the gastrocnemius

                    Fig.  447.                       Fig. 448.
  Fig- 447.—Outside view of Varus, showing the Bursal Pad or Tumor upon which the patient walks, this pad
presenting a full, rounded, cushion-like point of support. (After Nature.)
  Fig 4i8.— View of the Sole of the Foot in a marked case of Varus, showing the contraction of the plantar
fascia, etc. (After Nature.)

and soleus, and the tibialis anticus.   The tibialis posticus and the abductor
pollicis are also contracted, while the peronei and other muscles antagonistic
to those just named are  generally lengthened.
 
630
PRINCIPLES AND PRACTICE  OF SURGERY.
  As the disease continues and  the child begins to walk, certain changes
will  be  noticed  in the external  tissues, consequent upon  pressure.   Thus,
there will usually be found a thickening of the skin, and  true  hypertrophy
of this tissue  at the  point at which the  foot comes in contact with the
ground.   Sometimes a bursa—Fig. 447—forms between  the thickened skin
and the  deeper-seated parts.
                            SECTION IV.

                                VALGUS.

   Valgus is a very rare form of club foot.   The disposition here is to turn
 the toes and metatarsal bones outward; and this variety is, therefore, just the
 reverse of varus.  The changes produced  by this deformity are readily under-
 stood : thus there is a perfect flattening down of the tarsus, Fig. 449, the sole
                            of the foot  becoming as flat as that of a negro,
           Fig- 449.          while there is the total loss of that fullness of
                            the  instep which  exists in  the  white  man.
                            Valgus is also more common in the negro than
                            in the white  man, and among the several ne-
                            groes known  to me who labor under this com-
                            plaint, almost every case is combined with  a
                            marked degree  of weakness of intellect,  the
                            patient being moreover  knock-kneed, in con-
                            nection with  the inclination  of the foot out-
                            ward.  The muscles contracted in this deform-
                            ity are those antagonistic to the muscles con-
                            tracted  in  varus.   They  are  generally  the
  a front view of valgus, showing the  peronei muscles, especially the peroneus longus
 7^m%h^S£^S^  and the muscles of the same gro«P. wh»e there
 instep. (After Nature.)             is  an elongation of the  plantar fascia and of
                            most of the muscles contracted in varus.  The
 changes affect here principally the astragalus  and the cuboides  among  the
 bones of the tarsus.

                            SECTION V.

                       PES TALUS OR PLANTARIS.

   The last variety of club-foot is a very rare one, and is called Pes Talus or
 Plantans, the foot being so deformed that  the patient walks upon the dor-
 sal surface of the toes, of the metatarsal bones, or of  the tarsus;  in other
 words, walks upon the top of the foot instead of the sole.  Sometimes this
 form is combined  with varus, and  then  the joint of the  little toe  with its
 metatarsal bone, becomes the point of support  when the patient walks.

                                •

                            SECTION VI.

           TREATMENT OP ALL  THE VARIETIES OP CLUB-FOOT.

  In the treatment of any of these varieties  of club-foot, much may be done
while the infant is yet in the arms, and too tender to be treated by raechan'
ical contrivances or by operative  means,  if  the nurse, by proper manipula
 
TREATMENT OF  ALL THE  VARIETIES OF CLUB-FOOT.
tions with her hands, will draw the toes up carefully from time to time if the
form of  the affection be  pes equinus, or bend the instep outward, if it  is a
case of varus.   As the child approaches the  age at which mechanical  con-
trivances can judiciously be applied—say from  six  to twelve  months—the
skin should be hardened  by soaking  it in oak-bark tea, as before directed.
In any of these varieties, where the heel is elevated, operative measures—as
the  division of  the tendo-Achillis, before alluded to—may be  demanded.
After which, or from the first, if operative means are not used, some  mechan-
ical  apparatus will be required, these being persevered in for many months,
and  a firm  support, in the shape of a stiff boot, worn for years subsequently.
   One of the best forms of apparatus that I know of  is  a modification of
Scarpa's shoe, which can be made  to adjust itself, by means of a screw, to
any  angle  of inclination  required, Fig. 450.   When this  contrivance has
Fig. 450.                            Fig. 451.
  Fig. 450.__A view of Kolbe's Club-foot Apparatus.—This ingenious instrument is applicable to all the
forms of Club-foot, the position of the foot being changed by means of the key attached to the shoe, thus
presenting  an advantage over some other forms of apparatus,  that, when the key is removed, the friends
cannot displace the angle of the apparatus, although they can remove it entirely from the foot.  It also can
be worn while the patient walks about, which is not the case with somo other varieties of the adjusting shoe.
(After Nature.)
  Fig. 451.__A three-quarter view of Kolb£'s Adjusting Shoe for Varus.—This apparatus is especially
applicable to Varus, and may be adjusted to any angle of the foot, and deviation of the heel, by means of a
universaljoint, though it will not permit the patient to walk.—1. Pivot for key to move the joint. 2. Joint
which revolves three-quarters of a circle laterally and ante»o-posteriorly. (AfterNature.)

been fastened to the foot, by means of properly adjusted and padded straps,
the motion of a  screw, by changing the position of  the  sole  to which  the
foot is strapped, can be made to bring the foot gradually into  any position
which may be required, while  the child will yet be able to walk about, as the
apparatus is so jointed as to permit it.
  For varus, and  especially for a case  in which  no effort has been made to 
632           PRINCIPLES  AND PRACTICE OF  SURGERY.
 bring  the  metatarsal bones into the proper line, a special  apparatus will
 prove useful, and sufficient to accomplish the cure, without tenotomy or any
 incision of the plantar fascia. As in this form of club-foot it is desirable that
 the patient should  not walk, lest one of the  pads, formed  by the  bursa, be
 created, and subsequently make a deformity, an  apparatus similar to that
 shown in Fig. 451 may be required, and Kolbe has so arranged  this shoe
 that it may be adapted to almost any length of leg, or any inclination of the
 foot.
   If a finished apparatus cannot be obtained, a  ruder article,  upon  the same
 principle, might be  fashioned, under  the  surgeon's direction, at any black-
 smith's-shop in the country ; and a very little mechanical ingenuity will often
 produce  one that will prove quite as useful as that furnished  in the cutler's
 shop.
   Much good may be  accomplished, in the simple cases of pes equinus, by
 surrounding the foot by a handkerchief, binding another around  the calf,
 and then connecting the two together by a third, or by a bandage or string,
 which from day to day may be  tightened; or strips of adhesive plaster or
 bandages  can be employed, in  the same  way, instead  of handkerchiefs, so
 as to draw the toes toward the tibia.
   After from six to nine months'careful use of such an apparatus, the patient
 may wear an ordinary shoe, with club-foot or side irons if the foot  has been
 brought to its correct  position.   But generally some apparatus  will  be
 required to be worn by a child a full twelvemonth, before the ordinary shoes
 can be well adapted to it.   No greater error, however,  can be committed in
 the treatment of club-foot, than an anxiety to establish a prompt cure.  The
 reduction of the deformity must be very gradually accomplished, and main-
 tained by continuous perseverance in the use of an appropriate  boot for years,
 while  the  child is  growing.  It is therefore generally advisable to explain
these facts to the parents before commencing the treatment.
                           CHAPTER II.


        LIGATION OF THE ARTERIES  OF THE  EXTREMITIES.

  The Arteries of the Extremities may be ligated at any point of their
course, and are to be operated on by the  same rules as have been already
stated in the chapter on Aneurisms.*  The present account will, therefore,
be limited to the  operative  steps required in the  special application of  the
ligature to these vessels, the anatomical relations of each artery being given
in connection  with  the operation practiced upon  it.   Compression as a
means of  curing  aneurism is especially applicable  to the blood-vessels of
the extremities, and is to be accomplished in  accordance with the views
before given, j*
  In the description of these operations, I shall chiefly follow the rules of the
French surgeons, as their fondness for practicing the ligation of arteries in
* Vol. i. Part xi. p. 791.
f Vol. i. p. 7D7. 
LIGATION OF THE AXILLARY  ARTERY.
633
the dissecting-room makes thera excellent authorities, and I shall  the more
freely state these, as I have in every instance tested their accuracy annually
with the operating classes of the University of Pennsylvania, and am able to
furnish extended  personal experience of the  value of those hereafter given.
                             SECTION I.

          LIGATION OP THE AXILLARY ARTERY IN THE AXILLA.

            \ 1.—Anatomical Relations of the Axillary Artery.

   The  region of the Axilla has been differently described by authors, the
 French surgeons including in it nearly all the parts found between the  arm
 and the clavicle, while others, among whom is Geddings, of Charleston,* limit-
 ing it to the triangular depression included between the upper part of the arm,
 shoulders, and side of the chest, which is formed by the edge of the pectoralis
 major in front, the  latissimus dorsi  and teres major muscles behind, as they
 tend to their insertion into the humerus, and by the ribs covered by the ser-
 ratus magnus at the sides. As the parts about the clavicle have been already
 referred to,  I shall  adopt the latter limits.
   The depth of the axilla depends very much upon the position of the arm
 and the obesity of the patient.  When the arm is elevated perpendicularly,
 the head of  the humerus is forced down, and nearly effaces the depression of
 the axilla, or sometimes renders it convex, and when the patient is fat, a
 deposit of adipose matter so fills up this space as barely to leave  a depres-
 sion.
   In the region thus bounded by the  pectoralis major muscle in front, and
 the latissimus dorsi behind, and which, in the adult, contains a  luxuriant
 growth of hair,  are to  be found  the axillary artery and  vein,  with their
 branches, as well as the nerves of the brachial plexus, together with the lym-
 phatic  glands; all  these parts being  united together by a loose connective
 tissue,  and surrounded by fat.
   The  vessels and nerves of the axilla are so  arranged as to form a plaited
cord, the vein being generally anterior and internal, while the artery  which
was between the vein and the nerves near the clavicle is here so interlaced
by the  latter as to be difficult of access.   The whole bundle of vessels  and
nerves traverses the axilla diagonally from above downward, and frora within
outward.  The lymphatic ganglia occupy the  course of the vessels, and are
abundantly developed, Plate LXY. Fig. 1.
                  2 2.—Ligation of the Axillary Artery.

   The ligation of the Axillary Artery may be performed by various methods,
some surgeons preferring one and some another.  The two hereafter stated
are amply sufficient, and as I  have frequently tested their correctness, I
recommend them to special consideration.
   Operation of Lisfranc.—The patient lying down, and the arm forcibly
extended, the distance  between the  latissimus  and pectoralis  major mus-
cles  should be  divided  by imaginary lines into  three equal parts,  and a
longitudinal incision  three inches  long made  through the  skin  and areolar
* Amer. Cyclop, of Med. and Surg., vol. i. p. 559. 
                           PLATE   LXV.

       LIGATION OF THE ARTERIES OF THE UPPER EXTREMITY.

  Fig. 1. A view of the Anatomical Relations of the parts about the Axilla and
upper  portion of the Arm.  1.  Brachial artery.   2. Director beneath it.   3.
Median nerve.   4.  Internal cutaneous  nerve.  5.  Ulnar  nerve.   6.  Brachial
vein.   7. Axillary lymphatics.  8. Branches of the axillary artery.   9. Pectoralis
minor  muscle.  10.  Pectoralis major.  11. The anterior margin  of the axilla
drawn  back by a hook.   12. The cut edge of brachial fascia  13. The biceps
muscle.  14. The coraco-brachialis.  15. Lymphatics.
                                                After Bernard and Huette.

  Fig. 2. Ligation of the Axillary Artery in  the Axilla.  1, 2. Incision in the
skiu and fat. 3. That in the fascia.   4. The axillary artery raised on a director.
5. The axillary vein drawn back  by a blunt hook forceps. 6. The median nerve.
7. The internal cutaneous nerve.                  After Bernard and Huette.


  Fig. 3. Anatomical Relations of the Brachial Artery.  1. Brachial artery.   2.
Radial  artery.   3.  Coraco-brachialis muscle. 4.  Biceps  muscle.  5. Median
nerve.   6.  Brachial vein.  7.  Profunda minor  artery. 8. Ulnar nerve.   9.
Fascia formed over the artery at the elbow by the expansion from biceps tendon.
10.  Median basilic vein.  11. Cephalic vein.        After Bernard and Huette.


  Fig. 4. Anatomical Relations of  the superficial parts  about the bend of the
Arm.  1, 3. Cephalic vein.  2.  Median cephalic.  4. Median vein.  5. Median
basilic vein.   6. Brachial  artery.   7. Biceps tendon.   8.  Median nerve.   9.
Ulnar  nerve.  10. Radial nerve.  11. Branch  of the external cutaneous nerve.
12.  Main trunk  of the external  cutaneous.  13.  Branch of the median nerve.
14.  Branch of the internal cutaneous. 15. Its main trunk.
                                                After Bernard and Huette.

  Fig.  5. Anatomical Relations of the parts about the Wrist.  1. The  posterior
annular ligament. 2. Tendon of the extensor primi internodii.  3. Tendon of the
extensor secundi internodii.  4.  The radialis indicis artery.
                                                After Bernard and Huette.

  Fig.  6. Ligation of the Radialis Indicis Artery.   1. The skin.  2. The fascia.
3. The artery with the ligature beneath it.          After Bernard and Huette.
(634) 
; late  65
•'   *"\'r,^
   7    %'l?           '   \o
 
 
LIGATION  OF THE AXILLARY ARTERY.             635
 tissue in a line corresponding with the union of the anterior and middle
 third of the axilla, Plate LXV.  Fig. 2.  The fascia, being then seized in
 the forceps, should be  nicked and slit  up on a director in the same direc-
 tion  as  the  external incision, or, if this  does not expose  the  parts  suffi-
 ciently, it may also be divided to a slight extent transversely.   The nerves
 and vessels  being now reached, the arm  should  be lowered, and the con-
 nective tissue  around the vessels lacerated by the point of the director suf-
 ficiently to distinguish  each part.  The vein being then pushed to one side,
 seek  on  the anterior side of the axilla for the median nerve, underneath and
 inside of which is found the  artery, which may now be secured by passing
 the aneurism-needle from  behind forward, care being taken to  avoid the
 axillary vein.
   Remarks.—As it is often difficult to find the artery at  this  point, the
 operator, when he experiences a difficulty, should bear in mind the relations
 of the nerves to each other as well as to the surrounding parts, and, counting
 from the coraco-brachialis muscle backward and inward, find:   1st. The
 median nerve.  2d. The artery on the inner side and beneath  this nerve.
 3d. The internal cutaneous nerve.  4th.  The ulnar nerve.  5th. The radial
 nerve.
   Operation of Malgaigne.*—By a similar incision  in the skin, or by one
 three-fourths of an inch from the anterior border of  the axilla—as advised
 by Manec—the fascia is exposed, opened as before directed, and the internal
 border of the coraco-brachialis  muscle sought for as the first indication.
 Division of the sheath of this  muscle, on a level with its internal border, leads
 directly to the median nerve,  which is the second indication;  and inside and
 beneath it is the artery, which should be ligated as before directed.
   Remarks—The ligation of the axillary artery  in  the axilla may be de-
 manded in cases of aneurism  or wound of  the  brachial artery high up; the
 primary hemorrhage in the case of wounds being restrained  by  pressure of
 the subclavian artery upon the first rib, while, if the wounded vessel can  be
 drawn out at the lower part of the wound, the ligature may be more readily
 applied than it can be higher up, where it is surrounded by nerves.  In aneurism
 the same rule holds good, and the difficulty of ligating the vessel high in the
 axilla, without injuring  either the nerves or the vein, has, therefore, generally
 prevented the  operation from being attempted.  As the  application of the
 ligature in the axilla does not make so unfavorable a wound for suppuration
 as the operation below  the clavicle, I should prefer ligating the vessel at this
 point when practicable.  Occasionally, fainting from  loss of blood will de-
 prive the operator of the aid to be obtained from noting the pulsation of the
 vessel in its full force, while the interlacing of the numerous nerves will add
 to his embarrassment.   In one case the patient was so exhausted that I could
 only tell the nerves from the artery by the hollowness of the latter.  In simi-
 lar cases the directions  just given can alone show the  operator where he is;
 and to prove this, he should at once cease to search for the artery, and being
 to trace the parts methodically from the muscle backward, when he will  find,
 as before stated, the median nerve next to the coraco-brachialis muscle, inside
 of it the internal cutaneous nerve, and behind this the ulnar and radial nerves.
 If, then, he follows the directions  before given, he will  find that even the or-
dinary amount of anatomical knowledge possessed by those long absent from
the dissecting-rooms may suffice for the operation.
* M6d. Op^ratoire. 
636
PRINCIPLES AND  PRACTICE OF  SURGERY.
                            SECTION II.

                  LIGATION OP  THE BRACHIAL  ARTERY.

  The Brachial Artery, in its ordinary course down the  limb, may require
to be ligated at any point, close  attention being  paid to the relations of the
superficial and deep-seated veins and the nerves  of the arm.


            g 1.—Anatomical Relations of the Brachial Artery.

  At the lower border of the latissimus dorsi, and upon the anterior face of
its insertion, the axillary artery takes the name of Brachial, and keeps it as
far  as the bend of the elbow.   Throughout  its length, the course of this
artery is down the  arm on its inner side, winding gradually forward to reach
the middle of the anterior face of the bend of the elbow.   At first it runs
along the  inner edge of the coraco-brachialis muscle; then, from its insertion,
it lies upon the brachialis internus, following the inner edge of the biceps mus-
cle, Plate  LXY. Fig. 3.   In the upper three-fourths of its course, it is only
covered by the integuments and fascia;  but at the bend of the elbow it per-
forates  the  fascia,  and  passes beneath the fascia-like expansion connected
with the tendon of the biceps.   Passing under  this, it sinks deep  into the
middle of the bend of the arm, and divides into the radial  and ulnar arteries
about a finger's breadth  below the joint.  Two  venae satellites accompany
it;  the  basilic vein is superficial, but runs parallel with it; and the median
nerve courses along its outer side, at its upper part, between it and the coraco-
brachialis muscle.  Sometimes this nerve crosses the artery obliquely in front
of this point, and sometimes lower down, till  it gets on the ulnar side of the
vessel.  As a general rule, therefore, it may be  said  that  the median nerve
is at the outer side of the brachial artery, above; in front of it, at the mid-
dle; and on its inner side, at the lower third of the arm.  The radial, ulnar,
and internal cutaneous nerves are also upon its inner side, high up the arm;
but lower down they advance toward the posterior and  internal face of the
limb, and  recede from the artery.   The brachial artery  is liable  to great
varieties, sometimes giving off the radial and ulnar arteries as high up as the
axilla, and being only one inch long.
      \ 2.—Ligation of the Brachial Artery at the Middle of the Arm.

  Lying on the inner side of the coraco-brachialis muscle, high  up, and on
the inner  edge of the biceps muscle, lower down, the median nerve is ex-
ternal, or  more frequently directly over or anterior to the course of the
artery.  Four indications point out the line of the incision :  1. The internal
edge of the biceps, and, higher up, the coraco-brachialis, (Hodgson.)  2. A
line drawn from the middle of the axilla to a point a little inside the middle
of the bend of the elbow, (Sabatier.)  3. The ends of four  fingers placed
upon the median nerve,  which is here on the outside of the artery, and can
often  be felt beneath the skin as a  tense  cord, the incision  beiug made
parallel with, and inside of the fingers, (Lisfranc.)   4.  The pulsation of the
vessel.
  Ordinary Operation.—Carry the limb a little off from the body; flex the 
LIGATION  OF THE RRACHIAL ARTERY.
637
forearm, and lay it over upon its back; feel for the bicipital fossa, and incise
the skin for three inches in the line of the artery.  On coming to the fascia,
feel for the pulsation of the artery, and, carefully picking up the  fascia in
the forceps, lay the blade of the scalpel flat upon  its side, nick the fascia,
insert the director, and slit up the fascia to the extent of two and a half inches,
so as to expose the inner edge of the biceps muscle, when the thick yellow
sheath of  the vessel will be readily seen.  Incise this cautiously on its inner
edge, when the median nerve—which is the first white cord on the inside of
the muscle—being found, the artery may be readily exposed  beneath  it by
tearing the connective tissue with the point of the director, when the vessel
may be easily ligated from without inward  by drawing the nerve a little to
the outside, Plate LXVI. Fig. 2.   The internal cutaneous nerve is internal
to, and the ulnar nerve half an inch behind, the artery.
   If, by the division of the axillary artery, high up, the brachial is deficient,
the radial and ulnar arteries will be found in very much the same position as
that above assigned to  the brachial, the ulnar being, however, a little more
to the inner and posterior side of the arm than the radial.


           \ 3.—Ligation of the Brachial Artery near the Elbow.

   Ordinary Operation.—Make an incision  through the skin on the  inner
edge of the biceps  muscle, or in the line from the axilla to the elbow before
mentioned.   Open the fascia and sheath as before directed, and  the median
nerve will be found about a quarter or half an  inch on the  inner side of the
vessel.  Separate the artery a little from its  sheath  with the point of the
director, and apply the aneurismal needle, so that the ligature may be carried
around the vessel from within outward,  Plate LXVI.  Fig.  2.  As the median
nerve passes underneath the artery, two inches above the epitrochlea, it should
be remembered  that, though it  is  on  its anterior and external side at the
upper part of the arm,  it is here posterior and internal to  it.
   Remarks.—The ligation of the brachial artery at any point, is not a diffi-
cult operation to one familiar with the general relations of the median nerve
to the artery; and though these vary a little, as mentioned above, the nerve
is never far from the artery.  The most  troublesome cases are  those in which
the radial and ulnar arteries are given off near the axilla; but  these anom-
alies are not very common.   After the ligature is  applied upon the vessel,
one end should be cut off, the wound closed by adhesive strips,  and the arm
kept  moderately warm  for a few hours,  until  the circulation  is  established
through the muscular and anastomosing branches.   When, in  ligating the
artery,  the arm is much swelled, the line described  by Sabatier will furnish
the best direction for the incision; but when  it is  not, the course of the
biceps or coraco-brachialis muscles will suffice.   The rapid enlargement of
the anastomosing arteries, though soon  advantageously restoring the circula-
tion, sometimes creates trouble in cases of aneurism at the bend of the elbow,
and occasionally necessitates the application of two ligatures,  one above and
the other below the  tumor. 
                          PLATE  LXVI.
      LIGATION OF THE ARTERIES  OF THE UPPER EXTREMITY.

  Fig. 1. Surgical Anatomy of the Blood-vessels of the Forearm and Hand.  1.
Brachial artery.  2.  Radial artery.  3. Ulnar artery.  4.  Position of the radial
artery at the wrist.  5. Position of the ulnar at the wrist.   6. Palmar arch.
7.  Radialis indicis.  8. Basilic vein. 9. The cephalic vein.  10. Vena; satellites
of the  radial artery.   11. Yense satellites  of the  ulnar  artery.  12. Median
nerve.  13. Radial nerve. 14. Ulnar nerve.  15. Biceps tendon.  16. The supi-
nator radii longus.   17. The flexor carpi radialis.   18. Flexor carpi  ulnaris
tendon.                                          After Bernard and Huette.


  Fig. 2. Ligation of the Brachial Artery.  Upper Incision.—1. The skin.  2.
The fascia.  3.  The brachial  vein.  4. The median nerve.  5. The artery on a
director.
  Second Incision near the Elbow.—1. Skin.  2. Fascia.  3.  Inner edge of
biceps.   4. Median nerve.  5. The artery on director.
                                                After Bernard and Huette.

  Fig. 3. Ligation of the Radial and Ulnar Arteries.  Upper Third.—1. The
skin.   2. The  fascia.   3. The radial  artery.   4.  The radial  nerve.   5. The
director under  the artery.  6. Inner  edge of  the supinator  radii longus.   At
 Wrist.—1. Skin. 2. Fascia.  3. Artery on director.  4.  Radial nerve.   Liga-
tion of  the Ulnar Artery at the Middle of the  Forearm.—1.  Skin.  2. Fascia.
3. Artery.  4  Vein.   Ligation of the Ulnar Artery at the Wrist.—1. Skin.
2. Fascia.   3.  Artery on director.  4. Nerve.    After Bernard and  Huette.


   Fig. 4. Anatomical Relations  of the Arteria Dorsalis Pedis.   1. The ante-
rior tibial artery.  2. The anterior tibial nerve.  3. The anterior annular liga-
ment.   4. The tendon of the extensor proprius pollicis.  5. The extensor brevis
digitorum pedis.                                 After Bernard and  Huette.


   Fig.  5. Ligation of the Anterior Tibial Artery on the  Foot.  1. Skin.   2.
 Fascia.  3. Director.   4. Artery raised on it.     After Bernard and  Huette.
        (638) 
Fig.Z.
HZ
mm.




Vii
-
Fi
£4 ':H
Fig.l.
#-

f
Fi£.5.
^1 v.> 
 
LIGATION OF THE RADIAL ARTERY.
639
                            SECTION III.

                   LIGATION OP THE RADIAL ARTERY.

  The Radial Artery is seldom ligated, except at the points hereafter men-
tioned, owing to its muscular relations.
            \ 1.—Anatomical Relations of the Radial Artery.

  At the upper third of the  forearm, the Radial Artery is placed in  the
groove that separates the supinator radii longus  frora the pronator radii
teres and flexor carpi radialis muscles, where it is covered by the inner edge
of the supinator muscle, by the fascia, and by the skin.   The radial nerve
is on  its  outside, and the venae satellites accompanying it  as usual, Plate
LXVI. Fig.  1.
  At the lower third of the forearm, the artery  is only covered by the skin
and fascia; has the tendon of  the flexor carpi  radialis on its inner side, and
the radial nerve far outside of it.
  When the limb is too much  swollen to permit the distinguishing of these
marks of reference, a line drawn from a  point half an inch outside of  the
middle of the front of the elbow to  a point on the outer side of the forearm,
two inches and a half below, would indicate its course  above, (Lisfranc,) or
frora  a similar point at the elbow to the middle of the space which separates
the styloid process of the radius from the tendon of the flexor carpi radialis,
(Malgaigne,)  would show its position below.
                   \ 2.—Ligation of the Radial Artery.

  The Radial Artery may be tied either at its upper or at its lower third.
  I. Ordinary Operation at the  Upper Third of  the  Forearm.—The
ligation of the radial  artery at its upper third may be readily accomplished
by an incision in the line just described, which it takes from the elbow to the
hand.   In doing this, the  skin should be divided  to  the extent of two and
a half or  three inches, the median  vein pushed to  one side, the  supinator
muscle exposed by laying open the fascia, and then its internal border raised
with the finger or director, when the sheath of the vessels may be seen and
opened, Plate LXVI. Fig. 3.  As the artery passes in the depression that
exists  between the supinator radii longus  and the pronator radii teres and
flexor carpi radialis muscles covered by the inner edge of the supinator, it is
important carefully to incise the fascia, and then press the finger between the
muscles so  as not  to separate the fibres  of either  muscle, but so as to fall
into the intermuscular  space.  If the artery  is not readily met with, draw
the  muscle  outward until  the radial nerve is  seen, which is never absent;
and seeking between this nerve and the median line of the  arm, the artery
will surely be found, unless there is  an anomaly.
  II. Ligation of  the Radial at the Wrist.—Make an incision two inches
long, parallel with  and  on the radial side of the tendon of the flexor carpi
radialis about half an inch from the wrist-joint, pick up the fascia  in the for-
ceps, nick it cautiously,  and open it upon a director, when the artery will be
found on  the outer or radial side of the tendon, Plate LXVI. Fig. 3.
  Remarks.—The ligation of the radial artery at the points mentioned may 
640           PRINCIPLES AND  PRACTICE OF SURGERY.

be required in cases of wounds of the palmar arch or at the wrist, and may
be surely accomplished under the directions just given.
  III. Ligation of the Radial Artery at the Thumb.—The ligation of the
Magna Pollicis, or of the Radialis Indicis, at the root of the  thumb, can
seldom be required iu practice; compression, or the ligation of the artery at
the wrist, answering a better purpose.  The  operation, as an  exercise, is
shown in  Plate LXV. Fig. 6, the  incision  being made in the  line of the
tendons of the extensor ossis, metacarpi pollicis,  and  extensor secundi inter-
nodii pollicis.  The tendons being made prominent by forcibly extending the
thumb, a little depression is created, into which the French students drop their
snuff when, having dirty hands, desirous of taking a pinch ; hence it has with
them the name of the " Snuff-box," "La Tabatiere."  The incision  should
be made in its middle.
                            SECTION IV.

                   LIGATION OF THE  ULNAR ARTERY.

  As the Ulnar Artery lies more deeply than the radial, its relations require
a little more attention.


             \ 1.—Anatomical Relations of the Ulnar Artery.

  The thickness of the flexor muscles near  the elbow placing the Ulnar
Artery very deep at this point, no operation is usually attempted here, and
it is therefore unnecessary to study its relations at  its upper third.   In the
middle and  lower third  of the  forearm, it lies upon the flexor  profundus
muscle,  between the  flexor  sublimis and  the  flexor carpi ulnaris,  Plate
LXVI. Fig. 1.   The  ulnar nerve is on its ulnar or inner side, and the vein
upon its outside; but  this  artery is  subject to  many anomalies, in  some of
which it is quite superficially  placed.


                   \  2.—Ligation of the Ulnar Artery.

  The Ulnar Artery may be tied in its middle and lower third as follows :—
  I. Ligation of the  Ulnar Artery at the Middle Third of the Forearm.
—Ordinary Operation.—A line drawn from the internal condyle to  the
radial side of the pisiform bone, will indicate the usual course of the vessel;
or a line  may  be drawn from the inner edge of the tendon of the biceps
muscle, at the bend of the  elbow,  to the ulna at the junction of  the upper
and middle  third of the forearm, and from this point to the pisiform bone,
should the first  fail to  point out its pulsations.  Upon  either of these lines
make  an incision three  inches long, and not extending higher than three
fingers' breadth  below  the internal condyle ; pick up the fascia, open it upon
a director; carry the inner  lip of the  wound inward with the forefinger until
the  internal edge of the ulna can be felt, and then the first yellowish line,
which indicates a muscular interspace, met with on the median or radial side,
will point out the junction of  the flexor carpi  ulnaris and the flexor sublimis
muscles.   Separate  this interstice with the finger or knife-handle, and at the
bottom of the space there will  be seen a large yellow or  whitish cord, the
ulnar nerve, with the artery and  its two venae satellites on its radial side,
when  the ligature  may  be passed from within outward,  the  hand  being
strongly flexed  to relax the muscles, Plate LXVI. Fig. 3. 
LIGATION OF  THE  FEMORAL  ARTERY.
641
  II. Ligation of the Ulnar Artery above the "Wrist.—Ordinary Opera-
tion.—Make an incision two inches  long, and  one inch above the joint,
parallel with the tendon of the flexor carpi  ulnaris; pick up the fascia, di-
vide it, draw the tendon a little inward, and the artery will be found on its
external or radial side beneath the deep fascia, the  ulnar nerve being on its
inside and posteriorly.  Open this deep fascia, and pass  the  ligature  from
within outward,  Plate LXVI  Fig. 3.
  Remarks.—The  ligation of the ulnar  artery at its upper third is  now
never attempted, on account of the difficulty of finding the vessel, as well as
the subsequent free suppuration of the wound.  It is also better to avoid, if
possible, ligating this vessel in its middle third, for the same reason;  the
ligation  near  the  wrist being usually sufficient  for wounds of the palmar
arch, as it is generally these cases which most frequently demand the opera-
tion.
                         CHAPTER III.

     LIGATION  OF  THE  ARTERIES  OF THE  LOWER EXTREMITY.

  The main artery supplying the lower extremity being the continuation of
the external  iliac, it is  at different  points named Femoral and Popliteal,
according to its position.  It may be ligated at any portion of its course.
                             SECTION  I.

                  LIGATION OF THE FEMORAL ARTERY.

            § 1.—Anatomical  Relations of the Femoral Artery.

   The line of the groin, or that caused by the  attachment of Poupart's liga-
ment to the bones of the pelvis, constituting the upper boundary of  the
Femoral Artery, the vessel continues under this name throughout its entire
course,  until it passes through  the  insertion  of the adductor muscle, at a
point which is about one-third of the whole length of the femur, above  the
knee-joint, when it takes the name of Popliteal Artery.  In the space thus
described, the femoral artery  runs a winding course, being first  on  the  an-
terior, then on the inner side,  and lastly near the posterior face of the thigh,
following thus the direction of a line drawn frora the middle of the crural
arch to the posterior and internal part of the condyle of the femur, or  the
course of the sartorius muscle.  It is inclosed in a common  sheath with the fem-
oral vein, the latter being on its inner or pubic side near  the groin, behind it
in the middle of the  thigh, and a little to its  outer side, below the middle
third, Plate LXVII.  Fig. 1.
  The anterior crural nerve lies upon the external  side of the artery outside
the sheath of the vessels, while the long  saphenous nerve enters the upper
fourth  of the  sheath, and lies upon the outer side of the artery,  Plate
LXVII. Fig.  1.  At its  upper fourth, the artery is only covered by  the
skin and fascia, and may be easily compressed against the bones of the pel-
    VOL.  ii.—41 
PLATE  LXVII.
      LIGATION OF  THE  ARTERIES OF THE  LOWER  EXTREMITY.

  Fig. 1. Anatomy of the Femoral Vessels.  1,  1. The femoral artery.   2, 2.
The femoral vein.  3.  The internal saphena vein.  4 Muscular branch of the
artery.  5.  The long saphenous nerve.  6. The branch in front of the sheath of
the vessels.  7. Arteria profunda.  8. Opening in  the adductor muscle.   9. The
musculo-cutaneous  nerves.   10. The  anterior crural nerve.  11, 11. Hooks
holding aside the sartorius muscle.                After Bernard and Huette.

  Fig. 2. Ligation of the Femoral Artery.  At its Upper Third.—1. The skin.
2. The fascia.   3. The  sheath  of the vessels.   4.  The artery raised on the
director.   5. The femoral vein.  6. The  long  saphenous  nerve.  7. The  inner
edge of the sartorius muscle. At its Lower Third.—1. The skin.  2. The fascia
3. The external  edge of the sartorius muscle. 4. The femoral vein.  5. The
long saphenous nerve.  6. The artery exposed in  its sheath.
                                               After Bernard and Huette.

  Fig. 3. Anatomy of the Popliteal Artery.   1.  The artery.  2. The vein.  3.
The  semi meinbranosus muscle.  4. The gastrocnemius.   5,  5. Hooks holding
aside the muscles.                               After Bernard  and Huette.

  Fig. 4. The course and relations of the Popliteal Artery to the  Joint.   1, 1.
The  artery.  2. The femur.   3. The tibia.  4, 4. The posterior face of the knee-
joint.  5, 6, 7. The articulating arteries.          After Bernard and Huette.

  Fig. 5. Ligation of the Popliteal Artery in its Upper Half.  1.  The skin.  '1
The  fascia.  3. The fat.  4.  The peroneal nerve.  5.  The external saphena vein.
6. The popliteal vein.  7. The artery as shown by 8 the hook holding aside the
veins.                                          After Bernard and Huette.

  Fig. 6. Ligation of the Posterior Tibial Artery.  At its  Upper Third.—1.
The  skin.   2. The fascia.   3, 3. The gastrocnemius muscle held aside  by a
blunt hook.  4.  The artery on the needle.  5. The soleus  muscle.  At its Mid-
dle TJiird.—l. The skin.   2. The fascia.  3.  The external edge of soleus.  4.
The artery.  5. The needle under it.  6. The posterior tibial nerve. At the
Ankle.—1. The skin.  2. The director under the artery. 3. The posterior tibial
nerve.                                          After Bernard and Huette.
        (642) 
Plate  67
 
 
LIGATION OF THE FEMORAL ARTERY.
643
 vis;  but below it  is crossed obliquely by the sartorius muscle, so that at
 the upper part of  the thigh this  muscle is on the outer side of the artery,
 covers it in its middle, and leaves the artery on its outer side low down the
 thigh.   The regular course of this muscle makes it a most useful point of
 reference when attention is  given to its relations at the different points of
 the limb.
   Mott, of New York,  whose experience in the ligation of this  artery has
 been very great, thinks it advisable to study the relations of the vessel at the
 three points in which it may be ligated—thus: 1st, at Scarpa's triangle, or
 the space bounded above by  Poupart's  ligament, outside  by the  sartorius,
 and  inside  by the  adductor longus muscles; 2d, where it is covered by the
 sartorius muscle;  and 3d, near the  opening made for its passage  through
 the adductor magnus muscle.*

                   \ 2.—Ligation  of the Femoral Artery.

   The Femoral Artery may be tied either at its inferior, middle, or superior
 portions; the first two points being those most commonly resorted to, though
 it has been  occasionally tied at its upper end.   In all  cases it is  important
 after the operation to preserve the warmth of the limb by artificial heat until
 the circulation is restored.
   I.  Ligation of the Femoral Artery at the Upper Part of the Thigh.—
 Scarpa's Operation.—At Scarpa's triangle the artery is quite superficial,
 and  may be readily felt pulsating in  the  triangular space formed by  the
 juuction of the sartorius, adductor longus, and Poupart's ligament, the base
 of the triangle being above or at  the groin, and its apex below.   The most
 favorable point, according to Hodgson, for the application  of a ligature, is
 about four or five inches below the crural arch, because it gives room for the
 formation of a coagulum above the origin of  the  profunda.  The  operation
 should be performed as follows :—
   Operation.—Feel for the pulsation of the artery, and note the spot where
 it is faintest, which will indicate the point where the vessel is crossed by the
 sartorius muscle, and commencing  at this part incise the skin obliquely down-
 ward to the extent of three inches,  taking care to push the saphena vein
 inward.   On exposing the fascia  lata, pick up a fold at the lower point of
 the incision; nick it, introduce a director, and slit the fascia up to the same
 extent as the  skin ;  open the  sheath in the  same manner, and expose the
 artery with  the point of the director, the nerve being  on  its outside, and
 the veiu still at its inner side,  and tie the artery by passing the needle frora,
 within outward, so as to avoid the vein.
   II.  Ligation of the Femoral  Artery in the Middle of the  Thigh.—
 Operation of Hunter.—Flex the thigh on the pelvis, and the leg on the
 thigh, and lay the  latter upon its outer face, so as to relax the muscles.
 Then, feeling for the  inner edge of the sartorius  muscle, make an  incision
 three inches long, so that its lower end shall be about two lines from the
 inner edge of the muscle, and its upper about four,  but  without dividing the
 saphena  vein.  After incising  the skin  and fat, pick  up the fascia in the
 forceps, nick it, introduce a director,  and slit  it up to the extent  of the in-
cision in the skin, so as to expose the  internal border of the sartorius muscle,
 which may be recognized by the course of its fibres.  Then carefully opening.
the sheath of the vessels, which here  appears as a thick yellowish  structure,
incise it slightly upon a director, separate the vein from the inner side of the
artery with  the point of the director, and pass the aneurismal needle frora
* New York Register, vol. i. p. 185. 
644
PRINCIPLES AND  PRACTICE OF  SURGERY.
within outward, Plate LXVII. Fig. 2.   If the needle is passed in the op-
posite  direction, its point may wound the vein, and the  escape of  even a
little blood will materially interfere with the sight of the surgeon and delay
the operation.                                                      ,,
  Operation of Mott.*—In the operations upon the femoral artery,  Mott
advises the surgeon always to open the sheath of the vessels in front, and
never to use the edge  of the knife near the sides of  the artery, or within its
sheath, lest he wound some of the  branches which generally are given off
from its sides.
  Remarks.—The  cedematous condition  of the  thigh,  sometimes seen in
cases demanding  the  ligation of the  femoral  artery, adds materially to the
difficulties attending this operation when required upon the patient. As above
described, these methods  are chiefly adapted  to  the dissecting-room,  or to
the natural condition of the parts.   When, therefore, any difficulty  is expe-
rienced in recognizing the muscular spaces in the middle of the thigh, a line
drawn from the middle of the groin, as directed, will prove of great service.
Occasionally, the Femoral artery  has been tied  close to  the crural  arch,
where its position can be  readily recognized as being half way between the
spine of the pubis and the auterior superior spinous process of  the ilium in
man, though a little nearer to the pubis in woman;  but this operation is not
so favorable as that lower down, as it exposes the  patient to greater risks
from the occurrence of gangrene,  the  origin of the profunda favoring the
course of the circulation  when the ligature is applied in the middle of the
thigh.  The ligation  of the  femoral artery, as practiced  in  the lower third
of the thigh, is shown in  Plate LXVII. Fig.  2;  but as it requires  the divi-
sion of the arterial canal through the adductor magnus, and also  makes a
deep wound, it is seldom resorted to on the patient.
                            SECTION  II.

                 LIGATION OF  THE POPLITEAL ARTERY.

           \ 1.—Anatomical Relations of the Popliteal Artery.

  The Popliteal Artery being a continuation  of  the femoral, extends from
the insertion of the adductor magnus tendon to the inferior margin of the
popliteus muscle, being covered by the vein which is between it and the skin,
and somewhat internal to it above, but external below.  The belly of the semi-
membranosus and the two heads of the gastrocnemius muscles also cover it.
The artery is first on the inner side of the femur, then approaches its poste-
rior face, and, passing between the condyles, is in contact with the back of
the knee-joint.

                 \ 2.—Ligation of the Popliteal Artery.

  When the application of a ligature  to this artery is deemed advisable, it
may be accomplished by the method hereafter mentioned.  But in aneurisms
of this vessel its ligation would be very difficult, if not impossible, and com-
pression had better be applied to the Femoral  artery in the thigh, in accord-
ance with the principles before stated,-]" or the  ligature applied in the middle
of the thigh.
   Lisfranc's Operation.—The patient being  laid  upon his face, with the
* New York Register, vol. i. p. 186.
t Vol. i. p. 797. 
            LIGATION  OF THE POSTERIOR TIBIAL  ARTERY.         645

limb extended, feel for the interval between the two heads of the gastrocne-
mius muscle, and make  in this line a longitudinal incision three inches long,
commencing at  one-third of an inch below the joint and a little outside of
the median  line.   Then, pushing aside  the external  saphena vein, pick up
the fascia, nick  it, introduce a director, and incise it to the extent  of the
opening in the skin; flex the leg on the thigh, and feel for the space between
the two heads of the gastrocnemius, at  the bottom of which  the vessels and
nerves will be found.  Of these, the popliteal nerve is first seen, and  on the
inside of it is  the vein, the  artery being on the  outside in the majority of
cases, when it only remains to draw the nerve and vein inward, and pass the
needle under the artery from within outward,*  Plate  LXVII. Fig. 5.
   Remarks.—The ligation  of the popliteal artery, as above described, is an
operation that is seldom or never undertaken, except in rare cases of wounds
exposing  the vessel,  the depth at  which the artery is placed, its proximity
to the joint, and the liability of the latter to  inflame, as well  as  the risk
arising from the suppuration traveling beneath the fascia of the leg, inducing
surgeons to avoid it.   In all cases of aneurism, or wounds of the tibial arte-
ries high  up,  it is easier and safer  to tie  the femoral at the middle  of the
thigh;  and in the case of aneurism of the popliteal itself, the  position of the
tumor, as just stated, would render it absolutely necessary to place the liga-
ture higher up.   The operation is one,  therefore, which is seldom practiced
except  in the dissecting-room.   Lord, of Portland, Maine, succeeded, in
1855, in ligating it in a case of wound from a chisel.   The majority of sur-
geons  would probably  prefer to  tie the femoral, unless in similar cases of
wounds of this region directly opening the vessel.
                             SECTION III.

               LIGATION OF  THE POSTERIOR TIBIAL ARTERY.

         \ 1.—Anatomical Relations of the Posterior Tibial Artery.

   The  Posterior Tibial Artery  arises from the popliteal, and terminates
beneath the internal annular ligament of the ankle, where it gives off the two
plantar arteries.   Its course is indicated by a line drawn from the middle of
the ham to a point half way between the internal malleolus and the tendo-
Achillis.  At its upper third it lies very deep, being beueath the tibialis pos-
ticus, and being also covered by the deep fascia and the muscles of the calf.
In its middle third it is more superficial, and passes along  parallel with the
inner side of the tibia, from which it is separated by the flexor  longus digi-
torum pedis,  though it is also covered by the deep fascia and internal margin
of the soleus, Plate LXVIII. Fig. 4.
  At its lower  third,  it is immediately beneath the fascia, passes posteriorly
the tendons of  the tibialis posticus and flexor longus digitorum  pedis, and is
almost parallel  with the posterior  margin of the malleolus internus.  It may
be ligated at  its upper, middle, or lower third.

              \ 2.—Ligation of the Posterior Tibial Artery.

  The Ligation of the  Posterior Tibial Artery may be  accomplished, as
stated, at any part of its course, but is seldom attempted except in its middle
* Malgaigne. 
PLATE  LXVIII.
               LIGATION OF THE ARTERIES OF THE LEG.

  Fig. 1. Anatomical Relations of the Popliteal Region, as shown after removal
of the integumeuts.   1. External saphena vein. 2. Popliteal nerve. 3.  Peroneal
nerve.   4. External saphenous nerve.   5. Superficial branch of peroneal nerve.
6. Superficial nerves outside the fascia of the leg.  7. Semi-membranosus muscle.
9.  Internal saphena vein.  8, 8, 10.  Cutaneous veius.
                                                After Bernard and Huette.

  Fig. 2. Anterior view of the Knee-Joint.  1. The femur.  2. The patella.  3.
The tibia.  4. The fibula.   5. The tendon of the patella.  6.  The external and
internal lateral ligament.                          After Bernard and Huette.

  Fig. 3. An Antero-Posterior Section of the Knee-Joint, showing the relation
of the artery and internal  parts of the joint.  1.  Section of the femur. 2. The
tibia.  3. The patella.  4. The crucial ligament.   5. The popliteal artery.
                                                After Bernard and Huette.

  Fig. 4. Anatomical Relations of the Posterior Tibial Artery.   1. The poste-
rior tibial artery.  2, 3. Its  two venae comites.  4, 4.  The section of the  inter-
nal saphena vein.  5. The fascia of the leg.   6, 6.  The  hook  holding back the
fascia anteriorly, and the soleus muscle posteriorly, so  as to expose  the deep-
seated parts.  7. The tibialis posticus  muscle. 8. The flexor  longus digitorum.
9. The internal malleolus.   10.  The tendo-Achillis.
                                                After Bernard and Huette.

  Fig. 5. Anatomical Relations of the Anterior  Tibial Artery.  1,  1, 1. The
anterior tibial artery in its  entire course.  2, 2. The  anterior tibial veins.  3.
The anterior tibial nerve.  4. The peroneal artery and vein raised on a director.
5.  The  flexor longus pollicis.  6. The  fibula.   7.  The peroneus longus  and
brevis cut across.  8.  The  tibialis anticus,  held back by the hook.  9. The
extensor proprius pollicis.   10. The external malleolus, covered by the fascia.
                                                After Bernard and Huette.

  Fig. 6. Ligation of the  Anterior Tibial and Peroneal Arteries.  Upper In-
cision.—Ligation of the Anterior Tibial, near its  Upper Third.   1. The skin.
2.  The fascia.  3. The tibialis anticus muscle.  4.  The extensor proprius pol-
licis.  5. The vein.  6. The artery raised on the needle.   Middle or Poste-
rior Incision.—Ligation of the Peroneal Artery below its Middle.  1.  The skin.
2.  The fascia.  3. The peroneus longus.  4. External border  of the soleus.  5.
The needle under 6, the peroneal artery. Lower Incision.—Ligation of the An-
terior Tibial at its Lower Third. 1. The artery. 2.  The anterior tibial nerve.
                                                After Bernard and Huette.
        (646) 
Plate  68

Fir. 3,
.....  f
Fid. 5
- - m
 
 
LIGATION OF THE POSTERIOR  TIBIAL  ARTERY.        647
 and lower third.   Should it be desired  to tie it above, the surgeon should
 be careful not to lose sight of its muscular relations, as an error in separa-
 ting the proper muscles, as hereafter detailed, will probably cause the failure
 of the operation.
   I.  Operation at its  Upper Third.—Malgaigne's Operation.—Make an
 incision at least four inches long, entirely through the skin, connective tissue,
 and fascia, commencing about half an inch from the  inner  margin of the
 tibia; introduce the forefinger, and  detach  and carry  outward the internal
 head of the gastrocnemius as well as the soleus.   Then, while  an  assistant
 holds  these muscles  backward and outward, open the  deep fascia upon a
 director,  and  look for the artery; on finding it,  separate it from its accom-
 panying veins, and ligate it, Plate LXVII. Fig. 6.
   Remarks.—This operation is an  exceedingly troublesome one,  in conse-
 quence of the depth of the incision and the contraction of the muscles.   A
 trial upon the subject will soon satisfy any one of the  difficulties to be en-
 countered in the patient.   It is, therefore, rarely resorted to.
   II.  Ligation of the Posterior Tibial Artery  at its  Middle  Third.—
 Ordinary Operation.—Make  an  incision two and a half inches long  and
 three-quarters of  an inch frora the internal edge of  the tibia, as advised
 by Manec, and,  cutting through the skin and fat, pick up the superficial
 fascia, nick it, introduce the director, and slit it  up.  Then push the soleus
 muscle upward and outward, so as to expose the deep  fascia, or that which
 forms the posterior sheath of the muscle,  divide it on the director, and, sepa-
 rating the artery from its vena? satellites, carry the ligature around it either
 from  without  inward or the reverse.  The posterior tibial nerve lies upon
 the outer side of the  artery at this part of the leg, and is a good point of
 reference.
   Velpeau's Operation.*—Make a straight incision, about three inches long,
 at an equal distance between the inner margin of  the  tibia and the tendo-
 Achillis, so as to divide the skin and fat; pick up the fascia, nick it, introduce
 a director, and slit it up to the  same distance.    Denude the deep  fascia by
 separating the fibres of the muscle with the point of the director;   incise it
 to the same extent as the skin; separate the artery, and tie it, Plate LXVII.
 Fig. 6.
   Ill Ligation of the  Posterior  Tibial  Artery behind the Malleolus
 Internus.—Lisfranc's  Operation___Make a longitudinal or a semicircular
 incision in the skin parallel with the internal malleolus, but two lines posterior
 to it,  extending half an  inch below and one inch and a quarter above it; pick
 up the fascia,  and divide it carefully upon a director, when the artery will be
 fully exposed, accompanied by its vena? satellites.  The posterior tibial nerve
 lies posteriorly and externally to the artery,  Plate LXVII. Fig. 6.
   Remarks.—The ligation of the posterior tibial artery near the malleolus
 is  a simple operation, and one that is well adapted to the treatment of wounds
 of the plantar arteries.  Velpeau prefers that the incision should be made at
 least half an inch behind the internal malleolus, and Manec, that it should be
 half way between the tendo-Achillis and the malleolus.   Of these methods I
 prefer the incision of Lisfranc, as its line will enable the operator to search
to either side  of it if he fails to fall upon the artery.   As  the vessel lies be-
neath the deep fascia, two layers must be divided after the skin, in  order to
expose it.  The  nerve, which is of some size, lies upon its outer or posterior
side.  The  artery may  also be found  by seeking first  the  tendons of the
tibialis posticus  and flexor longus  pollicis pedis, in their groove behind the
* Operat. Surgery, by Mott and Townsend, vol. ii. p. 127. 
648
PRINCIPLES AND  PRACTICE OF  SURGERY.
Binuosity of the os calcis, and, finding thera, the artery will be seen beneath
and posterior to thera, or between these tendons and the tendo-Achillis.
  The operation in the middle of the leg, as previously described, is some-
what more difficult, owing to the depth at which the artery is placed.
                            SECTION  IV.

              LIGATION  OF TIIE  ANTERIOR  TIBIAL ARTERY.

        \ 1.—Anatomical Relations of the Anterior Tibial Artery.

  The Anterior Tibial Artery, after passing through the interosseous liga-
ment in the upper part of the leg, lies upon the interosseous  ligament in the
upper two-thirds of the leg, but is upon the anterior face of the tibia below,
till it gets upon the dorsum of the foot, where it terminates by dipping into
the first  metatarsal interosseous space to  anastomose with the branches of
the plantar arch, Plate LXVIII. Fig  5.   In  its  course  on the leg, it fol-
lows a line which is drawn, frora the middle of the space between the head of
the fibula and the spine of the tibia to the middle of the intermalleolar space,
and from this space to the middle of the first metatarsal interosseous space
of the  foot.   The anterior tibial nerve is successively seen on the outer side
of the  artery above, in front of it in the middle of the leg, and inside  of it
below, though throughout its entire course it is  very close to  the artery.
Owing to its depth, the anterior tibial artery is seldom tied high up, though
this  may be  accomplished,  while, in  consequence of the proximity of the
ankle-joint, it is seldom tied near the joint.  The most  common points are,
therefore, its middle third and that on the  dorsum of the foot.
      \ 2.—Operations for the Ligation of the Anterior Tibial Artery.

  I. Ligation  of the Anterior Tibial at its Middle Third—Ordinary
Operation.—The patient lying, or sitting with  the  leg  extended, move the
foot, so as to cause the tendon of the tibialis anticus to become  prominent,
and, following the course of the tendon when it can be felt, or the line above
described when it cannot, make an incision three inches long through the
Bkin and fascia; open the fascia freely, and seek for the first tendon, or the
first intermuscular space from the spine of the tibia.  When  difficulty occurs
in finding the intermuscular space, lay bare the tibialis anticus muscle, and,
pressing the forefinger from the spine of the tibia outward, the belly of the
muscle will roll upward and the finger sink into the space between it and the
extensor proprius pollicis.   Separate  the muscles at this point with the finger
or director; flex the foot; hold back the muscles at the side of the  wound with
blunt hooks, and the artery will be seen at the bottom of the space, with the
anterior tibial nerve crossing it at this point of  the limb, though  it is on the
inner side of the vessel lower  down.  Pass the needle from the fibula toward
the tibia, and frora below upward, and apply the ligature, Plate LXVIII.
Fig. 6.  Should the operator carry the incision too far outward, the second
intermuscular space  may be found, and mislead him;  to remedy which it is
better, in case of doubt, to feel from  the spine of the tibia outward, aud the
error will soon  be indicated.
  II. Ligation of the Anterior Tibial on the  Dorsum of the Foot, some-
times  called the Pedal Artery.—Ordinary Operation.—Draw  a line  from 
RESECTIONS IN GENERAL.
649
the middle of the space between the two malleoli to the first metatarsal in-
terosseous space, and make an incision  through the skin along the external
border of the tendon of the extensor proprius  pollicis pedis, but parallel to
it, or between it and the first fasciculus of the  tendons of the extensor com-
munis, which may be made prominent  by causing the patient to extend his
toes.   After which, the sheath of the extensor communis, or the deep fascia,
should be incised and opened upon a director,  when the artery,  with its two
veins, will  be clearly seen.  The branch of the nerve lies to its inner side,
Plate LXVI. Fig.  4.
   Remarks.—This operation is very simple, and  may be performed  in less
time than it takes to describe it, as a little practice upon the subject will soon
prove, the most common mistake being the disposition to look for the vessel
on the inner, instead of the outer side of the tendon of the extensor proprius
pollicis.   The first fasciculus of the  extensor communis tendon is, there-
fore, a better point of reference.   The operation  on this vessel may be re-
quired in the treatment of aneurism or for wounds, though most frequently
pressure suffices for the latter.  The spica bandage of the instep will be the
proper dressing after the operation.  In operating for the cure  of aneurism
of this artery, it will be safer to place a ligature above and one below the
tumor, in order to prevent recurrent hemorrhage..
                          CHAPTER  IV.

     OPERATIONS ON THE  BONES OF  THE UPPER  EXTREMITY.

  The operations  performed for the relief of the affections of the  bones of
the upper extremity do not differ from those practiced in the lower limbs,
except in the slight modifications rendered necessary by their relations to
surrounding parts.   Certain general rules are, therefore,  applicable to both
extremities, and  such additional remarks as are required  beyond what were
made in connection with the resection of the clavicle,* will be given  here-
after, the special operative proceedings being detailed in connection with
the extremity to which they belong.
                             SECTION  I. *

                        RESECTIONS IN GENERAL.

  By Resection of the Bones of the Extremities, as has been before stated, is
usually meant such an operation as removes  a sufficient portion of their struc-
ture to create a void or solution  of continuity, but yet retains the limb, and
subsequently permits  a considerable degree of motion in it.   In  many in-
stances, though resection of these bones results in more or less shortening,
even then  the member  will prove  to  be much more serviceable than an
artificial lirab; and the operation is, therefore, one which enables the surgeon
to remove the disease, and  yet not  destroy the usefulness of the extremity.
* Vol. ii. p. 334. 
650
PRINCIPLES AND  PRACTICE OF  SURGERY.
 The advantages of resection over amputation in disorders limited to the ar-
 ticulations is therefore very apparent.   In amputation, the entire member is
 often removed in consequence of a disorder which is comparatively limited,
 as in caries of the shoulder, or of the hip or knee-joint; whereas by a resec-
 tion the diseased part is  alone extirpated, the sound portions  of the  lirab
 being left to  perform their functions.   For these reasons, the experience of
 surgeons is now gradually establishing the superiority of this operation over
 amputation, and  the  propriety of attempting the  relief of diseases  of the
joints, by  means of a resection of the articulation, should therefore be always
 thought of before resorting  to any other.   A looseness of expression has,
 however,  led some surgeons to describe as resections operations which are
 really amputations.   When,  therefore, in any case, a bone is removed with
 the limb,  the operation can only be regarded  as  an amputation, and not as
 a resection, the  utility and chief characteristics of the latter class of opera-
 tions consisting in the preservation of the motion of the extremity.
  The general conditions which are essential for the proper  performance of
 a resection may be divided into such as  concern the patient, aud such as per-
 tain to the surgeon.
  On the  part of the patient  it is  essential that the disorder, whether caries,
 necrosis, exostosis, or other bony  tumor, should  be limited in its extent, so
 that the surgeon  may be certain of removing the entire complaint.  The sur-
 rounding  soft parts should also be in a condition favorable to the healing of
 the wound, without being liable to such contraction, suppuration, or ulcer-
 ation as may  subsequently impair the  motion of  the limb,  the function of
 which should always be preserved after the operation, if only in  a modified
 form.
  The surgeon, in addition to the ordinary attributes  of an operator, such
as coolness and dexterity, should have an accurate knowledge of the relations
of the adjoining structures, as the various muscles, tendons, nerves, and blood-
vessels in the neighborhood  must all be left untouched, if possible.  Espe-
cially is it  important to avoid unnecessary injury to the periosteum,  as
through this membrane the new structure will often  be replaced in such a
manner as to  add much to the usefulness of the limb, as has been already
stated in connection with the subject of Callus in Fractures.
  As the resection of the bones of the extremities is also very liable to induce
severe constitutional  disturbance, and  to  give rise to fever, erysipelas, or
long-continued suppuration, much medical skill will be necessary to conduct
the  case to a favorable termination;  it being essential to success that the
after-treatment of the case be judiciously directed, the diet and  internal as
well as local remedies being carefully superintended by the operator.
  For the performance of any resection, various saws, chisels, gouges, bone-
nippers, etc. will  be required, together with proper means for accomplishing
the  division of the soft parts, arresting hemorrhage, and dressing the wound.
As  the number of instruments resorted to in operations upon the bones is
nearly indefinite, the reader is simply referred to Plate V. for a view of such
as are most frequently wanted.
  Scooping of Bone, and Preservation  of Periosteum.—Since the influence
of the periosteum in  producing boue has been strengthened by the results
pointed out by Flourens and others, and it has  been  shown by Oilier that
bone will  be formed even by portions of periosteum  everted, transplanted,
etc., surgeons  have given their attention to such operative  proceedings as
were particularly calculated to preserve this important  membrane as  far as
possible, or to prevent its unnecessary displacement in resections.   In  these
operations especially, as demanded for  caries, Sedillot, of Strasbourg, has
warmly, and,  we think, very  correctly, advocated  leaving  the  compact 
RESECTION  OF THE SHOULDER-JOINT.
651
matter of a bone wherever practicable, and scooping  out  only the affected
portion.
  Of thirteen cases reported to the Academy of Medicine of Paris, ten recov-
ered and three died, including that of a young girl, the lower part of whose
femnr, with the condyles, was scooped out and cured, so that she walked well;
while a man, in whom the whole articulating surface and inside  of the mal-
leolus of the tibia was removed, was able eventually to walk  many miles.
  Verneuil, of Paris, has likewise shown to the Academy of Paris that by
dissecting very carefully whatever periosteum is left in disease of the elbow-
joint the result is very satisfactory. In caries of the tarsal  bones, the author
has also  had very good results, preserving a useful foot by scooping out all
the bone, except a thin shell.
                             SECTION II.

          RESECTION OP  THE BOXES OF THE  UPPER EXTREMITIES.

   The Resection of the Bones of the Upper Extremities may be practiced
 either upon their diaphyses or upon their articulating extremities. In oper-
 ating upon the diaphysis, a free external incision is necessary in order that
 the entire removal of the diseased structure by saws, chisels, and gouges may
 be accomplished without creating a fracture.
   As resection of the scapula and  clavicle has been before  referred  to, in
 connection with the operations on the chest, it only remains to describe the
 operations practiced on the upper limb, from  the glenoid cavity down to the
 fingers.

                  \ 1.—Resection of the Shoulder-Joint.

   The Head of the Humerus and the articulating surfaces of the scapula may,
 from caries, necrosis, or other complaints, demand resection, so as to free the
 patient frora a source of irritation which might otherwise exhaust  the powers
 of life ; and may be accomplished by exposing the articulation, and removing
 the diseased portion by means of the saw or gouge.
   Operation of White, of England.—Make  an incision down to the bone
 parallel with the fibres of the deltoid muscles, and  extending  from the apex
 of the acromion four or five inches downward, so as to open the  capsule on
 the outer side of the joint; then carry the elbow in toward the body; luxate
 the head of the bone through the muscle, and saw it off.
   Syme's Operation.—While an assistant compresses the subclavian artery,
 make a longitudinal incision, three and a half inches long, in the middle of the
 deltoid  muscle, and  a  shorter one  from its inferior extremity upward and
 backward, toward the posterior border of the axilla, so as to form a trian-
 gular flap. Raise it up, and while it is held by the  assistant, carry the elbow
 in toward the side of the body, so as to render the capsular ligament tense.
 Open it by a circular incision around the head of the bone, luxate it, slip a
 piece of  binders' board  under it, and saw it  off with  the  amputating saw.
 Then cleanse the wound, Plate LXIX. Fig. 1, bring down  the flap, and
 attach its point to the skin of the  arm by a single  stitch of the interrupted
 suture, taking care to insure a vent for  any pus that may accumulate; after
 which it only remains to apply the starch bandage and spica of the shoulder,
so as to leave the wound open.
   Lisfranc's Operation.—In this operation, a posterior flap is  formed similar
to that hereafter directed in the account of his  amputation of the shoulder, 
PLATE   LXIX.
       RESECTION OF THE BONES OF THE UPPER EXTREMITY.

  Fig. 1. Syme's Operation for Resection of the Head of  the  Humerus.  The
patient being seated, an assistant compresses the subclavian artery with 1, his
right forefinger, while with 2, the fingers of his left, hand, he holds up the trian-
gular flap.  As the operation is just completed, 4 shows the glenoid cavity, and
5 the section of the humerus.                     After Bourgery and Jacob.

  Fig. 2. Bourgery's Operation for Resection of the Head of the Humerus. The
arm being carried off from the body by 2, the left hand of the surgeon, the sub-
clavian artery is compressed by one assistant, while the surgeon transfixes the
soft parts near the end of the bone by a catlin, and cuts downward, parallel with
the humerus, to the length of three inches.   Another assistant then passes 1,1,
a piece of bandage, through the wound and around the bone above and below,
so as to protect the soft parts.  The head of the bone being now isolated, it is
sawed off by the chain-saw.                      After Bourgery and Jacob.

  Fig. 3.  Moreau's Operation  for Resection of the  Elbow-Joint.  1. Hand of
assistant  reverting the quadrilateral flap.   2. Condyles of humerus.   3. Strip
beneath the bone to protect the soft parts from the action of 4, the saw.
                                               After  Bernard and Huette.

  Fig. 4.  The same operation concluded.  1, 2, 3, 4.  The quadrilateral  flap re-
placed and held in position by the sutures.          After Bernard and Huette.

  Fig. 5.  Resection of the Radius.  1, 2. The incision. 3. Hand of the surgeon,
disarticulating the bone.   4. The knife.  5. The inferior end of  the radius.  6.
Its superior portion.  This operation should have been represented as the extir-
pation of the ulna, which has been accomplished by Butt, of Virginia, in a sim-
ilar matter.                                     After Bernard and Huette.

  Fig. 6.  Resection of the Lower End of the Ulna.   1. Triangular flap turned
back.   2. The articulating surface of the bone.  3. A strip passed beneath the
bone to protect the soft parts from 4, the saw.    After Bernard and Huette.

   Fig. 7. Velpeau's Operation for Resection of the carpal surface of the Radius
 and Ulna.  1, 1. The vertical  incision.  2, 3. The transverse cut.  This trans-
 verse incision  is incorrectly represented, as it should have been carried  across
 from 1, 1, so as to revert the flap downward.       After Bernard and Huette.
(652) 
Plutr  69
L''i«. 2
Pig,. A

'. '
FijS,6.
L,

■-}/\ A 
 
RESECTION  FOR  FALSE  JOINT IN  THE  HUMERUS.
653
the head  of the  bone being luxated, sawed off, and treated  as  before di-
rected.
  Remarks.—Resection of the head of the humerus is an operation that has
been repeatedly performed with success in cases of caries of the head of the
bone, as well as of the glenoid cavity, the removal of the latter being readily
accomplished by  the bone-nippers, after the articulation is exposed.   As  a
means of saving the patient the partial use of an important member, which in
former times would have been amputated, this operation must be regarded
as one of the most useful of those suggested within the last century.  Although
the scapula and  end of the humerus are no longer in contact after the per-
formance  of this  resection, a considerable amount of motion will yet be pre-
served at the shoulder, and in a case reported by Syme the use of the arm
was almost  completely established.
   Resection of the head of the humerus  has  been frequently performed by
surgeons in the United  States, being cases reported by Hunt, of Washing-
ton,* and one of a partial character by Pinkney, U. S. Navy.y   Since the
war, many others have been performed with satisfactory results. In selecting
a method, that of White should be preferred, if the induration and other
injury to  the soft parts do not forbid it, as it  preserves the more  perfect
action of the deltoid, and thus  facilitates the  subsequent motion of the
shoulder; but the section of the deltoid, as advised by  Syme  and Lisfranc,
exposes  the joint more freely, and  is better adapted to such cases as may
also require resection of  the glenoid cavity of the scapula.


              § 2.—Resection for False Joint in the Humerus.

   Resection of the ends of a false joint in the Humerus has been attempted
in several instances;  but as this complaint has frequently been cured by the
introduction of a seton, as suggested by Physick,! and by the  application  of
caustic by Barton, of Philadelphia,§ the resection of the bones has not often
been necessary.   It has, however,  been  accomplished in the United States,
by Kearny  Rodgers, of New York,|| and many others, by making  an incision
over  the seat of  the joint,  exposing  the ends of the bones, turning thera out,
sawing them off,  and then treating the case as a recent compound fracture of
the arm.
   As a means of curing  false joint, a resection, or any other operation which
creates a wound, is  liable to very serious objections, while the  use of the
apparatus which I have  suggested^ under the head of False  Joint, and the
certainty  of the cure, or at least the  restoration of the usefulness of the limb,
is an additional objection against any operation.
   When desired, the  treatment of a false joint by the use of a seton may be
accomplished in  accordance with the original  plan of Physick.
   Operation of  Physick, of  Philadelphia. — In  the year  1802, a patient
afflicted with a false joint in the middle of the humerus was cured in the fol-
lowing manner:—
   A long seton-needle, armed with a skein of silk, being prepared, extension
and counter-extension of the limb was made by two assistants, and the seton
passed between the fractured ends of the bone in such a manner  as to avoid
* Med. Recorder, vol. i. p. 36o, 1818.
■}• Am. Journ. Med. Sciences, N. S. vol. xii. p. 330, 1846.
J Med. Repository, vol. vii. p. 1122, 1804.
g Med. Recorder, vol. ix. p. 275, 1826.
|| New York Med. and Phys. Journ., vol. vi. p. 521, 1827.
fl Vol. i. p. 664. 
654
PRINCIPLES AND  PRACTICE OF SURGERY.
the course of the artery.  A pledget being then applied on each orifice made
by the needle, the silk was left in the wound, the arm in a few days placed in
the splints, and the dressing renewed daily.  For twelve weeks no amendment
was perceptible;  but, soon after, the patient complained of pain, the bend-
ing at the seat of fracture became  less apparent, and in about five months
the arm was as strong as ever.
  Brainard's operation by drilling has been already alluded to in connection
with the subject of false joint.

                 g 3 —Resection of the Elbow-Joint.

  Resection of the Bones  of the Elbow-Joint, like that of the shoulder, is
also among the more modern operations of surgery, having  been suggested
by Park, of England, in 1781, and performed in 1782 by Moreau.  The pro-
cess of Moreau is that which has been most  generally approved, and it  has
been selected with occasional modification as the plan of most of the opera-
tions performed in the United States.
   Operation of Harris, of Philadelphia.*—In the case of a woman, twenty-
six years of age, laboring under hectic fever with  suppuration in the elbow-
joint, the following operation was performed :—
   The operating table being covered  by a mattress, the patient was placed on
it with her face downward, and with the posterior internal portion of the elbow
presenting to the surgeon, while the point of  a strong bistoury was passed
transversely so as to divide the  skin, connective  tissue, and tendon of the
triceps, above and close to the olecranon process, and extend from the radial
side of one condyle of the humerus to near the inner condyle, avoiding  the
position of the ulnar nerve.  Two longitudinal incisions, three inches long,
were then made on each side of the transverse  one, so as to form a  letter h>
and make two quadrilateral flaps, which, on being  dissected off, fully exposed
the joint.  The soft parts at each side, including the ulnar nerve, being now
drawn to one side, by means of curved spatula?, the olecranon  process  was
removed by the common amputating saw, Plate LXIX.  Fig. 3.  The con-
dition of the joint was then carefully examined, and all the articulating  sur-
faces being found in a carious condition, the head of the radius and the  dis-
eased  surfaces of the ulna and  humerus were perfectly  removed  with  the
bone-nippers, two branches of the articulating arteries  tied, the joint care-
fully cleansed, and the parts closed by sutures, and dressed with  angular
splints.  The patient ultimately  recovered with considerable motion  iu  the
joint.
  Remarks.—Since the introduction of anaesthetics, the pain and shock from
this operation have  been  materially reduced, and the chances of  success
thereby increased.  One of the chief difficulties  attendant on  its  performance
is the  risk of wounding the ulnar nerve,  and in the patient operated on by
Harris this was increased by the thickening  and adhesion of the soft parts.
To obviate this, Dupuytren proposed to open the sheath of the nerve cau-
tiously behind the internal condyle, as soon as  the upper flap was dissected,
and have it held inward and forward by an  assistant during the operation.
A reference to the Bibliographical Index  at the  end of this part will show
the reports of the operations performed by (Jurdon Buck, Jr., and Stone, of
New York.f and by  others.  In the  operation of Buck, (for the removal of
the olecranon process,) two longitudinal incisions were substituted for that
of the H, the horizontal cut being omitted, and the sides dissected up so as
to expose the bone without dividing  the  attachment of the biceps tendon.
* Am. Journ. Med. Sciences, vol. xix. p. 341.
f Ibid., vol. v. N. S. p. 299. 
       RESECTION OF  THE  BONES OF THE FOREARM  AND  HAND.   655

This is a valuable improvement on the H incision, and should be employed
wherever it is admissible.
  In two instances I have operated by an L-shaped incision, and once by the
H, with entire satisfaction.  When the latter incision is preferred, it is better
to make the first longitudinal cut directly over the course of the ulnar nerve,
and have  it  held to one side during the remainder of the operation.   The
single  vertical incision in the middle of the elbow does not usually expose
the joint with sufficient freedom.
          § 4.—Resection of the Bones of the Forearm and Hand.

   The Bones of the Forearm may be resected at any portion of their length;
 the removal of the upper articulating surfaces, and especially of the olecranon
 process, belong, however, to the operation just detailed as resection of the
 elbow-joint, while  the  removal of the  lower constitutes  resection of  the
 wrist.
   I. Resection of both Radius and TJlna.—Operation of Compton,* of New
 Orleans.—A boy, aged fifteen, having received  a compound  comminuted
 fracture of both the radius and ulna, as well as other injuries, on board ship,
 remained some days without proper treatment, the arm being in a sloughing
 condition, and the  bones protruding several inches out of the mass of  mus-
 cles.  About two months subsequently,  having otherwise recovered, Comp-
 ton made a straight incision the whole length of the inner side of the radius,
 and a counter-opening  opposite the olecranon process; dissected out  both
 bones carefully; disarticulated  them at the elbow, and removed them entire
 with  the  exception of the lower end of the radius, a great portion of the
 periosteum being, however, detached by nature and left in the wound.
   This  patient subsequently recovered;  had entire use of the hand, so as to
 open  and shut it; could  grasp objects firmly, and had a firm forearm, although
 it was shortened about three inches.  The  forearm remained  at a right angle
 with  the humerus; but it could be flexed and  extended so that the hand
 moved  through  eight or ten degrees of an arc of a circle.   The pulse was
 readily  perceptible  in the boneless forearm.
   II. Resection of the Body of the Ulna.—The ulna or radius, when dis-
 eased to a considerable  extent, may be removed from the arm without neces-
 sarily destroying the usefulness of the limb.
   Operation of Butt,t of Virginia.—This operation, which was  performed
 in 1825, has generally been referred to  by European writers as extirpation
 of the Radius instead of the ulna, which  was the bone resected by Butt, in
 consequence of a long-continued necrosis, each writer who has  quoted it
 having apparently copied the previous statement without investigating the
 original paper.
   Operation.—The patient being seated in a chair, and the tourniquet ap-
 plied  as usual, a transverse incision was made down to the bone, about four
 inches and a half below the olecranon, and extending to a little more  than
 half the diameter of the arm.   A longitudinal one intersecting  the lower
 part of  this cut being then made in the line of the most superficial part of
the bone, and extended to the wrist-joint, the dissection of the  soft  parts
around  the bone was commenced at the transverse incision,  and carried
down  three inches, until a spatula could be insinuated beneath  the bone, so
  * New York Journ. of Med., vol. x. N. S. p  133, 18-33, from the New Orleans Medi-
cal Register.
  f Phila. Journ. Med. and Phys.  Sciences, vol. i. N. S. p.  115, 1825. 
656
PRINCIPLES AND  PRACTICE OF SURGERY.
as to protect  the  soft parts from  the action of the saw.   The ulna being
now divided transversely,  the  dissection was continued  along the  whole
course of the bone down to  the wrist-joint, a piece of twine  being passed
around the denuded  end of the bone, so  as to enable an assistant to elevate
it, after which the bone was disarticulated from the wrist and removed, Plate
LXIX  Fig. 5.  The wound being cleansed, the tourniquet was loosened,
the  ulnar and  interosseous arteries tied, and the edges of the longitudinal
incision closed by adhesive  strips, and that of the transverse  by sutures.   In
three months the  patient was enabled to pursue his  usual avocation as a
carpenter, flexion,  extension,  and rotation of the wrist being as free and un-
interrupted as ever;  declaring subsequently that he had as much strength in
his  haud (the left) as most  people had in the right.
  III. Resection  of the Inferior  Extremity of the Ulna—Operation.—
"The hand  being  carried  outward, make a longitudinal  incision along the
internal border of the  ulna, and terminate it inferiorly by a transverse cut
across the  back of the joint.   The  triangular flap thus  made being now
raised and carefully dissected back, the tendons  should be drawn aside, the
artery avoided, and the bone  disarticulated.   A  small piece of wood  being
then passed beneath  the end of the bone,  it may be readily sawed through,"*
Plate LXIX.  Fig. 6.
  Remarks.—The success attending resection of the ulna has certainly been
such as may induce others  to  repeat  the operation in similar cases rather
than  amputate the limb; and iu the  variety of diseases of this bone  which
are met  with  from time to time,  the surgeon should hesitate a long time
before consenting to such a mutilation as is caused by amputation, especially
if the arm is the right one.  Resection of  the ulna, like resection of the head
of the humerus, is an operation that has hardly been fairly developed by
American surgeons, though a case  of  resection of the middle  two-thirds of
the  bone, which resulted most fortunately, was reportedf by Carter Johnson,
of Richmond,  Va.
  In operating upon the  radius, the same steps would be  required as are
described for the resection of  the ulna; but the subsequent usefulness  of the
limb will be  necessarily much  more impaired, as the hand would be  thrown
out of its line  with the arm, and pronation and supination  destroyed.
  IV. Resection of  the  Wrist-Joint—In the case of a dislocation of the
bones of the forearm  upon those of the carpus, in such  a manner as to forbid
their  reduction, the resection of the  inferior  extremities of the  radius and
ulna has been advised and successfully practiced.   It has also been recom-
mended to apply this resection to cases of caries of the wrist; but any one
at all familiar with the structure of this joint must readily see that such an
operation could offer but little prospect of success, except  at the expense of
a stiff wrist, as, under such circumstances, the bones  of the carpus would
probably participate  in the  complaint.  Many cases will, however, be  found
in which, even with a stiff wrist, there may be considerable motion in  the
fingers, especially if  the surgeon is careful throughout the treatment to flex
them frequently, so as to prevent the tendons from becoming  adherent to the
front of the  capsule of the  inflamed joint.
  Operation of Velpeau.J—By an incision  on  each side of the forearm,
reaching from the  root of the thumb, and from the last  metacarpal bone
upward, for  two inches above the level of the styloid  process of the radius,
aud united by  a transverse  incision, a  flap is formed and turned from  above
* Bernard and Huette.
f Philadelphia Med. Examiner, vol. vii. N. S. p. 644, 1851.
j Velpeau, Op. Surg. 
RESECTION OF THE  FEMUR.                 657
downward over the back of the hand.  The articulation being now carefully
opened, and the ends of the bones turned out, the tissues on the front of the
arm are to be dissected off, so as uot to injure the radial  and ulnar arteries,
when  a thin piece of board or lead being passed beneath, the bones may be
readily sawed off  with the amputating saw.   The flap being replaced and
united by sutures, Plate LXIX.  Fig. 7,  gentle pressure will unite it to the
anterior surface, and the hand be ultimately useful to some extent.
  V.  Resection of the Metacarpus.—One or more of the last  four meta-
carpal bones may occasionally require resection in their middle, in  conse-
quence of a limited caries, or deformed  fracture.   When  needed, the bone
should be carefully exposed from the back of the hand by  an incision parallel
with its length, the tendons and other soft parts being  protected from the
knife, and then the bone either  disarticulated at its  extremities, or else a
portion excised by the bone-nippers.
  Resection of the Metacarpal Bone of the Thumb is to be accomplished
by a  longitudinal incision, similar to  that referred to under amputations,
and shown in Plate LXXIV. Fig. 7.
  The operation presents, however, but  an uncertain prospect of success, as
regards the ultimate usefulness of the remaining portion of the thumb.
  VI. Resection of the Bones of the Hand.—The  phalangeal  articula-
tions  may require resection, in consequence of their becoming anchylosed in
a straight position, and  causing the patient the inconvenience of a straight
and stiff  finger.   Under such circumstances, the bone should be  exposed on
the back of the finger, a V-shaped piece  sawed out with a fine watch spring
saw, the  finger  kept flexed like a hook, and the ptrts allowed to  heal in this
position.
CHAPTER V.
     OPERATIONS ON  THE  BONES OF THE LOWER  EXTREMITY.


  The success attending the resection of the bones of the  lower extremity
has been much more  brilliant than that ensuing upon the operations per-
formed on the thoracic limbs; and it is to the surgeons of the United States,
and  especially to Barton,  of Philadelphia, that the  world  is indebted for a
most happy illustration of the advantages to be gained  from  a scientific
application of mechanical  principles, especially when aided by the efforts of
nature, in the formation  of a new joint.
                             SECTION I.

                       RESECTION OF THE FEMUR.

  The Femnr  has  been resected  at  its head, trochanters, shaft, and con-
dyles, either for the removal of such portions as were diseased, or to restore
the usefulness of the limb.
     vol. ii.—42 
PLATE  LXX.
      RESECTION OF THE BONES  OF THE LOWER EXTREMITIES.

  Fig. 1. Barton's Operation for Resection of the Neck of the Femur, and the
formation of a False Joint in a case of Anchylosis of the Hip.  1,1. The flaps
of the integument formed by a crucial incision, and turned back.  2. The in-
cision of the muscles  over the trochanter major.  3.  The retractor passed
around the bone, to protect the soft  parts from 4, the narrow saw.
                                                           After Nature.

  Fig. 2. Sedillot's Operation for Resection of the Head of the Femur in Caries.
1, 1, 1.  The semilunar incision through the soft parts, convex  above, and ex-
posing the joint.  2. A strip slipped beneath the bone.  3, 4. The chain-saw in
the act of excising the head of the  bone.          After Bernard and Huette.

  Fig. 3. Barton's Resection of the Femur by the removal of a V-shaped piece
in order to straighten a lirab which  was anchylosed at the knee nearly to a right
angle.   The flap has been reverted  to show the section of the bone.
                                                           After Nature.

  Fig. 4. Resection of the Lower Extremity of the Femur.  1, 1. A Retractor
applied to the soft parts.  2.  Strips beneath the  bone.   3. The portion of the
femur to be excised.  4.  The amputating saw.     After Bernard and Huette.

  Fig. 5. Resection of the External  Malleolus.  1.  The left hand of the surgeon.
2.  The chisel.   3. A steel hammer.               After Bernard and Huette.

  Fig. 6. Roux's Operation for Resection of the Lower Extremity of the Tibia.
The soft parts being freed by a vertical  incision, a retractor, 1, has been passed
beneath the anterior flap to elevate  it.  2. A strip beneath  the posterior  edge
of the bone.  3. A small saw, dividing  the bone  before it is reverted aud dis-
articulated.                                     After Bernard and Huette.
(658) 
Plate  7(J
fii£.2
 
 
RESECTION  OF THE KNEE-JOINT.
659
                \ 1.—Resection of the Head of the Femur.

   The Head of the Femur has been removed in cases of compound fracture,
 coxalgia, and caries, especially the latter; but though some few patients have
 ultimately recovered, it has only been after a long-continued and dangerous
 illness arising from the free suppuration and  hectic fever which supervened;
 and these few were children about fourteen years of age,  who were afflicted
 with caries.   The operation should  therefore be considered as a most dan-
 gerous one, and as  especially unjustifiable in  Coxalgia, as the natural tend-
 ency of the complaint is to a cure, and anchylosis is more apt to follow the
 resection than it is  to ensue on the progress of the disease under the recent
 improvements in its treatment suggested by Davis, of New York,  and already
 described.  A reference to Plate LXX. Fig. 2, will sufficiently  explain the
 steps to  be pursued should any surgeon feel justified in attempting it.


 \ 2.—Resection of the Femur for Anchylosis, and Formation of a new Joint
                               at the Hip.

   Operation of Barton, of Philadelphia.*—A young man, twenty-one years
 of age, having his  thigh immovably flexed at a right angle  with his pelvis,
 and carried across  the opposite thigh, while the foot rotated  inward, was
 operated on as follows:—
   The patient being  laid  partially on the opposite side,  a  crucial  incision,
 seven inches long, was made  over the prominence of the trochanter major,
 and a transverse cut of five  inches made to cross it at the  same point.  The
 four flaps thus  formed being dissected  back, the fascia was freely opened,
 and the muscular fibres over the trochanter incised and detached from around
 the bone, so as to permit the two index fingers to be passed  around the neck
 of the femur, until  they met on the opposite  side.   With the strong, narrow
 saw, Plate LXX I.  Fig. 12, the bone was then nearly divided through the
 upper part of the great trochanter;  and the neck, when the limb had  been
 adducted, was drawn into its proper line,  and the remaining portion snapped.
 No artery was cut; the wound was closed by a few sutures, and then dressed
 in Physick's modification  of  Desault's splints.   The  patient subsequently
 recovered, and by the formation of  a false joiut, produced  at the  resected
 portion, had, during  six years, a limb  upon  which he  could walk without
 apparent lameness.    Kearny Rodgers, of New  York, about  four years after-
„ward successfully performed a similar operation, f
                             SECTION  II.

                    RESECTION OP THE KNEE-JOINT.

  In cases of anchylosis of the knee-joint, the resection of a V-shaped piece
of the femur was suggested by Barton as a means of furnishing a useful limb,
especially when  the joint is bent.  As this operation  has since been suc-
cessfully performed, and repeated by various surgeons in the United States,
it is now justly regarded as a standard one in cases of true anchylosis result-
ing in permanent flexion of the knee.
* North Amer. Med. and Surg. Journ., vol. iii. pp. 279, 400, 1827.
f Am. Journ. Med. Sciences, vol. i. N. S. p. 507, 1840. 
660
PRINCIPLES AND  PRACTICE OF SURGERY.
   Operation of Barton, of Philadelphia.*—A physician,  having his leg
perniaiiently flexed  and anchylosed upon the thigh, to  a degree  somewhat
less than a right angle, as the result of inflammation  which had  existed in
childhood, determined to obtain relief, and underwent the following opera-
tion  iu  the  hands and at the suggestion of Barton,  on the 27th of May,
1835:—
   Operation.—By an incision which commenced at  a  point  opposite the
upper and anterior margin of the external condyle of  the femur, and passed
obliquely across  the front of the thigh  to  terminate  on the inner side, the
soft  tissues were  incised.  A second, which commenced on  the outer  side,
about two and  a half  inches above the first, and  also  passed obliquely
across the thigh  to join the other in an  acute  angle, being now  made, the
tendon of the quadriceps femoris, and some  of the fibres of the muscles,  were
divided, the flap  turned back, the bone freely exposed, and  a triangular, or
wedge, or V-shaped piece of bone, Plate LXX. Fig. 3, easily removed  by
means of a small narrow-bladed saw.  This wedge of" bone not including the
entire diameter of the femur at this point, a portion of the shaft of the  bone
was left undivided posteriorly, that it might at  first protect  the artery  from
the saw, and, by  subsequently interlocking the fragments, prevent  the sharp
edges of the bone from injuring the soft parts.  By slightly  bending the leg
backward, these  fibres were  now gently  broken, and  the operation,  which
lasted about five minutes, entirely completed.
   No blood-vessels being injured, the flap was restored to its place, the wound
lightly dressed, the  patient placed in bed upon his back, and the  limb  sup-
ported upon a splint of an angle corresponding to that  of the knee before
the operation.   This position being retained until it was supposed that the
asperities of the  bone were removed, a splint with  a more  obtuse  angle was
applied, aud changed from time to time until  the limb had attained a posi-
tion  almost straight, when it was kept permanently  in that line until the
bones united.  During the treatment, special care was taken to protect the
popliteal vessels  from  pressure by employing long hair  bags at the sides of
the splint, so as to leave a vacancy in the course of the artery, the interspace
being filled with lightly-carded cotton.  The constitutional symptoms, though
somewhat severe, resembled  those usually seen in a compound fracture; but
in four months the patient stood  erect, with  the feet in  their natural position,
and both heels touching the  floor, although a slight angle had been design-
edly  left at the knee  in order to  obviate  the  necessity of throwing out the
limb  in the act of walking, which would have been the case if the knee had
been  kept  perfectly straight.  The patient ultimately recovered  perfectly.
A reference to the Bibliographical  Index at the end  of this part will show
that  this operation has been repeated iu the United States by Gibson, Pan-
coast, and Mutter, of Philadelphia;  by Burr, of Louisiana, and in a modified
form  by  Buck, of New York, and Wedderburn, of New Orleans.
   Remarks.—In the observations of Barton, connected with the  history of
this case, there may be found some most valuable remarks on the advantages
of the plan which he pursued, and especially on the value of the  section of
the bone at a proper angle.  To obtain  this,  and it is essential to the cure,
it will be found advantageous to resort to the rule proposed by Goddard, of
Philadelphia,! and  practiced by Mutter, which is as follows: " Take the
angle of deformity, and then remove from  the  bone the complement of the
angle."   The use of Strorueyer's splint, as  employed  by Mutter in his case,
would also  be an improvement on the original dressing,  as the popliteal

              *  Am. Journ. Med. Sciences, vol. xxi. p.  332, 1837.
              f  Philad. Med. Examiner, vol. vii. N. S. p. 39, 1851. 
     REMOVAL OF  A PORTION  OF THE PATELLA, CONDYLES, ETC.  661

space will thus be left entirely free frora pressure, and the limb may be readily
and gradually extended as required.
 \ 1-—Removal of a Portion of the Patella, Condyles, and Articulating
                         Surfaces of the Tibia.

  Operation of Gurdon Buck, Jr., of New York.*—A patient, twenty-two
years of age, had his right knee anchylosed at a right angle, in consequence
of traumatic inflammation, seven years previous.  The condyles of the femur
were prominent, and stood in advance of the tuberosity of the tibia, with the
patella deeply and immovably imbedded between  them;  the tendons in the
ham stood out in bold relief from  the limb, but the surrounding soft tissues
were healthy, though the deformed limb was shortened and less developed  in
every respect than its fellow.   By modifying the operation of Barton, it was
supposed that it  would be feasible to obtain greater strength of limb, and
less remaining deformity.
  Operation.—The hamstring tendons  having been divided, some days be-
fore, by a subcutaneous section in which the peroneal nerve was cut across,
the patient was placed in  a proper position, the tourniquet applied, and an
incision made frora the outer to the inner condyle, across the middle of the
patella, and a second incision from the middle of this, perpendicularly, down-
ward to the tuberosity of the tibia.  The integuments being dissected as low
down as a finger's breadth below and parallel with the margin of the articu-
lating surface of the tibia, the ligament of the patella and the fibro-ligainent-
ous tissues on either side were cut through on the same  level, to nearly the
extent of two-thirds of the circumference of the bone.   A section  of the
tibia was then made, three-fourths of an inch below  the joint anteriorly, and
directed obliquely upward so as to terminate at the margin of the articula-
ting surface posteriorly, two-thirds of this section being accomplished by the
amputating saw.  Another section was then made  with the same saw through
the upper part of the  patella, parallel with the first, and  on a plane forming
an  angle with  it  less than a right angle, and continued to about the same
extent, the remainder of  the section  through the tibia  and condyles being
completed with a metacarpal saw.  This wedge-shaped piece  being  now
removed, it was found that the section had not divided the posterior portion
of the condyles, which still  remained consolidated  with the tibia.  A new
section  was therefore undertaken, commencing upon the cut surface of the
femur three-fourths of an inch  anterior to the angle at which the previous
sections  met, and directed more  obliquely upward and backward.   The re-
maining  points of connection being then cautiously ruptured by  flexing the
leg, the  rough prominences were  pared away  with  the bone-nippers.  On
attempting to extend  the  leg, it was found that the bony surfaces could only
be  brought to  within a finger's breadth anteriorly, as the soft parts in the
ham offered  great resistance.  These were therefore dissected  up, and a
further section, five-eighths of an inch thick, removed from the anterior two-
thirds of the femur, which enabled  the surgeon to extend the leg and bring
the bony surfaces in contact.   The section of the  condyles now exceeding
that of the tibia  in its anteroposterior diameter, there was an overlapping
in front of about  half an  inch.   But  two  ligatures  were required ; and the
soft parts posterior to the joint, and separating it from the artery, were very
little disturbed, but the angular flaps of integument being redundant  were
pared away to the requisite extent, and  secured in contact by seven sutures.
* Am. Journ. Med. Sciences, vol. x. N. S. p. 277. 
662
PRINCIPLES  AND  PRACTICE OF SURGERY.
The limb being then placed on an inclined plane, adhesive strips were applied
between the sutures, and dry lint laid over the whole.  The operation  lasted
forty minutes, and the  patient left his bed in about three months with an
apparatus, but  shortly  recoverd, and was able to walk on  a sort of stirrup-
iron beneath the foot,  the  leg  on this side being about five inches shorter
than the other at the heel, though half of this might  be ascribed to the de-
fective development of  the  limb subsequent to the inflammation of the joint.
  Remarks.—Resection  of the knee-joint, for the cure of more or less ex-
tensive disease of this articulation, is an operation suggested nearly a century
since, but only especially lauded by the English surgeons since the year ISftO,
when its advantages were described by Fergusson.  That the former opinions
of surgeons in  regard to the  serious constitutional disturbance consequent
on wounds of the larger articulations should  be modified, is not surprising,
in view of the facts collected  in connection with  the often  useful injection of
iodine into cavities formerly thought to be safely approachable.   Hence we
find modern  surgery counseling the extensive opening of  the knee and hip-
joint, with removal of  the  diseased articulating  surfaces, and offering some
cases of success as evidence  of the propriety of this operation.   As com-
pared with the  mortality consequent on amputation of  the thigh, resection
of the knee has been by many  regarded as the  more favorable operation;
and statistics, while augmenting the field of observation, has not materially,
changed the proportion of deaths.  Watson* and Butcher, f of Great Britain,
have recently shown that of 91 cases 63 recovered, with limbs that were com-
paratively useful, or  only 28  deaths; while of  128 secondary  amputations
through the thigh for disease, only 63 recovered.    That  is, after resection of
the knee-joint, there  was nearly one-third less deaths than after amputation.
   Operation of Watson.—Make a straight incision across the middle of the
patella, from one side  of the knee to the other.  Cut out the  patella, thus
opening the joint, and  remove the diseased surface of the  bone  by the saw,
inclining it on the condyles of the femur at an angle of 45°.   Then cut off
the head of the tibia, so  as to  make a concavity to  receive the end of the
femur; any other diseased  parts  being also removed.   After straightening
the limb, close  the flap by a few stitches of the metallic suture, keeping the
angles or ends of the incision open to give exit to the discharge.  Ligation
of the articulating arteries arrests the heraorrhage.
   In  bad cases attended  by  marked swelling and flexion of the leg,  an in-
cision  somewhat similar to that of Bauden's  for amputation—that is, semi-
circularly and convex  downward—would  answer  better.   In all  cases the
after-treatment  should be  carefully attended to—opium,  quinine, iron, etc.
being judiciously administered, to counteract  the tendency to  hectic; while
the limb should be carefully  kept in  the  extended position, by any hollow
splint or support, as that similar to Amesbury's, that will obviate pressure
on the popliteal region.   Much of the success  will, it must  be recollected,
depend on a  judicious  selection of patients, and careful constitutional treat-
ment subsequently; the cure  being  tedious, and the patient apparently
brought to the verge of the grave.
   Remarks.—The selection  of any plan of operating being  probably influ-
enced by the peculiar difficulties of the case, it is not possible to make a just
comparison between any two methods.   The opinion of a want of strength
in the support  afforded  by the  operation  of  Barton, which  seeras to have
originated the  plan pursued  by Buck, is, however, an erroneous one,  as has
been  proved in several instances; while the section above the condyles, as
practiced by Barton, can be  made to remove the obstacles connected with
* Glasgow Med. Journ., Oct. 1859.
f Dublin Journal Med. Sciences, No. 53. 
RESECTION  OF THE RONES OF  THE  LEG.           663
 contractions about the ham.   Except  under peculiar circumstances, I think
 therefore that  the  operation above the knee would be the best, as it causes
 little deformity from shortening, and is much more simple.


                 \ 2.—Resection of the Bones of the Leg.

   Resection of the Bones of the Leg,  in order to cure a false joint, has been
 repeatedly performed, but requires no special description, being effected usu-
 ally by incising the soft parts,  turning out the ends of the bones, sawing
 them off, and then treating the case  as a compound fracture.   In the leg
 this operation  is much more  serious in its results  than it is in the humerus,
 and it is also one that exposes the patient's life unnecessarily,  especially as
 a cure may be accomplished, or a useful limb obtained  with  less risk, by
 means of the artificial limb or splints  applied so as to enable the patient to
 walk about during the progress of the  cure, as has been stated in the section
 on False Joint.
   A partial resection or perforation of the tibia, or a perforation of its shaft
 by a trephine,  is  sometimes required in order  to give vent to accumulations
 of pus within its  cancellated structure, when the diagnosis is positive, as has
 been already alluded to under the head of Ostitis.
   Removal of seven inches of the Tibia.*—E. S Cooper, of San Francisco,
 relates a case in which seven inches of the shaft of the tibia were successfully
 removed.   The patient,  aged 28 years, had suffered from  constant pain in
 the right tibia  for 17 years, and for six months been able to walk but little.
 The upper part of the tibia was greatly enlarged  and painful to the touch.
 Suppuration of the bone was diagnosed, and the diseased bone removed by
 the following operation :—
   Operation.—The patient being chloroformed, an incision was made, nine
 inches long, commencing at the tubercle of the tibia and continuing down its
 spine.  The first incision  was carried through the  integument, fascia, and
 periosteum, down to the enlarged and softened bone.  The periosteum, thick-
 ened to four or six times its natural condition, aud but loosely attached to the
 bone, was next turned aside with the soft parts, leaving the bone naked for
 more than seven  inches.   The tibia being then divided with a chain-saw near
 the lower terminus of the incision, and at the tubercle, the diseased portion
 was removed, the wound packed with lint, the flaps of the soft parts laid loosely
 over it, and the whole secured with a bandage.   The upper part of the  tibia
 which was left, being somewhat  diseased,  was  stimulated from time to time,
 after suppuration  was established, by a weak solution of  chloride of  lime,
 attenuated with black lotion.   The bone thus removed was rapidly repro-
 duced, and four months after the operation  the patient could walk with the
 aid of a cane.
   About this  time he fell and fractured the new  bone, thus creating  a
 pseudarthrosis.   When this  condition was recognized, Cooper  cut  down
 upon the bone, removed, a partly developed  synovial membrane  from be-
 tween the ends of the fragments, and, drilling them in two places, introduced
 two silver ligatures, which kept the  ends  of the fragments in apposition
 until bony union  was effected, which was in about  three months.  The wires
 were removed about the tenth week.
   Five months subsequent to this last operation the bone was  almost as
 strong and firm as the tibia of the opposite leg.   The patient has  since en-
joyed good  health.

      * In the New Orleans Medical News and  Hospital Gazette for Dec. 1859. 
664
PRINCIPLES AND  PRACTICE OF  SURGERY.
                     \ 3.—Resection of the Fibula.

  The Fibula has been  resected as follows: Make an incision down to the
bone at its central portion, denude it of the soft  parts, pass the chain-saw
around, saw it across, and then disarticulate it at each extremity   But in
removing the upper portion the surgeon will  probably be compelled to divide
the anterior tibial nerve, where it winds round the neck of the bone.*
  Remarks.—As this bone is seldom diseased without the tibia being simi-
larly affected, its separate resection is a rare operation.


                            SECTION III.

                       RESECTION OF  THE ANKLE.

  One or both bones of  the leg may be  resected  at the ankle-joint, in the
manner described in  the ensuing cases.


    § 1 —Resection of the Inferior Extremity of the Tibia and Fibula.

  Resection of the Inferior Extremity of the Bones of the Leg has been per-
formed in cases of severe wounds of the ankle-joint complicated with disloca-
tion, as well as in those of compound fracture.  These operations  have, in
a few instances, been attended with more success than  might have been anti-
cipated from a  knowledge  of the structure concerned;  a  French  surgeon
named Josse " having removed, in one instance, two inches of the right tibia,
and in another more than an inch from the left tibia and fibula of a patient,
who yet,  at the end of three months, walked with  the aid of  a  cane."f
Cooper's case, of San Francisco, has also been just stated. Such cases must,
however,  be regarded as wonderful instances rather  than  as ordinary ex-
amples of success.  More frequently the patient will suffer from severe con-
stitutional disturbance, and, if he recovers, is apt to have a limb considerably
shortened, as well as a stiff ankle.  It becomes, therefore, questionable whether,
under such circumstances, an artificial  foot and leg would not answer better
than the natural one.   When, however, it is desired to perform this resec-
tion, it may be accomplished in several ways.
  Roux's Operation.—Make  a longitudinal incision, three  inches  long, on
the outer side of the fibula, commencing above the external malleolus. From
the inferior extremity of this,  carry a transverse incision as far as the tendon
of the  peroneus tertius.   Dissect up the flap, and  open the sheath of the  two
other peronei tendons, push them back, expose the fibula from behind, avoid-
ing the vessels and nerves; insinuate a chain-saw between the tibia and fibula
from within outward, divide the bone,  raise  up its lower extremity, and  dis-
articulate it.  Then  place the leg on  its external side, and  make a longitu-
dinal incision on the tibia from the internal malleolus, about  three and a  half
inches upward, and from its extremity make a transverse cut as far as the
tendon of the tibialis anticus.   Dissect up the flap, and isolate the surround-
ing parts by passing a piece of pasteboard beneath the bone, drawing the
vessels and tendon to one side, and then cut across the bone with a narrow
saw.   The tibia  being  thus  divided, it is to be  disarticulated in the same
manner as the fibula,! Plate LXX. Fig. 6.
* Malgaigne.     f Velpenu, Op. Surgery, by Mott and Townsend, vol. ii. p. 822.
               \ Bernard and Huette, Med. Operat., p. 103. 
RESECTION  OF THE OS  CALCIS.
665
                    \ 2.—Resection of the Astragalus.

   The removal of any of the bones of the  tarsus must be the result of cir-
cumstances, and the only direction which can be  given in relation to thera
is  to open the integuments freely at the most prominent  point of the bone,
and  then free  its attachments.   It is, however, desirable  that  the wound
should be so contrived as to place the cicatrix at such a point as will not ex-
pose it to pressure or friction in the act of walking, in order to prevent the
constant recurrence of ulcers in this part.
   The Astragalus has been successfully removed in cases of compound dislo-
cation, by Stevens, of New York ;* Gillespie, of Virginia ;f Barton, of Phila-
delphia,  in 1831;|  Norris, of Philadelphia, and by several other surgeons.
There is, therefore,  sufficient evidence to  show that, in compound  disloca-
tions of this bone, it is desirable to attempt its resection or extirpation before
resorting to  amputation  of the leg.   As the operation has been  limited to
compound  dislocation, the  removal consists in  freeing the  bone from its
attachments through the  wound caused by the injury.
                     \ 3.—Resection of the Os Calcis.

   Within the  last few years the progress of conservative surgery has  led
 several surgeons to  attempt the  resection of bones which it was formerly
 thought could not be removed without destroying the utility of the limb.
 Among the most marked of these has been  the  resection of the entire os
 calcis, which, in the hands of Hancock. Wakley, Greenhow, Potter, Page, Gay,
 Simon, Lowe,  Field, and others in  England, has resulted favorably.  In a
 report on this  operation by Greenhow, of Newcastle, England,§ twelve cases
 are  mentioned, of which ten were reported as successful, the  caries or ne-
 crosis having, in  several instances, involved the other bones of  the tarsus to
 some extent.   The disease had lasted from eight weeks to ten years, and in
 some of Greenhow's  cases the bone was so carious "as to resemble a very
 porous sponge."   The  experience of the surgeons above named has shown
 that the preconceived objections to this operation are invalid: "the incisions
 healed  readily, in some instances even by the first intention;  the joint was
 generally very  movable; the tendo-Achillis attached itself perfectly to the
 soft parts, (muscles and  integuments of the heel,) adapted itself to the new
 condition of the ankle;  the foot was at once put in a comfortable state; and
 the patient at  last had  a limb which was almost as serviceable to him as its
 fellow."  The  mode of  operating has necessarily  been varied, owing to the
 peculiarities of each  case, some of the  surgeons preserving the sole of the
 foot entire,  and others forming a flap or flaps  from it.
  Hancock's Operation.—A single flap was formed in the sole of the foot,
 with its convexity looking forward, by an incision which commenced at one
 malleolus and ended at the other.
  Greenhow's  Operation.—In four cases this surgeon operated as follows:
 In three cases the incisions were made first from the inner aud outer malleoli
to meet at the apex of the heel, and then others extended along the side of
the foot, the flaps being  dissected back so as to freely expose the bone and
* New York Med. and Phys. Journal, vol. v. p. 560. 1826.
f Am. Journ. Med. Sciences, vol. xii. p. 552.  1833.
\ Liston's Pract. Surgery, Philada. edit. p. 141. 1842.
I Brit, and Foreign Med.-Chirurg. Rev., No. xxiii. p. 233, July, 1853. 
666
PRINCIPLES AND  PRACTICE  OF SURGERY.
its connections.  In the fourth case the  incision commenced at the point of
the heel, was carried slightly upward toward the inner malleolus, and then
slightly downward and  forward.  This being repeated on the external side,
two curved flaps were formed and dissected upward and downward.
         \ 4—Resection of the Metatarsal Bones and Phalanges.

  The resection of the Metatarsal  Bones and the  Phalanges of the toe is
to be conducted on the same principles as similar operations in the hand, the
incisions to expose the bone being similar to those described hereafter under
Amputations of the Foot.
CHAPTER  VI.
GENERAL  REMARKS ON  AMPUTATIONS.
  As the  amputation of a large  limb necessarily destroys the  equilibrium
which had previously existed in the forces of the  economy, it should always
be regarded as a serious operation, and  liable to involve the life of the pa-
tient.  As it also removes a part which is often essential to the daily main-
tenance of the  individual, and, in too many instances among the laboring
classes, renders  them paupers for life, it is an operation which should be
resorted to  as  seldom as possible, and  only when a careful  review of the
moral  and physical condition of  the  patient establishes the  fact that the
mutilation of the body is better than the loss of life.   Possessed of a very
moderate  amount of mechanical skill, and  with a little  resolution, any one
may be able  to perform an amputation; aud  the renown sometimes supposed
by young surgeons to be attached  to the performance of  this operation may
well be deemed of  a doubtful  character, as it tacitly implies that, by a more
judicious and  skillful treatment, they  might perhaps have avoided such a
mutilation.  As such an  operation is also liable  to affect  injuriously the
reputation of a young surgeon, it will prove  to be a  good rule never to ampu-
tate a limb  without  having a consultation with two or  more practitioners,
if it  is at all possible to  obtain their opinion, as the  most serious cases have
occasionally recovered without losing the limb, even when the surgeon has
openly declared such  an event was impossible; while,  on the  other hand,
legal proceedings on a charge of  malpractice have been subsequently insti-
tuted agaist the surgeon, when a patient has been disposed either to escape
the payment of a bill or gratify a  malicious disposition.   Too much caution
can then hardly be shown by the  young surgeon in resorting to this opera-
tion, especially when it is not  sanctioned by the opinion of his  seniors.   It
is generally admitted that the average  mortality  after all amputations is
about one in three of those operated on  properly. 
AMPUTATION  IN GUNSHOT  WOUNDS.
667
                             SECTION  I.

                        CASES  FOR AMPUTATION.

   The propriety of performing amputation in cases of gunshot wounds and
 compound fractures, in gangrene, or for the removal of malignant growths,
 is a question on which there  has been much diversity of sentiment; and, if
 my present limits permitted, this subject might be advantageously allowed
 to occupy several pages.  I shall, however, be compelled to confine its con-
 sideration to a condensed statement of the opinions of distinguished authori-
 ties in a few of the more serious cases, and to the general statement that
 amputation is proper in any case only when the  disease or injury which
 appears to demand it is  otherwise incurable, or when the  patient is so cir-
 cumstanced that the omission of the amputation would increase the chances
 of death.

                         \ 1.—Gunshot Wounds.

   The necessity of Amputating  in Gunshot Injuries has generally been ad-
 mitted to  be regulated by the fact of the ball producing a compound fracture
 opening into a large joint, or mutilating some of the principal blood-vessels
 and  nerves; but, in all these  cases, the position and circumstances of the
 patient should not be  overlooked, as injuries may demand amputation in the
 field, which, in private life, would recover without it.
  The views of surgeons  in regard to  the indications for amputation in gun-
 shot fractures differ somewhat, according to the position of the injury.  In
 the femur, it is nearly  universally admitted to be imperative.   Thus, Ravaton
 thinks such a fracture is nearly always fatal; Ribes mentions that, in an
 aggregate of four thousand cases at the Hotel des Invalides. in Paris,  there
 was not a single cure; De Claubry, surgeon of the  Imperial  Guard, was of
 the same opinion,  most of the soldiers in  Spain dying  unless the limb was
 promptly amputated ;  while Percy, Thompson, Larrey, Guthrie, and Hennen
 express nearly the same views.*
  In opposition to such extended authority, it becomes any one to hesitate
 at the correctness of  an  opinion which is contrary to that thus expressed.
 Yet, having in five cases  of bad compound fractures of the  thigh from Minie
 balls  succeeded  in curing the  patient, so that two were again able to  enter
 the field, I dissent from so general a conclusion, and await the result of the
 extended experience furnished by the  present war in which a great number
 of these injuries have been most admirably treated, owing to the comparative
 proximity of large towns  and  good hospitals to the field of battle.  The cases
referred to  by me were treated  by cold water and  by simple  extension by
 means of a weight, and without splints.
  In  the  upper extremity the result  has always been more favorable, and
 Guthrie states that "this limb  should not be  amputated for almost any
accident that can be produced in this way."f
  In four  cases of Minie  fractures of  the humerus comminuting the bone, I
removed several large portions of bone, and the patients in about nine weeks
had useful arms.   A noted  instance of this was in  the ca"se of the Quarter-
master of the 104th Regiment P. Y.
  In gunshot wounds  of  large joints,  which produce fracture, the  necessity
* Velpeau's Op. Surg., by Mott, vol. ii. p. 454.              f Velpeau, loc. cit. 
                         PLATE   LXXI.

                INSTRUMENTS FOR AMPUTATION, ETC.

  Fig. 1. Trocar for Tapping the Bladder through the Rectum.
                                                          Kolbe's pattern.

  Fig. 2. Petit's Tourniquet.                                   "

  Fig. 3. A Large Round-bellied Scalpel for dissecting back the integuments
in the circular amputation.                                  Kolbe's pattern.

  Fig. 4. A Small Catlin for the interosseous space.             "

  Fig. 5. A Large Amputating Knife for the circular operation   "

  Fig. 6. The Long Ten-Inch Catlin for the flap operation.       "       "

  Fig. 7. An Eight-Inch Catlin for the flap  operation.           "       "

  Fig. 8. Bone-Nippera for removing any sharp points left by the action of the
saw.                                                      Kolbe's pattern.

  Fig. 9. Dissecting Forceps to  hold the integuments while they are dissected
from the fascia before "they are reverted, as in the circular operation.
                                                          Kolbe's pattern.

  Fig. 10. Spring Forceps, often called " Bulldog."              "       "

  Fig. 11. Artery Tenaculum.                                  "       "

  Fig. 12. Barton's Metacarpal Saw.                           "       "

  Fig. 13. Ordinary Metacarpal Saw.                           "       "

  Fig. 14. The Large Amputating Saw.                         "       "

       (668) 
 
 
AMPUTATION  IN RAILROAD ACCIDENTS.            669
for amputation is generally regarded as settled, gangrene or tetanus being
apt to follow ; yet the success that has attended the use of the  cold water-
dressing, even in Minie wounds of the  knee-joint, not inducing fracture of
the bones, should be sufficient to cause a conservative surgeon  to defer an
amputation;  and many cases can now be shown to have  recovered in whom
the knee-joint was directly opened. When, in any case, tetanus is developed
or threatening, especially  if the symptoms are well  marked, it is useless to
amputate, as it  is only possible to remove the wound, but not  the  tetanic
symptoms.
   The advantages of secondary over primary amputations, in these as well
as in other cases, will be referred to hereafter.
                       § 2.—Railroad Accidents.

  A class of injuries unknown to the older surgeons are now so common as
to furnish those of the present day with many examples of compound frac-
tures  and dislocations of the most serious kind.  These injuries, together
with such  as  result from  the use of thrashing-machines, as well as those
created in mills and cotton gins, are the result of the application of force to
the limb, in such a manner as to produce extensive contusion of the neigh-
boring parts, as well as laceration at the seat of injury.  It is therefore not
uncommon,  in amputations performed for the relief of  such injuries, for the
stump  to slough after an attempt has been made to heal it, and this should
always be  guarded against by amputating  sufficiently far from the  seat of
injury to be sure of a sound circulation in the  flaps.   This sloughing arises,
according to Hayward, of Boston,* " from a condition of parts resembling
that which has been spoken of by military surgeons as a local anaesthesia, and
is a state of suspended  animation differing from death only in the fact that
the power of resisting decomposition is retained for a time, though certainly
destroyed by the debilitating effects of the operation."   The shock created
by these  accidents usually results in a state  of extreme depression, and in
such cases I think the amputation should always be delayed until reaction is
established ; though on  this point there  is a diversity of sentiment.  One
reason which has always influenced me in opposing immediate ampntations,
in cases of railroad accidents, is the fact of having repeatedly found  them
complicated with such internal injury as would result in death, independent
of the condition of  the limb.  In nearly all instances of railroad injuries of
the limbs, the patient is either first knocked down by a blow from the cars, or
else falls or is thrown with  violence upon the ground, the latter being gener-
ally uneven, and it is while in this position that the limb is injured by being
run over.   Contusions of the abdominal or thoracic viscera, or concussion of
the spinal  marrow or brain, with violent muscular inflammation, will there-
fore often be found to coexist with the compound fracture or luxation.  In
one instance in my own observation, this contusion resulted in laceration of
the spleen, which caused death  within twelve hours after the performance of
amputation, although no complaint was made by the  patient  of any other
injury  than  that of the  leg; and in another,  a rupture of a hepatic vein
caused the  death, though the amputation  seemed likely to  do well.   By
waiting till reaction is fully established, and the sensibility of the entire body
restored, (say three days,)  we will be rendered more certain of the patient's
true condition ; while, by resorting to anaesthetics, the  shock of the amputa-
  * Paper on Amputations in Massachusetts General Hospital, p. 1G.  Boston, Sep-
tember, 1850. 
670            PRINCIPLES  AND  PRACTICE OF SURGERY.
tion can then be fully obviated.   Should a bad compound comminuted frac-
ture of the extremities require amputation in order to arrest the hemorrhage,
it would be desirable simply to divide the integuments, and remove the limb
at the seat of fracture, and  subsequently (two or three weeks) perform an
amputation for the  better formation of a stump.  This  suggestion,* which
may be termed a partial or temporary amputation, is due to Horner, of Phil-
adelphia, who tried it satisfactorily in two cases.   My subsequent experience
has altogether confirmed it, and the  subject is well worthy the  investigation
of surgeons in charge of large hospitals in cities where railroad accidents
are numerous.

                   \ 3.—The Period for Amputating.

  The advantages  of Primary over Secondary Amputations are serious
questions, and with respect to which there  is  a diversity of sentiment,
  Larreyf asserts  that, in the  American war,  the French  surgeons lost
almost all their patients by deferring their amputations, while the Americans,
by immediate amputation, saved nearly all of theirs.
  Velpeau,^ after a careful and learned examination of  this question, states
that amputation should in these cases be performed within the first twenty-
four hours after the accident.
  Sir George Ballingall§ is  "satisfied  that  in civil hospitals  primary am-
putations  do not do  so  well  as  in military  life, owing to the  difference
of moral  causes in these two conditions; the soldier  being  robust  at the
time of the accident,  and brought to a purer air in a hospital than he  had
had in barracks."
  Guthrie|| states that he regards the  advantageous results of primary am-
putations, or  those  done within forty-eight hours, over  all ordinary ampu-
tations, or those done  at the end of several days or weeks, as being so firmly
established as not to admit of dispute.
  Sanson  agrees with Ballingall  in the statement that  the striking advant-
ages claimed for primary over secondary amputations, as observed in mili-
tary practice, do not hold good to the same  extent in  civil hospitals, and
explains it on various grounds; the  most important of which is the transfer
of a man accustomed to active labor and full diet with fresh air, to the close
wards and  life of a  hospital, this alone being sufficient to excite  constitutional
disturbance.
  Norris,^[ in furnishing the statistics of the amputations in the Pennsylvania
Hospital for the seven preceding years, shows that of 24 primary operations,
14 were cured and 10 died.  In another paper,** containing the results of the
same hospital from  1838  to 1840, he also  shows that of 35 primary opera-
tions,  24 were cured and 11 died, and that of 25 secondary amputations, 13
were cured and 11  died.   By combining these tables, he therefore  concludes
"that immediate amputations after injuries are less fatal than secondary, the
mortality after the   former being 1 in 3T--,-, and in the latter 1 in 2^."
  Hay ward, of the  Massachusetts General Hospital at Boston, in some valu-
able statistics from  that institution.ff affords the observer an opportunity of
learning this fact,  by comparing the date of admission with  that of the
operation,  though  he does not directly mention the fact of the  operation
being primary.  From an examination of his  dates, it appears that of four-
 * Philadelphia Med. Examiner, February, 1853.
 f Clinique Chirurg., tome iii. p. 518.       \ Op. Surg., by Mott. vol. ii. p. 470.
 \ Ibid.. 471, note by Dr. Townsend.        || London Lancet tor M.iy, 1853.
 \ Am. Journ. of Med. Sciences, vol. xxii. p. 356,  1838.
** Ibid., vol. i. N. S. p. 38, 1840.          ft Ibid > vo1- »■ N- S< P- 64> 184°- 
THE PERIOD FOR AMPUTATING.                671
teen primary amputations, ten were cured and four died; but he fears that
the operation in recent injuries is often resorted to too early.*
  Buel.f of the New  York City Hospital, in an exceedingly well-arranged
statistical table of the amputations performed in that hospital from 1839 to
1848, says: "That it  is customary in the New York Hospital to amputate
before the  accession  of inflammatory  action,  so  that  the occasions for
secondary  amputations are rare."   The mortality  after primary amputa-
tions was 27"77; of others 30 76 per cent.  The mortality after amputations
for chronic affections was 20 67.
  Guersent, of the Children's Hospital in Paris, is opposed to hasty opera-
tions in  the cases of  children suffering from chronic diseases,  especially
white  swelling, as the lymphatic  habit  may often  be ameliorated, and  a
valuable though imperfect lirab preserved.  As a general rule, Guersent has
saved  eight or nine out  of every ten operations.   Much of his success is,
however, attributed,  by a writer in the Bulletin de Therapeutique, tome xl.
p. 81, to his practice of ordering good and nutritious diet as soon as possi-
ble after the operation. J
  The most valuable  contribution that has been  recently made,  to  our
knowledge, of the results  of primary and secondary amputations in  civil
practice, is, however, that  furnished in  a recent paper  by Stone,§ of  New
York City, and is  among the most satisfactory of all the papers  that  have
been published on  this subject; the practice of military surgeons having ap-
parently so settled  the  views of the civil surgeons  on  the advantages of
primary amputations over secondary, that comparatively  few have examined
the subject without being previously prejudiced to their  opinions.  The
Astor Place riots in New York having presented a large number of  gun-
shot wounds and compound fractures, the advocates of primary amputations
were surprised  at  the  results of the  practice in these cases, "nearly every
case" being stated by Stone to have terminated unfavorably that was touched
by the knife.  He therefore collected extended statistics  of the civil practice
elsewhere,  and found that the favorite doctrine of primary amputations was
not supported by the result.   After  presenting several extended statistical
tables of amputations in European and American hospitals, as well as in the
military and civil practice, Stone|| arrived at the following conclusions:—
  " 1st. That primary amputations of the upper extremities are equally suc-
cessful, and to be preferred both in military and civil practice.
  "2d. That in military  surgery, primary amputations of the lower extrem-
ities are twice as successful as secondary.
  " 3d. That in civil surgery—that is, in American hospitals—it is immate-
rial whether primary or secondary amputations of the lower extremities are
resorted to.
  "4th.  That secondary amputations of  the  upper extremities  in civil sur-
gery are 8  per cent,  less fatal than in military surgery.
  "5th.  That secondary amputations in civil surgery are 12 per cent, less
fatal than in military surgery.
  "By adding together all accessible information in regard to amputations
of the lower extremities  in civil hospitals, both European and American,
and comparing it with the results  obtained in  military hospitals," Stone
found  "that the mortality in primary amputations  of the lower extremities
in civil practice was  53^  per  cent., and of secondary amputations  12^ per
cent., or 32  per  cent, in favor of primary amputations in military service
* Opus citat., p. 70.             f Am. Journ. of Med. Sciences, vol. xvi. p. 39.
X South.  Med. and Surg. Journ., vol. vii. p. 379, from Med.-Chir. Review.
\ New York Journ. of Med., vol. iii. p. 297.                   || Ibid., p. 305. 
672            PRINCIPLES AND PRACTICE  OF SURGERY.
compared with  civil  practice, and 36 per cent, in favor of secondary ampu-
tations  of the lower extremities over  primary in  civil surgery.   He  also
found that there was a difference of 41  per cent, in favor of secondary am-
putations over  primary in civil practice, and a difference of 9 per cent, in
favor of secondary amputations in civil practice compared with the primary
amputations of military surgery.
  "He  therefore concludes that in military surgery, primary amputations
are to be preferred; that in civil practice, secondary amputations are to
be preferred;  and  that the secondary amputations of civil surgery are
more successful than the primary of military surgery."   Stone  then
closes his paper with some  valuable data to show that, in  all compound
fractures, it  is better to attempt to save the limb, and that very often the
attempt  will succeed under the most doubtful circumstances.   It would
afford me much pleasure  to  extend the circulation of the  many  valuable
facts  collected  by  Stone's labors, were it compatible  with  my  plan;  but,
under present circumstances, I can only advise the reader to  study his valu-
able contribution to  conservative surgery, being satisfied  that he will  then
attempt to save many limbs that would otherwise have been amputated.
  The question of the advantages of secondary over  primary amputations
has also been discussed in a paper by Horner,* of Philadelphia, where  this
surgeon advocated the delaying of amputations, founding his opinions upon
his  own experience  with  the American army in 1812; and upon those of
Mann and Trowbridge, also surgeons in the army at  that period.   Mann
states that, after the  battles of Little York and Fort Greene, a less number
survived primitive than consecutive amputations, three or four dying imme-
diately after the primitive operation, while there was not a single death oc-
casioned by consecutive amputation during the campaign of 1813.   Trow-
bridge gives his testimony in favor of immediate amputation only when there
is no prospect of saving the limb.   Blandin, in France,  as late as 1829,  was
thought to entertain  the same  sentiments.  Fergusson, in referringf to the
former opinions of surgeons in relation to the advantages of  primary ampu-
tations  over those which  are secondary, thinks that modern  practitioners
have  been too  much guided  by the opinions of military surgeons, the  ma-
jority of whom have decided  in favor of primary amputations; whereas an
inspection of the valuable  tables of Reid, of  Manchester, has induced  him
to think that the  balance is greatly in favor of the delayed or secondary
operations, the  intermediary being  more fatal, however,  than the primary.
He therefore, in revising his personal experience, declares his inclination for
delay.   Miller| also  expresses  the  opinion that secondary  amputations in
civil always prove more successful than they do in military  practice, and
thinks it due to the superior accommodations  and conveniences presented in
civil cases.
  My own experience, which has been considerably varied, is decidedly favor-
able to  the performance of secondary amputations in civil practice, particu-
larly railroad accidents, as it gives sufficient time to learn  whether the inter-
nal injuries which nearly always accompany the necessity for amputation are
not sufficient to destroy life  without the performance of  the operation.  I
now usually simply check the heraorrhage by pressure;  or, if the  limb is
mangled, divide the torn tissues,  and  leave the further treatment of the
wound to subsequent consideration.
  I therefore advise the reader to delay the  performance of amputation in
any accident until after reaction is fairly established — that  is,  until  the
* Ranking's Abstract, No. xvii., 1853.       f Pract. Surg. 4th Am. edit. p. 158.
                   X Prin. Surg., 4th Am. edit. p. 632. 
THE PLACE OF  ELECTION FOR AMPUTATION.         673
warmth of the body  and a free circulation have returned — and then  to
etherize the patient fully before the performance of the operation, so as to
avoid the shock;  but in amputations for gunshot wounds in civil practice,
or for diseased joints or other similar complaints, I would advise him to wait
as long as it is possible, or until hectic fever is fairly established, before am-
putating, believing that  the results of secondary amputations, under these
circumstances, will prove to be preferable to the primary; and this opinion
is, I think, sustained by the facts cited above.
                             SECTION II.

             POINTS FOR THE PERFORMANCE OF  AMPUTATION.

   Amputation of an  extremity may be performed either at the place of
 election or  at the place of necessity, and  by a circular, oval, or  flap-like
 incision of the soft parts which are to cover the bone and form the stump.


                       § 1.—The Place of Election.

   The selection of a spot in which amputation can be most advantageously
 performed  is a point which  the character of the lirab, the occupation of the
 patient, and the probable substitute for the limb subsequently to be obtained,
 must chiefly decide, it  being performed either through the shaft of the bone
 —continuity—or through its articulation—contiguity—in accordance with
 the nature of the accident, the character of the artificial support that is to be
 subsequently worn, or the views of the surgeon  either for or against amputa-
 tions through joints.   The general rule for all amputations, where the pecu-
 niary circumstances of the patient admit of his obtaining an artificial limb, is
 to leave as long a stump as  possible, in order to secure a firmer attachment;
 but when the amputation is  to be performed on the leg of a poor man, whose
 means  will compel the use of  the common peg or wooden leg, to make the
 stump  comparatively short,  or at least within four fingers' breadth of the
 tubercle of the tibia, in  order to prevent its protrusion behind the thigh,
 when the knee is  bent  upon the peg.
   Surgeons of all countries  yet differ widely in regard to the advantages of
 amputating through a joint in preference to above it, arguing that as every
 articulating surface is covered by a synovial membrane, this is liable to keep
 up a secretion,  prevent the  healing of the flap, and  thus form a fistula, and
 that, as a general rule, many joints present prominences of bone which often
 can only be covered by the integuments, and that the latter will subsequently
 sustain friction very badly.   These arguments, though very specious,  have
 not been sustained by facts,  and the efforts of Syme, and also of the younger
 surgeons in the United States, have had a tendency to create a doubt as to
 these objections.   When an artificial limb, as  an arm or leg, is desired, it
 will, I think, be found that the  increase in the  length of the stump, by adding
to its motion, more than compensates for any  delay in  healing  the wound,
and that it will subsequently have sufficient ability to resist pressure without
the creation of ulcers.    For the further consideration of this question, the
reader  is, however, referred to the section on Amputation at the Knee-Joint.
"The place of necessity knows no law."
     vol. ii.—43 
G74
PRINCIPLES AND  PRACTICE  OF  SURGERY.
                            SECTION III.

                 THE DIFFERENT KINDS OF AMPUTATION.

   Three principal methods are employed in incising the soft tissues in an
amputation, and they are usually designated as the Circular, the Oval,  and
the Flap operations.

                     \ 1.—The Circular Operation.

   The circular method  of operating has been described by all surgeons from
the earliest  periods,  especially from the time of Celsus, though it has been
modified so as to guard against a conical stump, or to  prevent such a re-
traction of the muscles as would diminish the  amount of covering to the bone.
Without specifying these modifications, it must suffice to  state that the plan
of operating at present  generally pursued by the profession, and suggested
by Petit, of France,  appears  to have been adopted with a full knowledge of
the views of the surgeons of a preceding period, in respect to the advantages
of each, and may therefore  be presumed to  be the best for the forearm  and
leg, while that modified  by Alanson is the  best for  the  thigh and arm, on
account of the round full stump that it forms.
   Petit's Operation.—After  applying  the tourniquet or  some other means
for arresting the circulation,  the skin should then  be divided  by a circular
sweep of the large amputating  knife, held with its point well over the limb
while the surgeon  stoops so that the incision  may commence with the heel
of the blade, on one side, and  terminate with the same  point on the other
side of the limb.  The attachment of the skin to the fascia being then divided,
and the skin dissected off so  that they can be turned back like the cuff of a
coat, the muscles should be incised down to  the bone by a second sweep of
the knife, at the reverted edge of the skin, taking care not to cut this edge,
the division of the fibres which adhere directly to the  bone being  thoroughly
accomplished by two or three  shorter cuts. The soft parts being now forced
or drawn back by means of  a  retractor in the hands of an  assistant, the bone
should be cut transversely across, and the operation completed by tying  the
arteries and closing the stump, as will be subsequently described.
  The necessary instruments  may be seen in  Plate  LXXI.
  Remarks.—In the formation of a stump by the circular  operation of Petit,
the surgeon should be particular in turning back sufficient of the skin and
bring the sides of the integuments together vertically or antero-posteriorly, it
being desirable always to approximate the integuments in such a manner as
to favor the subsequent escape of any purulent collections.  In the United
States it is the almost universal practice to attempt union by the first inten-
tion, and it is under such circumstances  that the line of  union in a circular
operation may become a matter of importance.
  An important point, in the practice of every young operator, is to  decide
the proper amount of integuments necessary to cover the stump, and I there-
fore advise  him to proceed as follows: Take the circumference of the limb
with  a piece of tape,  fold it into five equal parts, and then incise the integu-
ments at the distance of one of them from the point at which the bone is to
be sawed across, or make the reverted portion with the divided muscles equal
to one-fifth of the circumference of the stump. This calculation is sufficiently
free to permit of the  ordinary amount of retraction during the healing of the
stump.
  Alanson's modification of the circular operation will be described in con-
nection with the thigh. 
THE*DIFFERENT KINDS OF.AMPUTATION.
675
                        \ 2.—The Oval Method.'

  The oblique or oval form of the flap is the result of such an incision as is
made by carrying the knife a little higher on one side of the limb than on
the other, so as to form an  oval  instead of a circular wound, and is especi-
ally  applicable to amputations through the joints.   In  performing  it the
knife should be carried around the limb by two distinct sweeps, and not in
one continuous cut,  as was done in the circular operation, so that each inci-
sion may be carried around half the limb in a direction which is oblique to its
perpendicular diameter, thus dividing  all the  parts down to the bone and
forming a wound which will  be angular at its point of commencement and
termination, but rounded in  the intermediate part something like the  letter
U, when its two ends are brought nearly in contact.
  Remarks.—The  oval method  is seldom  applied  to amputations  of the
shaft of the bones, though where there is a large amount of muscle and in-
tegument, as  in  a well-developed  thigh  or arm, I have found it to form a
better stump than the circular method, as it avoids the folds and puckering
so generally caused  by the approximation of the edges of a circular wound.
The selection of the amount of the flaps will be decided as before.
                       \ 3.—The Flap Operation.

  In incising the integuments for the formation of a flap to cover the end
of the bone, two methods have been  employed, the difference being chiefly in
the formation of one or two flaps, according to circumstances.
  When two flaps  are desired, they may be formed either by cutting from
the skin to the bone, or from the bone outward.
  In operating from without inward, the  soft parts are  punctured by the
catlin, and the cut made on one side through all the tissues from within out-
ward, at an angle capable of furnishing a sufficient amount to form a cushion
for  the end of the bone.   This flap  being then held back  by an  assistant,  a
second one is formed on the  side of  the vessels of the limb, by commencing
at the bone, and cutting outward, when the latter is to be  sawed  off, and the
flaps approximated.
  In the single flap operation, the structures are divided on one  side, either
with or without other incisions.
  The calculation of the amount of integuments requisite to cover the stump,
in this method of operating, would  be about one-fourth instead of one-fifth,
as there is more retraction of the soft parts when they are thus divided.
  In 1855, Teale, of Leeds,  England, recommended the formation of a long
anterior and a short posterior flap, with  square ends.  The long  anterior
flap, not including the main vessels and nerves, should be  equal in length to
one-half the circumference  of the  limb; two longitudinal lines of  this length,
measuring from the  point where the  bone is to be sawed off, being first traced
on the limb, and met at their lower  points by a transverse line of the same
length.   The short flap is indicated  by a transverse line of the length of one-
fourth of the long one—that is, assuming the circumference of the limb to be
sixteen inches, the  length of the long flap would be eight inches, and the
leno-th of  the short flap two  inches.   The two lateral  incisions  of the long
flap should be made only through the integuments. The transverse cut of this
flap is made by a free sweep of the knife through all the tissues to the bone,
and then shaved from the front of the bone and from below upward as high
as is necessary.   The posterior short flap is to be made by one sweep of the 
676           PRINCIPLES AND  PRACTICE OF  SURGERY.

knife down to the  bone, the soft parts being afterward separated from the
periosteum as far upward—two inches—as the intended place of sawing the
bone.*
  Remarks.—The flap operation is the favorite mode of amputating with
some surgeons, on account, apparently, of the rapidity with which it may be
performed; but it is especially liable to secondary hemorrhage, owing to the
oblique division of the vessels of the stump.  Sometimes, however, it is the
result of  necessity, as in cases of laceration, where  the integuments are de-
stroyed on one side of the  limb, and a sufficient covering for a stump cannot
otherwise be  obtained.
          § 4.—Estimate of the Different Kinds of Amputation.

  The variety of cases requiring amputation, and the different results obtained
under such circumstances, have apparently caused a want of harmony among
experienced surgeons in deciding on the merits of either plan, which it is diffi-
cult to credit, especially when it is recollected that these opinions are the result
of each surgeon's experience. Such a diversity of sentiment is, however, rather
apparent than real, and must be ascribed to  the predilections consequent on
the force of circumstances;  thus, an amputation that might be instantly de-
manded on a field of battle and without assistants, might be performed very
differently when the operator was in a civil hospital, and with every conveni-
ence, so that, if two surgeons were similarly situated, they would  doubtless
coincide perfectly on this, as on most other practical points.
  The advocates of the  flap operation state  that it is  more prompt, less
painful, exposes less to hemorrhage, obtains a rapid cure,  and forms a stump
well adapted to an artificial limb.
  Its  opponents contend  that  it exposes a greater surface for suppuration;
that there is greater difficulty in finding the vessels that are to be tied, owing
to their being obliquely divided; and that the secondary hemorrhage is there-
fore more common after the flap than after the circular operation.
  The advocates of the circular operation claim that it is most likely to form
a good "apple-dumpling-like stump;"  that the arteries may be easily found
and tied;  that secondary heraorrhage is rare; and that, by giving the wound
a conical shape,  with the bone in the centre, the flesh is  placed in the most
favorable condition for properly covering the bone and sustaining pressure.
  Its  opponents object to its slowness, to the pain caused by dissecting back
the cuff-like portion of the skin in the operation of Petit when  anaesthetics
are not employed, and to  the excessive  and irregular  contraction of the
various layers of the muscles when transversely divided.
  Chelius,f from "personal experience, prefers  amputation  by  the circular
cut, with the eversion of the skin, believing the advantages ascribed to the
flap operation to be groundless."
  Velpeau! thinks "too  much importance  has  generally been  accorded to
the flap operation; that it has many partisans in  the dissecting-room, but is
seldom resorted to for amputations in the continuity of the lirab."
  Fergusson,§  although  performing  the flap operation  most frequently,
owing to special  circumstances, states "that at the present day  more ampu-
tations are done by the circular than by the flap operation; and that, fifteen
  * On amputation by a long and a short rectangular flap, p. 35, et seq., by Thos. P.
Teale, F.R.C.S.  Leeds, 1858.
  f System of Surgery, by South, vol. iii. p. 652.
  X Operat. Surg., by Mott, yol. iii. p. 484.           g Practical Surgery, p. 162. 
           GENERAL MEASURES REQUISITE IN AMPUTATION.       677

or twenty years back, not one surgeon  in  fifty ever thought of performing
any other;" and he therefore doubts whether the flap can present any special
advantages.
  In the United States, Gibson* advocates the circular operation upon the
thigh, and the flap in the leg.
  Norrisf states "that, with  very few exceptions, the circular amputation is
the operation performed in the  Pennsylvania Hospital, union being always
attempted by the first intention."
  HaywardJ says "that, in  the Massachusetts General Hospital, a large
proportion  of the amputations  were  done by the circular  method, the flap
being adopted only when it was  thought likely to afford a better stump."
  Buel§ remarks "that, in 49 cases occurring in the  New  York City Hos-
pital, 24 were performed by the double flap  operation, and 25 by the circular
method.   Of the flap  operations, the mortality was 1766 per cent., and  of
the circular, only 12 per cent."  He, however, thinks that the greater mor-
tality of the flap operation may have been due to the greater proportion of
thighs in which it was  performed.
  Porter, U. S. A., who served in the Mexican war, expresses the  opinion||
that the army surgeons were  greatly  in favor of the circular operation  in
Mexico,  one of them of extended experience, and who previously advocated
the flap operation, changing his  opinion and practice on the ground that the
stump  made by the circular operation was the  best; his own opinion is
decidedly in favor of the circular method.
  Teale recommends his flap  operations as furnishing stumps that are better
able to support pressure than any other. I  have, however, seen trouble from
the want of circulation in the anterior flap  formed by this method.
  Personal experience  has long induced me to think that, in attempting to
settle this question, there has been too much ascribed to the defects of each
method  of operating; that the circular operation is the best in the middle of
the  limb, but that the flap is the  best adapted to the articulations;  and that
the rapidity with which one can  be performed instead  of the other is  owing
rather to the practice of such surgeons as confine themselves to one kind of
operation than to  the  superiority  of either in respect to  time.   In some
cases, as in laceration, the flap  is the only means of forming a covering  to
the  stump  without removing a large  amount  of  the limb.   But  it  should
always be remembered that  the  flap  exposes the patient to greater  risk of
secondary  hemorrhage  than  the other methods, either from  the oblique
division of the  end of the artery,  or, as I have sometimes seen, frora its
being punctured  or bruised  in  the transfixing of the soft parts in the first
introduction of the  catlin.   Owing to  the beveled edge of this  flap, it  is
also more likely to induce a conical  stump.
                            SECTION  IY.

             GENERAL MEASURES REQUISITE  IN AMPUTATION.

  The mere division and removal of the limb being the simplest portion of
an amputation, the surgeon should pay special  attention to the other meas-
ures connected with the operation, as these are mainly conducive to its prompt
* Practice of Surg., vol. ii. pp. 488, 489.
f Am. Journ. Med. Sciences, vol. xxii. p. 359.    \ Ibid., vol. xvi. N. S. p. 38.
X Ibid., vol.  i. N. S. p. 65, 1840.              || Ibid., vol. xxiv. N. S. p. 24,1852. 
678
PRINCIPLES AND  PRACTICE OF  SURGERY.
and fortunate performance.   In every important amputation, the duties of
the assistants, and  the preparatory as well  as  the  secondary steps, should
therefore be thoroughly considered.
                      \ 1.—Preparatory Measures.

  The general preparatory measures required in an amputation are very
much the same as those demanded  in other operations,* and do not require
any further notice, except  the caution that they should be made in accord-
ance with the general  health of the patient.   Thus, one who is to undergo
amputation in full  health, may  be benefited by a moderate  loss of blood,
while one who was  enfeebled by disease, would be  killed by the  loss of a
few ounces.   The diet  also should  be regulated accordingly.
  The propriety of employing anaesthetic agents in amputations,  and their
effects upon  the  subsequent condition  of the  patient,  are questions that,
since the general introduction of anaesthetics in operative  surgery, have ex-
cited considerable interest.   They are,  however, questions that  must now
be regarded  as  settled, thousands having been  operated on without the
slightest evil, and with  marked benefit  in the  subsequent nervous disturb-
ance.  Few circumstances would lead me to amputate, without first inducing
perfect anaesthesia.  The  advocates of  the utility of suffering are fast dis-
appearing, or have ceased to promulgate such antiquated  notions.
  The necessary instruments are shown  in Plate LXXL, and should always
be kept in complete order  for immediate use.   The ligatures should be care-
fully made.   At the moment, the bandage and compress should be prepared
for the tourniquet, if it is  to be employed;  the hair shaved off the skin, so
as not to interfere with the subsequent dressings; a retractor of muslin or
buckskin, cut with one or  two tails, so as to protect the soft parts from the
saw; and the limb elevated for a few hours previous to the operation, so as
to drain it of blood, if the debilitated  condition of the patient  renders  it
desirable to prevent the loss of even a moderate amount.
  The dressings for an amputation were formerly very varied; but a more
enlightened view of the changes in the  condition of parts after an amputa-
tion has led to a most judicious change.   Instead of the spread cerate, Mal-
tese cross, tow, bandages,  etc., which were prepared to  envelop  the stump,
many  surgeons now resort to  the water-dressing, and  require, therefore, a
few  needles aud metallic ligatures to make the interrupted suture, a piece of
oiled cloth to place under the limb to protect the  bed, and sufficient lint or
wet  cloths to cover the stump and  guard it from external irritants.
                       \ 2.—Duties of Assistants.

  Before commencing an important amputation, as that of the  thigh, for
example, the surgeon should select four capable assistants, and assign to them
their special duties :  thus, the first may attend to the etherization, and care-
fully watch its effects; the second control the heraorrhage, either by pressing
on the main artery or by the application of the tourniquet; the  third sup-
port the lower portion of the limb, and  be especially careful in  holding it
steady during the action of the saw, neither raising it so as to bind  the instru-
ment, nor depressing it so as to  snap and splinter the bone ; while the fourth
should hand the instruments, attend to retracting the soft parts, so as to pro-
* Vol. i. Part i. p. 167. 
           GENERAL  MEASURES REQUISITE IN  AMPUTATION.       679

tect thera from the saw, and tie the arteries as they are picked out by the
surgeon.  This assistant may also aid in approximating the flaps during the
dressing, while the third warms the adhesive strips when  they are required.
                         \ 3.—After-Treatment.

  As the general rules for the after-treatment of all operations have been
before described, I shall limit this  account to such special  means as are
required in amputations.
  The dressing of an amputation may be advautageously performed as soon
as the hemorrhage is entirely checked, in the following manner: Cleanse the
surface of the stump by gently squeezing on it the water from a sponge, but
do  not  brush it roughly with the sponge;  gather together the ends of the
ligatures, and bring as many as possible out of the lower angle of the wound.
If the stump presents a large surface, it will also  prove useful to introduce
a small strip of linen  at one angle between the edges of the skin, as was
the practice of  Physick.   Then with the needle  and metallic ligature make
two or three stitches of the interrupted suture,  in order to  close the skin,
placing the first stitch so as to unite the flaps in the centre, adding to these,
if deemed useful, two or three strips of  adhesive  plaster.  Place over this a
soft linen towel or piece of lint wet  with  tepid water, and  then place the
patient in bed, with the limb slightly elevated by means of a pillow doubled
under it, and covered by the oil-cloth.  The tourniquet  may either be left
loosely applied  around the  limb, or kept  near the bed ready for use.   In
order to  prevent  spasm of the stump, and such  muscular contraction  as
might derange the dressing,  a broad bandage should be carried over the limb
above the stump,  and its ends  pinned  fast to the bed, after which a hoop
should be so arranged as to keep off  the weight of the bedclothes.   One
assistant should then be left on guard for twenty-four hours, and an anodyne
administered, if the patient require it.
   During the first forty-eight hours after a  primary amputation, on a patient
in  good health, the diet may consist of light nutritious  articles, as broths,
etc., and then, if fever, or a tendency to active inflammation is not apparent,
he  may be allowed to eat meat and resume his ordiuary diet.   But if he has
been previously confined  to bed by a chronic disease, no change should  be
made in the diet previously given.
   The only attention required by the stump, in  many instances, during the
first forty-eight or seventy-two hours after the first dressing, is to keep the
lint or cloth moist by squeezing  upon  it water of such a temperature as is
most agreeable to the feelings of the  patient, some liking it cold and others
tepid, the oiled cloth beneath the limb being so arranged as  to carry off the
surplus water and keep the patient dry.   On the fifth day, if ulceration is
apparent about the stitches, one or more may be removed, and the flaps sup-
ported  by long adhesive strips, or by  the turns of a bandage; but usually
the metallic  sutures will retain their  position for ten or fifteen days without
inducing ulceration.  About the sixth or tenth day, one or more of the liga-
tures will be loosened, and may be  quietly drawn away;  but,  should they
adhere too long, and delay the cure,  then the means before referred to*
should be resorted to.   As soon as the ligatures  have separated, the stump
may be advantageously compressed  by the  gentle traction of a  bandage
until the newly-formed adhesions  have acquired firmness.   When, in  the
course of the treatment, the stump shows  a disposition to high inflamma-
* Vol. i. Part i. p. 198. 
680
PRINCIPLES AND  PRACTICE OF  SURGERY.
tion, cloths wrung out of hot water, and then dusted with  powdered  cam-
phor, so as to place it between two layers,  may be substituted, if suppura-
tion  seems likely to relieve it;  but whenever the latter is freely established,
the stump should  be  placed horizontally, or slightly inclined downward, so
as to favor the escape of the matter, and prevent its burrowing in the
muscular interspaces.   Although the water-dressing,  as usually practiced,
occasionally presents  examples of union by the first intention throughout
a considerable portion  of the stump, it will  not  always  do  so.   When,
therefore,  suppuration is  freely established, the wet cloths should be fre-
quently changed  and fresh ones substituted,  so as  to  prevent decompo-
sition of the pus and subsequent irritation.   By these means, the secretions
never become offensive, and both  patient and surgeon obtain  a degree of
comfort that was impracticable under the old  method of dressing.  When
there is a short stump, and  a tendency to  retraction of the  muscles, the
application of the bandage and straps, as shown in Fig.  452, will be useful.

                                Fig. 452
           Dressing of a Stump by Metallic Sutures and Strips attached to a Bandage.

Fouilley, of Brest, has advised that in cases of a short flap, with a marked
tendency to retraction, we should resist it by applying several straps of adhe-
sive plaster vertically from a point several inches above the incision in front,
to a corresponding  point  behind, making the straps  long enough for their
centres to project about four inches beyond the end  of the stump.   Then,
running a cord through  the loops so as to project beyond the stump made,
attach a weight to the cord.
     \ 4.—Accidents that may occur either during or after Amputation.

  The occurrence of an  accident during an  amputation is an event which
proper foresight will always prevent, and it  should therefore be regarded,
like many other " accidents," as positive evidence of the carelessness of the 
  ACCIDENTS THAT  MAY OCCUR DURING  OR AFTER AMPUTATION.   681

 operator. This carelessness may be shown : 1. In the occurrence of hemor-
 rhage.   2.  In  cutting openings iu the flaps.   3.  In splintering the bone.
   The  occurrence  of  hemorrhage  during  an amputation  may arise frora
 breaking the tourniquet, or from failure, by the assistant intrusted with it,
 to compress the artery;  both of which can be avoided by proper care.
   The flaps may be cut or perforated, in the circular operation, by careless
 dissection of the skin, or by thoughtlessly transfixing one  point  instead of
 another; while splintering of the bone may arise from  want of ability or
 proper  information in the assistant who holds the limb during  the act of
 sawing.   Such accidents require merely to be enumerated in order to be
 avoided.  Fainting is the only event  truly  accidental that can occur during
 an amputation, and it  may be readily remedied  by lowering  the patient's
 head, and administering stimulants.
   After an operation, hemorrhage may occur at any moment.   If it shows
 itself within forty-eight hours, it is evidence of the neglect of the surgeon in
 ligating the vessels of the stump; and if not severe, may be checked by com-
 pression, but if more profuse, it may be requisite to open the stump and
 seek for the bleeding vessels, and then ligate them properly.
   Spasm, or twitching of the  stump,  is not an unfrequent occurrence after
 an amputation, and is due to the irregular contraction of the muscles, some-
 times caused by the  pressure against  the sharp end of the  boue, and some-
 times due to nervous irritation.  Gentle circular compression of the  limb,
 and the free use of opiates internally, will usually afford relief.   Should the
 recurrent bandage of stumps have been applied, the turns should be examined
 to see  that they do not compress the end of the soft parts of the  stump
 against the freshly sawed edge of the bone.
   "At  Guy's Hospital, for the last two  years, Hilton has been  in the habit
 of supporting the stumps of amputated thighs by applying a short and broad
 splint under the stump, which is elevated at an angle of  forty degrees; be-
 neath the splint  is a  small cushion,  and  a light bandage  is  applied over
 all."*
   Inflammation of the stump, abscesses, or exfoliation of a lamina of bone
 may also complicate the after-treatment;  but they may be relieved on the
 ordinary principles of the treatment of such affections elsewhere.   The exfo-
 liation  of the bone is often caused by  the careless use of  the saw lacerating
 the periosteum  and endosteum, and  thus separating them from  the bone, so
 as to impair its nutrition.
   When the removal  of the  ligature is delayed beyond the  proper time,
 (three to four weeks,) a resort to the  means referred tof  is  all  that is neces-
 sary.
  Neuralgia of the stump may arise either from  the inflammation and en-
 largement of the  end of  a nerve, or from its adhesion to the cicatrix.   The
 principles before spoken  of in connection with neuralgia will here suffice for
 the relief of this condition of the part.
  A tender  condition of the stump, or a constant tendency to  ulceration, is
 sometimes the result of the delicacy of the skin until  it becomes accustomed
to pressure,  and at other times is due to the  contraction of the  soft  parts
upon the bone.  Under either circumstance the patient will be benefited from
soaking the  stump daily, for half an hour, in a strong decoction of white-oak
bark, which, by acting  on the gelatin of the skin,  will tan or harden it.
* London Lancet, 1859.
f Vol. i. p. 198. 
                        CHAPTER  VII.

            AMPUTATIONS OF THE UPPER EXTREMITY.

  In describing the various methods of amputating, I shall chiefly present
the methods of the French operators, though,  whenever there is occasion, I
shall embrace the views of others, while offering the results of individual ex-
perience, as tested in daily practice, for nearly  thirty years, as well as in the
operations of the classes of the University of  Pennsylvania  upon the dead
body.


                            SECTION I.

                AMPUTATION AT THE SHOULDER-JOINT.

  Amputation at the Shoulder-Joint is  an operation that dates back to a
very early period of surgery, being stated to  have been  performed in the
year 1686.   From  this time it has been more or less frequently repeated,
especially by military  surgeons,  among the most prominent of whom  was
Larrey, who amputated at the shoulder-joint sixteen times during Napoleon's
campaign in Egypt,  only losing two cases, and fourteen  times  after the
battles of Wagram  and Essling.   Subsequently, as stated in his Memoirs, he
amputated at the shoulder more than a hundred times, of which ninety cases
were cured.
  Amputation at the  shoulder-joint has  also  been frequently performed in
the United States,  having been done by John_Warren, of Boston, as early
as 1781; by Bayley, of New York, in 1182; and" subsequently by Trowbridge,
of New York, in 1809; Gibson, of  Philadelphia, in 1812;  Bpwen, of Provi-  ?
dence; Whitridge,  of South Carolina;  G. M'Clellan, six times successfully;  k
and also by Mussey,  of Cincinnati;  Horner, Randolph,  D. Gilbert, and
Page,  of Philadelphia; N. Pinkiiey, U.  S. Navy; Eye, of Georgia;  May,
of Washington;  J. Mason Warren, of Boston; Sanburn, of Massachusetts;
Howard, of Georgia;   Pensler, of  New York; and  Freiott, of  Troy.  Of
these, a large proportion proved successful.
                \ 1.—Amputation at the Shoulder-Joint.

  The necessity for  amputating the  arm at its very highest point has in
some instances led to its removal above the articulation, though the opera-
tion at the shoulder-joint  has.been much  the  more common.  The latter
amputation has been performed by nearly all the known methods of ampu-
tating elsewhere, though that of the flap, with its various modifications, has
generally been deemed preferable to the  circular  operation, when circum-
stances permitted it, owing to the importance of covering the prominence
       (682) 
AMPUTATION AT THE SHOULDER-JOINT.
683
 caused  by the projection of the acromion process  above the glenoid cavity,
 when the head of the humerus has been removed.
   The  operation  above the  shoulder-joint may be performed whenever the
 disorder for which amputation of this extremity is  demanded involves either
 the scapula or clavicle, or both.  The following cases illustrate sufficiently
 such  modifications of the  ordinary operations at  the  articulation as have
 been specially resorted to.
   I. Amputation of the  Arm above the  Shoulder-Joint.—Operation of
 Geo. M'Clellan, of Philadelphia.* — A young man having an encephaloid
 tumor which extended from the lower part of the  right arm  upward to the
 shoulder-joint, and involved  the clavicle and  scapula entirely within it, the
 amputation was commenced  by securing the subclavian artery just as it
 emerged from between the scaleni muscles, after which the clavicle was sawn
 through close to its articulation with the sternum,  and  the scapula dissected
 off from the chest so as  to permit the removal of the arm with the entire
 mass, enough sound skin  being saved to form a flap front and back.  The
 wound  healed readily, and in a few weeks the patient was walking about, but
 his subsequent condition is not stated.
   Operation of Gilbert, of Philadelphia.f—A gentleman with a pancreatic
 sarcomatous tumor of the shoulder, urgently requiring  relief, it was decided,
 in consultation, to amputate the arm above  the shoulder-joint, and remove
 portions of the clavicle and scapula, which was done as follows:—
   The  subclavian artery beiug compressed on the first rib, and an anodyne
 administered, an incision  was made with a large scalpel, commencing at the
 posterior border of the axilla, and extending upward one inch above the
 highest portion of the spine of the  scapula.    The next incision commenced
 where the first crossed the spine of the scapula, and extended downward and
 forward to the point of the shoulder, thence upward and inward, along the
 lower edge of the clavicle, to  the extent of its outer third, and then upward
 above its superior margin, so  as to  form  a triangular flap.  This being dis-
 sected  up, the  clavicle, inside of its outer third, was  isolated by passing a
 retractor under it, when  the  bone  was divided by Hey's  saw.  The  skin
 posterior to the first incision  being now reflected  backward,  the latissimus
 dorsi and teres major muscles were divided, as well as the infra and supra-
 spinal, beyond the limits  of the disease, so as  to expose the neck and upper
 portion of the body of the scapula, after which  the  spinous process was
 divided obliquely from behind  forward and inward to the neck of the scapula,
 by means of the amputating  saw.   The  neck and part of the body of the
 scapula being then sawn through with a long  narrow saw, and all the bony
 connections  severed, the  skin  and  pectoralis  major muscle were carefully
 incised from the axilla forward aud upward,  so as to expose the  axillary
 artery, which being promptly secured, all the remaining attachments were
 divided, and the wound closed.  This patient recovered from  the immediate
 effects  of the operation,  but died  five months subsequently, the  axillary
 lymphatics presenting evidence of the reproduction of the disorder.
  II.  Amputation of the Arm at the Shoulder-Joint.—The following
 methods are those best adapted to this articulation :—
  Lisfranc's Operation.—In  this method of operating it is of great conse-
 quence  that there should be  sufficient space behind the patient's shoulder
 to permit the introduction of the catlin.  The patient must, therefore, be
either seated or  propped up in the bed, so near to  its edge that the scapula
will be exposed, while the arm should be placed close to the side, in order
* M'Clellan, Pract. of Surgery, p. 412; nole by J. H. B. M'Clellan, M.D., 1847.
f Am. Journ. of Med. Sciences, vol. xiv. N. S. p. 360. 
PLATE
L X X11.
                      AMPUTATION OF THE ARM.

  Fig. 1. View of the Head of the Humerus, showing its Hemispherical Char-
acter.  1. The greater tuberosity.                After Bernard and  Huette.

  Fig. 2. A side view of the Bones forming the Shoulder-Joint.  1. The head of
the humerus.  2. The clavicle.  3. Acromion process of the scapula.  4. Cora-
coid process.  5. Dorsum of the scapula.  6. Section of the biceps tendon.
                                               After Bernard and Huette.

  Fig. 3. A Three-quarter view of the Scapula.  1.  Glenoid cavity.   2. Spine
of the scapula.   3. Coracoid process.             After Bernard and Huette.

  Fig. 4. Lisfranc's Operation for Amputation  at the Shoulder-Joint.   1. The
long ten-inch catlin transfixing the deltoid muscle from behind.   2. Its point of
exit in front. 2, 3, 4. The shape  of the posterior flap.
                                               After  Bernard and Huette.
  Fig. 5. The same Operation, showing the Formation of the Anterior or Inter-
nal Flap.  1. The long catlin.  2. The hand of the surgeon.  3. The anterior
angle  of the flaps, or point of exit of the catlin.  3, 4,  5. The posterior flap
raised up, so as to show (6) the head of the humerus.
                                               After Bernard and Huette.
  Fig. 6. Larrey's Operation for Amputation at the Shoulder-Joint.  1,  2. The
first, or vertical  incision.  3, 4.  The  posterior  incision, commencing  near  the
middle of the first.  5. The anterior incision, starting from the same point.
                                               After Bernard and Huette.
  Fig. 7. The wound left  by the  preceding Operation.   1, 2, 3, 4. The shape
of the wound.  5. The glenoid cavity.  6, 6. The axillary vessel.
                                               After Bernard and Huette.
  Fig. 8. Velpeau's Flap Amputation of the Arm.   1, 2.  The flaps and their
relation to the bone, which is shown in the dotted lines.
                                               After Bernard and Huette.
  Fig. 9. The Ordinary Circular Operation for Amputation of the Arm.  1. The
knife.   2. The hand of an assistant retracting the soft parts.
                                               After Bernard and Huette.
  Fig. 10. Appearance of the Stump after the Operation.  1, 2. The brachial
and profunda arteries.                            After Bernard and Huette.

       (684) 
Plate 7J
fig. 4.
Vi£.2
 
 
                AMPUTATION AT  THE  SHOULDER-JOINT.           685

that the head of the humerus may be pushed upward and outward as much
as possible, by carrying the elbow upward and inward.  Then feeling for the
acromion and coracoid processes, or for the coraco-acromial triangle, plunge
an eight-inch catlin in at the external side of the posterior  margin of the
axilla above the tendons of the latissimus dorsi and teres major muscles, and
carry it across the shoulder, with its blade inclined  flatwise, till the point
touches the under surface of the acromion process.  Then raising the handle
sufficiently to lower the point beneath this process,  bring it out below the
clavicle in the triangular space between the clavicle and the coracoid and
acromion processes.   Let an assistant now raise the arm  from the side, and
carry it off from the body, while the surgeon, grasping the relaxed deltoid
in his left hand, elevates it as much as possible from  the bone, and shaves it
off so as to form a posterior semicircular flap about three inches long, Plate
LXXII. Fig. 4.  This incision should divide the external  portion of the
capsular ligament and the  tendons of the latissimus and teres major and
minor muscles, as  well as the deltoid; but if the capsule has  not been freely
divided by the point of the knife passing  over it as it was introduced, it may
now be effected  by incising it with its heel, while the assistant holds up the
flap.
   On again  carrying the elbow a little toward the side, the head of the
humerus will escape  through the opening in the capsule, when the knife
should  be passed around it to the inside of the bone,  and  carried downward
and forward, so as to shave off an internal flap of about two and a half inches,
Plate LXXII. Fig. 5, the artery which remains  in the flap being held by an
assistant grasping the flap before it is detached from the arm below.
   When operating on the right  shoulder, the same steps are taken; but the
point of the  knife is inserted in front of the axilla  at the coraco-acromial
triangle, and  made to come out behind at the same point as  was above directed
for its insertion  in the  left shoulder.
  Larrey's Operation.—Amputation of the shoulder by the formation of an
oval  flap is  the method sanctioned by the experience of this  well-known
surgeon, who  had frequent occasion to perform it in his campaigns.
  Operation.—Make a vertical incision on the external side of the shoulder,
down to the  bone, and carry it from the edge  of the acromion process to
within  about  one  inch of the level of the surgical  neck of the humerus.
Then, commencing at this point, make two oblique incisions, one anteriorly
and the other posteriorly, so as to divide the integuments and flesh on the
anterior and  posterior parietes of the axilla, as well as the insertions of the
pectoralis and latissimus  muscles, Plate LXXII. Fig. 6.  Push back the
edges of this  wound, and open the joint by a single cut of the knife, drawing
slightly upon the humerus, so as to put the ligaments  on the stretch.  Luxate
the head of the bone, pass the knife behind it, and terminate the operation
by dividing the  structure in the axilla, in which are  found the arteries and
nerves,  which should, at the moment, be compressed  by an assistant.   The
wound  which is left is perfectly oval, and well adapted to  healing,  Plate
LXXII. Fig. 7.
  As the injury which demands  this amputation  is often the result of a lace-
rated wound which leaves but little choice as to a flap, the following account
is cited as illustrative of one course of proceeding under these circum-
stances :—
  Operation  of Peaslee, of New York.*—A musket being accidentally dis-
charged into  the shoulder, the entire charge passed directly through the arm,
entering on the inside just above the insertion of the  deltoid; it then passed
* New York Journ. of Med., vol. x. N. S. p. 297.   1853. 
686           PRINCIPLES AND PRACTICE OF SURGERY.
obliquely backward, upward, and outward, and, emerging directly below the
acromion process, after shattering the bone and blowing away several ounces
of the deltoid, left a wound capable of receiving an ordinary teacup.  Ampu-
tation being decided on, and the ordinary methods being impracticable, the
operation was performed as follows:—
   Operation.—A catlin was passed through  the  inner edge of the deltoid
muscle at a point two inches below the joint, and brought out at the edge of
the external wound so as to form a very small anterior flap;  after which the
knife was carried through the joint, and a posterior flap made of the skin and
triceps muscle by extending the incision nearly to the elbow.
   This patient subsequently recovered and  had a good stump, the greater
portion of which was formed by the skin aud triceps muscle being turned up
so as to meet the lower edge of the  anterior flap nearly on  a line with the
coracoid process.
   Remarks. — As all  the plans above  stated present excellent methods of
amputating at this joint, it is unnecessary to enter into a description of the
various  modifications that have been proposed  by  others.   The  circular
operation at this joint presents us with nothing peculiar.   Sanson,  of Paris,
who, in  connection with Velpeau, recommended it strongly, divided all the
structures at one sweep of the kuife, applied one inch below the acromion,
and then disarticulated the bone.
   The objection  to  this method of amputating, or rather the advantages
possessed by either that of Lisfranc or Larrey over the circular operation, is
that, as the artery in the flap is not  divided  until the last  moment, it can
then be promptly seized and tied, in consequence of the disarticulation plac-
ing the arm out of the way.  I believe that this'operation is  generally pre-
ferred by surgeons in the United States.
   From the account furnished  by Stephen Smith, of  New York,* in an ex-
cellent paper on  amputations of large joints, it appears that  amputation at
the shoulder-joint has generally been  more fatal both in hospital and private
practice than amputations of the arm or thigh.  He, however, regards the
primary as more  successful than the secondary amputation at this joint, both
in military and" private practice.
   Statistics  of  Amputations at the  Shoulder-Joint.f—From  the  same
statistics,^ including the cases of this amputation  previously reported by
Buel and Lente,  of the  same city, it appears that of 39 operations performed
in the United States, 13 were fatal and  1 doubtful, being a mortality of 33
per cent.   In 7 cases anaesthetics were used, of which one was fatal.  From
a careful  examination of the tables formed by  collecting the operations of
many of the European hospitals, as well as those in New York, Smith there-
fore concludes that amputation at the shoulder-joint is more fatal than ampu-
tations of the arm or  thigh in the same hospitals, and that the same rule
holds good in private practice.
                            SECTION  II.

                       AMPUTATION OF THE ARM.

  The Amputation of the Arm may be accomplished  at  any point  of its
length, either by the circular or flap operation.
  Circular Operation of Alanson.—The patient being etherized, and then
* New York Journal of Med , vol. x. N. S. p. lo.
f Transactions American Medical Association, and Am. Journ. Med. Sci.
X New York Journal of Med., vol. x. p. 9.  1853. 
AMPUTATION  OF THE ARM.
687
placed in a suitable position, the tourniquet, or manual compression, should
be applied to the artery, and the limb carried  off from the trunk to nearly a
right angle with the body, while  the surgeon places himself in such a position
as will give him perfect freedom in his movements.  Then, holding the large
amputating-knife firmly in the right hand, let him grasp the upper  part of
the patient's  arm with his left  hand, the lower portion being supported by
an assistant, and, stooping down, carry the  knife so far round the arm that
he can commence the incision well on the top of  it, the point of the knife
presenting to his own shoulder.   On applying the blade to the skin,  let him
now divide it by one steady circular  sweep, by bringing his elbow to his side,
and turning the knife-handle in his hand, as he sweeps around the limb, so as
to cause the heel of the blade to terminate the  incision.  The looseness of
the attachment of the skin to the fascia permitting considerable motion, it is
only necessary for the assistant to retract it with his  hands, Plate LXXII.
Fig. 9, while the surgeon again, by one sweep and with firm pressure on  the
knife, divides all the tissues down to the bone.   The double-tailed retractor
being now applied, the bone should  be  carefully sawed off, any spiculae that
remain excised by the bone-nippers,  the main artery picked out and tied, and
then the tourniquet loosened, or the  compression lessened so as to show  the
smaller vessels.
   The hemorrhage being thus carefully arrested, the  ligatures should be so
arranged that they may be brought out of the angles  of  the wound, the two
sides of which should then be closed and  united by one or two sutures, and
the stump—Plate LXXII. Fig. 10—dressed  with the cold or tepid water-
dressing, according to the season.
   Should the inflammation of the part, or the effects  of disease, have led to
thickening and adhesions of the skin to the fascia,  the  former may be turned
back, like the cuff of a coat, before the division of the  muscles, as in  the cir-
cular amputation of the leg.
   The Flap Operation in the arm is the same in principle as that spoken of
in connection with amputation of  the thigh, and is also  shown in Plate
LXXII. Fig. 8.
                                Fig. 453.
Lines for Teale's operation on the Arm. (After Teale.)
  Teale's Operation.—In operating for the arm, Teale marks out the lines
shown in Fig. 453, taking care that the inner line of the  long anterior flap 
PLATE  LXXIII.
                 AMPUTATION AT THE ELBOW-JOINT.

  Fig. 1. A  front view of the Articulating Surfaces of the Bones composing
the Elbow-Joint.  1.  The humerus.   2. The radius.   3. The ulna.
                                              After Bernard and Huette.

  Fig. 2. A  side view of the Elbow-Joint.  1. The humerus.   2.  Head of the
radius.  3. The ulna.                           After Bernard and Huette.

  Fig. 3. A  front view of the Elbow-Joint.  1. The humerus.   2. The radius.
3.  The ulna.  4. The external  condyle.  5. The internal condyle.  6. Articu-
lating surface of the radius.  7. Articulating surface of the ulna.
                                              After Bernard and Huette.

  Fig. 4. Amputation at the Elbow-Joint by the Flap Operation.  1, 2, 3. The
shape of the anterior flap.                      After Bernard and Huette.

  Fig. 5. Continuation of the same Operation.  1,2,  3. The anterior flap turned
upward.  4. The knife in the act of completing the  division of  the anterior lig-
ament of the joint.   5,  6, 7.  Shape  of the surface from which the flap has been
cut.                                           After Bernard and Huette.

  Fig. 6. Velpeau's Circular Operation  at the  Elbow-Joint.   1, 2. Fold of
integuments turned up, showing the knife dividing the capsular ligament.
                                              After Bernard and Huette.
  Fig. 7. The Wound left by the preceding Operation.  1. The epitrochlea of
the humerus.  A ligature has been placed on the brachial artery.
                                              After Bernard and Huette.

   Fig. 8. Circular Amputation of the Forearm.   1. Hand of assistant retract-
ing the soft  parts.  2. The flap of skin turned back.  The hand of the surgeon
holding the knife firmly in  its  grasp, with the point inclined to the  surgeon's
shoulder, so as to sweep entirely around the arm, is  also shown.
                                              After Bernard and Huette.
   Fig. 9. Showing the  Bones of the  Forearm in the same Operation.  A re-
tractor has been passed through the interosseous space and arouud the bones,
so as to protect the soft parts from the action of  the saw.
                                               After Bernard and Huette.
   Fig. 10.   The Appearance of the Wound after a  Circular Amputation of the
Thigh.  1.  The femur.  2, 2. The arteries.         After Bernard and Huette.
(688) 
Plate 73.
Fi£. 7
 
 
AMPUTATION AT THE ELBOW-JOINT.              689
should fall as near as possible to the brachial artery without including it in
thf?8'3'   ^fter sawin£ off the bone and arresting the hemorrhage, bring
    flaps together and unite them by metallic sutures as shown in Fig. 454.
Fig. 454.
Stump formed by Teale's operation on the Arm, showing the points for the sutures. (After Teale.)
  Remarks—The results of amputations of the arm are among the most
favorable of those presented in connection with amputations, death being a
rare exception in  the success attendant on this operation.   Teale's operation
forms a good stump, but Alanson's  is a better operation where  it can be
done.

                           SECTION III.
                   AMPUTATION AT THE  ELBOW-JOINT.

   Amputation at the Elbow-Joint, like amputation  at the knee, has  long
been considered by surgeons as an objectionable operation, from the fact that
the condyles and epitrochlea of the humerus, owing to their prominence and
irregular form, were thought  to be badly adapted for sustaining pressure,
while the continued secretion of synovia it was supposed would be likely to
keep the wound open some time. Although these objections are by no means
accurately proved in relation to amputations through  the articulations gen-
erally, yet, as there is nothing gained in a disarticulation of the elbow over
an amputation immediately above  the joint, the operation has not been fre-
quently performed.   Originally suggested  by Ambrose Pare, in 1580, it has
been repeated by several European and American surgeons, among the latter
of whom were James Mann, of Connecticut, iu 1812,  and  Kearny Rodgers,
of New York, in 1827.  Mann, in bis operation, created  double flaps, and
Rodgers autero-posterior flaps.   The circular operation has also been per-
formed by Velpeau, of France, and the oval method by Textor, of Germany.
   I am satisfied, from a careful examination of American surgical works and
journals, that, with the exception of the cases above mentioned, this amputa-
tion has seldom been repeated in  the United  States;  and in furnishing an
account of the methods by which it may be accomplished, I desire rather to
complete the  enumeration of surgical operations than to be regarded as re-
commending this one.   Velpeau's  operation  was performed as follows:—
   Velpeau's Operation.—The hand being strongly supinated, and the fore-
arm slightly flexed, a circular cut  is to be made through the integuments
about three  fingers' width below the bend of the elbow; then, dissecting up
    vol. n.—44 
PLATE  LXXIV.
                     AMPUTATION OF THE HAND.

  Fig. 1. A view of the Anatomical Relations of the Bones of the Wrist. 1. The
lower extremity of the radius.  2.  The ulna. 3. The first row  of the carpal
bones.  4. The second row.  5. The bones of the metacarpus.
                                               After Bernard and Huette.

  Fig. 2. Circular Amputation at  the Wrist-Joint.   1.  The radius.  2. The
ulna.  3, 3. The flap of skin reverted.  4. The catlin dividing the front of the
joint.                                           After Bernard and Huette.

  Fig. 3. Denonvillier's Operation at the  Wrist.  1. The radius.  2. The ulna.
3. The semicircular incision on the back of  the wrist.  4. The knife about to
cut a  flap from the palm of the hand.              After Bernard and Huette.

  Fig. 4. The Stump after the preceding Operation.    "       "       "

  Fig. 5. Maingault's Operation for Amputation of all  the Metacarpal Bones,
except that of the Thumb.  1, 2, 3. The anterior flap. 4. The knife,  which, having
transfixed the palm, is about to cut the flap.       After Bernard and Huette.

  Fig. 6. Completion of the same  Operation.  1,  2, 3. The posterior section.
4. The knife incising the joint.                   After Bernard and Huette.

  Fig. 7. Disarticulation of the Thumb.   1, 2, 3. Line of the incision so as to
form an oval wound.                            After Bernard and Huette.

  Fig. 8. The Thumb, being carried across the Palm of the Joint, is opened on
its External Side.  1.  The head of  the metacarpal  bone.  2.  The bistoury.
                                               After Bernard and Huette.

  Fig. 9. Union of the Wound, showing the Line of the Cicatrix and the Ap-
pearance of the Hand after the Amputation.      After Bernard and Huette.
        (690) 
- Plate 74
 
 
AMPUTATION OF THE FOREARM.                691
and  reverting this flap, Plate LXXIII. Fig. 6, cut through the muscles at
one  sweep, divide the lateral ligaments, open the joint in front, and then
divide the triceps tendon above the olecranon process.   The main trunk of
the brachial is the principal artery to  be tied, after which the wound can be
readily closed by uniting the skin transversely.
  Flap Operation.—The circular amputation of this joint is by no means
the  best method of forming a stump.   As the  muscles of the forearm are
chiefly developed in front of the elbow-joint, I should prefer the flap opera-
tion by the following plan :—
   Operation.—Place the forearm  in a semiflexed position, and, grasping the
muscles of the forearm in the left hand, raise them, and pass an eight-inch
catlin through, so as to shave the bones immediately in  front of the coro-
noid process, and cut an  oval flap about four inches long;  then passing the
catlin rapidly round the back of the elbow, just on a line with the upper edge
of the olecranon process, connect this  incision with the  point of entrance
and  exit of the  catlin.  On dividing the back of the capsule and the tendon
of the triceps, cut the internal and external lateral ligaments, and, reverting
the front flap, divide the  front of  the capsule of the joint, remove the limb,
and  unite the flap on the  back of the arm, above the line of the condyles, by
the interrupted suture.
  Remarks.—I have often amputated  in  this  way upon the subject, and
obtained a good covering for the end of the humerus, though  I know of no
case in this country in which the operation  has been thus performed on the
patient.
                            SECTION IV.

                     AMPUTATION OP THE  FOREARM.

   In Amputation of the Forearm, every effort should be made to preserve
 as great au amount of the member as possible, in order to facilitate its sub-
 sequent usefulness, whether the  patient contemplates using an artificial limb,
 or merely a hook.
   This amputation may be best accomplished by the ordinary circular method,
 as directed in the amputation of the arm, Plate LXXIII. Fig. 8, a retractor of
 two tails being prepared, in order to protect the parts more effectually; one
 tail being passed through the interosseous space, Plate LXXIII. Fig. 9.
  The flap operation is also applicable to this member, but does not form  so
 good a stump when the  amputation is required  at the lower third of the
 arm.   At its upper third  it may be performed by forming a flap anteriorly
 and  posteriorly  out of the thickness of the  flexor and extensor  muscles.
 The  circular  operation   at  the wrist-joint  forms  a  good  stump, Plate
 LXXIV. Fig. 2, and should be performed in preference to the amputation
 at the upper third of the forearm whenever  the injury is  confined  to the
 hand.
  Remarks.—Whatever method is selected for the performance of the am-
 putation of the  soft parts iu the forearm, it is necessary to avoid sawing the
 bones, except when they are perfectly parallel.  If the  hand is either pro-
 nated or supinated while the saw is employed, one bone or the other will be
liable to protrude through the stump, create  ulceration,  or lead to a conical
stump.  In this, as in all other  amputations of the  upper extremtieis, it is
important to leave the stump as long as possible, as every inch of the upper
extremity is valuable. 
PLATE
LXXV.
                    AMPUTATION OF THE FINGERS.

   Fig. 1. Amputation of all the Fingers at once.  1, 2, 3. The semicircular line
 of incision over the metacarpo-phalangeal articulations.  4. The catlin about to
 form flaps from the palmar surfaces of the four fingers.
                                               After Bernard and Huette.

   Fig. 2. The Stump after the preceding Operation.  1,  2, 3. The palmar flap.
                                               After Bernard and Huette.

   Fig. 3. A Circular Amputation through the Metacarpal Bones. 1,1. Retract-
 ors passed between each bone.   2. The saw in the act of dividing them.
                                               After Bernard and Huette.

   Fig. 4. Disarticulation of the Metacarpal Bone of the Little Finger by the
 Oval Method.  1, 2, 3.  The line of the incision.    After Bernard and Huette.

   Fig. 5. Amputation through the Fifth Metacarpal Bone.  The bone has been
 sawed through obliquely, while a compress protects the soft parts.
                                               After Bernard and Huette.

   Fig. 6. Appearance of the Cicatrix after the Operation of Fig. 4.
                                               After Bernard and Huette.

   Fig. 7. Disarticulation of a Finger by the Oval and Flap Operations.  Little
finger, 1, 2, 3. Wound left by the oval  method.  Middle  finger, 1, 2, 3. Wound
 left by the flap operation.                        After Bernard and Huette.

   Fig. 8. The Anatomical  Relations of the Palmar Surface of the Phalanges  of
 a Finger. 1. The metacarpal bone. 2. The first phalanx.  3.  Its lower extremity.
 4. Second phalanx.  5.  The third phalanx.        After Bernard and Huette.

   Fig. 9. Relations of the Flexor Tendons to the Bones.   1, 1, 1. The three
 phalanges. 2. Tendon of the flexor sublimis. 3. Tendon of the flexor profundus.
                                               After Bernard and Huette.

   Fig. 10. A side view of the Relations of the Bones of a Finger, when flexed,
 as in Amputation at the Joints.                  After Bernard and Huette.

   Fig. 11. Lisfranc's Amputation of the Phalanx of a Finger at  the Joint,
 showing the position of the finger and the knife in the first incision.
                                               After Bernard and Huette.

   Fig. 12. The same Operation.  A flap is about to be formed from the palmar
 surface of the finger.                             After Bernard and Huette.

  Fig. 13. Palmar view of Lisfranc's Operation, when it is commenced  on the
 Front of the Finger.  1, 2, 3. The flap.           After Bernard and Huette.

   Fig. 14. The flap turned up to show  the Disarticulation.   "           "

   Figs. 15,16, 17. Different Stumps resulting from the  flap, oval, and circular
 operations.                                     After Bernard and Huette.
       (692) 
 
 
AMPUTATION AT THE  HIP-JOINT.
693
                            SECTION V.

                     AMPUTATION OF THE  FINGERS.

  Amputation of the various Phalanges may be accomplished either by the
flap, oval, or circular methods, and is sufficiently explained in Plate LXXV.
  The flap method, by the plan of Lisfranc, Plate LXXV. Figs. 11, 12, is
generally the best for an  amputation at the  different articulations of the
phalanges with  each other;  the circular  is best adapted to  the operation
through the body of each phalanx; and the oval  to the removal of the finger
at the metacarpo-phalangeal  articulation, as  shown in Plate LXXV. Fig. 7.
As  the plate exhibits these operations very clearly, a detailed description is
here unnecessary.
                        CHAPTER  VIII.

             AMPUTATIONS  OF  THE  LOWER  EXTREMITY.

  Amputation of the Lower Extremity requires the observance of nearly
the same general rules as have been detailed under the head of amputations
in general.  The necessity for the preservation of as great a length of limb
as possible is also absolute in  this  extremity, except when the amputation is
to be performed on the leg, and the patient anticipates wearing the common
wooden leg or peg.   Under  these circumstances, the lirab should not be
taken off at more than four fingers' breadth from the tubercle of the tibia, as
a greater length of stump would incommode the patient, in consequence of
its protruding behind the perpendicular line of the opposite limb in walking.
  Amputation of the lower extremity may be performed either at its different
articulations or in the continuity of the bones.


                            SECTION I.

                    AMPUTATION  AT THE HIP-JOINT.

  Amputation of the Thigh  in its contiguity, or by disarticulating the head
of the bone, has occasionally been practiced; but, as it generally leaves a
large suppurating surface, and a stump upon which it is exceedingly difficult
to apply an  artificial limb, it  should  not  be resorted to if it is possible to
remove the disease by an amputation high up through the  shaft of the bone,
and without disarticulating it.
  This amputation was first suggested by the elder Moraud, and brought to
the notice of the French Academy of Surgery in  1739, though not performed
until 1748, when La Croix operated at the Hotel-Dieu of Orleans, in France,
in a case of gangrene which had severed the limb, with the exception of the
round ligament of the femur.*
* Chelius, by South. 
694           PRINCIPLES  AND  PRACTICE OF SURGERY.
   In the United  States, it was first performed  by Brashear, of Kentucky,
—since of New Orleans—in 1806,* and by Mott, of New York, in October,
1824,f by disarticulating the bone after ligating the femoral artery.  It has
since been performed by Brainard, of Chicago,%  in  1837 ;  by Buel, of  New
York, in 1847 ; by Lente, of  New York, in 1849;  by Van Buren, of  New
York,§ in 1850, in a case in which the shaft of the femur had been previously
amputated;  by May, of  Washington;||  by Richards and Clagget, of Mary-
land,^ in 1851; by Bradbury** and Fuller, both of Connecticut, in 1851;
and  by Clark,  of  Detroit,tf  in 1853;  Buchanan, of Nashville, and  many
others.   Of these  13 cases, 9 were cured  and 4  died;  8 of the cases  were
flap  operations, 1 circular, and 4 not described.
   Of the various methods of operating, the  flap  and oval are the best; the
circular being objectionable on various  grounds.   When the flap operation
can  be attempted, the method  by the formation  of one  flap,  as  shown in
Plate  LXXVI. Figs.  2, 3,  will  prove  the best.  In  either case, how-
ever, it is essential that the anatomical  relations of  the articulations should
be kept distinctly in view by the operator.   Although these are figured in
Plate  LXXVI. Fig. 1, in connection with  the  bones, yet the necessity of
accurately establishing the position  of the head of the femur before the  flaps
are formed, is so important that the  following measurements, as furnished by
Lisfranc, may well be carefully studied.   Having tested them a great num-
ber of times, I  can bear  my testimony to the correctness of this, as well as
the other excellent data furnished by this well-known surgeon.
                \ 1.—Surgical Anatomy of the Hip-Joint.

  The following  indications of the position  of  the  hip-joint having been
furnished by Lisfranc, J! and repeatedly tested by others, may be relied on as
accurate:—
  " 1st. Let fall from the anterior superior  spinous process of the ilium a
perpendicular line one inch  and five lines long, and you will  find the exter-
nal and anterior face of the joint half an inch inside of its extremity.
  " 2d. Let fall  from the anterior inferior spinous  process of the ilium a
perpendicular line half an inch long, and its extremity will correspond to the
upper part of the joint.
  " 3d. Draw a line transversely outward  for two inches  from  the  spinous
process of the  pubis, and drop a  perpendicular  line a quarter of an  inch
long from its extremity, and it will fall directly on the joint."
                   \ 2.—Amputation  at the Hip-Joint.

  The following cases will illustrate the methods of amputating that may be
pursued at this articulation :—
  Lalouette's Operation.§§—The patient lying on the sound side, make a
 * Trans. Am. Med. Association, vol. iv. p. 269, 1851.
 t Phil. Journ. Med. and Phys. Sciences, vol. xiv. or v. N. S. p. 107, 1837.
 X Am. Journ. Med. Sciences, vol. xxii p. 37, 1838.
 \ Trans, of New York Academy of Medicine, vol. i. p. 123.
 || Am. Journ. of Med. Science*, vol. xxii. N. S. p. 313.
 \ Trans. Am. Med. Association, vol. iv. p. 270.
** Boston Med. and Surg. Journal, vol. xlvi.  p. 349.
ft Peninsular Journ. Med., vol. i. p. 59, 1853.
XX Malgaigne's Op. Surg. Philad. edit. p. 264.         \\ Ibid., p. 266. 
AMPUTATION  AT THE HIP-JOINT.
695
semicircular incision from the upper and external part of the great trochan-
ter to the tuberosity of the ischium, so as to divide all the soft parts down
to the joint.   On recognizing the articulation, direct the  assistant to rotate
the limb inward, so as to cause the external surface of the capsular ligament
to be put upon the stretch, and then  with  a strong bistoury or the  knife
divide the  posterior and  external face of the capsule, as well as the round
ligament; flex the thigh strongly on the abdomen, so as to disarticulate the
head of the bone, traverse  the front of the joint with the knife, and,  passing
along the internal side of the thigh, cut a flap on its inner side, four or five
inches long, Plate LXXVI. Fig. 3, the artery being compressed in the  flap,
or upon the bones of the pelvis by the hand of an assistant.   After checking
the  hemorrhage, bring the flaps together, and let the ligatures  come out
below, unite  the skin  by a stitch or two, and then  apply adhesive strips, a
compress and firm bandage, in order to facilitate  the union of the  deeper-
seated parts.
  Operation of Van Buren, of New York.*—Having amputated the thigh
two years previously, near its middle, in consequence of the formation  of a
" true osteo-cartilaginous exostosis," and the disease having subsequently
returned, Van Buren advised amputation  at the  hip-joint, to  which the
patient consented.
  Operation.—The  patient, being  in a perfect state of anaesthesia through
the influence of chloroform,  was  placed upon the  table, with the buttocks
projecting over the  edge,  the diseased limb held by an assistant previously
instructed as to its management, and the other limb and scrotum  being  held
out of the way, the artery was firmly compressed against the pubes.
  The surgeon, having now placed himself on the outer  side of the limb,
seizes it near its middle with bis left hand, with the long ten-inch catlin in
his right hand transfixes the  hip by entering the knife about one inch above
the great trochanter, grazing the head and neck of the femur, if possible, as
it passes in front of it, and then  pushes its point  through the integuments
near the  anus, at a point diametrically opposite to its point of entrance, so
as to cut an anterior flap at least six inches long.  The first assistant should
now pass one hand into the wound behind the knife, and grasp the flap, and
with it the artery, carrying the flap  forcibly upward with both  hands over
the groin,  Plate LXXVI. Fig.  7.  The surgeon, then  kneeling a little,
should carry the knife to the inner side of the thigh, taking care not to injure
the neighboring parts  with  its  point, as it  is carried round, and,  placing
the heel of the knife on the integuments at the internal angle of the  wound,
Plate LXXVI  Fig. 7, carry it across the tissues on the back of the thigh,
down to  the bone, so as to join the opposite angle of the anterior incision.
The catlin being now laid down, the femur should  be forcibly abducted,  and
the capsule of  the joint opened by a strong  and  large scalpel, as near as
possible to the acetabulum;  the round ligament and the rotator muscle near
the trochanter divided, and the limb removed.   A  large compress or folded
towel being then immediately applied to the surface of the posterior flap by
the assi taut who lays down the amputated  limb, the arteries are to be se-
cured in detail, the  gluteal and  ischiatic being tied before the femoral  and
profunda if the latter are well controlled in the anterior flap.  The  wound
is then closed, as before directed.
  Operation of May, of Washington.f—The patient, being in  a state of
complete anaesthesia from  chloric ether, was  laid on a narrow table, so  that
the nates projected well over its edge, when the artery was compressed upon
* Trans. New York Academy of Medicine, p. 135.
f Am. Journ. of Med. Sciences, vol. xxii. N. S. p. 315. 
PLATE   LXXVI.
                   AMPUTATION  AT THE  HIP-JOINT.

  Fig. 1. Anatomical Relations of the Bones forming the Joint, together with
the Position of the Artery.   1. The iliac fossa.   2. The shaft of the femur.
3. Position of its head in the joint. 4. The external iliac artery.  5, 6. Anterior,
superior, and inferior spinous processes.  7.  Trochanter minor of the femur.
8. The ischium.  9.  The pubis.                   After Bernard and Huette.

  Fig. 2. Amputation at the Hip-Joint by the Flap Operation.  1, 2, 3. The
anterior flap.  4. The long catlin about to cut the anterior flap.
                                               After Bernard and Huette.

  Fig. 3. Amputation aA the Hip-Joint by Lateral or External and  Internal
Flaps.  1. The long catbn transfixing the limb  directly behind the head and
neck of the  femur.  2, 3, 4. The line of the external flap.  2, 5, 6.  The line of
the internal  flap.                                After Bernard and Huette.

  Fig. 4. Continuation of this Operation, when it only remains to disarticulate
the Bone.   1, 2, 3.  The  external flap.  4. The  internal flap.  5.  The femur.
The position of the vessels is shown by the ligatures.
                                                After Bernard and Huette.

  Fig. 5. Continuation of the Flap Operation, as shown in Fig. 2.   1. Hand of
an assistant raising the anterior flap.  2.  The head of the femur disarticulated.
3, 4. The arteries as tied.  5. A compress protecting the scrotum and opposite
thigh.  6. The long catlin, which, after dividing the capsular ligament, is about
to shave the posterior flap from the bone.          After Bernard and Huette.

  Fig. 6.  Appearance of the Wound left in the  preceding Operation.  1, 2, 3.
Line of the  anterior flap, as  reverted upward in order to show  the position of
the vessels,  as well as  the acetabulum.   1, 3, 4. The posterior flap.   5. The
acetabulum.                                    After Bernard and Huette.

   Fig. 7. Van Buren's Operation for Amputation  at  the  Hip-Joint by the
formation of an Anterior Flap in front and a Circular Incision behind, so as to
diminish the time  required in the  formation of two flaps by the withdrawal of
the catlin.   1. The right hand of the surgeon.  2. The position of the catlin in the
posterior or circular incision.  3. The left hand of the  surgeon abducting the
thigh, so as to disarticulate the bone.  4.  Hands  of the first assistant  holding
up the anterior flap, and compressing the artery in it.  5. Hands of the second
assistant.                                                After  Van Buren.
        (696) 
Plate  76
 
 
AMPUTATION  AT THE HIP-JOINT.
697
the pubis by the thumb of an assistant.  The limb being then slightly raised
and  flexed upon the pelvis so as to  relax the muscles on the anterior and
upper part  of the thigh, the testicles were  drawn out of the way, and  the
sound limb  separated as far as possible.  The long catlin (ten inches) being
then introduced a little above the tuberosity of the ischium, was carried as near
as possible to the neck of the femur and brought out one inch and a half below
the anterior superior spinous process of the ilium, so as to cut a flap down-
ward from the front of the thigh by shaving it from the  bone, the femoral
vessels not being divided until the lower edge of the flap was  being cut, when
they were grasped in the flap above the knife by the hand of an assistant.
This flap being now raised  and drawn forcibly upward, the femoral artery
was  still so  securely held that scarcely a drop of blood escaped from it.  The
thigh being then abducted  and forcibly depressed by the assistant, the head
of the femur was thrown forward, and as much out of the acetabulum as pos-
sible, when the capsular ligament was freely divided,  and the round ligament
and  the  head  of the femur  being thrown out of the acetabulum, the knife
was  passed behind it, and a posterior flap cut a little longer than  the ante-
rior  one.  As soon as the limb was removed, the vessels in the posterior flap
were compressed  by sponges until  they were separately ligated, when  the
femoral, profunda, and other branches in  the anterior  flap were secured,
twelve arteries in all requiring the ligature.   The flaps being then united by
four points of the twisted suture, owing  to their great weight,  adhesive
strips covered by the water-dressing  were applied to  the wound.   Not more
than eight ounces  of blood were lost, and the operation only occupied about
thirty seconds, the patient being entirely unconscious  until placed in bed.
   As illustrative of the suppuration in this extensive amputation, May esti-
mates  the discharge in twenty-four  hours  as equal  to half a pint, yet  the
patient was able to move about in five weeks after the operation.   The diet
throughout was  good: thus, the next day after the operation, he took a little
beef-steak for  dinner, with coffee, and tea and toast for breakfast and supper;
on the second day, stewed oysters; third  day, chicken-soup and  chicken;
fourth day, half  a  pint of oysters; fifth day, roasted chicken  and potatoes;
Bixth day, half a pint of stewed  oysters  and potatoes; eighth day, brown-
stout; ninth day, beef-steaks, etc.  At the same time he took iron and opiates.
   Remarks.—This operation is a slight modification of Beclard's, the catlin
being introduced from the tuberosity of the ischium  and brought  out near
the anterior superior spinous process instead of the reverse, and in some
cases may prove more  convenient.  It is important in an amputation like
that of the hip-joint, where a very free suppuration is to be anticipated, that
it should be remembered that the diet and  treatment are to be of the most
invigorating kind, unless fever or violent inflammatory symptoms supervene.
  Various modifications of the  amputation at the hip-joint  have been from
time to time suggested, among which is that of Ashmead, of Philadelphia,
in which flaps were formed by cutting from  the surface  inward, and then
disarticulating the bones.   But I prefer the method of Lalouette to all of
thera, when  circumstances perrait it,  as the  hemorrhage can be more readily
and coolly arrested by tying the vessels in the outer incision  before dividing
those in the flap  formed on the inside of the  limb.   The surface of the flap
is also well adapted to closing up the acetabulum and covering the surround-
ing bony structures.  But  when this plan  is not available, I would select
the lateral flaps  either by Beclard's method, or by that of May.  In a case
reported by Buchanan, of Nashville, the patient returned to his home on the
twenty-ninth day.*

         * Amputation of Hip-Joint, by  A. H. Buchanan.   Nashville, 1859. 
                       PLATE  LXXVII.

                    AMPUTATIONS OF THE THIGH.

  Fig 1. The Circular Operation.  1. The knife dividing the  muscles.  2. The
hand of an assistant  favoring their retraction, and holding back  the  skin.  3.
The hand of another assistant compressing the femoral artery when the tourni-
quet is not employed.  4. The circular incision in the integuments.  The per-
spective of this line is slightly misrepresented in the drawing.
                                               After Bernard and Huette.

  Fig. 2. Amputation of the Thigh  by the Double Flap  Operation of Sedillot.
1.  The tourniquet applied on the artery.   2.  The long catlin  about to form the
second flap.   3. Hand of the surgeon grasping the soft parts,  and drawing them
off from the bone.  4. First or exterior flap, as cut from the centre of the thigh
outward.  5, 6. The line of incision for the inner flap.
                                               After Bernard and Huette.

   Fig. 3. Sawiug the Bone  in the Circular Operation.  1. A  retractor protect-
ing and retracting  the soft parts.  2. The large amputating saw.
                                               After Bernard and Huette.

   Fig. 4. Amputation through the Knee-Joint by the Flap Operation.  1, 2, 3.
The line of anterior incision.                     After Bernard and Huette.

   Fig. 5. Circular Amputation through the Knee-Joint.   1, 2, 3. The line of the
incision below the  joint.  4. The integuments turned back.   5. The knife open-
ing the joint in front.                           After Bernard and Huette.

   Fig. 6. Amputation by the Oval  Method.  1, 2, 3. The line of the incision
below the joint.  4. The flap reverted.  5. The knife disarticulating the bones.
                                               After Bernard and Huette.

   Fig. 7. Continuation of the Flap Operation as commenced  in Fig. 4.  1, 2, 3.
The line of incision  for the formation of the posterior flap. 4. The  front of
the condyles of femur.   5.  The catlin.  6. The hand of the surgeon holding the
tibia so as to favor the formation of  the flap.      After Bernard and Huette.
        (698) 
Fig. 2.
Hg.4.
Kg.3.
vMlllll \ s

Fig.5.

*   A.
Fig.
K4.7. 
 
AMPUTATION  OF THE THIGH.
699
              \ 3.—Statistics of Amputation at the Hip-Joint.

   In a valuable paper by Stephen Smith, of New York,* "On Amputation
at the Hip-Joint," we find some carefully elaborated statistics of the results
of this operation.
   From  this it appears that amputation at the hip-joint has been performed
in continental practice 35 times, of which 14 were successful and 21 fatal,
being a mortality of 60 per cent.   Four died in 24 hours, of which 2 were
in military surgery and amputations "of complaisance."
   In the United States this  amputation has  been performed 11 times, of
which  8  were successful and 3 fatal, being a  mortality of 27T3T per cent.   In
3 cases the operation was  performed by the lateral flaps,  1 successful and 2
fatal;  3  with the  antero-posterior  flaps, all  successful;  1  by the circular
method,  which was fatal;  and in 4  others the method is  not stated.   In 3
cases anaesthetics were employed, and in all  the operation  was successful.
   Summary.—The entire number of these cases of amputation is stated by
Smith to be as follows:—
                                   Cases.      Died.      Cured.      Mortality.
     Continental practice....................   53        33        20        62^4
     British practice..........................   34        20        14        56
     American practice......................   11         3         8        '^fi

  I am unable to say positively whether all the cases alluded to in the above
statistics include those collected by myself, and mentioned at the commence-
ment of this chapter;  but it is evident that I make 13  cases, of which 9 were
cured and 4 died, while the above table shows in the United States 11 cases
and 8 cures.  If these are added to those I have collected, it would make 24
operations in the United States, of which 17 were cured and 7 died.
                             SECTION  II.

                      AMPUTATION OP  THE THIGH.

   Amputation in the Continuity of the Thigh, or the division of the femur
through its shaft, may be required in any portion of its length, the selection
of the point for the amputation being generally regulated by circumstances.
As much of the thigh as is possible should, however, always be preserved in
order to facilitate the subsequent application either of an artificial limb or of
the wooden peg.  In the formation of the portion of the soft parts that is to
form the stump, any of the methods of amputating may be selected, though
the circular operation of Petit,  with reversion of the skin  and a circular
division of the muscles, or the  plan of Alanson, as hereafter  described, will
generally form better stumps than either the flap or oval method.
  As usually performed, this operation corresponds with those described in
connection with amputation of the humerus, the same kind of retractor—two
tails—and  the same dressings being, in most instances, requisite.  In a large
and muscular limb, the following operation may be made to form quite  as
good  a  stump, and be more quickly performed than the ordinary circular
method, as it does away with the necessity of dissecting up the "cuff" of the
skin.
* New York Journ. Med., vol. ix. p. 184.  1852. 
700
PRINCIPLES AND  PRACTICE OF  SURGERY.
                   \ 1-—Circular Operation of Alanson.

  Operation.—The limb to be amputated being carried off from its fellow, and
the artery compressed, the surgeon should place himself between  the patient's
limbs or upon the outer side of them, as he finds it most convenient, and then,
while the skin is strongly retracted by the hands of an assistant, divide it
circularly, by holding the knife as directed for amputation of the arm.  After
making this incision, touch with the point of the knife the loose attachments
of the  skin to the fascia, so as to favor its retraction by the assistant, Plate
LXXVI I. Fig. l,and again applying the knife with its edge directed obliquely
upward, at an angle of  13° to the  bone, divide the outer layer of the mus-
cles ; have them  also retracted by the  hand, and, with the blade of the knife
still inclined upward, cut through the  deep layer of the muscles  dividing the
few fibres adherent to the bone, a little higher up, by carrying the point of the
knife around them.  Then apply the retractor, and saw the bone close to the
muscles, when a conical hollow stump will be formed with  the  bone in the
apex of the cone.  Ligate the femoral and other arteries; see that the ischi-
atic nerve does not protrude; cut it short, if it does ; bring  the ligatures out
of the  lower side of the wound, and unite it longitudinally, or parallel with
the axis  of the limb,  by two  sutures and  adhesive  strips, applying subse-
quently the water-dressing.


                         \ 2.—Flap  Operation.

  The  Flap Operation may be performed  either by making an anterior or
posterior flap, or by an external and internal one, Plate LXXVII. Fig. 2.

                                Fig. 455.
Lino of incisions for Teale's amputation of the Thigh. (After Teale.)
The first is preferable, as it prevents the tendency of the end of the bone to
project at the anterior end of the angle formed by the union of the internal
and external flaps, which is very apt to ensue unless care is taken to support
the muscles and prevent their gravitating toward the back of the limb.  The
operation by the  external and internal flaps is shown in Plate LXXVII.
and the antero-posterior flaps may be formed as follows:— 
AMPUTATION OF THE  THIGH.                  701
  Teale's Operation.*—Assuming the circumference of the thigh to be six-
teen inches, trace two longitudinal lines on each side of the limb, eight inches
long, making the inner line to fall as near as possible to the femoral vessels,
without including them in the long flap, or anterior.  Join these two lines

                                Fig. 456.
The Flaps as formed in the Thigh by Teale's method. (After Teale.)
by a transverse line of eight inches, Fig. 455.   Then mark a short flap of two
inches from the upper end  of the long flap, cut through the integuments only
in the lateral lines of the long flap with the front of the catlin, and make the

                                Fig. 457.
 The Points of the Sutures, and the appearance of the Stump formed by Teale's amputation. (After Teale.)
transverse cut directly to the bone, shaving off all the structures from below
upward close to the bone.  Then, by one sweep of the knife down to the bone,
form the short flap, shaving this flap from the  bone to the  point where the
latter is  to be sawn through, Fig. 456.   Take up the arteries, and adjust the
flaps by placing the sutures, as shown in Fig.  457.   The stump should be
* Op. citat. 
702
PRINCIPLES AND  PRACTICE OF  SURGERY.
laid on a sheet of gutta-percha, a cradle placed over, and the stump not raised
from the sheet for five days, so as to insure union and prevent an accumula-
tion  of  pus.
  Operation of Vermale.—Seize the muscles on the front of the thigh with
the left hand, elevate them from the  bone,  and, transfixing them  with the
long catlin, cut a flap of proper length  by  passing  the  catlin  from within
outward, and frora above downward.  Then insert the point of the knife at
the same spot, working it around the bone; bring it out at the spot where it
appeared in the formation of the first flap;  and then, cutting the  posterior
flap,  divide the few fibres immediately  around the  bone,  apply the retractor,
draw back the flaps, saw the  bone, and  unite the flaps transversely.   Care
should be subsequently taken, in the cold water-dressing, to  make pressure
on the lower flap by the pillow, so as to guard against collections of pus.

               § 3.—Statistics of Amputation of the Thigh.

  In the tables reported*  by  Buel, of New  York, of the  amputations per-
formed  in the New York  Hospital, we find  that  in 34  cases 10 were fatal,
making the  mortality 2916 per cent.; 15 of those amputated at the thigh
were by double flap operations, of which 2 were fatal, or one-fifth of all the
fatal cases.
  In the statistics furnished by  Norris.f of the amputations in the  Pennsyl-
vania Hospital, from 1838 to  1840, we find four cases of the thigh, of which
all were cured, showing the difference  in the  results of a few and of a series
of operations, and indicating the little value that can be attached to  statistics
in these cases.  Except in a very few cases, the propriety of an amputation
will be decided by the anxiety of the patient  to prolong life, few being found
willing to die if the surgeon will admit there is a solitary chance of success
by performing the operation, and unfortunately the science of surgery is not
yet so firmly based as to render the result obtained from  auy calculation cer-
tainly correct.


                            SECTION III.

                   AMPUTATION AT THE KNEE-JOINT.

  Amputation at the Knee-Joint has been accomplished by all the methods
before mentioned, in connection with amputations generally, the stump being
differently formed by different surgeons.   Plate  LXXVII. exhibits several
of these methods very well.   Velpeau advises  the circular operation ; Hoin
one flap; Nathan Smith, of New Haven, two flaps; and Baudens, of France,
an oval  flap, all of which may  be made available under certain circumstances,
as where  the injury has  destroyed  portions of the  integuments.   Nathan
Smith, of Connecticut, being the first to perform this amputation in the United
States, succeeded in accomplishing this operation by an original and useful
method.
  Operation of Nathan Smith, of Conn. J—Mark two  points, one on the
outside  and the other on the inside of  the limb, the latter being half an inch
below the head of the tibia, and the other opposite to it.   Then draw a semi-
circular line from one point to the other over the anterior part of the leg, in
such a direction that its lower part shall touch the lower part of the tubercle
  * Am. Journ. Med. Sciences, vol. xvi. N. S. p. 33.
  f Ibid., vol. xxvi. p. 35, May, 1840.
  X New York Journ. Med., vol. ix. p. 313, on Amputation of Knee-Joint, by Willard
Parker, M.D., N. Y., from Am. Med. Review, vol. ii. p. 370. 
AMPUTATION  AT THE KNEE-JOINT.               703
of the tibia, and then mark another circle on the  posterior part of the leg
exactly corresponding to the former, so as to form two flaps, the anterior of
which will be formed  by the patella and its  ligament, and the  posterior by
the head of the gastrocnemius, tendons of the flexor muscles, and the popli-
teal blood-vessels and nerves.  In operating,  the anterior flap should be first
raised with the patella  by cutting through its ligament, which will expose
the front of the joint and render the division of the lateral ligaments easy;
after which two or three strokes of the knife will complete the section of the
crucial ligaments and the posterior flap.  This patient recovered with a good
limb, the stump being formed  at its lower part by the patella, which became
adherent to the femur.
  Operation of Parker, of New York.*—The patient being  placed on a
table of suitable height,  anaesthesia was induced by a mixture of chloroform
and ether; pressure made  upon the femoral artery in the groin  ; the integu-
ments of the thigh forcibly drawn upward from the knee, and the leg held in
a flexed position.  Then, an incision being made  upon the front of the leg,
about one inch below the insertion of the ligament of the patella, an anterior
flap was formed by dissecting up the  integuments as far as the upper portion
of the joint,  when the patella was  removed  from its attachments, and the
knife  passed through the  joint over the head of the tibia, the  flap being
completed by cutting it from the posterior part of the calf.  The integuments
being then brought together, were united by  sutures, and the stump dressed.
  Operation of Baudens,  of  Paris, f—The patient being laid  on the table,
as in the amputation of the leg, draw with a  pen a line, which, starting frora
the spine of the tibia, three fingers'  breadth  below its tubercle, shall ascend
obliquely backward, and from below upward, toward the  popliteal space, to
terminate two fingers' breadth below a line corresponding to the insertion
of  the ligament of the patella.  An  assistant now retracting the  skin as
much as  possible, cut with  a large scalpel, or small catlin, through the skin
in the line just described, and  reflect the integuments to the level of the knee-
joint ;  then, dividing the ligament of the patella, flex the leg, open the joint,
cut the crucial and lateral ligaments, and by one sweep cut through  the
structures behind the joint. After arresting the hemorrhage, force down the
patella and integuments, and  unite the latter on the  back of the thigh by  a
few stitches, dressing the stump with the water-dressing.


            \ 1.—Statistics of Amputation at  the Knee-Joint.

   In  the  paper by Parker, of New York,J  it is stated that amputation in
this joint, as performed  in  the United  States,  bears a flattering comparison
with  that  of any other  country, 12 operations having  been performed, of
which 7  were completely successful, being a mortality of one-fourth, or 25
per cent.;  2  required reamputation, 1 for gangrene  and  1 for a chronic dis-
ease.   In foreign  practice, there were 28 cases, 12 deaths, and 16 cured, or
a  mortality of 42| per  cent.   As  tabulated by Parker, the  results are as
follows:—
                                      Cases.    Cured.    Died.   Mortality.
    American practice...........................  12       9      3      25 per cent.
    Foreign    "    ...........................  28      16     12      42f  «
    Malgaigne's collection......................   9       2      7      77|  "
    Jager's        "    .......................  37      22     15      40   «

        Total.......................................  86      49     37      43

  * New York Journ. Med., vol.  ix. N. S. p. 308.    f Malgaigne, Philada. edition.
                X New York Journ. Med., vol.  ix. N. S. p. 308. 
704
PRINCIPLES AND  PRACTICE OF  SURGERY.
   Parker therefore concludes :—
   1st. That amputation at the knee-joint is a justifiable operation as respects
the nature of the structures engaged.
   2d. That it is a justifiable operation as respects the point of election.
   3d. That the  stump is well calculated to sustain pressure, and  also well
adapted to the adjustment of an artificial lirab.
   Remarks.—The  question of " the  propriety of  amputating through  the
joints,"  is  one which has engaged considerable attention at different periods,
and was for many years regarded as settled by the general  opinion  of sur-
geons that it was more dangerous to amputate through the joints than through
the shaft of a bone,  in consequence of the presence of the synovial membrane,
etc. giving rise to severe constitutional  disturbance.  In the first edition of
my Operative Surgery, I coincided  in these views, and discountenanced the
operation; but subsequent observation, and  an investigation of the more
recent accounts  of  the effects of inflammation on  articular cartilages, have
induced rae to believe that I was in  error, and  that  the opinion generally
advanced  on the subject is, perhaps, like ray own, somewhat the result of the
general tendency of many to " follow the leader," or  travel  in  the  beaten
path  rather than investigate for themselves.   A close examination of the
evidence for and against these  amputations in joints will show that  among
the ancients Celsus  condemned, but  Galen and Heliodorus advocated them;
while Sabatier,  Nathan Smith, of Connecticut,  Brasdor, Larrey, Velpeau,
Blandin, Textor, Fergusson, and Malgaigne,  among the  moderns, advocate
them, the  latter having been ably seconded by Baudens, of France, Parker, of
New York, and Pancoast, Agnew, and  others, of Philadelphia.  I am therefore
induced to regard this question as  unsettled, and  to incline to the opinion
that experience will yet demonstrate its propriety.   The idea which appears
to  have been  so very prevalent as to  the  effects  of inflammation  of  the
articular cartilages, synovial membrane, etc., is  certainly not sustained by
facts, and  seems to have been rather a theoretical than a practical objection.
In the case reported by  Pancoast, of  Philadelphia,* cicatrization was com-
pleted at  the end of the fourth week, and was unattended by a single bad
symptom.  As one  of the condyles also became exposed from the unavoid-
able shortness of the  flaps, the  changes in the articulation could be  readily
noted, and it was found that " the articular cartilages neither became  red-
dened nor painful, nor exhibited any coating of synovial membrane, or other
appearance of organization;  but by the end of a week became soft and pulpy
on  its free surface,  like a recent joint while  macerating for the  anatomist.
This pulpy layer was, however, insensibly removed  with the discharges, and
the articular face of the condyles being completely bared in the third week,
granulated and adhered to the  cutaneous  granulations.  No  appearance of
synovial inflammation of the bursa above the joint was  manifested  during
the treatment, and the patella continued movable on the upper anterior face
of the condyles."   As articular cartilages, when inflamed, pass through a
process  similar to the  degeneration of inflamed bones—that is, either soften
and liquefy or tend  to fatty degeneration—and  as they possess few or no
blood-vessels, there  is reason to think that, after  amputation through  the
knee-joint, this process  must be the  usual one,  and that the skin and soft
structures will therefore  readily adhere to the condyles of the femur, thus in-
suring the action of  the flexors and extensors of the leg, while, by transferring
their  action to the  end of the femur, they facilitate very materially the  sub-
sequent progression of the patient.  In  most  instances, where nature  throws
off a  part, in  the manner  formerly designated as ulceration, but now more
* Op. Surg., p. 170. 
AMPUTATION  OF THE LEG.
705
correctly spoken of as interstitial absorption and liquefaction, there is suf-
ficient lymph effused to serve as a limit to the action, and there is, therefore,
no good reason to think that the removal of the articular cartilages from the
condyles of the femur will predispose the latter to carious inflammation.   In
Pancoast's case the cure was prompt, being within thirty days, so that the
liquefying removal of  the cartilages  does not  necessarily lead to sinuses,
fistula, and the other tedious symptoms formerly charged as an objection to
articular amputations.  But, admitting that the healing of the stump should
be tedious, will not  the patient be the gainer  in the end by the increased
ability with which he can move the limb, to say nothing of the increased ease
and gracefulness of his progression ?  When the patella is left, and brought
down so as to fill up the trochlea and equalize the condyles, it gives a breadth
and roundness to  the stump,  which adapts it remarkably well for a point of
support, while the skin over  it is likewise well calculated to sustain pressure
without the development  of inflammation.  It also  secures to the patient
the usual flexion and extension of the thigh, and does away with  the compass-
like movement caused by the rotating muscles, which is so apparent in those
who  walk on the common  peg or wooden leg.   I therefore commend this
amputation to special consideration in all cases requiring amputation of the
leg above the tubercle of the  tibia, when the femur is  not diseased.
                            SECTION IV.

                        AMPUTATION OP THE LEG.

   Amputation of the Leg is to be  accomplished by any of the  preceding
 methods, care being taken to leave as long a stump as possible, if the patient
 is to wear an artificial limb, but to saw off the bone at about three fingers'
 breadth below the tubercle of the tibia, if he is to wear "the peg," as a long
 stump,  under these circumstances, would  be a constant source of incon-
 venience to the patient, from its projecting behind the body, when  the peg
 was applied.

                  I 1.—Circular Amputation of the Leg.

   The circular operation for amputation of the leg may be accomplished as
 follows:—
   Ordinary Operation.—The patient being placed on a table, or bedstead,
 with the injured  limb projecting over the side of the bed at least as far as
 the knee, let one assistant apply the tourniquet on the femoral  artery, as
 before directed, or compress it with the fingers while the anaesthetic  is being
 administered.   Let a second assistant now support the lower portion of the
 lirab, and a  third be ready to control the movements of the sound  limb, or
 let the foot of the sound limb be attached, by a  towel or bandage, to the bedi-
 post or table-leg.  Then, standing so that the left hand will grasp the upper
 portion of the leg, take the large amputating-knife firmly in the right hand,,
 kneel or stoop down, and,  passing the hand so far around the  limb that the
 point of the knife will be directed to the right shoulder, apply the heel of the
 knife to the skin, and, by a circular sweep, cut it around the leg; rising up
 and strongly flexing and  pronating the hand, in order to terminate the in-
cision at the spot where it commenced.  Then, laying down the knife, seize the
skin and dissect it up by long sweeps of a large  scalpel, until a portion can
be reverted all round the limb, to about the extent of one-sixth of its diam-
    vol. n.—45 
PLATE  LXXVIII.
                   AMPUTATIONS  OF THE LEG.
   Fig. 1. The Circular Amputation of the Leg, as usually performed below the
 Knee.  1, 2, 3. The line of the circular incision through the skin.   4. The cuff
 of the skin reverted.  5. The hand of the surgeon holding the knife in its proper
 position for commencing the circular sweep which divides the muscles.
                                                After Bernard and Huette.
   Fig. 2. Continuation of the same Operation.  1,2, 3. The line of incision in the
 skin.  4.  The retractor protecting the soft parts. 5. The large amputating saw
 applied so as to divide the fibula and tibia nearly at the same moment.
                                               After Bernard and Huette.
   Fig. 3. Appearance of the Wound left in this Operation.  1. The hand holding
 up the integuments.  2, 2, 2. The position of the blood-vessels in  the stump.  3.
 The section of the tibia.  4.  The section of the fibula.
                                                After Bernard and Huette.
   Fig. 4. Different Positions of the Catlin in  dividing the Muscles close to the
 Bones and  in the Interosseous Space.  1. The tibia.   2. The fibula.  3. The
 position of the catlin in clearing the superior and inner side of the fibula.  4. The
 same for the parts around the tibia.              After Bernard and Huette.

   Fig. 5. The same Operation, as performed on the Under Side of the  Leg.
 1, 2. Tibia and fibula.  3. The first position of the knife.
                                                After Bernard and Huette.
   Fig. 6. The Appearance of the Wound after Lenoir's Amputation of the Right
 Leg.  1, 2.  The lateral angles  of the flap.  3. The tibia.   4. The fibula.
                                               After Bernard and Huette.
   Fig. 7.  The changes made by Nature in the Femur after an Amputation.  1.
 The shaft.   2. The cut extremity as closed and rounded by nature.
                                               After Bourgery and Jacob.
   Fig. 8.  Changes in the Stump, as seen several months after an Amputation.
 1. Upper part of  the  stump.   2. Integuments on its end. 3. The  muscles cut
 across.   4. The artery.  5, 5. The veins.   6. The nerve.   7. A muscular branch
 of the artery.                                   After Bourgery and Jacob.

   Fig. 9.  Appearance of the Tibia after Amputation.  1.  Its head.  2. The por-
 tion  cut by the saw, and rounded off by nature.    After Bourgery and Jacob.

   Fig. 10. Application of a Boot to the  Stump formed  by amputating at the
 Ankle-Joint.  1.  The leg.  2.  A cushion.   3. A cork in the heel of the boot.
                                               After Bourgery and Jacob.
  Fig. 11. A Boot adapted to the Stump of the Foot, after Lisfranc's Operation.
1.  The leg.  2. A cushion.  3. A cork to fill up the toe of the boot.
       . ^                                    After Bourgery and Jacob. 

'■--
'%
<^JkA*/ _l-
Fig.10.
Kg. 2.

FiS.5.

Fig. 8.
F^. 9.
■V-.5
F^ 7
Fig. 11

■v- 
 
FLAP OPERATION ON THE LEG.                707
 I?*!'-    uer!,a.ga!n t,aklng  the lar£e knife> aPP]y [t as before to the muscles,
 withm a half inch of the reverted edge of the skin, and by one sweep, with a
 slight sawmg motion, cut all the muscles to the bone; perforate the interos-
 seous space with the catlin,  or the knife,  if not too large; pass in a three-
 tailed retractor and saw the bones  close to the retractor, taking care to
 divide the fibula  before the tibia  is entirely sawed  through.   Then, after
 tying the anterior and posterior tibial with the  peroneal  arteries, and any
 muscular branches that may bleed, bring the ligatures out at one corner, aud
 close the skin with three sutures, so that the cicatrix  may  be vertical; after
 which apply the water-dressing.
  Remarks—In  this  amputation, attention should be given to  the length
 ot the  stump  before  commencing  the  operation—a  long stump being
 requisite for the  attachment of an artificial leg, while  if  the stump  is to
 rest on the "peg," the  bone should be divided within three fingers' breadth
 or the tubercle of the tibia, for the reasons before assigned.  The  remarks in
relation to the advantages  of a stump formed by the circular operation over
one formed by the flap, as before  made, are  also  especially applicable to
amputation of the leg.
                     \ 2.—Flap Operation on the Leg.

  Teale's Operation.*—Supposing the circumference of the leg low down
to be nine inches, make a long anterior flap of four and a half inches, the
outer side being formed along the posterior  edge of the fibula, and the inner
line four and a  half inches from this, as shown  in  Fig. 458.   Then, after

                                Fig. 458.
forming this flap as before directed, cut the short flap one-fourth the length
of the long one.  In dissecting up the long flap cut freely, so as to include
all  the tissues in front of the tibia,  interosseous ligament, and fibula, cut-
ting close to the periosteum and interosseous ligament.  On reverting this
flap, make the transverse cut on the posterior surface of the leg so as to join
the two sides of the anterior flap, and dissect  back to the extent of two
* Op. citat. 
708           PRINCIPLES AND PRACTICE  OF SURGERY.

inches the short flap;  separating the short flap, cut close to the periosteum
as high as the point where it is desired to make the section of the bone.
Saw this through carefully, so as not to divide the tibia before the fibula is
entirely sawn through.   Then close the sutures, as shown in Fig. 45l>.

                               Fig. 459.
  Remarks.—Teale's operation has never seemed to me as well adapted to
the leg as to the thigh, arm, and forearm.
  Flap Operation of Verduin.—The artery being compressed on the thigh,
and the leg carried somewhat off  from its fellow, stand on the inner side of
the limb for the left leg, and on the outer for the right, unless  ambidexter;
then, feeling for the fibula, draw the muscles of the calf off from the  bones,
transfix them with an  eight-inch catlin, passed close to the bones, but not so
as to pass between the interosseous space, and cut a flap about three and a
half inches long.  Withdrawing the catlin, place it with its heel on the far
side of the limb, at the point where the catlin punctured the skin, and form
an anterior semicircular flap, by drawing it toward the opposite side  of the
limb, terminating the  incision at the internal point of puncture.   Perforate
the interosseous ligament with a small catlin, cut the fibres around the bones,
Plate LXXVIII. Figs. 4 and 5, apply the double retractor, saw the  bones,
and unite the flaps by one or two  sutures.


                           § 3—Oval  Method.

   Lenoir's Operation, which is figured in Plate LXXVIII.  Fig 6, forms  a
good stump, and is well calculated for the attachment of an artificial limb.
In this operation, a circular cut is made in the skin an inch and a half below
the point of amputation, and  a vertical  cut, two inches long, afterward made
in the skin on the spine of the tibia, commencing at the line where the  bone
is to be divided.  After this, revert the flaps, and make an oval incision around
the limb  on each side, so as to divide the muscles, and complete the  opera-
tion as before.   The vertical cut freeing the skin from pressure against the
tibia prevents, it is said, subsequent ulceration  from the contraction of the
tissues consequent on cicatrization of the stump. 
AMPUTATION  AT THE ANKLE-JOINT.
709
                             SECTION V.

                   AMPUTATION AT THE  ANKLE-JOINT.

  The importance of preserving as much as possible of the leg, in order that
the patient may not be compelled to obtain the support of  an artificial one,
has induced many surgeons, and especially Syme, of England, to revive the
amputation  formerly practiced  through  the  tibio-tarsal articulation when
the disorder or injury was  limited  to the foot.  The amputation may be
accomplished by either of the following methods :—
  Operation of Syme, of England.—Make a semilunar incision of the skin,
with its  couvexity toward  the toes, by carrying a short catlin around the
front of the ankle from one malleolus to the other, and dissect up the flap.
Then placing the foot at a  right angle to  the leg, form the  posterior flap by
drawing the knife through the skin from the centre of one  malleolus to the
other directly across the sole of the foot,  so that the  points of the  anterior
and posterior incisions may join and form  an angle of 45°.  On dividing the
front of the capsular ligament of the ankle, free the astragalus and dissect the
posterior flap off from  the  os calcis by working close  to the bone, so as to
preserve  as  much as possible of the posterior  tibial artery for the nourish-
ment of the  posterior flap.   Then, either  sawing off the projecting malleoli
or cutting them with the bone-nippers, arrest the hemorrhage and close the
flaps with sutures.  Apply  the  warm water-dressing uutil the vitality of the
flaps is certain.
  Operation of Velpeau.—Make  two semilunar incisions convex forward
through the skin, one over the instep and the other above the heel, twelve or
fifteen lines  in front of and  behind  the joint, and unite thera so as to form
another semilunar incision on each side about an inch  below the ends of the
malleoli.   On dissecting back the skin, divide as near the  joint as  possible
the extensor tendons of the toes, the peronei tendons, the tibialis anticus, the
flexors of the foot, the tendo-Achillis, and the external and  internal lateral
with the capsular ligaments.  Disarticulate the bones, and bring the antero-
posterior flaps  together,  so that the lateral flaps may  cover the ends of the
malleoli—these ends, according to  Brasdor, being rounded off by nature, and
not therefore requiring  to  be  excised.   If the astragalus can be left, as
advised by Ligneroles, it will improve the surface for  pressure.
  Operation of Pirogoff.—Pirogoff has  recently called  professional atten-
tion to a modification of the amputation at the tibio-tarsal articulation, which
is performed as follows:—
  Operation.—Make a perpendicular incision by a small catlin through all
the soft  parts,  commencing two lines in  front of the external and running
round  the sole of the foot to a similar point at the  internal malleolus, or
the reverse.   Then connect the end of this incision by a second cut in front
of the tibio-tarsal articulation, making it  slightly convex anteriorly, and,
opening the joint, divide the lateral ligaments, dislodge the astragalus, and
with a narrow saw  cut obliquely and frora above downward, through the os
calcis in a line directly posterior to the head of the astragalus.  The flaps being
now dissected from the tibia and fibula, saw off the malleoli, and bring the
posterior flap__heel and tendo-Achillis—forward so as to coaptate the cut sur-
face of the calcis with the cut surface of the tibia, and unite the flaps by sutures.
  Remarks.__Of all the amputations at the ankle-joint Pirogoff's is the best,
the posterior flap being less likely to slough than in Syme's operation; but as
it gives the  patient a comparatively small  point of support, it will  generally 
710           PRINCIPLES AND PRACTICE  OF SURGERY.

be better to amputate the leg above the ankle.  Pirrie and Watson, of Eng-
land, advise sawing through the os calcis from below upward ;  but in either
method it is important to make the section of the bone at such an angle as
will cause it to adapt itself to the flat end of  the tibia.   It will also prove
advantageous  to divide subsequently the tendo-Achillis, as in the operation
for Pes Equinus.   Various other  modifications of Pirogoff's method have
been made, but there is nothing in them specially worthy of notice.   The
advantages  of the  amputation at the ankle-joint, like those at the  knee-
joint, have  been  much  discussed,  and many  arguments advanced for and
against it.  Of four cases that have come under  my notice, three did well,
the patients being  able  to walk with a boot  similar to that shown in  Plate
LXXVIII. Fig.  10.   There is, however, as far  as  I  have seen, always
trouble in preventing the accumulation of pus beneath the posterior flap, in
Syme's operation, and  also a tendency to sloughing in the edges of  the
flaps, which sometimes  goes to a greater  extent.   Pirogoff's  operation,
though requiring  great care in the subsequent dressing to prevent suppura-
tion  in the sheaths of tendons, etc., is a better method, if it is necessary to
amputate  at the joint.   As the circular amputation immediately  above  the
joint furnishes a good stump for an artificial leg, the foot of which is less
unnatural in its appearance than the inflexible cork, which must be employed
to fill up the shoe that  is required  after amputation at the ankle-joint, and
as the  point of the heel does not afford a good basis of support, the patient
walking like a boy  on  stilts, I prefer amputation  of the leg low down, and
the adaptation of a good artificial limb.
  Borckel, of  Strasburg, in a  pamphlet entitled "Les Avantages et les  In-
convenients de l'Amputation de la Jambe au  lieu d'election comparee aux
Amputation sus Malleolaire et partiel du Pied," states that statistics prove
that the supra-malleolar amputation of the leg is more favorable in  its results
than that three or four inches below the knee; the mortality in the first case
being, according to Fenwick, 1 in  4£; in the second, 1 in 2|.   This he at-
tributes to the wound being smaller and farther from the body, and to  the
rare occurrence of pyemia and phlebitis.   There is also a better support for
artificial contrivances, if these are judiciously made.
  In tibio-tarsal  exarticulations, the average mortality is 1  in  7 2.   He
prefers the plantar flap of Syme to the dorsal of Bouden.
  The  patients operated on by exarticulation below the astragalus and  by
Pirogoff's operation are not sufficiently numerous  for a definite conclusion
as to their value.   Borckel reports seven  favorable cases of the former and
nine of the latter, of which one was fatal.
                            SECTION VI.

               AMPUTATION OP THE FOOT AT THE  TARSUS.

  In  order  to  save  as  much of the foot as might suffice to support  the
patient, amputation through the tarsal and metatarsal joints  has been sug-
gested, and often practiced.  Either of these amputations requires an accu-
rate knowledge of the relations of the articulating surfaces of the bones, and
should not be attempted without a recent examination of the part by those
not perfectly familiar with it.  In the hands of an anatomist, they constitute
two of the most valuable  and  scientific raethods of  amputating resorted to
in connection with the lower extremity, preserving a valuable  portion of the
foot, and one which adds greatly to steady progression.    To facilitate refer-
ence, the parts have been fully shown in Plates LXXIX. and LXXX., and 
AMPUTATION  OF THE FOOT AT THE TARSUS.          711
their anatomical relations may, therefore, be omitted here.  This amputation
may be performed at one of two points, either between the articulation of the
cuboid and scaphoid with the  os calcis  and astragalus, or at the metatarso-
tarsal articulation.   The  first is usually described as Chopart's, the second
as Lisfranc's or Hey's operation.
  Chopart's Operation.—After recognizing the position of the joint, grasp
the foot with the left hand, so that its palm may present to the sole of the
patient, placing the thumb upon the external extremity of the joint, and the
forefinger upon the internal.   The thumb in the right  foot would rest
against the  cuboid, and the forefinger on the scaphoid bones, while in the
left  foot it would be the reverse.   As this position indicates  the joint, the
thumb and finger should be held there until the skin is divided.
  Then, being sure of  the joint, carry  a small catlin across the top of the
foot, from the  thumb to  the  point of the forefinger, making a semicircular
incision slightly convex forward, which shall descend  about half an inch in
front of the articulation, and, directing the assistant to draw  up the skin,
divide  the extensor tendons and the dorsal ligaments, rendering the latter
tense by pressing the toes downward, Plate LXXIX.  Fig. 2.   Then divide
the lateral ligaments, and pass the knife through the articulation at such an
angle of inclination as will enable it to adapt itself to the surface of the bones,
after which the flap should be formed by shaving it off from the sole of the
foot, Plate LXXIX. Fig. 3.
  Lisfranc's or  Hey's  Operation. — Amputation at the  metatarso-tarsal
articulation was  suggested by  Hey, of England, who accomplished it  by
sawing off  the ends of the metatarsal bones;  and the amputation is, there-
fore, now often spoken  of as Hey's operation.  As  the section of the ends
of these metatarsal bones was frequently followed  by caries and subsequent
abscesses, it  has  generally been deemed best  to disarticulate  them,  as pro-
posed  by Lisfranc;  and as this is an important modification, the disarticu-
lation should be designated as the operation  of Lisfranc, and so described.
Various rules have been given to find the joint, but I have always found the
following one sufficient, i.e. to "draw a transverse line across the foot, from
the  superior extremity  of the fifth metatarsal  bone,  and it  will fall upon the
inside  of the foot, two-thirds of an inch behind (or above) the articulation."
  Operation.—After finding the position of the joint,  seize the foot, so that
the thumb, if in the right foot, shall rest on the tuberosity  of the fifth meta-
tarsal  bone, and  the index or second finger  half  an inch in advance of the
internal side of the joint at the cuneiforme internum, and retain them in this
position until the first incision is made, Plate  LXXIX. Fig. 9.  Then, with
a strong, short catlin, make a semicircular flap incision on the dorsum of the
foot, cutting from the thumb toward the finger, half an inch in front of the
articulation,  and, by a few touches of the point of the knife upon the adhe-
sions, facilitate its  retraction  by an  assistant.  Then, placing  the  heel of
the knife close to the end of the fifth metatarsal bone, divide the lateral and
dorsal  ligaments, and open the joint as far as the third metatarsal bone; and,
on  reaching this point, carry the  knife half an inch backward, or nearer to
the ankle, cut the dorsal ligaments, and expose the  second metatarsal bone.
Now, acting only with the point of the knife, and holding it perpendicularly,
Plate LXXIX. Fig. 10, insert its point between  the  bones on a  line with
either the first  or second metatarsal  spaces, or close to the side of the head
of the  second metatarsal bone, and rocking it backward and forward, cause
it to graze the lateral surface of the  first metatarsal bone; and then, by a
sawing motion, open the joint between it and the internal  cuneiform.  Do
the same thing on the outer side of the head of the bone, and, dividing the
interosseous  ligament, press upon  the metatarsus,  and complete the division 
PLATE  LXXIX.
                       AMPUTATIONS OF THE  FOOT.

   Fig. 1. A view of the Bones composing the Tarsal Articulation, as involved
 in Chopart's Operation. 1. The astragalus.   2. The os calcis.  3. The cuboid.
 4. The scaphoid.  5. Internal point of the joint, or tuberosity of the scaphoid
 bone.  6. External point of the articulation.  7.  Head of the fifth metatarsal
 bone.  8. The fibula.   9. The tibia.  10, 10. Two pins to show the direction of
 the  articulating surfaces or line in which the knife must be passed.
                                                After Bernard and Huette.

   Fig. 2. Position of the Hand of the Surgeon, and the Line of Incision in Cho-
 part's Operation.  1, 2, 3.  The line of incision.    After Bernard and Huette.

   Fig. 3. Continuation  of  the same Operation.   The joint being opened, the
 knife is about to  form  a flap from the  sole  of the foot.  1. The anterior tibial
 artery.  2. The knife.                            After Bernard and Huette.

   Fig. 4. Sedillot's Operation.  1, 2, 3.  The line of incision.
                                                After Bernard and Huette.

   Fig. 5. A side view of the Outer  Side of  the Bones of the  Tarsus, showing
 the  Oblique Direction of the Articulating Surfaces over which the Knife is to
 pass.  1. The  os  calcis.  2. The cuboid.  3. A pin in the joint.  4.  The joint
 between the astragalus and scaphoid, with a pin in it to show its inclination.
                                                After Bernard and Huette.

   Fig. 6. Side  view of the Inner Side of the same Bones.  1.  The astragalus.
 2. The scaphoid.  3, 4.  Pins in the joints.          After Bernard and Huette.

   Fig. 7. Dorsal view of the Bones of the entire  Foot.  1. The tibia.  2. The
 fibula.   3. Astragalus.  4. The os  calcis.  5. The  scaphoid.   6. The cuboid.  7.
 Internal cuneiform.  10,11, 12, 13, 14. The five bones of the metatarsus.  15.
 The  phalanges  of the toes.                        After Bernard and Huette.

   Fig. 8. Dorsal Articulating Ligaments of the Foot. 1,1. Anterior tibio-tarsal
 ligament.  2. The anterior  portion of the external  lateral  ligament.  3. The
 internal  calcaneo-scaphoid  ligament.  4. The external calcaneo-scaphoid.  5.
 The  astragalo-scaphoid.   6.  The calcaneocuboid.   7. The scaphoideo-cuneifbrm.
 8. The cuboideo-metatarsal.  9. The cuneiforme metatarsal ligaments.
                                                After Bernard and Huette.
   Fig. 9. Lisfranc's Operation  on the Right Foot.   1, 2, 3. The line of the  in-
 cision in the skin.  4. The  thumb of the surgeon  on the  extremity of the fifth
metatarsal bone.   5.  His forefinger on the metatarsal bone of the first toe.
                                                After Bernard and Huette.
  Fig. 10. Manner of opening  the Articulation of the Second  Metatarsal with
the Middle  Cuneiform Boue.  1, 2, 3. The arch  of  the  circle formed by the
knife in  its different  positions.  4. The  second metatarsal bone.  5. The first
metatarsal bone.  6.  The end of the fifth metatarsal bone.
                                               After Bernard and Huette.
       (712> 
Plate 79
 
 
         ORGANIC CHANGES RESULTING  FROM AMPUTATIONS.     713

of the remaining ligaments;  when, passing  the  knife flatwise beneath the
foot, form a flap out of the integuments on the sole of the foot, by shaving
them  off close to the metatarsal bones, making the flap longest on its inner
edge so as to meet the increased thickness of the tarsus on this side.
  Remarks—The circumstances under which either Lisfranc's or Chopart's
operation would be performed being very different, it is  hardly desirable to
attempt any comparative estimate of their value.  Lisfranc's  operation is
certainly preferable to Chopart's when  it is  admissible, in consequence of its
affording a greater length of foot, and thus adding to the patient's stability,
and, with a good shoe, constructed  as shown in Plate LXXVIII. Fig. 11, a
very useful limb can  be obtained.
  Borckel states* that in Chopart's operation the average mortality is one
iu nine.
  The amputation at the metatarsal bones  and Lisfranc's tarso-metatarsal
exarticulations produce better results than  all other partial amputations of
the foot.
                           SECTION  VII.

                       AMPUTATION OF  THE TOES.

  Amputation of the Toes—Plate LXXX.—may usually be accomplished
by the same methods as the fingers, with the exception of the articulation
of the metatarsal bone  of the first toe.  In  this amputation, whether per-
formed  by the  flap, oval, or circular method, it has been recommended to
saw off  the round  head of the  first  metatarsal bone  after the phalanx is
removed, as it is apt to become a source of irritation from pressure against
the boot.  But  as the hard skin of the under surface of the foot can be made
to cover it thoroughly in many instances, I think it is better not to remove it,
as this end of the bone is of great service in giving the patient a  firm step,
and preventing an inclination of  the foot inward, it being one abutment of
the foot.   The other amputations of the toes are sufficiently explained in
Plate LXXX.  Figs. 5 to 12.
                           SECTION  VIII.

           ORGANIC CHANGES RESULTING PROM AMPUTATIONS.

   The changes which result from the removal of a portion of the extremities
by amputation may be noticed both in the part and in the general health of
the patient within a short period after the operation.
  Local Changes.—In the stump, the approximation of the superficial to the
deeper-seated parts, produced by closing the wound, naturally leads to a gen-
eral  matting  together of the skin, fascia, muscles, blood-vessels, and nerves ;
while the inflammatory changes connected with the process of healing often
create bands of condensed areolar tissue, which, when thickened by pressure,
become almost cartilaginous in their density.  The changes  produced in the
muscles, it has usually been thought were due to  atrophy, and that the differ-
ence in the development of a stump, as compared with the muscles of the oppo-
site limb, was the result of a defect of circulation.  The observations of Spence,
* Op. citat. 
PLATE LXXX.
                      AMPUTATION OF THE TOES.

  Fig. 1. A view from above of the Dorsal Ligaments as opened by the point
of the knife in Lisfranc's Operation, as previously shown in Fig. 10,  Plate
LXXIX.  1, 2, 3. The points opened.  4. The hand of the surgeon.
                                               After Bernard and Huette.

  Fig. 2. Manner of forming the Flap from the Sole of the Foot  in Lisfranc's
Operation.   1. The anterior tibial artery.  2.  The position of the  hand of the
surgeon on  the foot while forming the flap.  3. The position of the knife.
                                               After Bernard and Huette.
  Fig. 3. The Wound left after Lisfranc's Operation.  1, 2, 3. The shape of the
plantar flap.  4. The dorsal flap.                 After Bernard and Huette.

  Fig. 4. The Wound left in Chopart's Operation. 1, 2, 3. The plantar flap.  4, 4.
The blood-vessels.                               After Bernard and Huette.

  Fig. 5. Amputation of all the Toes through the Metatarsal Bones.  1. The
retractor passed into each interosseous space.  2. The saw.
                                               After Bernard and Huette.
  Fig. 6. The Wound left by the preceding Operation.  1,2,3. The plantar flap.
                                               After Bernard and Huette.

  Fig. 7. Disarticulation of all the Toes.   1, 2, 3. The line of the dorsal incision
in front of the joints.                            After Bernard and Huette.

  Fig. 8. Continuation of the same Operation.  1, 2, 3. The dorsal incision.  4.
The catlin,  after opening the joints, about to form a plantar flap.
                                               After Bernard and Huette.
  Fig. 9. The Wound left  by the preceding Operation
                                               After Bernard and Huette.
  Fig. 10. Disarticulation of the Third and First Toes. 1, 2, 3, 4. The wounds
resulting from the oval method on the great toe.  1, 2, 3. The wound formed by
the two flaps on the third toe.                    After Bernard and Huette.

  Fig. 11.  1, 2, 3. The line of the incision in disarticulation or resection  of the
first metatarsal bone.                            After Bernard and Huette.

  Fig. 12. Amputation of the Great Toe.  1, 2, 3,4. The line of incision in the
oval operation.                                  After Bernard and Huette.
       (714) 
 
 
ORGANIC  CHANGES RESULTING FROM  AMPUTATIONS.      715
 of Scotland,  as  stated* to the Medico-Chirurgical Society of Edinburgh,
 seem, however, to disprove this.   In one stump, formed  by a flap operation
 twelve years previous, dissection showed it to be well formed and covered
 by muscle.  For a few weeks after the healing of a stump, any angles caused
 by closing the wound remain  prominent, and the cicatrices which are formed
 near them cause a wrinkling of the surrounding integuments; but ultimately
 the process of absorption and deposition equalizes the surface to a consider-
 able extent, making it much more round and ball-like than before, provided
 a free amount of integument has been preserved in forming the flap.
   The division of the  nerves of the part is most frequently followed by a
 bulbous enlargement at or near the point of section ; and if their extremities
 become inflamed or involved in the line of the cicatrix, the contraction of
 the latter, by  pressing upon thera, will occasionally induce severe neuralgia,
 which, in  some instances, has required the stump  to  be opened, and the
 nerves to be dissected from the part.   Spencef believes that Neuromata are
 unavoidably formed when nerves are divided, no matter how deeply covered
 or in what method the amputation is  performed. When a nerve is cut across,
 he has generally found  that its neurilemma contracted, and that the nervous
 fibrillse projected and ultimately became firmly connected with the lymph
 effused about  the point of section, some fibrillar being spread out on the sur-
 face of the lymph and others imbedded and interwoven in it.  These tumors,
 however, were not productive  of pain, unless exposed to pressure against the
 bone, or so thinly covered as to  be exposed to atmospheric influence.  The
 size of these neuromatous tumors was not dependent on  their being more or
 less thickly covered, as some were found, of large size, very deeply seated in
 the stump.
   The cancellated structure of the bone becoming also more or less inflamed
 after its section, deposit of lymph ensues, granulations are formed at the ex-
 tremity of the medullary membrane,  and, as these  become organized, a new
 deposition of  bone follows, which closes the medullary  cavity and gives to
 the extremity a sort of cap, which,  becoming rounded  and convex, Plate
 LXXVIII. Figs. 7, 9,  is well adapted to sustain pressure without irritating
 the soft parts  when they are forced against it.  In some instances there has
 been  an evident  growth of the end  of the bone, and an apparent increase
 in its length.
   General Changes.—The  general  changes ensuing upon amputation  are
 often not less  marked than the local alterations.  In amputations for chronic
 diseases, and especially  in those  accompanied by hectic fever, the first night
 of comfort obtained by the patient is often that immediately ensuing on the
 operation,  while the fever will sometimes disappear  promptly.   When the
 portion of  the extremity that has been removed is considerable, there is apt
 to be a marked disturbance of the equilibrium of the system, the process of
 nutrition going on rapidly, and the patient increasing in size to a remarkable
degree, the patient often becoming very  fleshy, generally by a deposit of fat
beneath the skin.  At  the  same time there is a liability to plethora, which
may require treatment on the general antiphlogistic plan.
* New York Journ. Med., vol. iii p. 408, from London Journ. Med.      -j- Ibid. 
716
PRINCIPLES  AND PRACTICE  OF SURGERY.
SECTION  IX.
SUBSTITUTES FOR THE NATURAL LIMB.
Fig. 460.
  After the healing of a stump, the surgeon should make it his duty to direct
the patient in the attainment of some useful substitute for the portion which
has been removed.   This must, of course, vary with his social condition.
  For the arm of the laboring  man,  a cap formed of strong leather, to which
an iron hook can be attached, and which can be made to strap on to the stump,
will  answer  the  purposes of prehension; while patients of larger incomes
can now obtain excellent substitutes for the arm and  hand from various in-
                          genious mechanics.  In numerous instances,  arti-
                          ficial arms have been made by  means of which
                          the patient was able to grasp his hat and hold a
                          pen or other light  articles  by a neat mechanism
                          that caused the fingers  to  approach the  palm of
                          the hand.  Fig. 460 shows  an excellent one made
                          by Kolbe, of South Ninth  Street, Philadelphia.
                            Many  varieties of artificial legs can now also
                          be readily obtained, in which the  support is fur-
                          nished  by a graduated pressure around the stump;
                          but it  is to be hoped that every surgeon will, in
                          accordance with the sentiments expressed by the
                          American  Medical Association against  this va-
                          riety of charlatanism, abstain from recommending
                          limbs which are patented.   Those of Kolbk  have
                          been made in accordance with my special direc-
tions, are light, neat, possess every  movement, are cheap, and manufactured
 Kolbe's Artificial Arm uncovered
by the sleeve and glove. (After the
Arm.)
Fis. 463.
 Fig. 461.—Kolbe's Peg. with extra ends, for slippery pavements, etc.
 Fig. 462.—Kolbe's Artifi ial Leg. as it appears uncovered by the stocking.
 Fig. 4P3.—A Section of Kolbe's Leg, showing its general mechanism.  In the motion of the foot and the
ankle-joint it is usually perfect. (After the Leg.) 
PAPERS ON DISORDERS  AND OPERATIONS  ON  THE EXTREMITIES.   717

with the distinct  understanding that the crippled sufferers from amputation
shall  not be subjected to  the evils caused by taking out a patent, Figs. 461,
462, and 463.
   In  Plate LXXVIII. Figs. 10, 11, are represented two  boots, which will
prove useful in affording support to the foot after the performance of Lis-
franc's or Chopart's operation.
   As a general rule, few stumps  will be able to sustain the pressure arising
frora  the constant use of a peg  or an artificial limb under ten weeks after
the entire healing of the wound,  even when  the  stump is well  soaked every
night in a strong  decoction of white-oak bark to harden the skin.   In the
best-formed  artificial limbs, although the main support is borne by the limb
above the stump,  yet the strain thus  put upon the newly-formed cicatrix is
also very apt  to   induce  ulceration, and this, when repeatedly established,
becomes very difficult to heal.   It will therefore prove desirable to omit the
use of all artificial support for about three months, and then, on the appear-
ance of increased redness in the stump, to intermit the use of the limb until
the congestion of the skin has  passed  away.  The anxiety of patients to
try their artificial  limbs will often  create so much irritation in a newly-formed
stump as to  require that the movements  should be regulated by the surgeon,
before ulceration  or  sloughing of the stump is induced  by ignorance or im-
prudence.
AMERICAN  PAPERS  ON DISORDERS  OF,  AND OPERATIONS  ON,  THE
                            EXTREMITIES.
GENERAL OPERATIONS ON THE
         EXTREMITIES.
  by Division of the Nerve, by T. Nelson,
  M.D.  New York.—New York Med.  and
  Phys. Journ., vol. iii. p. 62.       1824
An  Operation for  Inverted Toe-Nail, by
  John D. Godman, M.D.  Philadelphia.—
  Philadelphia Journ. Med. and Phys. Sci.,
  vol. iii. p. 338.                  1826.
Case of liuptureofthe Tendo-Achillis, with
  an Account of the Method of Treatment,
  by Wm. E. Horner, M.D.  Philadelphia.
  —Philada. Journ. Med. and Phys. Sciences,
  vol. xii. p. 407.                 1826.
Cases of Neuralgia or Painful Affection of
  the Nerves from  Injury, etc., by Jno. C.
  Warren,  M.D.  Boston.—Boston Medical
  and Surg. Journ., vol. ii. p. 98.    1829.
Case of Diseased Sciatic Nerve, in which
  the Nerve was  removed by  Excision,
  (death,)  by Robert Bayard, M.D.  St.
  John's, New Brunswick.—New York Med.
  and Physical Journal, vol. ii. N. S. p. 37.
                                1830.
Abnormal Elongation of the Tibia conse-
  quent on extensive Ulceration of the Leg,
  by Alexander Baron, M D.   S. Carolina.
  —North  American  Archives, vol. ii.  p.
  290.                           1834
An Inquiry into the Pathology and Treat-
  ment of Secondary Abscesses, etc., re-
  sulting from Injuries and Surgical Opera-
On the Arrest of the Progress of Whitlow,
  by  means of Caustic,  by Dr. Perkins.
  Philadelphia.—Amer. Medical Recorder,
  vol. ii. p. 490.                   1819.
Surgical  Account of the Naval Battle on
  Lake Erie, (Gunshot Wounds,) by Usher
  Parsons, M.D., U. S. N., (now of Rhode
  Island.)—Eclectic Repertory, vol. ix. p.
  28.                             1819.
On the Best Method of Removing Contrac-
  tions in the Limbs from Burns, by Wm.
  G. Nice, M.D. Virginia.—American Med.
  Recorder, vol. iii.  p. 341.          1820.
Hydrops Articuli in the Shoulder, by James
  Kent Piatt, M.D.  Pittsburg.—Am. Med.
  Recorder, vol. iv. p. 209.          1821.
Case in Proof of the efficacy of the Actual
  Cautery in  Deep Sinuses, by  Nathan
  Smith,  M.D.  Burlington, Vt.—Philada.
  Journ. of Med. and Phys. Sciences, vol. vi.
  p. 128.                          1823.
Removal of a large indolent Tumor on the
  Thigh,  by the Application of Caustic, by
  H. G. Jameson, M.D.  Baltimore.—Am.
  Medical Recorder, vol. vi. p. 59     1823
Case of Wounded Nerve from Bleeding in
  the  Forearm just below the Elbow, cured 
718             PRINCIPLES  AND  PRACTICE OF SURGERY.
  tions, by Jno. Watson, M.D.  New York.
  —Am. Journ. Med. Sciences,  vol. xxi. p.
  17.                              1837.
Case of Varicose Veins cured by means of
  Needles passed through the Veins after
  the Method proposed by Davat, by Henry
  H. Smith, M.D.  Philadelphia.—Amer.
  Journal Med. Sciences, vol. xxii.  p. 525.
                                  1838.
On  the  Treatment of Varicose Veins, by
  Henry H. Smith, M.D.   Philadelphia.—
  Medical Examiner, vol. ii. p. 821.   1839.
On Enlargement of Bursa over the Patella,
  by George  Hayward, M.D.   Boston.—
  Am.  Journ.  Med. Sciences, vol.  iv. N. S.
  p. 513, 1842;  also New Eng. Quarterly
  Journal, July.                    1842.
On the Pathology and Treatmen tof Varices,
  by John Watson,  M.D.   New  York.—
  Am Journ. Med. Set., vol. v.  N. S. p. 36.
                                  1843.
Adipose  Sarcomatous  Tumor, (removed
  from the lower border of the shoulder,
  over a half  yard in  circumference, ten
  inches in diameter, and  eight inches in
  thickness.) by M. Stephenson, M.D.  New
  York.—New York Journal of Medicine, vol.
  iv. N. S. p. 346.                  1850.
Chronic  Inflammation and Abscess of the
  Head of the  Tibia, cured by application
  of the Trephine, by R. McSherry, M.D.,
  U. S. Navy.—Am. Journ.  Med. Sciences,
  vol. xxii. p. 118.                 1851
Cases (four) of Tetanus cured by the  Divi-
  sion of the Injured  Nerve, by Moses
  Sweat, M.D.   North Parsonfield, Maine.
  —New York Med. Journ.,  vol. vi. N. S.
  p. 194.                         1851.
Paronychia, an  Epidemic,  by James  E.
  Morgan, M.D.  Washington.—Am. Jour.
  Med. Sciences, vol. xxiii.  p. 144.    1852.
Two Cases of Foreign  Bodies  (cartilages)
  successfully  removed from  the Knee-
  joint, by Jno  Fred. May, M.D.  Wash-
  ington.—Amer. Journ. Med. Sciences, vol.
  xxiii. N. S. p.  415.               1852.
Enormous Development of a Steatomatous
  Tumor, (upon the shoulder—weight eight
  pounds,) successfully removed,  by J. S.
  Crane, M.D.  Columbia, S. C.—Charles-
  ton Med. Journ., vol vii. p. 56      1852.
Successful Removal of a Foreign Body from
  the Knee-joint, by J.  Washington Smith,
  M.D.  Croton, N. Y.—Medical Examiner,
  vol. viii. N. S. p. 578.             1852.
Singular Epidemic, Paronychia or Whitlow,
  by  L.  A.  Dugas, M.D.   Ga.— Southern
  Medical and Surg. Journ., vol. viii.  N. S.
  p. 256.                          1852.
Case of Femoral Exostosis, with Remarks,
  by  L. A  Dugas, M.D.   Ga.—Southern
  Med. and Surg. Journal,  vol. ix. N. S. p.
  718.                             1853.
Epidemic Furuncles and Whitlows, by L. A.
  Dugas, M D. Ga.—Southern Med. and Sur-
  gical Journal, vol. ix N. S. p. 642.    1853.
Two Cases of Bleeding Ulcer at the Bend of
  the Elbow, following Venesection, cured
  by Extension of the Arm aud the use of a
  Straight Splint, by C. R. Agnew,  M.D.
  New York. — New  York Journ. of  Medi-
  cine, vol. xiii. N. S. p. 378.         1854.
Femoral  Exostosis, by L. A.  Dugas, M.D.
  Ga.—Am. Journ. Med. Sciences, vol. xxvii.
  N. S. p. 281.                     1854.
Removal  of  a  Ring from the Finger, with
  Quicksilver, by A. C. Castle,  M.D.  Bos-
  ton,  Mass.—Charleston Med. Journ., vol.
  ix. p. 241.                       1854.
Gunshot  Wound  of the Knee-joint, (re-
  covery,)  by W. H.Cobb, M.D.  Mo.—
  Western Journ. of Med. and  Surg., vol.  ii.
  N. S. p. 435.                     1854.
Hydatid Tumor of the Arm, by S. D. Gross,
  M.D.  Louisville.— Western  Journal  of
  Med. and Surgery, vol. i. N. S. p. 116.
                                   1854.
Gunshot Wound, by H. W.  Reynolds. M.D.
  Illinois.— Western Lancet, vol. xv. p. 405.
                                   1854.
Coxalgia, by Alden  March, M.D.  Albany,
  N. Y.—New York Journ.  of Medicine, vol.
  xii. N.  S.  p. 251.                  1854.
Benefits of Early Exercise in  Coxalgia, by
  E. S. Cooper, M.D. Peoria, III— South.
  Med. and  Surg. Journ., vol. xi. N. S.  p.
  378.                             1855.
Ulcers over  the Patella, causing Necrosis,
  followed by Suppurative Inflammation of
  the Knee-joint, by John  0. Stone,  M.D.
  New York.—New York Journal of  Med.,
  vol. xiv. N.  S. p. 342.             1855.
Removal of a Fungous  Tumor from the
  Arm, under the influence of Local Anaes-
  thesia  induced by Cold, by L. A. Dugas,
  M.D.  Augusta, Ga.—Am. Journ. Med.
  Sciences, vol. xxx. N. S. p. 279.    1855.
Wound of  the Ulnar Artery,  treated by
  Compression,  by  Jno.  S.  Rich,  M.D.
  Fiiendship, S. C. — Charleston Medical
  Journ., vol. x. p.  637.             1855.
Inverted  or Imbedded Toe-nail,  by  J.  P.
  Batchelder, M.D.   New York. — N.  Y.
  Medical Journal, vol. i. 3d S. p. 9.   1856.
Traumatic Arthritis, by M.  A. Pallen, M.D.
  St. Louis.—St. Louis Med. and Surgical
  Journ., vol. xiv. p.  401.           1856.
Inverted Toe-nail, treated  without Opera-
  tion, by Robert Campbell,  M.D.  Ga.—
  Southern Med. and Surg. Journ., vol. xiii.
  N. S. p. 72.                      1857.
Remarkable Gunshot Wound of the  Arm,
  by Wm.  F.  Edgar,  M.D., U. S. Army  —
  Amer. Journ. Med. Sci., vol. xxxiii. N. S.
  p. 50.                            1857.
Adipose Tumor of the Thigh,  involving the
  Saphena Vein, Removal, Phlebitis, (Re-
  covery,) by Daniel Ayres, M.D. Brooklyn,
  N.  Y.—New York  Journal of Medicine,
  vol. ii. 3d S. p. 9.                1857.
Gunshot Wound of the Shoulder, 1\ inches
  of  the  clavicle  removed, (reproduction 
PAPERS  ON  DISORDERS AND OPERATIONS  ON THE  EXTREMITIES.   719
  and complete recovery,) by Daniel Ayres,
  M.D.  Brooklyn, N. Y.—N.  York Journ.
  of Med., vol. ii. 3d S. p. 9.        1857.
Operation for Necrosis of the  Femur, fol-
  lowed by  Tetanus, with recovery,  by  J.
  J. Chisolm, M.D.  Charleston, S. C—
  Charleston, Med. Journal, vol. xii. p. 616.
                                   1857.
New Splint for Diseases  and  Injuries  of
  the Elbow-Joint, by Henry  Bond.  M.D.
  Philadelphia.—Am. Journ. Med. Sciences,
  vol. xxxiv. N. S. p. 344.           1857.
Reproduction of the Bones and Joints after
  removal in cases of Whitlow, by H. H.
  Toland, M.D.   San  Francisco, Cal —
  Charleston Med. Journ., vol.  xii. p. 721.
                                   1857.
Inverted Toe-nail, treated without an Opera-
  tion, by R. Campbell," I.D.—Am. Journ.
  Med. Sciences,  vol. xxxv.  N. S.  p. 568.
                                   4858.
Osteoid Growth, connected with the Cap-
  sular Ligament of the Right Hip-Joint,
  by A. F. Sawyer, M.D.  San Francisco,
  Cal.—Amer. Journ. Med. Sci., vol.  xxxv.
  N. S. p. 109.                     1858.
Unusual Deformity of the Knee,  with Re-
  marks, by C. A. Pope, M.D. St. Louis.
  —St. Louis Med. and Surg. Journ., vol.
  xvi. p. 193.                      1858.
Case of Removal of a Tumor from the Calf
  of the leg, which had caused Neuralgia
  for 16 years, (recovery,) by C. E. Isaacs,
  M.D.  New York.—New York Journ. of
  Medicine, vol. v. 3d S. p. 13.       1858.
Vienna Paste, the best Treatment for Vari-
  cose Ulcers and Varicose Veins, by Wm.
  A. Green, M.D.  Ga.—Southern Medical
  and Surg. Journal, vol. xv. N. S. p. 322.
                                   1859.
            ON  CLUB-FOOT.

Report of several Cases of Club-Foot suc-
  cessfully treated by dividing the Tendo-
  Achillis, by W. Detmold, M.D. New York.
  —Am. Journ.  Med. Sciences, vol. xxii. p.
  105, 1838; also,  Phila.  Med. Examiner,
  vol. i. p. 198.                     1838.
On Division of the Tendo-Achillis in Club-
  Foot, by James H. Dickson,  M.D.  New
  York.—Am. Journ.  Med. Set., vol. xxii.
  p. 512.                           1838.
Congenital Club-Foot, and Division of the
  Tendo-Achillis, by  G. W.  Norris, M.D.
  Philadelphia—Am. Journ.  Med. Sciences,
  vol. xxiii. p. 257.                 1839.
Division of the Tendo-Achillis in  Club-
  Foot, by N. R. Smith, M.D.  Baltimore.
  __Am  Journ.  Med. Sciences, vol. xxiii. p.
  61.                              1839.
Case of Talipes Equinus,  cured  by Stro-
  meyer's Operation, by James H. Dickson,
  M D  New York.—Am. Journ. Med. Sci.,
  vol. xxiii. p. 96.                  1839.
Successful Club-Foot Operations, (ten,) by
  A.  G. Walton, M.D.  Pennsylvania.—
  Am. Journ. Medical Sciences, vol. xxiii. p.
  259.                            1839.
Club-Foot, Division of the Tendo-Achillis,
  by Thomas J. Garden, M.D.  Virginia.—
  Am. Journ.  Med. Sciences, vol.  xxiv. p.
  257.                            1839.
Cases of Deformed Feet treated by mechan-
  ical means alone, with a  description of
  the Apparatus, by Heber Chase, M.D.
  Philadelphia.—Am. Journ. Med. Sciences,
  vol. i. N. S. p. 88.               1841.
Club-Foot cured at an Advanced Age, by
  J. B. Brown,  M.D. Boston.—Am. Journ.
  Medical Sciences, vol. vii. N. S. p. 256.
                                  1844.
Case of Varus, (cured by  Tenotomy  and
  Apparatus,)  by  John  O'Reilly, M.D.
  New York.—A^.  Y. Journ.  Med, vol. v.
  N. S.  p. 22.                      1851.
Case of Double Club-Foot (Varus and  Pes
  Equinus)  treated  by Tenotomy and a
  Shoe, (cure perfect five years afterward,)
  by Henry H. Smith, M D.  Philadelphia.
  —Med. Examiner, vol. vii. N. S. p. 181.
                                  1851.
Non-Congenital Talipes Equinus, by L. A.
  Dugas, M.D.  Georgia.—Southern  Med.
  and Surg.  Journ., vol. ix. N. S. p. 142.
                                  1853.
Non-Congenital Talipes Varus,  by L. A.
  Dugas, M.D.  Georgia.—Southern  Med.
  and Surg.  Journ., vol. x. N. S. p. 210.
                                  1854.
Orthopaedic Institutions, by J. C Nott, M.D.
  Alabama.—New  Orlea.ns Med.  and Surg.
  Journ., vol. xi. p. 460.           1855.
Non-Congenital Talipes, by L. A. Dugas,
  M.D. Georgia.—Southern Med. and Surg.
  Journ., vol. xii. N. S. p. 17.       1856.
ON ANEURISMS  AND THE  LIGATION
  OF THE ARTERIES  OF  THE  EX-
  TREMITIES.

Aneurism of the Thigh, cured by an Oper-
  ation, (two Ligatures,)  and use of the
  Limb preserved, by Thomas Kast, A.M.
  Boston.—Communications and  Disserta-
  tions of Mass. Med. Society, vol. i. p. 96.
                                  1790.
Case of Varicose Aneurism at the Bend of
  the Arm, cured by Ligation of the Bra-
  chial  Artery, by P. S.  Physick, M.D.
  Philadelphia.—Phila.  Med. Museum,  vol.
  i. p. 65.                         1805.
Ligation of the Femoral  Artery for  a
  Wound, by John C.  Warren, M.D.  Bos-
  ton.—Communications  and  Dissertations
  of Mass. Med. Soc , vol. i. p. 40.   1806.
Ligation of the Femoral Artery, (cured,)
  by  David Hosack, M.D.  New York.—
  New York Medical Repository, vol. xii. p.
  103.                            1809. 
720
PRINCIPLES AND  PRACTICE  OF  SURGERY.
 Case of Aneurism of the Femoral Artery,
    (successful ligation.) by  David Hosack,
    M.D.  New York.—Am Med. and Philo-
    sophical Register, vol.  ii. p. 49.      1811.
 Account of a Case of Aneurism of the Fem-
    oral Artery, cured, (byrestand pressure,)
    by Joseph Parrish, M.D.   Philadelphia.
    (In this paper there is the suggestion of
    P. S. Physick to apply pressure by means
    of a pad and screw, which could be tight-
    ened gradually till a  cure was  effected.)
   —Eclectic Repert., vol. i. p. 506.   1811.
 Case  of  Popliteal Aneurism  successfully
   treated by Ligating the Femoral Artery,
   by  Henry  U. Onderdonk,  M.D.  New
   York.—Am. Med. and Philosoph. Register,
   vol. iv. p. 44.                    1814.
 Successful Ligation of the Femoral Artery
   for a Wound in the Knee-Joint,  by Henry
   U. Onderdonk, M.D.   New  York.—Am
   Med. and Philosoph.  Register, vol. iv. p.
   176.                            1814.
 Case of Brachial Aneurism cured by tying
   the Subclavian Artery above the Clavi-
   cle, by Wright  Post,  M.D.  New York.
   Communicated  by J.  C.  Bliss, M.D.—
   Transactions of New  York Physico-Med.
   Society, vol. i. p. 367.             1817.
 Case of Popliteal Aneurism, etc.,  by Hora-
   tio Gates Jameson, M.D.   Baltimore.—
   Am. Med. Recorder, vol  iv. p. 94.  1821.
 On the Utility of  Tying large Arteries in
   preventing Inflammation  in  Wounds of
   the principal Joints, with Cases, by Da-
   vid L. Rogers, M.D.   New York.—N. Y.
   Med. and Phys Journal, vol. iii. p. 453.
                                   1824.
 Case of Aneurism of the Brachial Artery
   cured by Compression, by W. B. Fahnes-
   tock, M.D.    Pennsylvania.—Philada.
   Journ. of Med. and Phys. Sciences, vol. ii.
   N. S. p. 363.                     1825.
 Spontaneous Cure of Aneurism, with Ob-
   servations on the Obliteration of Arteries,
   by W. Darrach, M.D.  Philadelphia.—
   Phila. Journ. Med. and Phys Sciences, vol.
   iv. N.S. p. 115.                  1826.
 Case of Femoral  Aneurism of  the  Left
   Thigh,  anf  Popliteal  Aneurism of  the
   Right Leg, successfully treated, by  Val-
   entine Mott, M.D.  (The Femoral  was
   tied first for the Popliteal Aneurism, and
   the External Iliac fourteen  days subse-
   quently, both  successful.)—Am. Journ.
   Med. Sciences, vol. i p. 483.         1828.
 Diffused Aneurism at the Bend of the Arm,
   produced  by puncture with a Lancet  in
   Bleeding,  cured by an Operation, (open-
   ing the  Sac  and tying the Artery above
  and below,) by Horatio G. Jameson, M.D.
  Baltimore.—Maryland Med. Recorder, vol.
  i. p. 460.                        1829.
Case of Aneurism of the Brachial Artery,
  cured by Compression, by J. W.  Heustis,
  M.D.  Alabama—Am. Journ. Med. Sci.,
  vol. ix. p.  261.                   1831.
 Pressure applied to the Femoral Artery as
   a means of  curing Popliteal Aneurism.
   (Dec, 1826.) by  George Bushe.  M.D.
   New York.—Medico-Chirurgical Bulletin,
   vol. ii. p. 213.                    1832.
 Wound of the  Ulnar Artery at the Heel of
   the Hand, successfully treated  by  Com-
   pression after the Ligature had failed, by   v
   H. G Jameson, M.D. Baltimore.—Mary-
   land Med. Record., vol. iii. p. 40.   1832.
 Ligation of the Femoral Artery for Popliteal
   Aneurism, Hemorrhage from the Femoral
   on the twelfth day; second application
   of the  Ligature  above  the  Profunda,
   Hemorrhage on the eighth day, arrested
   by Compression, (cured,) by N. R. Smith,
   M.D.   Baltimore.—Baltimore  Med. and
   Surg. Journ., voj ii. p. 61.         1634.
 Femoro-Popliteal Aneurism: Spontaneous
   Cure of the  Popliteal by the occurrence
   of the Femoral Aneurism; Arteries Dis-
   eased;  Ligation of the Femoral; Hem-
   orrhage on the eleventh day ; Separation
   of the  Ligature on the nineteenth day;
   recovery,  by Nathan  R. Smith,  M.D.
   Baltimore.—North Am. Archives, vol. ii.
   p. 75.                            1835.
 Ligation of the Brachial Artery for Veno-   /
   Arterial Aneurism, (cured,)  by Nathan  J
   R. Smith, M.D. Baltimore.—North Am.
   Arch. Med. and Surg. Sci., vol.  i. p. 241.
                                   1835.
 Two  Cases of  Aneurism,  (Femoral  and
   Brachial,) exhibiting the necessity of a  j
   Ligature  both above  and below the Tu-
   mor, by Wm. E. Horner, M.D. Philadel-
   phia.—Am. Journ. Med. Sciences, vol i.
   N.  S. p. 74.                      1841.
 Ligation of the Femoral  Artery  for  Pop-
   liteal Aneurism,  (cured,) also of  the
   Brachial, (cured,)  by A. W  Shipman,
   M.D.  New York.—Med,  Examiner, vol.
   iv.  p. 441                        1841.
 Aneurism of the Femoral Artery,  showing
   the importance of  applying a  Ligature
   below as well as above the Sac,  by Wm.
   E.  Horner,  M.D.   Philadelphia.—Am.
   Journ. Med. Sciences, vol. iv. N. S. p. 332.
                                   1842.
 Aneurism of the Femoral Artery from Frac-
   ture of  the Femur, Ligation of  the Ex-
   ternal  Iliac Artery, (cured,) by Daniel
   Brainard, M.D.   St. Louis—Am. Journ.
   Med. Sci., vol. vi. N. S. p. 359.     1843.
Varicose  Aneurism, successfully treated by
   Pressure, by  William  Johnston,  M.D.
   New Jersey.—Am.  Journ. Med.  Sciences,
   vol. xii. N. S. p. 378.            1846.
Tabic, showing the Mortality following the
   Operation of Tying the Iliac Arteries, by
   G. W. Norris, M.D. Philadelphia.—Am.
  Journ.  Med.  Sciences,  vol. xiii. N. S. p.
   13.                             1847.
Popliteal Aneurism, successfully treated by
  Compression, by J. Knight, M.D.  New
   Haven. — Am. Journ. Med. Sciences,  vol. 
PAPERS  ON  DISORDERS AND OPERATIONS  ON THE  EXTREMITIES.   721
  xvi. N. S. p. 255, 1848; also,  Boston
  Med. and  Surg. Journ., vol.  xxxviii.  p.
  293.                             1848.
Statistics of the Mortality following the
  Operation of Tying the Femoral Artery,
  by G. W. Norris,  M.D.  Philadelphia.—
  Am. Journ. Med. Sciences, vol. xviii. N. S.
  p. 313.                          1849.
Successful Ligation of the Femoral Artery
  for Wound of the Anterior Tibial, by  E.
  P.Bennett, M.D.  Connecticut.—Am.
  Journ. Med. Sciences,  vol.  xix.  N.  S.  p.
  272,1850 ; also, New York Journ. of Med.,
  vol. iv. N.  S. p. 199.              18.50.
Ligation of  the  Femoral Artery for Popli-
  teal Aneurism, (successful,)  by Charles
  A. Tope,  M D.   St.  Louis.—St. Louis
  Med. and  Surg. Journ.,  vol. vii. p. 292,
                                   1850.
Femoral   Aneurism  cured,   (in  eighteen
  days,) by Compression, by W. H. Church,
  M.D.  New York.—N. Y. Journ. of Med.,
  vol. vi. N.  S. p. 196              1851.
Two Cases of Popliteal  Aneurism success-
  fully treated  by Compression, by James
  R. Wood,  M.D.   New York— New York
  Journal of Med.,  vol.  vi.  N.  S. p.  304.
                                   1851.
Case of Popliteal Aneurism cured by Com-
  pression over  the Tumor, by H. N. Ben-
  nett,  M.D.  Bethel, Connecticut.—New
  York Journal of Medicine,  vol. vii. p. 26.
                                   1851.
Popliteal Aneurism successfully treated by
  Compression, (of the  Femoral Artery—
  Dupuytren's  Instrument,) by Wm. H.
  Van Buren, M.D.  New York —New York
  Med. Times, vol. i. p. 33.           1851.
Traumatic Aueurism of the Posterior Tibial
  Artery, (by shears puncturing six inches
  below the knee;) Ligation of the Artery;
  Secondary  Hemorrhage,  Amputation,
  (cured,) by J. H. Brown, M.D.  Paris,
  Maine. —New York Journ. of Medicine,
  vol. ix. N. S. p. 362.             1852.
Ligation of the  Right Femoral Artery for
  the cure of Elephantiasis Arabicum, by
  J. M.  Carnochan, M.D.  New York.—
  New York Journ.  of Med., vol. ix. N. S. p.
  161.                             1852.
Ligation  (successful)  of the Ulnar Artery
  for Aneurism, by A.J.Crittenden, M.D.
  Heathsville, Virginia. —Stethoscope, vol.
  ii. p. 491.                         18-52.
Ligation  of the Femoral Artery for Popliteal
  Aneurism,  Recovery,  by  Daniel Brain-
  ard, M.D.  Chicago.—Northwest Med.
  and  Surgical Journal,  vol.  iv.  p. 414.
                                  18t52.
Ligation  of  the  Femoral Artery for Pop-
  liteal Aneurism, by James Deane, M.D.
  Massachusetts.— Boston Med.  and Surg.
  Journ., vol. xlix.  p. 141.          1853.
Appearance  of the Parts concerned in a
  Popliteal  Aneurism,  which  had  been
  cured  by   Compression, by  J. Knight,
     vol. ii.—46
  M.D.   New Haven. — Am. Journ. Med.
  Sciences, vol. xxviii. N. S  p. 305.   1854.
Aneurism of the Posterior Tibial Artery
 ' treated by Compression, by Charles Bell
  Gibson, M.D —Amer. Journ.  Med. Sci-
  ences,  vol. xxvii. N.  S. p. 278.     1854.
Ligation of the  Arteries, by  W.  J. C. Du-
  hamel, M.D.  Washington, D. C.—South-
  ern Med. and Surg. Journ., vol  xi. N. S.
  p. 565.                          1855.
Femoral Aneurism cured by Veratrum Vi-
  ride, Manipulation, and Compression,  by
  Geo. C.  Blackman, M.D.  Ohio. — Am.
  Journ. Med. Sciences, vol. xxxiv. N. S. p.
  290.                            1857.
Remarkable Case of Aneurism of the Tho-
  racic  Aortn, by  J.  H.  Packard, M.D.
  Philadelphia.—Am Journ. Med. Sciences,
  vol. xxxvi. N. S p. 48.           1858.
Four Cases of Ligation of the Femoral Ar-
  tery for Popliteal Aneurism.   Reported
  by J.  J. Campbell, M D., House Surgeon
  to Bellevue Hospital.  N. Y.—New York
  Journal of Medicine,  vol.  v. 3d S. p. 234.
                                  1858.
Cure of  Aneurism by Digital Compression,
  by  Bennet Dowler,  M.D.  N. O.—New
  Orleans Med. and Surg. Journ., vol. xv.
  p. 837.                          1858.
Aneurism of the Femoral Artery following a
  Popliteal Aneurism,cured by eight hours'
  Mechanical Compression, by E. J. Foun-
  tain,  M.D.  Davenport,  Iowa.—N.  Y.
  Journal of Medicine, vol. vi. 3d S. p. 75.
                                  1859.
 ON RESECTION OF  THE BONES OF
         THE EXTREMITIES.

Necrosis, two Cases operated on, by John
  H. Martin, M.D.  Maine.—New England
  Journ. of Med. and Surg.,  vol. i. p. 162.
                                  1812.
Case of Wounded Shoulder-Joint, in which
  the Head of the Humerus was removed
  successfully,  by Henry  Hunt.  M.D.
  Washington.—Med.  Record., vol.  i. p.
  365.                            1818.
Resection of nearly the whole of the Ulna,
  successfully,  by Robert  B. Butt, M.D.
  Virginia — Philadelphia Journ. of Med.
  and  Phys. Sciences, vol. i.  N. S.  p. 115.
                                  1825.
Successful Extirpation of the Astragalus
  after Compound  Luxation, by Alexander
  II. Stevens,  M.D.—New York Med  and
  Phys. Journal, vol. v.  p. 560.      1826.
Treatment of Anchylo-is of the Hip-Joint
  by the Formation of an Artificial Joint,
  a new Operation, devised and  executed
  by John  Rhea  Barton, M.D. Philadel-
  phia.— North American Med. and Surg.
  Journ., vol. iii. pp. 279, 400.      1827.
Case of Necrosis, with some peculiarities,
  (sequestrum  remaining too long,)  by 
722            PRINCIPLES  AND  PRACTICE  OF  SURGERY.
+
4-
   Horatio  G. Jameson, M.D.  Baltimore.
   —Maryland Med. Recorder, vol. i. p. 463.
                                   1829.
Successful Removal  of the  Astragalus  in
   Compound Dislocation,  by Wm. A. Gil-
   lespie, M.D.  Virginia.—Am. Journ. Med.
   Sciences,  vol.  xii. p. 552.           1833.
Resection of first three Metatarsal and the
   three Cuneiform Bones—leaving the cor-
   responding toes—cured, (patient able to
   walk well,)  by E.  Geddings, M D.   Bal-
   timore.— Amer. Archives Med. and Surg.
   Sciences,  vol.  i.  p. 36.              1835.
Resection of the Shaft of the Femur for Ne-
   crosis and Exostosis succeeding a com-
   pound comminuted fracture, cured, by E.
   Geddings, M.D.  Baltimore.—Am. Ar-
   chives  Med. and Surgical Sciences,  vol. i
   p. 34.                            1835.
Resection of the Astragalus, (for Necrosis
   —Removal of the  Entire Bone—cured,)
   by N. R. Smith, M.D.  Baltimore.—Am.
   Archives  Med. and  Surg. Sciences,  vol. i.
   p. 83.                           1835.
A Case of Resection of Elbow-Joint, (being
   the first in the United States,) by Thomas
   Harris, M.D.  Philadelphia.—Am. Journ.
   Med. Sci., vol. xix. p. 341.         1836.
A New Treatment  in a Case of Anchylosis
   of Knee,  (a V incision.) by J. Rhea Bar-
   ton,  M.D.  Philadelphia.—Am. Journ.
   Med. Sciences, vol.  xxi. p. 332.      1837.
Successful Operation  to remedy a Deformed
   Fracture of the Leg, by Charles Parry,
   M.D.  Indiana. — Am. Journ. Med. Sci-
   ences, vol. xxiv. p.  334.            1839.
Operation for remedying an Anchylosis  of
   the  Hip-Joint, by   J. Kearny  Rodgers,
   M.D.  New York.—Am. Journ. Med. Sci-
   ences, vol. i.  N. S. p. 507, 1840;  also,
   N. Y. Med. and Surg. Journ.,  January.
                                   1840.
Case of Resection  of the Elbow-Joint, by
  Gurdon  Buck, in., M.D.   New  York.—
  Am.  Journ.  Med. Sciences,  vol.  ii. N.  S.
   p. 249, 1841; also, N Y. Med. and  Surg.
   Journ., April.                    1841.
Case of Complete Anchylosis, in which the
   Knee Joint  was  permanently  Flexed,
  cured  by an Operation, by Wm. Gibson,
   M.D.  Philadelphia.—Am. Journ.  Med.
  Sciences, vol. iv. N.  S. p. 39.       1842.
Deformity  from  unsuccessfully  treated
  Fracture of  Leg, (treated by resection,)
  by John  Rhea  Barton, M.D.   Reported
  by W. S. Ruschenbcrger,  M.D.  Phila-
  delphia.—Medical Examiner, vol. i.  N.  S.
  p. 17.                            1842.
Resection of the Elbow-Joint, (cured,) by
  J. Pancoast,'M.D.   Philadelphia.—Med.
  Examiner, vol. i. N. S. p. 609.      1842.
Case of False Anchylosis of the Knee-Joint
  treated by mechanical means alone,  with-
  out the aid of Tenotomy, with a Descrip-
  tion  of the Apparatus, by Heber Chase,
   M.D.  Philadelphia.—Am.  Journ.  Med.
   Sciences, vol. iii. N. S. p. 101.     1842.
 Resection of the Olecranon Process for An-
   chylosis of the Elbow Joint, by Gurdon  •«*£.
   Buck, Jr., M.D.  New  York.—Am. Journ.
   Med.  Sci., vol. v. N. S. p. 297.     1843.
 Anchylosis of the Knee, successfully treated
   by Barton's Operation, by J. Piatt Burr,
   M D.  Louisiana.—Amer.  Journ.  Med.
   Sciences, vol.  viii. N. S. p. 270.    1841.
 The Knee-Joint  Anchylosed  at a  Right
   Angle.   Restored  nearly to  a straight
   position, after the Kxcision of a wedge-
   shaped  portion of the Bone,  consisting
   of the Patella, Condyles, and  Articula-
   ting Surface of the  Tibia,  by Gurdon
   Buck, Jr., M.D.  New York.—Am. Journ.
   Med.  Sci., vol. x. N. S. p. 277.     1845.
 Removal  of a  Third of the  Head  of the
   Humerus, by N. Pinkney, M.D., U. S. N.
   — Am.  Journal  Med.  Sciences, vol. xii.
   N. S. p. 330.                     1846.
 Resection  of the Elbow-Joint for Caries of   ^f
   the Articular Extremities of the Bones,    jp
   by Gurdon Buck, Jr., M.D    New  York.    I
  —Am. Journ. Med. Sciences,  vol. xii. N.
  S. p.  544.                        1846/
Resection  of the Condyles of Humerus for
   Compound Fracture of the Elbow-Joint, -</
   Recovery, with a new Joint, by John O.  /
  Stone, M.D.  New York.— N. Y. Journ.
  of Medicine, v'ol. vi. N. S.  p. 300.   1851.
Resection  of the Middle Two-thirds of the
   Ulna, (cured,) by Carter  P. Johnson,
   M.D.   Richmond.—Med. Examiner, vol.
  vii. p. 644.                       1851.
Resection  of the Femur for Deformed Frac-
  ture, (during etherization; died four days
  after  operation,) by  Wm.  E. Horner,
   M.D.  Philadelphia.—Medical Examiner,
  vol. vii. N. S. p.  32.               1851.
Resection  of the Femur above the Knee,
   (Barton's operation,)  successfully per-
  formed by Thos. D. Mutter, M.D.  Phila-
  delphia.—Med. Examiner, vol. vii.  N. S.
   P- 37.                           1851.
Successful  Resection, (by incision, disar-
  ticulation and resection  of Condyles  of
  the Femur and Head of Tibia,) by A. J.
   Wedderburn,  M.D.    New  Orleans.—
   Southern Med. and Surg. Journ., vol. viii.
   p. 443, 1852, from New  Orleans Medical
  Register.                         1852.
Resection  of the Scapula for a large Tumor,
  by S  D. Gross, M.D.  Louisville.— West-
  ern Journ. of Med.  and Surg., vol.  xi. p.
  419.                             1853.
A Case of Femoral Exostosis, with Remarks,
  by L. A. Dugas, M.D.  Georgia.—South-
   ern Med. and Surg. Journ., vol. ix.  N. S.
  p- 718.                           1853.
On Pulsating  Tumor of Bone,  (Aneurism
   of Bone,)  with Remarks, by Charles D.
   Smith, M.D.  New  York. — New  York
   Journ. of Med., vol. x. N. S. p. 153.  1853. 
PAPERS  ON  DISORDERS AND OPERATIONS  ON THE  EXTREMITIES.   723
 Pus within the Shaft of the Tibia,  (tre-
   phined, cured.) by Dr. Strong.  Boston.
   —Am. Journ. Med. Sciences, vol. xxv.  N.
   S- P-  81.                         1853.
 Removal  of  the  Astragalus,  by  F.  M.
   Robertson,  M.D.  Charleston,  S.  C—
   Am. Journ. Med. Sciences,  vol. xxvii.  N.
   S. p.  414.                        1854.
 Resection of the Knee-Joint for Anchylosis,
   by  Gurdon  Buck, M.D.   New York.—
   Am. Journ. Med. Sciences,  vol. xxvii.  N.
   S. p.  550.                        1854.
 Resection of the entire Ulna, by J. M. Car-
   nochan, M.D.  New  York.—Am. Journ.
   Med.  Sciences, vol. xxvii. N. S. p. 554.
                                    1854.
 Disarticulation  of the Femur at the Hip-
   Joint, Resection of the Headof the Femur,
   Recovery, by J. P. Stevens, M.D.  On-
   tario County, N. Y.—New  York Journ.  of
   Med.,  vol. xii. N.  S. p. 402.        1854.
 Resection of the Head  of the Femur, and
   removal of the  Upper  Rim of the Ace-
   tabulum for Morbus Coxarius, by Lewis
   A. Sayre, M.D.  New York.—Am. Journ.
   Med. Sci., vol. xxix. N. S.  p. 572. 1855.
 Resection of the Elbow-Joint, by Henry H.
   Smith, M.D.  Philadelphia.—New York
   Journal of Medicine,  vol.  xiv. N.  S.  p.
   310.                             1855.
 Resection of the Elbow-Joint, by C. E.
   Bellamy, M.D.   Columbus, Ga. — Am.
   Journ. Med. Sciences, vol. xxxii. N. S.  p.
   375.                             1856.
 Patella torn away by a Circular Saw, with
   other Serious Injuries, Recovery, by Wm.
   J. Alexander,  M.D.  Salem,  Va.—Am.
   Journ.  Med. Sciences, vol. xxxii.  N. S. p.
   558.                             1856.
 Resection of  the  Elbow-Joint, by  G. C.
   Blackman,  M.D.  Cincinnati.— Western
   Lancet, vol. xvii. p. 726.          1856.
 Resection of the Head of the Humerus, by
   G. C. Blackman, M.D.  Ohio.—Am. Journ.
   Med. Sciences, vol.  xxxiv.  N. S. p. 560.
                                   1857.
 Resection of the Os Calcis by an Improved
   Method of Operating, by  Clifford Mor-
   rogh, M.D.  New Jersey.—N. Y. Journ.
   of Med., vol. iii. 3d S. p. 79.       1857.
Resection of the Head of the Humerus, by
   G.  C.   Blackman,  M.D.   Cincinnati.—
   Western Lancet, vol. xviii. p. 551.   1857.
Resection of the Knee-Joint, (Barton's Op-
  eration,) for Straightening the Joint, by
  J. Mason Warren,  M.D.  Boston.—Bos-
  ton Med. and  Surg. Journ., vol. lix. pp.
  409, 411.                        1858.
Resection of the Entire Radius, by J. M.
  Carnochan,  M.D.  New York.—Amer.
  Journ.  Med. Sciences, vol. xxxv. N. S. p.
  363.                             1858.
Resection of the Lower  Four-Fifths of the
  Radius, by J. M. Carnochan, M.D.  New
  York.__Amer.  Journ.  Med.  Sciences, vol.
  xxxvi.  N. S. p. 89.                1858.
Resection of the Femur, and Removal of
  the Trochanter Major for the formation of
  an Artificial Joint, by A. G. Walter, M.D.
  Pittsburg,  Pa. — Am. Journ. Med. Sci.,
  vol. xxxv. N. S.  p. 354.           1858.
Resection of the Entire Fibula for Fibro-
  cartilaginous Degeneration of the Bone,
  by  A.  Reeves Jackson,  M.D.   Strouds-
  burg, Pa.—Am. Journ. Med. Sci., vol.
  xxxvi. N. S. p. 357.              1858.
Two Cases of Resection for Caries, by C.
  E. Isaacs, M.D.   New York.—New York
  Journal of Medicine,  vol. iv.  3d Series,
  p. 182.                          1858.
Barton's  Operation for Straightening  the
  Knee-Joint,  by  Excision  of  a   Wedge-
  shaped piece of Bone, by J. Mason War-
  ren, M.D. Boston.—Am. Journ. Med. Sci.,
  vol. xxxvii. N. S. p.  574.         1859.
Resection  of the Knee-Joint for Disease of
  the Synovial membrane and Cartilages,
  in a patient  58  years of  age, by It. A.
  Kinloch, M.D.   Charleston, S. C.—Am.
  Journ.  Med. Sciences, vol.  xxxviii. N. S.
  p. 67.                           1859.

         ON AMPUTATIONS.
 Amputation at the Shoulder, by Jno. War-
   ren, M.D.   Boston, 1781.  (First in the
   United States.)—Boston Med. and Surg.
   Journal, vol. xx. p. 210.          1839.
 Amputation of the Arm at the Shoulder,
   together withthe Acromion Process of the
   Scapula for Fungus Haernatodee after the
   Ligation of the Subclavian Artery, (died,)
   by Wm. C. Bowen, M.D.  Providence.—
   New Eng. Journ. of Med. and Surg.,  vol.
   iii. p.  314.                       1814.
 New  Tourniquet, by Francis Moore, M.D.
   Connecticut.—New England  Journal of
   Med. and Surg., vol. iv.  p. 209.     1815.
 Amputation at the Shoulder-Joint, (died,)
   by J.  B. Whitridge, M.D.  South Caro-
   lina.—New  England Journ. of Med. and
   Surg.,  vol. v. p. 21.               1816.
 Amputation of part of the  Foot, (cured,)
   by George  Hay ward, M.D.  Boston.—
   New England Journ.  of Med.  and Surg.,
   vol. v. p. 338.                   1816.
 Report of extraordinary Cases of Amputa-
   tion, by Amasa Trowbridge, M.D.  Wa-
   tertown—New York Med. Repository, vol.
   xix. p. 20.                       1819.
Case of Fungus Hasmatodes, amputated by
   George M'Clellan, M.D.  Philadelphia —
  Am. Med. Record., vol. v. p. 634.   1822.
Remarks on Amputation, (with the proposi-
   tion of a new method of performing the
   Flap Operation.) by Nathan Smith,  M.D.
  Yrale College.—New York Med. and Phys.
  Journ., vol.  iv.  p. 303.           1825.
Successful Amputation  at the  Hip Joint,
   by Valentine Mott, M.D.  New York.—
   Phila. Journ. Med. and Phys. Sciences, vol.
   v.  N. S. p. 101.                  1827. 
724
PRINCIPLES AND PRACTICE OF  SURGERY.
 Amputation at the Elbow-Joint, (Flap, first
   in the United States, cured.) by J. Kearny
   Rodgers, M.D.  New York.—Nw  York
   Med. and Phys. Journ., vol. vii. p. 85.  1828
 Case of Encephaloid Degeneration  (Fungus
   Hicmatodes) of the Knee and Lower Part
   of the Thigh, in which Amputation was
   performed,  by E.  Geddings, M.D.  Bal-
   timore.—Am. Journ. Med.  Sciences, vol.
   xi. p. 17.                         1832.
 On the Circular and Flap  Operations,  by
   R. Tolefree, Jr , M.D.  New York.—Am.
   Journ. Medical Scie?ices, vol. xiii. p. 370.
                                    1833.
 On Amputation of the Leg, (especially by
   the method  of Nathan Smith, M.D , Yale
   College,  by  Flaps,) by Nathan R. Smith,
   M.D.  Baltimore.—North Am. Archives,
   vol.  i. p. 377.                     1835.
 Dislocation and  Fracture of the Astragalus,
   unsuccessful efforts at Reduction, Extir
   pation,  Amputation, (death,)  by G.  W.
   Norris, M.D.  Philadelphia —Am. Journ.
   Med. Sci., vol. xx.  p. 378.        1837.
 Amputation of the Foot, by G. R. B. Horner,
   M.D.  U.S.N.—Am. Journal Med.  Sci.,
   vol.  xxi. p.  255.                  1837.
 Statistical  Account of the Amputations per-
   formed  at  the  Pennsylvania  Hospital
   from January, 1831,  to  January, 1838,
   by  George  W. Norris, M.D.  Philadel-
   phia.—Am. Journ. Med.  Sciences,  vol.
   xxii. p. 356.                     1838.
 Amputation at the Hip-Joint, (died in forty-
   eight days,) by Daniel Brainard,  M.D.
   Illinois.—Am. Journ. Med. Sciences, vol.
   xxii. p. 372.                     1838.
 Statistics  of  the  Amputations  of Large
   Limbs performed  in the  Massachusetts
/  General  Hospital, with Remarks,  by
   George Hayward,  M.D.   Boston—Am
   Journ. Med. Sciences, vol V W IS. p. 0 4.
                                    1840.
 Statistical  Account of the Amputations per-
   formed  in  the  Pennsylvania  Hospital
   from January, 1838,  to  January,  1840,
   by G. W. Norris, M.D.   Philadelphia.—
   Am. Journ.  Med. Sciences, vol. i.  N.  S. p.
   80.                              1840.
 Amputation at the Shoulder-Joint, (died,)
   with a Description of anew Instrument for
   securing deeply  seated Arteries, by  Wm.
   E.  Horner, M.D.   Philadelphia.—Med.
   Examiner, vol. viii. p. 540,  1840;  also
   Am. Journ.  Med. Sciences, vol. i. N.  S. p.
   266.                              1S41.
 Case of Gunshot Wound of the Hand, Fore-
   arm, and Arm,  with  a Fracture of the
   Humerus, successfully treated, (without
   Amputation,) by  R.  W.  Lindsay,  M.D
   District of Columbia.—Am. Journ.  Med.
   Sciences,  vol. i. N.  S. p. 117.       1841.
 Fungus Hueraatodes of the  Knee, Amputa-
   tion, (cured,)  by Henry L. Levert,  M.D.
   Mobile.—Am. Journ. Med. Sciences, vol.
   vi. N. S. p.  56.                   1841.
Amputation at the Shoulder-Joint, by N.
  Pinkney, M.D.   U.S.N.—Amer. Journ.
  Med. Sci., vol. xii N. S. p. 332.   1846.
Amputation of the Foot—Excessive Hemor-
  rhage from  the Stump, (over forty Liga-
  tures applied,) by J. C.  Butler, M.D.
  Virginia.—Am. Journ. Medical Sciences,
  vol. xii.  N.  S. p.  541.             1846.
Amputation above  the Shoulder-Joint, by
  David  Gilbert,  M.D.  Pennsylvania.—
  Am. Journ.  Med.  Sciences, vol. xiv. N. S.
  p. 360.                           1847.
Statistics of Amputations in the New York
  Hospital, from January 1, 1839, to Jan-
  uary 1,  1848, (ninety-one cases, twenty-
  six deaths,) by  Henry W. Buel, M.D.N/
  New York.—Am. Journ.  Med.  Sciences,
  vol. xvi. N.  S. p. 33.              1848.
Successful  Amputation  of  the  Shoulder-
  Joint, patient under Chloroform, by Paul
  F. Eve,  M.D.   Georgia.—Am.. Journal
  Med. Sci., vol.  xvii. N. S. p. 257, 1S49;
  also  Buffalo Medical Journ., vol. p. 533.
                                   1849.
Amputation of the Leg for Gangrene of the
  Foot, successfully performed on a Negro
  at the age of 102, (died of Pleurisy,) by
  Richard Jarrott,  M.D.—Charleston Sled.
  Journ., vol.  iv. p. 301.           1849.
Case of Secondary  Hemorrhage  after Am-
  putation at the Shoulder-Joint, (arrested
  by  Pressure,)  by  Charles  S.  Tripler,
  M.D.   U. S. A.— New York Journ. Med ,
  vol. iii. p. 40.                    1849.
Amputations   and  Compound  Fractures,
  with Statistics, by John O. Stone, M.D.
  New York. — New York Journ. of Med.,
  vol. iii.  N. S. p. 298.             1849.
Successful  Amputation   at  the  Shoulder-
  Joint, by Paul F.  Eve,  M.D.  Georgia.—
  Am. Journ.  Med.  Sciences, vol.  xviii.  N.
  S. p. 549.                       1849.
Successful  Amputation  at the Shoulder-
  Joint in  consequence of an injury sus-
  tained fifteen years previously, by Wm.
  Byrd Page,  M.D.   Philadelphia. — Med.
  Examiner, vol. v.  N. S.  p. 451.     1849.
Amputation of the Thigh, successful. Am-
  putation of the Leg, successful.  Ampu-
  tation of the Thigh, cured in two weeks,
  by Paul F. Eve, M.D.  Georgia.—South-
  ern Med, and Surg. Journ., vol. vi.  pp.
  261, 204.                        1850.
Amputation of the Leg, during  etheriza-
  tion, (cured.) by  Henry H. Smith, M D.
  Philadelphia. — Medical  Examiner,  vol.
  vii. N. S. p.  29.                  1851.
Amputation of the  Thigh, (for Disease of
  the Knee-Joint ;  cured,)  by  Henry  H.
  Smith, M.D. Philadelphia.—Med. Exam-
  iner, vol. vii. N. S. p. 99.         1851.
Amputation of the  Arm in a Case of Mol-
  luscum, (successful, but disease returned
  in a few weeks,) by  Henry  H. Smith,
  M.D.   Philadelphia.—Am. Journ. Med.
  Sciences, vol. xxii. N. S. p.  397.   1851. 
PAPERS  ON  DISORDERS AND OPERATIONS ON THE EXTREMITIES.   725
 Amputation at the Hip-Joint, (cured,) by
,*  John Fred.  May,  M.D.   Washington,
   D. C. —Am. Journ. Med. Sci.,  vol. xxii.
   N. S. p. 313.                     1851.
 Amputation of the Thigh near the Trochan-
   ter,  (cured,) by  Jno.  Fred. May. M.D.
   Washington.—Am.  Journ. Med. Sciences,
    vol. xxii. N. S. p. 321.            1851.
 Amputation of the Thigh for Tetanus, etc.
   (died,) by Jno. Fred. May, M.D.  Wash-
   ington.—Am. Journ  Med. Sciences, vol.
   xxii. N. S. p. 323.                1851.
 Amputation of both  Legs, (interval  of
   seven days;  cured,) by Jno. Fred. May,
   M.D.  Washington.—Am. Journ. Med.
   Sciences, vol. xxii. N. S. p. 325.    1851.
 Amputation at  the  Shoulder-Joint, (for
   Traumatic Mortification;  died,) by Jno.
   Fred. May,  M.D.  Washington.—Am.
   Journ. Med.  Sci., vol xxii. N.  S. p. 327.
                                    1851.
 Amputation at the Shoulder-Joint, (cured,)
   by J. Mason Warren,  M.D.   Boston.—
   Am.  Journ. Med. Sciences,  vol.  xxi. N. S.
   p. 338.                           1851.
 Amputation of the Thigh, and subsequent
 (  Amputation at the Hip-Joint, by Wm.
-  H. Van Buren, M.D.  New York.—New
   York Journ. Med.,  vol.  vii. N. S. p.  50,
   from Trans.  N. Y. Acad. Med.      1851.
 Encephaloid Carcinoma;  Amputation  of
   the Thigh, by L. A. Dugas, M.D.   Geor-
   gia.—South.  Med. and Surg. Journ , vol.
   vii. N. S.  p. 271.                 1851.
 Destruction of the Foot  by Fire, during
   Anaesthetic  Intoxication,  by  Spirits  of
   Turpentine; Amputation below the Knee,
   by L. A. Dugas, M.D.  Georgia.—South-
   ern Med. and Surg. Journ., vol. vii. N. S.
   p. 271.                           1851.
 Sloughing of the Knee;  Amputation of the
   Thigh, by L. A. Dugas. M.D.   Georgia.
   —Southern  Med. and  Surg. Journ., vol.
   vii. N. S.  p. 271.                 1851.
 Extensive Sloughing  of the Foot from  a
   Burn;  Amputation, by  L. A.  Dugas,
   M.D.  Georgia.—South. Med.  and  Surg
   Journ.; vol.  vii. N. S.  p. 271.       1851.
 Case of Amputation at the Shoulder-Joint,
   (cured,) by E. K. Sanborn, M. D.  Lowell,
   Massachusetts — Boston Med.  and Surg.
   Journ., vol.  xlvii. p. 89.            1852.
 Statistics of Amputation at the Hip-Joint,
   by Stephen  Smith.  M.D.  New York.—
   New York Journ. Med.,  vol. ix. N. S. p.
   184.                              1852.
 Amputation at the Knee-Joint, (cured,) by
   Willard Parker, M.D.  New York.  (This
   paper contains  statistics  of   knee-joint
   amputations.)— New York Journal  Med.,
   vol. ix. N. S. p. 307.              1852.
 Amputation  at the Shoulder-Joint, Cure,
   by Richard L. Howard, M.D  Columbus,
   Ohio.—Ohio Med. and Surg. Journ., vol.
   iv. p. 288.                        1852.
 Amputation  at the Hip-Joint, (boy, aged
   ten;  cured,)  by J. C. Bradbury.  Old
   Town, Maine. — Boston Med. and Surg.
   Journ., vol. xlvi. p. 349.          1852.
Amputation at the Hip-Joint, (adult; Fun-
   gus  Haematodes;   Lisfranc's  method ;
   three-fourths of the Flap healed by first
   intention,  but death  followed  on the
   forty-first  day after the operation,) by
   E. M Clark, M.D.   Detroit,— Peninsular
   Journ. of Med., vol  i. p. 59.       1853.
Amputation at the Shoulder-Joint, (cured,)
   by  E. R. Peaslee,  M D.  New York. —
   New  York Journ. Med., vol.  x. N. S.  p.
   297.                             1853.
Amputation of the Leg during the Progress
   of Gangrene of the Foot and Leg, (cured,)
   by  Wm. Brodie, M.D.   Detroit. — New
   York Journ. Med.,  vol. x.  N. S. p. 325.
                                   1853.
On the Comparative Merits of  the Partial
   Amputations of the Foot, (Chopart's and
   Hey's, and in favor of Hey's,) by J. M.
   Carnochan, M.D.   New York.—N. Y.
   Medical  Gazette, vol. iv.  N.  S. p. 193.
                                   1853.
Remarks on Osteo-Aneurism, with  a Case
   involvingthe Condyles of the Left Femur,
   (amputated; cured,) by J. M.  Carnochan,
   M.D.  New York.— N. Y.  Med. Gazette,
   vol.  iv. N.  S. p. 2.                1853.
A Case of Osteo Aneurism(?) occurring in
   the Os Calcis—Amputation and Recov-
   ery,   by  Willard  Parker,  M.D.   New
   York.—New  York Journ. Med., vol.  x.
   N. S. p. 316.                     1853.
Remarks on Double  Capital Amputation,
   with two Cases, by J. M. Carnochan, M.D.
   New York.—New York Med. Gazette, vol.
   iv. N. S. p. 145.                  1853.
Amputation at the Shoulder-Joint, (cured,)
   by Chas. Freiott, M.D. Troy, N.Y.—N. Y.
   Journ. Med, vol. xi. p.  331.       1853.
Amputation at the Large  Joints—Statistics
   of Ampu tat ion at the Shoulder and Elbow-
   Joints,  by Stephen  Smith, M.D.  New
   York.—New York Journ. Medicine, vol. x.
   N. S. p. 9.                       1853.
Amputation  at  the  Shoulder-Joint,  by
   Chas.  Freiott, M.D.  Troy, N. Y.—Am.
   Journ. Medical Sciences, vol. xxvii. N. S.
   p. 281.                           1854.
Statistical Account of the Cases  of Amputa-
   tion  performed at the Pennsylvania Hos-
   pital, from 1840 to 1850, by  George W.
   Norris, M D.  Philadelphia.—Am. Journ.
   Medical Sciences, vol. xxviii. N. S.  p. 13.
                                   1854.
Amputation at the Shoulder-Joint, by J. M.
   Carnochan, M.D.  New York.—American
   Journ. Med. Sciences, vol. xxviii.  N. S.
   p. 582.                           1854.
Statistics of Amputations of the  Lower Ex-
  tremities, at Bellevue Hospital, N.  Y., by
  John 0. Stone, M.D.   New York.—New
   York Journ. of Medicine, vol.  xiii.  N. S.
  p. 186.                           1854. 
726             PRINCIPLES  AND  PRACTICE  OF  SURGERY.
 Amputation at the Shoulder-Joint, by John
   Cochran, M.D.  Brooklyn,  N. Y.—Neit-
   York Journ. of Medicine, vol.  xiii. N. S.
   p 43.                           1854.
 Observations  on  Primary  and  Secondary
   Amputations, by W.  Stone, M.D.  New
   Orleans.—New York  Journ. of Medicine,
   vol. xiii. N. S.  p. 148             1854.
 Amputation at the Hip-Joint, (death,)  by
   Wm. H. Van Buren, M.D.  New York.—
   New York Journal of Medicine,  vol.  xii.
   N. S. p. 151.                     1854.
 Amputation at  the  Shoulder-Joint, (re-
   covery,) by Wm.  H. Van Buren, M.D.
   New York.—Nt-w York Journ. of Medicine,
   vol. xii. N.  S. p. 152.             1854.
 Causes of Permanent Flexion of the Knee-
   Joint after  Amputations of the  Leg,  by
   J. M. Carnochan.  M.D.  New  York.—
   Southern Med. and  Surg. Journ., vol.  x.
   N. S p. 365.                     1854.
 Amputation of the Thigh in Civil and Mili-
   tary Practice, showing the comparative
   success of Secondary Operations, by  R.
   McSherry. M.D.  Baltimore.—American
   Journal Medical Sciences, vol. xxix. N.  S.
   p. 123.                           1855.
 Injury of the  Hand, Amputation of the
   Finger; Ulcer of the Knee, Amputation;
   Disease of the  Great Toe, Amputation;
   Injury of the Finger, Amputation; Dis-
   sease of the Tibia, Amputation, by Juriah
   Harriss, M.D.  Augusta,  Ga.—Southern
  Med. and Surg. Journal, vol. xi. N. S.  p.
   399.                             1855.
Amputation at the Knee-Joint, by  Thomas
   M. Markoe,  M.D.  New York.—American
  Journ. Med.  Sciences, vol. xxxi. N. S.  p.
   555.                             1850.
Syme's Amputation through the  Knee, for
  Chronic Disease of the Joint, by Thomas
   M. Markoe, M.D.  New York.—New York
  Journal of Medicine, vol. i. 3d  series,  p.
  320.                             1856
Clinical Lectures  at the Commercial Hos-
  pital, Amputation of the Shoulder-Joint,
  by G. C. Blackman, M.D.  Cincinnati.—
   Western Lancet,  vol. xvii. p. 85.    1850.
Amputations at the Knee-Joint—Cases  in
  American practice, mainly those at the
  New York Hospital, by Thomas M. Mar-
  koe. M.D.  New York.—New York Journal
  of Medicine, vol. xvi. N. S. p. 19.    1856.
 Secondary Hemorrhage occurring fifty-six
   days after a Gunshot Wound of the Thigh;
   amputation, recovery, reported  by John
   II. Packard, M.D.   Philadelphia.—Am.
   Journ. Med. Sciences, vol. xxxiv. N. S. p.
   54.                               1857.
 Amputation at the Hip-Joint, recovery, by >,
   G.C. Blackman, M.D. Ohio.— Am. Journ. ^*\
   Med. Sciences, vol.  xxxiii.  N.  8. p.  574.
                                    1857.
 New Parisian Instrument for Amputations,
   by A. Means, M.D.  Georgia.—Southern
   Medical and Surg. Journ., vol. xiii.  N. S.
   p. 89.                             1 «57.
 Amputation  of the Hip-Joint, successful,
   by George  C. Blackman, M.D.  Ohio.—
   Western Lancet, vol. xviii. p.  7.     1857.
 Amputation at the Shoulder-Joint of a Gan- '
   grenous Arm, the gangrene having spread
   to and attacked the trunk before ampu-
   tation, by  J. F. Hammond, M.D.,  U. S.
   Army.—Am. Journ. Med.  Sciences, vol.
   xxxvi. N. S. p.  67.                1858.
 Mortification  of  both  Lower Extremi-
   ties, caused by Coagula in the Common
   Iliacs, Amputation  of both  limbs, au-
   topsy,  by J. C. Nott,  M.D.   Mobile —
   New Orleans Med. and Surg. Journ., vol.
   xv. p. 577.                       1858.
Comminuted  Fracture of the Thigh, Ampu-
   tation,  recovery,  by  W.  Stone,  M.D.
   Reported by John Morrison,  M D.  New
   Orleans.—New  Orleans  Med. and  Surg.
   Journ., vol. xv. p. 436.            1858.
Eight Cases of Amputations—Thigh 2, Leg
   2, Arm 1, Ankle-Joint 2, Shoulder-Joint
   1, (operator J  Watson, M.D.,) reported
   by George F. Shrady, M D , late  Resi-
   dent Surgeon New York Hospital.—New
   York Journal of Medicine., vol. vii. 3d
   series, p  376.                     1859.
Amputation at the Hip-Joint for Osteo-Sar-
  coma, by J. Mason  Warren, M.D.   Bos-
  ton —Boston Med. and Surg. Journal, vol.
  Ix p. 329.                        185!).
Amputation at the Shoulder-Joint, by J. D.
   Irwin,  M D., U. S.  Army.—Am Journ.
  Med. Sciences, vol. xxxviii. N. S. p  350.
                                   1.H59.
A  New Artificial Leg, by  M.  Bly,  M.D.
   Rochester,  N. Y.—New  York  Journil of
   Medicine, vol. vii. 3d series, p. 423.  1859. 
ALPHABETICAL  LIST
AMERICAN    SURGEONS,
FROM THE  YEAR  1783 to 1860  INCLUSIVE
WITH THE
TITLES OF THEIR BOOKS AND PAPERS AS QUOTED IN THE BIBLIOGRAPH-
        ICAL INDEXES OF THE VARIOUS PARTS OF THIS WORK.
  Tite dissimilarity that may be noted in the number and variety of the
papers assigned to the Surgeons quoted in  the  preceding portions of the
Bibliographical Index, must not be regarded as resulting solely from the
difference in the number of their publications, but rather as due to the fact
that their articles were so issued as  to be accessible to the Author.   Some
have doubtless escaped his notice, either in consequence of the limited cir-
culation of  the journals in which they were published, or from  the difficulty
attendant on their preservation in our libraries; but as he has  carefully ex-
amined most of those  printed in the last seventy-seven years, a large por-
tion of their writings will be found to be referred to.
                A.

ABERNETHY, JOHN  J.
    (Connecticut.)
  Case of Inguinal Hernia  ii.
ACKLEY,  Prof.  (Cleve-
    land.)
  Amputation of entire Lower
    Jaw                   ii.
ADAMS, J. G. (New York.)
  Fracture of the Skull      ii.
AGARD,  A. H.   (Ohio.)
  Ligation of External Iliac ii.
AGNEW, C.R. (New York.)
  Opacity of Cornea        ii.
  Extirpation of Eye        ii.
                "          ii.
  Ulcer at Bend  of Elbow    ii.
	AGNEW, SAML. (Harris-	
	burg.)	
	Evacuation of Water by the	
	Umbilicus ii.	458
459	AINSWORTH, F. S. (Bos-ton.) Anatomical Phenomena in Ligation of Subclavian	
235	Artery ii. ALEXANDER, WM. J.	366
228	(Virginia.)	
	Injury of Patella ii.	123
463	ALLEN, JONATHAN A. (Vermont.)	
230	Excision of a Fungus Cere-	
231	bri ii.	221
231	ALLEN, R. N. (Maryland.)	
118 |	Cephalaematoma i. (121)	409
 
728
ALPHABETICAL LIST OF AMERICAN SURGEONS.
 ALLIN, CHAS.  M.  (New
     York.)
   Retro-Pharyngeal Abscess ii. 363
 AMERMAN,  GEO.  (New
     York.)
   Laryngotomy for Syphilitic
     Disease               ii. 362
 ANDERSON,  G.   S.   D.
     (Louisiana.)
   Incised Wounds           i. 528
 ANDERSON,    W.    W.
     (Charleston.)
   Osteo-Sarcoma  of Lower
     Jaw                  ii. 234
 ANDERSON, WM.  (New
     York. )
   System  of  Surgical Ana-
     tomy                   i.  52
 ANNAN,  S. (Emmetsburg.)
   Three Cases  of Broncho-
     tomy
   Retention of Urine
 ANTONY MILTON. (Geor-
     gia.)
   Removal of part of Right
     Lung, etc.
 ARCHIBALD, W..L. (Mis-
     SISSIPPI.)
   Foreign  Bodies in Ear
 ASHBY,  CHARLES WM.
     (Alexandria.)
   Wound of Stomach
 ASHE, WM. C. (Alabama.)
   Yesico-Vaginal Fistula
 ATLEE, E.   (Lancaster.)
   Tracheotomy  in Cynanche
     Trachealis
 ATLEE, JNO. L. (Lancas-
     ter.)
   Operation  for   Diseased
     Ovaria
   Ovariotomy
ATLEE, J. L., Jr. (Lancas-
    ter.)
  Rupture of Trachea
ATLEE,   WALTER   F.
    (Philadelphia.)
  Remarkable Case of Hernia
ATLEE, WASH. L. (Phil-
    adelphia.)
  Cases of Ovariotomy      ii.
  Excision of Cervix Uteri   ii.
  Extirpation of Fibrous Tu-
    mor                   ii.
  Bilocular Ovarian Cyst     ii.
11.	360
ii.	610
ii.	368
ii.	238
ii.	458
ii.	616
  Case of Congenital  Tumor
    of Abdomen
  Removal of Tumor from
    Uterus
  Extirpation of Ovarian Tu-
    mor
  Two Cases of Ovariotomy
  Fibrous Tumors of Uterus
  Statistics of Ovariotomy
AYRES, DANIEL.  (New
    York. )
  Comminuted  Fracture   of
    Humerus
  Dislocation of Vertebrae
  Tracheotomy in Croup
  Imperforate Anus
  Adipose Tumor of Thigh
  Gunshot Wound of Shoulder
ii. 618

ii. 611

ii. 619
ii. 619
 i.  55
ii. 619
 i. 669
 i. 144
ii. 362
ii. 622
ii. 118
ii. 119
BACHE,  FRANKLIN.
    (Philadelphia.)
  On Acupuncturation
231
231
ii. 360
618
620
ii. 362
ii. 461
620
617

617
618
BADGER, F. H.   (Tennes-
    see.)
  Salivary Fistula          ii. 231
BAILEY, THOS. P. (South
    Carolina. )
  Case of Abdominal Wound ii. 459
BAKER,  A.,  Jr.   (New
    York. )          »
  Lithotomy in the Female   ii. 612
BAKER, ANDREW.  (New
    York. )
  Fracture of both Maxillae  i. 668
BARCLAY, A. (New York.)
  Occluded Os Tincae        ii. 617
BARKER, B. FORDYCE.
    (New York.)
  Catheterizing  of Air  Pas-
    sages                 ii. 362
BARKER, THOMAS   C.
  Simultaneous Dislocations  i. 744
BARNES,  ENOS.    (New
    York.)
  Foreign Bodies in the Tra-
    chea                  ii. 360
BARNWELL, WM. (Phil-
    adelphia.)
  Diseases of Warm and Viti-
    ated Atmospheres       i.  51 
ALPHABETICAL LIST OF AMERICAN SURGEONS.        729
 BARON,  ALEX.  (South
     Carolina.)
   Elongation of Tibia       ii  717
 BARTLETT, E. M. (Louisi-
     ana.)
   Extirpation of the Clavicle ii. 367
 BARTON, BENJ. S.  (Phil-
     adelphia.)
   Memoir on Goitre          i.  51
 BARTON, JOHN RHEA.
     (Philadelphia.)
   Artificial Joint  in Anchy-
     losis                   ii. 721
   Operation  for  Tumor  of
     Lower Jaw            ii. 234
   Operation  for  Artificial
     Anus                  ii. 461
   Lithotomy Forceps        ii. 611
   Inguinal Aneurism         ii. 462
   Recto-Vaginal Fistula     ii. 615
   Caustic in Pseudarthrosis    i. 670
   Treatment of Anchylosis of
     Hip                   ii. 721
   Treatment of Anchylosis of
     Knee                  ii. 722
   Deformity from Fracture of
     Leg                   ii. 722
 BATCHELDER,Dr. (Mass.)
   Resection of  Lower Jaw   ii.  235
 BATCHELDER, J. P. (New
     York.)
   Dislocation of Radius      i. 744
   On Strictures of the Ure-
     thra                   ii.  609
   Inverted Toe-Nail         ii  718
 BAUER,  LOUIS.   (Brook-
     lyn.)
   Caries of the  Vertebrae     ii.  464
 BAXTER,  JOHN.   (New
     York.)
   Seton in Pseudarthrosis     i.  670
 BAYARD, ROBERT. (New
     Brunswick.)
   Diseased Sciatic Nerve     ii.  717
 BAYLESS,  G. W.   (Mis-
     souri.)
   Ovariotomy               ii.  620
BAYNE, JNO. H.   (Mary-
     land.)
   Rupture of Uterus         ii. 620
BEAUMONT, WM.  (Fort
     Niagara.)
  Experiments on Digestion,
    through a Wound in Sto-
     mach                   ii. 458
(New
i. 745
ii. 615
617
 BECK, J. C.
   Old Dislocations
 BEDFORD,  G.  S
     York.)
   Vaginal Hysterotomy
   Sarcomatous   Tumor  of
     Uterus                 ii
 BEEZLE Y, THEOPHILUS
     E.  (New Jersey.)
   Scirrhous Tumor of Caecum ii. 458
 BELL, JOHN.  (Philadel-
     phia.)
   Averill's Operative Surgery i
 BELL, JOHN.  (Iowa.)
   Gastrotomy               ii
 BELLAMY, C.E. (Georgia.)
   Resection of Elbow-Joint  ii.
 BENNETT, E. S. (Charles-
     ton.)
   Tumor on Occiput         i
 BENNETT, E. P. (Connec-
     ticut.)
   Ascites                   ii
   Ovariotomy               ii
                           ii
   Ligation of Femoral Artery ii.
   Multilocular Cyst         ii.
 BENNETT, H. N. (Connec-
     ticut.)
   Ovariotomy               ii.
                           ii.
   Popliteal Aneurism        ii.
 BETHUNE, S. R.  (Boston.)
   Malignant Ophthalmic Dis-
     ease
 BETTON, THOS. F. (Phil-
     adelphia.)
   Lacerated Urethra from  a
     Fall
 BIGELOW,  HENRY  J.
     (Boston.)
   Manual  of Orthopedic Sur-
     gery
   Gutta-Percha in Strictures
   Ligation of Internal Iliac
   Anaesthetic Agents
   Tracheotomy in Croup
   Injection in Inguinal Hernia ii. 460
BIZZELL, H. A.  (North
     Carolina.)
   Caesarean Section         ii. 621
BLACKMAN, GEORGE C.
    (Cincinnati.)
  Hand-Book for Military Sur-
    geons                   i. 57
52
620
723
409
459
619
620
721
619
620
620
721
ii. 230
ii. 610
 i. 540
ii. 608
ii. 462
 i. 200
ii. 362 
730
ALPHABETICAL  LIST OF AMERICAN  SURGEONS.
  Strangulated Hernia       ii. 460
  Genio-plasty              ii. 236
  Ligation of Carotid       ii. 365
  Ligation of both Primitive
     Carotids               ii. 365
  Osteo-Sarcoma  of  Lower
     Jaw                   ii. 235
  Priority in Resecting Lower
     Jaw                   ii. 235
  Strangulated Hernia       ii. 460
  Reduction of Dislocation of
     Eighty days' Standing   i. 744
  Caries of Temporal Bone  ii. 228
  Black Cataract            ii. 231
  Removal of Lower Jaw    ii. 236
  Ligation of  Carotid  Arte-
     ries                    ii. 365
  Ligation of Primitive Caro-
     tid                    ii. 365
  Removal of Clavicle       ii. 367
             Scapula       ii. 367
  Wutzer's  Operation   for
     Hernia                 ii. 461
  Vesico-Vaginal  Fistula    ii. 616
  Femoral Aneurism         ii. 721
  Resection of Elbow-Joint  ii. 723
  Resection of Head of Hu-
     merus                  ii. 723
  Resection of Head of Hu-
     merus                  ii. 723
  On Amputation of Shoulder-
     Joint                  ii. 726
  Amputation at Hip-Joint . ii. 726
                           ii. 726
BLEEK, P.  C. (New York.)
  Abscess in Bone           i. 289
                           i. 704
BLY, M.   (Rochester.)
  Artificial Leg             ii. 726
BODENHAMER, W. (New
     York.)
  Diseases of Rectum       i.  57
BOLING, WM. M.   (Ala-
     bama.)
  Ligation of External  Iliac  ii. 463
BOLTON, JAMES.  (Rich-
     mond.)
  Test for Safety Point in An-
     aesthesia               i. 200
  Report on Utility of Anaes-
     thetics                 i. 200
  Hemorrhoids              ii. 622
BOLTON, JAMES.  (New
     York. )
  Extirpation of the Eye     ii. 230
BOND, HENRY.  (Phila-
    delphia. )
  Forceps for Bodies in CEso-
    phagus                 ii. 359
  New Splint for Elbow-Joint ii. 719
BOSSUET, JOS.  (Massa-
    chusetts.)
  Lithotomy  for  Extra-Ute-
    rine Foetus             ii. 611
BOWDITCH,  HENRY  J.
    (Boston.)
  Maunoir on Cataract       i.  53
  Paracentesis Thoracis      ii. 369
  Necessity of Operation     ii. 369
  Paracentesis Thoracis      ii. 369
BOWEN, WM. C.  (Provi-
    dence.)
  Amputation of Shoulder   ii. 723
BOWEN, WM.  S.  (New
    York. )
  Secondary Abscesses       i. 289
BOYD,  JOHN  M.  (Ten-
    nessee.)
  Extirpation of Uterus      ii. 617
BOZEMAN, N. (Alabama.)
  Elephantiasis of Scrotum   ii. 610
  Vesico-Vaginal Fistula    ii. 616
                           ii. 616
BRADBURY, J.C. (Maine.)
  Amputatiou at Hip-Joint  ii. 725
BRADLEY,  M.  D.  (Ala-
    bama.)
  Gastrotomy               ii. 619
BRAINARD, DANL. (Chi-
    cago. )           •
  Plastic  Operation for  Ec-
    tropion                 ii. 229
  Amputation   of   Superior
    Maxillary Bone         ii. 233
  Collodion  in  Erectile  Tu-
    mors                    i. 409
  Resection of Upper  Jaw   ii. 233
  Immobility of Lower Jaw  ii. 234
  Resection of Lower Jaw, etc. ii. 235
  Tracheotomy  for Abscess  ii. 361
  Iodine in Spina Bifida     ii. 464
  Ununited Fracture of Femur i. 670
  Amputation at Hip-Joint  ii. 724
  Aneurismof Femoral Artery ii. 720
  Pseudarthrosis—wired      i. 670
  Spina Bifida              ii. 464
  Ligation of Femoral Artery ii. 721
  Poisoned Wounds          i. 527
  Deformity after Fracture    i. 669
  Ununited Fractures         i. 670 
ALPHABETICAL  LIST  OF AMERICAN SURGEONS.        731
   Tracheotomy             ii. 263
   Paracentesis Thoracis      ii. 369
 BRANDER, Dr.
   Puncture of Bladder       ii. 611
 BRANDON, D.  S.  (Geor-
     gia.)
   Stone in the Bladder       ii. 613
 BRENT,  JOHN C.  (Ken-
     tucky.)
   Removal of  Tumor   from
     Neck                  ii. 363
 BRIGGS,   LEMUEL   W.
     (Rhode  Island.)
   Paracentesis Thoracis      ii. 369
 BRIGHAM,   AMARIAH.
     (Connecticut.)
   Brass Nail in Lungs for  a
     year                   ii. 360
   Removal of seventeen inches
     of Intestine            ii. 458
   Sequel to     do.    do.   ii. 458
 BRINTON,  JOHN H.
     (Philadelphia.)
   Valve in Right Spermatic
     Vein                   ii. 610
 BRITE.J. W.  (Kentucky.)
   Prolapsus Ani            ii. 621
   Extraction  of  Fish-Hook
     from Stomach          ii. 359
 BRODIE, R. L.   (U. S. A.)
   Dislocation of Femur        i. 745
 BRODIE, WM.  (Detroit.)
   Amputation of leg during
     gangrene               ii. 725
 BROOKE, A.
   On Caesarean Section      ii. 621
 BROOKS, B.   (Texas.)
   Tumors of the Neck       ii. 363
 BROWN, BEDFORD.
     (Virginia.)
   Hydrocele                ii. 619
 BROWN, J.  B.   (Boston.)
   Myotomy in Torticollis     ii. 359
   Club-Foot cured at an ad-
     vanced age             ii. 719
BROWN, J. H.   (Maine.)
   Traumatic Aneurism       ii. 721
BROWN, JOS. B.  (U. S.
     Army.)
   Ligation of Common  Ca-
     rotid                   ii- 365
BROWN, M. FRANKLIN.
     (Missouri.)
   Gastrotomy               ii- 619
   Diseases of the Bones       i.  704
(Phil-
Jr.
ii. 363
 i. 668

ii. 365
ii. 459
462
616
ii. 221
ii. 359
ii. 361
ii. 361
n.
ii. 722
ii. 722
ii. 723
BRYAN, JAMES.
     ADELPHIA.)
   Tumors
BUCK,  GURDON,
     (New York.)
   Treatment of Badly United
     Fractures
   Ligation of Common and
     Internal Carotids
   Post Fascial Abscess
   Ligation of  Femoral Ar-
     tery, etc.
   Vesico-Vaginal Fistula
   Researches on Hernia Ce-
     rebri
   Extension in Wry-Neck
   (Edematous Laryngitis
   Tracheotomy
   Operation for  Closure of
     Urethra                ii. 611
   Resection of Elbow-Joint   ii. 722
   Resection of Olecranon Pro-
     cess                   ii. 722
   Anchylosis of Knee
   Excision of Elbow-Joint
   Resection of Knee-Joint
BUCKNER, P. J.  (Ohio.)
   Ovariotomy               ii. 619
   Mesenteric Tumor         ii. 619
BUEL, HENRY W.  (New
     York. )
   Statistics of Amputations   ii.
BULLOCK, W. G.  (Savan-
     nah.)
   Resection of Lower Jaw    ii.
BURGE,  J.  II.  H.  (New
     York.)
   New  Apparatus for Frac-
     tures of Thigh          i.
BURGESS, RICHARD.
   Two Cases of Bronchotomy ii.
BURR, J. PL ATT.  (Louisi-
     ana.)
   Anchylosis of Knee
BUSH,  J. M. (Lexington.)
   Amussat's   Operation  for
     Artificial Anus
  Dudley's Operations of Li-
    thotomy
  Lithotomy and Lithotrity
BUSHE, GEORGE. (New
    York. )
  On Diseases of the Rectum
  Torsion of Arteries
  Telangiectasis             i. 409
724
235
669
360
ii. 722
ii. 461
11.	612
11.	612
i.	53
l.	199
 
732        ALPHABETICAL LIST OF AMERICAN  SURGEONS.
  Scirrhus of Lachrymal Gland ii. 229
  Excision of Tonsils        ii. 237
  Removal of Parotid Gland  ii. 358
  Telangiectasis of Cheek     ii. 364
  Aneurism of Carotid       ii. 364
  Ligation of Right Common
    Iliac                   ii. 462
  Operation for Phymosis     ii. 608
  On Hypospadias           ii. 608
  Congenital Hydrocele      ii. 610
  Bilateral  Operation  for
    Stone                  ii. 611
  On Popliteal Aneurism     ii. 720
BUTLER, J. C. (Virginia.)
  Amputation of Foot       ii. 724
BUTT, ROBERT B.  (Vir-
    ginia.)
  Resection of Ulna.         ii. 721
BYRD, H. L.  (Savannah.)
  Hydrocephalus            ii. 229
BYRNE,  CHAS.   (U.  S.
    Army.)
  Vaginal Fistula            ii. 614
  Fistula  between  Vagina,
    Bladder, and Rectum     ii. 615
               c.

CABELL, P. H.  (Alabama.)
  Easy mode of Constructing
    Bougies
CAIN, D. J. C.  (Charles-
    ton.)
  Nutritive Enemata to sus-
    tain Life
  Imperforate Prepuce
CALDWELL, CHARLES.
    (Philadelphia.)
  Translation of Bichat on the
    Bones
CALHOUN,P. (Louisiana.)
  Immobility of Lower Jaw
CAMPBELL, GEORGE W.
    (Tennessee.)
  Exsection of  half of Lower
    Jaw
  Case of Artificial Anus
  Operation of Lithotomy
CAMPBELL,  H. F.  (Geor-
    gia.)
  Traumatic Tetanus
  Injuries of Cranium
  Ligation  of  Primitive  Ca-
    rotid                  ii. 365
ii. 609
ii. 360
ii. 608
i.  51
ii. 234
ii.	234
ii.	461
ii.	611
i.	528
ii.	228
  Removal of Pin from Duct
    of Wharton             ii. 236
  Strangulated Ventral Hernia ii. 461
  Bilateral Lithotomy        ii. 612
CAMPBELL, J. J.   (New
    York.)           ,
  142 Cases of Fracture     i. 669
  Trephining                ii. 227
  Ligation of Femoral Artery ii. 721
CAMPBELL, ROBERT.
    (Georgia.)
  Inverted Toe-Nail         ii. 718
     "       "             ii. 118
CARNOCHAN,  JOHN
    MURRAY. (NewYork.)
  Exsection of Nerves in Neu-
    ralgia                  ii. 231
  Priority in Division of Mas-
    seter                   ii. 234
  Amputation of Lower Jaw  ii. 235
  Ligation of Femoral Artery
    for Elephantiasis
  Best Amputation for Foot
  Osteo-Aneurism
  Double Amputations
  Resection of Ulna
           " Radius
  Amputation  at  Shoulder-
    Joint
  Permanent Flexion at Knee-
    Joint
CARPENTER, B. D. (Long
    Island.)
  Ice in Tetanus
CARROLL, THOS. (Ohio.)
  Vaginal Rectocele and Va-
    ginal Herniae
CARTWRIGHT,  S.  A.
    (New Orleans.)
  Laryngotomy  for  Water-
    melon Seed
  Chloroform
  Ovarian Tumor
CASEY, H. R. (Georgia.)
  Eccentric Tetanus
CASTLE, A, C. (Boston.)
  Removal of Ring from Fin-
    ger with Quicksilver
CATHRALL, ISAAC.
    (Philadelphia.)
  Case of double Hare-lip
CATLETT, C. G.   (Mo.)
  Compression of the Brain
  Compression of the Brain
ii.  121
ii.  125
ii.  125
ii.  125
ii.  123
ii.  123
ii.  123
ii.  125

ii.  125
i. 527
ii. 461
ii. 360
 i. 200
ii. 619
i. 528
ii. 718
ii. 232

ii. 228
ii. 228 
ALPHABETICAL LIST OF AMERICAN SURGEONS.
733
 CHADBOURNE, THOS.
     (New York.)
   Cases of Uterine Polypus   ii 617
 CHAILLE, STANFORD.
     (New Orleans.)
   Resection of Lower Jaw   ii. 236
 CHANCELLOR, C.  W.
     (Virginia.)
   Diaphragmatic Herniae     ii. 614
 CHAPIN, ALONZO. (Bos-
     ton.)
   Apparatus for Fractures of
     the Leg                i. 669
 CHAPMAN, B. F.
   Accidental Impalement     ii 622
 CHASE, HEBER.  (Phila-
     delphia.)
   Report  of Committee  on
     Hernia                 i.  53
   Cases of Deformed Feet     ii. 719
   False Anchylosis of Knee-
     Joint                  ii. 722
 CHENY,E. D. (Mississippi.)
   Ligation of  Common  Ca-
     rotid                   ii 366
 CHEW, E. R.  (Louisiana.)
   Instrument to divide Stric-
     ture of Urethra         ii. 608
 CHISOLM, J. J. (Charles-
     ton.)
   Suture of Intestine         ii. 459
   Traumatic Tetanus        i. 528
   Bandage  for Fracture of
     Clavicle                i. 669
   Luxation of Femur        i. 744
   Trephining               ii. 228
   Impermeable Stricture      ii. 609
   Tubercular Testicle        ii. 610
   Necrosis of Femur         ii. 719
 CHURCH,  W.  II.   (New
     York.)
   Compression in Aneurism   ii. 721
 CLARK, ED. H.  (Boston.)
  Aural Surgery            ii. 238
  Perforation of Tympanum  ii. 238
 CLARK, E. M.  (Detroit.)
  Amputation at Hip-Joint   ii. 725
 CLARK, JOHN C. (Ohio.)
  Artificial Anus           ii. 460
 CLARKE, A.  (New York.)
  Oedema  Glottidis         ii. 361
CLARKE,  A.  BRYANT.
     (Massachusetts.)
  Imperforate Anus         ii. 622
 CLARKE,  J. HENRY.
     (New Jersey.)
   Constitutional   Effects  of
     Anaesthetics             i. 200
 COATES,   REYNELL.
     (Philadelphia.)
   Cases of Urinary Calculi   ii. 611
 COBB, W. H. (Missouri.)
   Gunshot Wound of Joint  ii. 718
 COCHRAN, JOHN.
     (Brooklyn.)
   Amputation at  Shoulder-
     Joint                 ii. 726
 COCKE, JOSEPH. (Mary-
     land.)
   Admission  of  Air  into
     Wounds              ii  458
 COGSWELL, MASON  F.
     (Connecticut.)
   Ligation of Carotid       ii  364
 COLLINS,  RANSOM M.
     (Louisiana.)
   Case of Blind Hemorrhoids ii. 621
 COMEGYS, C. G.  (Ohio.)
   History of Medicine        i.  56
 CONNELL, A. (Marietta.;
   Dry Gangrene             i  284
 COOK, J. H.
   Fistulous  Opening  in
     Stomach              ii  458
 COO LEY, F.  (Missouri.)
   Occlusion of the Vulva    ii. 615
 COOLIDGE, R.  H.  (Wash-
    ington.)
   Henderson on Recruits     i.  56
   Vital Statistics of War     i  528
 COOPER, E. S.   (Califor-
    nia.)
   Ligation of the  Innominata ii.  366
 COOPER, E. S.  (Illinois.)
   Exercise in Coxalgia      ii.  718
 COOPER,  SAMUEL.
    (Philadelphia.)
   Properties and  Effects  of
    Stramonium            i   51
 CORNELL, EDWARD.
    (New York  )
  Intestines  through Dia-
    phragm, etc.            ii.  368
CORSE,  JAS.   (Philadel-
    phia.)
  Foreign Body in Ear      ii.  238
COSGRAVE,M. (Illinois.)
  Extirpation of Lower Jaw  ii.  236 
734        ALPHABETICAL LIST OF AMERICAN  SURGEONS.
230
231
238
i31

620


718

369
ii. 609
COWLING, JAMES. (New
    Orleans.)
  Scirrhus  of  Lachrymal
    Gland
  Rupture of Cornea
  Thickening of Tympanum
COX, ABRAHAM L. (New
    York.)
  Instrument to excise Tonsils
CRAIG,  F.  (Kentucky.)
  Ovariotomy
CRANE, J. S. (South Caro-
    lina.)
  Steatomatous Tumor
CRAVEN, Dr.  (Virginia.)
  Paracentesis in Empyema
CRAWCOM, J. L.  (New
    Orleans.)
  Substances introduced into
    the Urethra
CRITTENDEN,A. J. (Vir-
    ginia.)
  Ligation of the Ulnar Ar-
    tery                   ii. 721
CROCKETT, R, (Virginia.)
  Death from Ether and Chlo-
    form                   i. 200
CROSBY, JOSIAH.  (New
    Hampshire. )
  Extension in Fractures     i. 668
CUMMINS, ROBERT  II.
    (Virginia.)
  Stricture of (Esophagus
CURTIS, R. S. (Chicago.)
  Extirpation of Clavicle
CUSACK, J. W.
  Ligation of Carotid
CUTTER, BENJ.  (Mass)
  Dislocation of Thumb
               D.

DALE,  THOS. F.  (Pitts-
    burg. )
  Depressed Fracture of Cra-
    nium                  ii. 227
DARET, H. (New Orleans.)
  Ligation of External Iliac  ii. 463
DARRACH, WM. (Phila-
    delphia.)
  Spontaneous  Cure of Aneu-
    rism                  ii. 366
  Drawings of  Anatomy  of
    Groin                   i.  52
11.	360
ii.	367
ii.	364
i.	745
  Obliteration of Arteries    ii. 720
  Spontaneous Cure of Aneu-
    rism                  ii. 120
DAVENPORT, E. J. (Bos-
    ton.)
  Encysted Tumors of Eyelids ii. 229
  Operation for Artificial Pu-
    pil                    ii. 230
  Operation for Strabismus  ii. 230
  Polypi of Meat. Audit. Ext. ii. 238
DAVIDSON.WM. (Indiana.)
  Tracheotomy for  Grain of
    Corn                  ii. 361
DAVIS, EDW'D G.  (Phil-
    adelphia.)
  Beck on Ligation of Arteries  i.  53
DAVIS, II. G. (New York.)
  Morbus Coxarius          i. 182
DAVIS, N. S.  (New York.)
  Congenital Double  Hare-lip ii. 232
DEADERICK, W. H. (Ten-
    nessee.)
  Excision of Lower  Jaw    ii. 234
DEANE, JAMES.  (Green-
    field.)
  Congenital  Fissures  of
    Palate
  Case of Gastrotomy
  Lithotripsy
  Ovariotomy
  Ligation of Femoral Artery ii
DEAS, E. H.
  Ligation of Common Carotid ii. 365
DEJARNETT.R. (Texas)
  Tracheotomy for Hydropho-
    bia
DELAFIELD, EDW. (New
  York. )
  Artificial Pupil           ii.
  Extirpation  of Eye       ii.
DELANEY, M. G.   (U. s.
    Navy. )
  Castration   of Enlarged
    Testis                 ii.
  Amputation in Glossocele  ii.
DEPEYRE, L. (New York.)
  Case of Lithotripsy       ii.
DETMOLD,  WM.   (New
    York.)
  Abscess in  Substance  of
    Brain                 ii
  Cases  of Club-Foot       ii
DE VESEY, LOUIS. (Cali-
    fornia. )
  Bibron's Antidote          i. 521
ii.  238
ii.  619
ii.  614
ii.  619
   721
ii. 362
230
229
609
236

614
228
119 
ALPHABETICAL  LIST  OF AMERICAN SURGEONS.        735
i. 668
ii. 369
ii.  719
ii.  719
ii. 369
 DEWEY, G.M.  (Missouri.)
   Five Fractures occurring in
     a Child
 DE  WITT,  STERNS.
     (Georgia.)
   Empyema
 DICKSON,  JAMES   II.
     (New York.)
   Division of Tendo-Achillis
   Case of Talipes Equinus
 DICKSON, S.  HOWARD.
     (Tennessee.)
   Paracentesis Thoracis
 DILLSON, J.  H.  (Pitts-
     burg.)
   Gum-Elastic  Catheter  in
     Bladder
 DIX, J. II. (Boston.)
   On Strabismus
 DIXON, E. II.  (Boston.)
   Interrupted Suture in Cleft
     Palate
 DOANE, A.SIDNEY. (New
     York.)
   Dupuytren's'Surgical  Clinic
   Blandiu's  Topographical
     Anatomy
   Surgery  illustrated   frora
     Cutler,  Hind,  Velpeau,
     and Blazius
 DOE, JOHN. (Vermont.)
   Luxation of Thumb
 DONNELLAN, M.  (La.)
   Ligature  in Carcinoma of
     Tongue
 DORSEY,  JOHN  SYNG.
     (Philadelphia.)
   Elements of Surgery
   Cooper's Surgical Dictionary i
   Trephining Fractured Skull ii. 227
   Copper Coin in Oesophagus ii. 359
   Ligation of External  Iliac  ii. 462
   Steatomatous  Tumor  from
     Back
DOUGHTY,W. H. (Georgia.)
  Pathology of Hydrophobia  i
DOUGLASS, JNO.  (South
     Carolina.)
  Ovarian Dropsy
DOWLER,  BENNETT
     (New Orleans.)
  Tarantula Poison
  Meningeal Tumors
  Cataract in the Aged
  Cure of Aneurism
ii.	614
ii.	230
ii.	228
i.	53
i.	53
i.	53
i.	744
ii.	236
i.	52
i.	511 r>r.te
ii. 463
527
ii.  619
 i.  527
ii.  228
ii.  230
   721
n.
DOWLER,  M.  M.  (New
     Orleans.)
  Fracture of Cranium       i. 668
DRAYTON, H. E.  (Phila-
     delphia.)
  Ligation  of  Right  Sub-
     clavian                 ii. 367
DUDLEY,  BENJ. WINS-
     LOW. (Lexington.)
  Bandage  in   Gunshot
     Wounds, etc.
  Injuries of the Head
  Trephine in Epilepsy
  Ligation of Subclavian
  On Hydrocele
DUDLEY,E. L. (Lexington
  Trephine in Epilepsy
DUGAS, L.  A.  (Georgia.)
  Tapping in Hydrocephalus
  Pharyngeal Tumors

  Tracheotomy
  Wounded Intestine
  Lithotomy
  Paronychia
  Femoral Exostosis
 Epidemic Furuncles
 Fungous Tumor of Arm
 Non-Congenital  Talipes
   Equinus                ii. 719
 Non-Congenital  Talipes
   Varus                 ii. 719
 Non-Congenital  Talipes
   Varus                 ii. 719
 Encephaloid Carcinoma    ii. 725
 Destruction of Foot by Fire ii. 725
 Sloughing of Knee        ii. 725
 Sloughing of Foot         ii. 725
 Spermatorrhoea            i. 344
 Collodion,  Gutta-percha,
  etc. in Burns            i. 199
 Fatal Effects of Chloroform
  and Ether              i. 200
 Discovery of Anaesthetics   i. 200
 Operations under Local An-
  aesthetics               i. 200
 Local Anaesthesia by Cold  i. 200
 On Gangrene             i. 289
 Lipoma of Occiput         i. 409
 Quinine in Tetanus        i. 527
Chloride of Soda iu Burns  i. 527
Glanders in Man           i. 527
Treatment of Fractures     i. 668
1	199
11.	227
ii.	227
11.	366
11.	610
■)	
11.	228
ii.	229
11.	234
11.	360
ii.	362
11.	459
ii.	613
ii.	718
ii.	718
11.	718
ii.	722
ii.	718
ii.	718
 
736        alphabetical list op  American  surgeons.
668
668
668
669
669
744
745,

228
    I

228
230
230
231

232 j

237

362
363

363
367
   Fractures of Clavicle
   Fractures in Country Practice
   Fracture of Scapula
   Fractures of Femur
   Fracture of Neck of Scapula
   Luxation of Radius and Ulna
   Diagnosis in Dislocations
   Fall from a Height of Fifty
     Feet                   ii.
   Fall from a Height of Twelve
»     Feet                   ii.
   Exophthalmia             ii.
   Eye Destroyed by Bird-shot ii.
   Gunshot Wound of Face    ii.
   Mouth  Ripped Open by a
     Cow's Horn             ii.
   Snoring Prevented  by Ex-
     cision of Uvula          ii.
   Foreign  Bodies in  Air-
     Passages               ii.
   Tumors of the Neck        ii
   Extirpation of a Cervical
     Tumor                 ii.
   Extirpation of the Mamma  ii.
   Extirpation of Scirrhus Tu-
     mors of the Mamma      ii. 367
   Fibrous  Tumors  of  the
     Mamma                 ii. 367
   Ligation of  the Ischiatic
     Artery                  ii.
   Genito-Urinary Apparatus  ii.
   Stricture of the Urethra    ii.
   Accidental Castration      ii.
   Lithotomy (3 papers)       ii.
   Case of Lithotrity         ii.
   Lithotrity                 ii.
   Report on  Lithotrity  and
     Lithotomy              ii. 614
   Report on  Lithotrity  and
     Lithotomy              ii.
   Lithotrity in the Female    ii.
   Use of Pessaries           ii.
   Utero-Abdominal Braces,
     etc.                     ii. 617
   Sudden Rupture of Ovarian
     Tumor                  ii.
   Prolapsus Recti            ii.
   On Hemorrhoids           ii.
DUHAMEL, W. J. C.
     (Washington.)
   Ligation of Arteries       ii.  721
DUN LAP, A.  (Ohio.)
   Ovariotomy                ii.
   Case of Ovariotomy        ii.
DURKEE, SILAS. (Mass.)
   Gonorrhoea and Syphilis    i.
462
608
609
609
613
614
614
614
614
617
620
622
622
619
620

 56
                E.

EDGAR, WM. F.   (U.  S.
     Army.)
  Gunshot Wound of Arm    ii. 718
ELLIS, JOHN. (Michigan.)
  Ligation of both Carotids   ii. 364
EMMET, THOMAS ADDIS.
     (New York.)
  Amputation  of  the  Mam-
     mary Gland             ii. 368
EMMET, S. S.  (Missouri.)
  Bullet in Bronchial Tube    ii. 362
ESSELMAN,  JOHN L.
     (Nashville.)
  Extirpation of Uterus      ii. 617
EVE, J. A. (Georgia.)
  Report  on Chloroform      i. 200
EVE, PAUL F.  (Georgia.)
  Ununited Fracture  of Rib   i. 670
  Laryngo-Tracheotomy      ii. 362
  Statistics of Ligation of In-
     nominata                ii. 365
  Hypertrophy  of the Male
     Mamma
  Remarkable Cases
  Cases of Urinary Calculus
     <<      t<       n
  Anaesthesia in Operations
  Compound Fracture of Cra-
    nium                   ii. 227
  Removal of  large  Polypus
    Narium through Pharynx ii. 232
  Immobility of Lower Jaw   ii. 234
  Amputation of half of Lower
    Jaw                    ii. 234
  Spina  Ventosa  of Lower
    Jaw                    ii. 235
  Foreign Body passing from
    Pharynx to Larynx     ii. 360
  Ligation of  Primitive Ca-
    rotid                   ii. 365
  Fungus   Haematodes of
    Face, etc.               ii. 368
  Dilating Strictures         ii. 608
  Bilateral  Operation for
    Stone
  Case of  Lithotomy
11.	368
i.	56
n.	613
ii.	613
l.	200
Bilateral Lithotomy
Excision of Uterus
Amputation at  Shoulder-
  Joint
Amputation at  Shoulder-
  Joint
Amputation at Thigh
ii. 612
ii. 612
ii. 612
ii. 612
ii. 617

ii. 724
124
124 
ALPHABETICAL LIST OF AMERICAN SURGEONS.
737
  Amputation  of Leg  and
    Thigh
EWART, D.  E.  (South
    Carolina.)
  Atresia Vaginae
EWING,  J.  HUNTER.
    (Philadelphia.)
  Acupuncturation  in  Neu-
    ralgia
ii. 124
ii. 616
ii. 231
P.
(Penn-
460
FAHNESTOCK, P
    SYLVAN I A.)
  Strangulated  Umbilical
    Hernia                ii
FAHNESTOCK,  WM. B.
    (Pennsylvania.)
  Instrument to Excise Tonsils ii. 231
  Aneurismof Brachial Artery ii. 120
FALCONER, CYRUS.
  Caesarean Section
FARRINGTON,  J.  M.
    (New York.)
  Trephining
FATTAWAY,A. (Georgia.)
  Polypus Uteri            ii
FENNER, C.  P. (Memphis.)
  On Chloroform             i
  On Cataract              i
  False Anchylosis of Jaw   ii
  Osteo-Sarcoma of Lower Jaw ii
  Lithotrity                ii
ii. 621
i. 228
618
  200
  231
  234
  235
  614
ii. 616
233
364
616
  Vesico-Vaginal Fistula
FINLEY,  MICHAEL   A.
    (Maryland. )
  Ligation  of  Carotid   for
    Fungus                ii.
  Ligation of Carotid       ii.
FIN NELL,   T.  C.   (New
    York. )
  Vesico-Vaginal Fistula    ii.
FLEMING, AND.   (Phila-
    delphia.)
  Spontaneous Rupture of Eye ii. 231
  Wound of Abdomen       ii. 459
FLINT, JOSHUA B. (Phil-
    adelphia.)
  Druitt's Modern Surgery
FOLSOM,  N.  L.  (New
    Hampshire.)
  Umbilical Hernia
FOLTZ.J.M. (U.S. Navy.)
  Enormous   Steatoma from
    Side                  ii
    VOL. II.—41
i.  54
ii. 460
368
FOSTER, Dr. (N. Orleans.)
  Tracheotomy             ii. 362
FOSTER,  S.  CONANT.
    (New York.)
  Compressed Sponge in Ab-
    scess of Breast          ii. 368
FOUNTAIN, E. J. (Iowa.)
  Cases of Dislocation       i. 144
  Aneurismof Femoral Artery ii. 121
FOX, GEO. (Philadelphia.)
  Compressed  Comminuted
    Fracture of Skull       ii. 221
  Ligation of Primitive Ca-
    rotid                  ii. 365
  Inguinal Aneurism        ii. 463
FRANKLIN, D. D.  (Ohio.)
  Ovariotomy              ii. 619
FREESE, J. R.  (Illinois.)
  Excrescence of Anus       ii. 622
FREIOTT, CHAS. (Troy.)
  Amputation at  Shoulder-
    Joint                 ii. 725
  Amputation at  Shoulder-
    Joint                ii. 725
FRICKE, G.  (Baltimore.)
  Operations for Cataract    ii. 230
             Artificial Pupil ii. 230
FRIES, G.   (Cincinnati.)
  Hydrocele                ii. 610
  Ovariotomy              ii. 620

              G.
GAINES, E. P. (Alabama.)
  Gunshot Wound of Lung
GAINES and  HENRY.
    (Kentucky.)
  Resection of Lower Jaw
GAITHER, N. (Kentucky.)
  Bandage in Wounded Ar-
    teries
GALBRAITH, B. A. (Louis
    VILLE.)
  Dry Gangrene
GALLUP,  JOSEPH  A.
    (Vermont.)
  Extirpation of Ovaria
GARDEN,  THOMAS  J.
    (Virginia.)
  Division of Tendo-Achillis
GARDNER, WILLIAM H.
    (Kentucky.)
  Stone in the Bladder
GARRAT, A. C.  (Mass.)
  Case of Impalement
ii.	368
ii.	235
i.	199
i.	289
ii.	618
ii.	719
ii.	613
ii.	368
 
738        ALPHABETICAL  LIST  OF AMERICAN SURGEONS.
GASTON,  J. F.   (South
    Carolina.)
  Operation for Immobility of
    Jaw                  ii.
GASTON, J. M. F. (South
    Carolina.)
  Removal of Hemorrhoids  ii.
GAUTIER, J.  (Alabama.)
  Laceration of the Urethra  ii.
GAY, Dr. (New York.)
  Fracture of Femur         i.
GEDDINGS, E.  (Charles-
    ton. )
  Sanguineous Tumors on
    Head                   i.
  Trephining               ii.
  Ligation of Common Carotid ii.
  New Urethra             ii.
  Extirpation of Uterus      ii.
  Ovarian Pathology
  Encephaloid Degeneration
  Resection of Femur
  Resection of Tarsal Bones
GEORGE, A.  (Maryland.)
  Ecraseur  Lineaire  of  M.
    Chassaignac
GIBBES,  ROBT.  W.,  Jr.
    (South Carolina.)
  Injury to Testicle
GIBBS, O. C.  (Ohio.)
  Tin Tumbler in Rectum
GIBSON,  CHAS.  BELL.
    (Baltimore.)
  Osteo-Sarcoma of  Lower
    Jaw
  Ligation of External  Iliac
  Report on Anaesthetics
  Resection of Lower Jaw
  Strangulated Hernia
  Castration
  Aneurism of Posterior Tibial
    Artery
GIBSON, JOHN MASON.
    (Baltimore.)
  Anatomy, etc. of the  Eye
GIBSON, WM.  (Phila-
    delphia.)
  Institutes of Surgery
  Goitre
  Operation  on  Tumor  in
    Neck
  Axillary Aneurism  i. 744,
  Wound of Common Iliac
  Resection of Lower Jaw
234


622

609

669
409
228
365
608
617
617
618
724
72-2
722
ii.	722
ii.	621
ii.	621
ii. 622
11.	610
ii.	622
ii.	235
ii.	463
i.	200
ii.	235
ii	460
ii.	609
ii. 721
53
1.	53
ii.	362
ii.	363
ii.	366
ii.	462
ii.	235
  Sketch of Lithotripsy      ii. 614
  Operation  for Anchylosed
    Knee-Joint
  Caesarean Section
  Second Caesarean Section
GILBERT, DAVID. (Penn-
    sylvania.)
  Adhesive Plaster  in Frac-
    tures of Thigh          i. 669
  Adhesive Plaster iu Oblique
    Fractures               i. 669
  Resection of Upper Jaw    ii. 233
  Rhinoplasty               ii. 232
  Resection of Lower Jaw    ii. 235
  Tracheotomy              ii. 361
  Hydrocele of Neck        ii. 363
  S.ircoma of Testis         ii. 609
  Amputation above Shoulder-
    Joint
GILLESPIE, WM. A. (Vir-
    ginia.)
  Removal of Astragalus
GILMAN, C.  R.   (New
    York.)
  Polypus Uteri
GODDARD,  P. B.   (Phil-
    adelphia.)
  Curling on Diseases of Tes-
    tis
  New Stomach-Pump
GODMAN, JOHN D. (Phil-
    adelphia.)
  Irritation of  Tarsi Carti-
    lages
  Coster on  Surgical Opera-
    tions                   i.  52
  Inverted Toe-Nail         ii. 717
  Pediculis Pubis  on Tarsi
    Cartilages              ii. 229
GOFF, THOS  J.  (Missis-
    sippi.)
  Laryngotomy             ii. 362
GORDON, F. E.  (Mobile.)
  Hydrophobia              i. 527
GORDON, JAMES  M.
    (Georgia.)
  Cases of Ranula          ii. 236
GORHAM, Dr. (Louisiana.)
  Caesarean Section          ii. 621
GRANT,.!. H.  (South Car-
    olina.)
  Gunshot Wound of Heart
    and Stomach            ii. 459
GREEN, C.   (New York.)
  Excision of  Tonsils        ii. 237
ii. 124
ii. 122
ii. 611
 54
359
ii. 229 
ALPHABETICAL  LTST  OF  AMERICAN SURGEONS.
739
464
719
n.
458
615
619


528
GREEN, HORACE.  (New
     York.)
  Polypi of Larynx          i   55
GREEN,  J.   MERCER.
     (Georgia.)
  Aneurisms of the Aorta    ii. 368
GREEN, W. A.  (Georgia.)
  Spina Bifida
  Vienna Paste
GREENE, ISAAC.   (New
     York )
  Resection of Lower Jaw   ii. 235
GREGORY,  E.  H.  (St.
     Louis.)
  Compound Fracture of Leg   i. 669
GRIFFIN, JOHN II.  (Vir-
     ginia.)
  Tapping in Ascites
  Vaginal Hysterotomy
GRIMSHAW, A. II.  (Del-
    aware. )
  Ovarian Dropsy
GRINSTEAD, R. H.  (St.
     Louis.)
  Wounds of Bladder        i.
GROSS,   SAMUEL  D.
    (Philadelphia.)
  Tavernier's Operative Sur-
    gery                    i.
  Diseases of Bones and Joints i.
  Liston's Elements of Surgery i.
  Treatise on Diseases of Blad-
    der, etc.                i.
  History of Kentucky Surgery i.
  A  System of Surgery       i.
  Lives of Eminent Surgeons  i.
  Foreign Bodies in Air Pas-
    sages                   i.
  Dislocation of Tibia        i.
  Strumous Ophthalmia      ii.
  Foreign Bodies in Air Pas
    sages                  ii.
  Seven Cases of Excision of
    Upper Jaw             ii.
  Fibrous  Tumor  of  Lower
    Jaw                   ii.
  Five Cases of Resection of
    Lower Jaw
  Ligation of Subclavian
  Encysted Tumor  of Side
  Varicocele
  Ovariotomy
  Excision of Scapula
  Hydatid Tumor of Arm
  Resection of Scapula
  52
  52
  54

  55
  55
  56
  57

  56
 744
 230

 362

 233

 235

 235 !
 366!
 368 ;
 609!
 6191
369 I
7181
722,
ii. 459
ii. 361
GUILD,  JAMES.   (Ala-
    bama.)
  Trephining in Epilepsy    ii. 227
GUNN, MOSES.   (Michi-
    gan.)
  Philosophy of Certain Lux-
    ations                  i. 744
  Air in Veins              ii. 236
               H.

HAHN, JOHN.   (Phila-
    delphia.)
  Strangulated Femoral Her-
    nia
HALL,  CHARLES  A.
    (Vermont.)
  Tracheotomy  for Foreign
    Bodies
  Inability  to  raise Upper
    Eyelid
  Paracentesis Thoracis
HALL, J.  C.  (Washing-
    ton.)
  Extirpation of Testes and
    Penis
  Ligation of External Iliac
HALL, RICHARD  W1L-
    MOT.  (Baltimore.;
  Ligation of Innominata
  Larrey's Military Surgery
HALSEY,  W. S.  (Phila-
    delphia. )
  Stricture of Urethra
  Resection of Lower Jaw
HAMILTON, F. H. (Roch-
    ester.)
  Rhinoplasty,  Cheiloplasty,
    etc.
  Horn  Excised from Face
  Three Cases of Hare-lip
  Resection of Lower Jaw
  Hemorrhage in  Tonsilot-
    omy
  Maggots removed from Ear
  Cases  of Hernias
  Varicocele and Extirpation ii
  Lithotomy in a Child
  Lithotomy in an Adult
  Treatise on Fractures
  Elkoplasty
  Felt Splints
  Recipe for Felt Splints
  Fracture Tables
11	229
ii	. 369
ii	609
11	463
ii.	364
1	52
ii	609
11.	236
ii.	231
11.	231
11.	232
11.	235
ii.	237
11.	238
11.	460
11.	609
11.	612
11.	612
1.	57
1.	289
1.	668
1.	668
1.	668
 
740         ALPHABETICAL LIST OF AMERICAN SURGEONS.
  Dislocation of Femur
  Compound Dislocations
  Reduction of Dislocations
  Epilepsy
  Extirpation of Parotid
HAMILTON, J. W. (Ohio.)
  Ovariotomy
HAMILTON, ROBERT.
  Stone in the Female
HAMMOND, D. W. (Geor-
    gia.)
  Calculi in Urethra
HAMMOND, J. F.   (U. S.
    Army.)
  Amputation  at  Shoulder-
    Joint
HAMMOND, W. A.  (U.S.
    Army.)
  Bibron's Autidote
  Operation for  Calculi  in
    Urethra
HAPPOLDT, C.   (South
    Carolina.)
  Perforation of Stomach
HARDEN,  JNO.  (Louis-
    ville.)
  Trephining in Fractures
HARDY, JOS. F. E. (North
    Carolina.)
  Laryngotomy  for  Water-
    melon  Seed
HARLAN, R.  (Philada.)
  Medical  aud Physical Re-
    ^pt rorips
HARRIS, JOSIAH.  (Geor-
    gia.)
  Fracture of Femur
  Phymosis
HARRIS, S. M.   (Savan-
    nah.)
  Strangulated Hernia
HARRIS, THOMAS. (Phil-
    adelphia.)
  Amputation  of  Enlarged
    Tongue                ii
  Congenital Enlargement of
     Tongue
  Resection of Elbow-Joint
HARRISS,  JURIAH.
     (Georgia.)
   Tumor of Lower Jaw
   Excision of Nipple
   Fibro-Plastic   Tumor
     Breast
   Axillary Tumor
i.	744
i.	744
i.	74.1
ii.	228
ii.	359
ii.	620
ii.	611
11.
ii.
ii.
ii.
ii. 618



ii. 720


 i. 527

ii. 613


ii. 459 |


ii. 228



ii. 360


 i.   53
464
609
610
610
459
i. 669
i.  51
ii. 463
i. 669
 55
463
668
608
ii. 460
236
  Excision  of  Atheromatous
    Tumor
  Varicocele
  Varicocele
  Hydrocele
  Injury of Hand, etc.        ii. 726
HART, W. W. (Mississippi.)
  Protrusion of Stomach, etc.  ii
HARTSHORNE, HENRY.
    (Philadelphia.)
  New Apparatus  for  Frac-
    tures of Thigh
HARTSHORNE,   JOS.
    (Philadelphia.)
  Boyer  on Diseases of the
    Bones
  Caustic in Tetanus
  Tardy Union in Fractures
HASTINGS, JOHN. (Phil-
    adelphia.)
  Practice of Surgery
  Ligation of External Iliac
IIAXALL,  ROBERT W.
    (Virginia.)
  Fistula Lachrymalis
HAYS, ISAAC. (Philadel-
    phia.)
  American Cyclopaedia
  Lawrence on Diseases of the
    Eye
  Parrish on Ruptures
  Anchylo-blepharon
  Plastic Operation in  Sym-
    blepharon
  Extraction  of Foreign
    Bodies from Eyes
  Operation for Artificial Pu-
    pil
  Knife Needle for Cataract
  Case of Urinary Calculus
HAYS,  JOHN  B.   (Mis-
    souri.)
  Gastrotomy
HAYWARD, GEO.   (Bos-
    ton.)
  Report on Hernia
ii. 229
53
 54
 51
229
ii. 229
ii. 230
ii. 230
ii. 230
ii. 614
ii. 620
of
11.	236
ii.	722
ii.	236
n.	368
ii.	368
ii.	368
                         i.  55
                        ii. 460
Comparative Value of dif-
  ferent Anaesthetics       i. 200
Needles, etc., in Naevi Ma-
  terni
Trephining in Epilepsy
Insect Pins in Hare-lip
Removal of  Cancer  from
  Tongue                ii. 236
1.	409
11.	227
11.	232
 
ALPHABETICAL LIST OF  AMERICAN SURGEONS.
741
Operation for Tumor in the
  Neck
Ligature of Carotid
Cases of Ascites
On Hydrocele
Vesico-Vaginal Fistula
Occlusion of Vagina
Prolapsus Ani
Enlarged Bursa  over  Pa-
  tella                  ii
Amputation of part of Foot ii
Cases of Vaginal  Fistulas
Imperforate Anus
Statistics of Amputations
363
365
459
610
615
616
G21

718
723
615
622
622
724
 56
  Miscellaneous Cases
HEARD, T. J.  (Texas.)
  Bites of Tarantula         i. 527
HEATON, J.   (Boston.)
  Strangulated Femoral Her-
    nia                    ii. 460
HEERY,  D. 0. C.  (Geor-
    gia.)
  Bibron's Antidote         i. 527
HENDERSON, THOMAS.
    (District of Columbia.)
  Ovarian Disease           ii. 618
HENING, WM. (U.S. Army.)
  Gunshot Ball discharged by
    Stool                  ii. 463
HENRY, G. R. (Iowa.)
  Necrosis of Lower Jaw    ii. 236
HERBERT, WILLIAM II.
    (New York.)
  Ducamp on Strictures      i.  52
HERNDON, BRODIE  S.
    (Boston.)
  Caesarean Section         ii. 621
HEUSTIS, J. W. (Mobile.)
  Compression  in  Wound of
    Brachial Artery         ii. 720
  Hernia Cerebri            ii. 227
  Strangulated Umbilical Her-
    nia                    ii.
  Prolapsus Recti          ii.
  Aneurism  of Brachial Ar-
    tery                    ii-
HEWITT,   H. STUART.
    (New York.)
  High Operation for Stone  ii.
HEWSON,   ADDINELL.
    (Philadelphia.)
  Wilde on Aural Surgery   i.
  Prominence of Eyeball after
    Strabismus             i.
460
621

720


614


 56

 56
HEWSON,  THOMAS  T.
    (Philadelphia.)
  Coagulation of Blood
  On Preternatural Joints
  Strangulated Umbilical Her-
    nia
HIBBARD, MOSES.  (New
    Hampshire.)
  Operation  on  Uterine  Tu-
    mor
HILDRETH,   CHAS.  T.
    (Haverhill.)
  Caustic in Strictured Oeso-
    phagus
HILL, JOHN.  (South Car-
    olina.)
  Artificial Pupil
HINKLE, F. (Lancaster.)
  Chloroform in Tetanus
  Fracture of Bones of Face
  Tumor of Uterus
HITCHCOCK,   ALFRED.
    (Massachusetts. )
  Early Operation in Hernia
HITT, N.   (Indiana.)
  Extirpation of  Tumor of
    Mamma
HIXSON, C.  (Indiana.)
  Traumatic Tetanus
HODGE, H LENOX. (Phil
    adelphia.)
  On Metallic Suture
HODGES,  RICHARD M.
    (Massachusetts. )
  Excision of Joints
HODGEN, JNO. J.   (St.
    Louis.)
  Dislocations with  Lacera-
    tions
HOLBROOK, AMOS. (Mas-
    sachusetts.)
  Paracentesis Abdominis
HOLLOCK, P.  M.   (Geor-
    gia.)
  Report on Vaginal Fistula
HOLMES,  H.  J.  (Missis-
    sippi.)
  Occlusion of Vagina
1IOLSTON, J. G.  F. (Ohio.)
  Trephining in  Epilepsy

  Resection  of  Lower  Jaw,
    etc.
  Aneurism of Carotid
  Ovariotomy
i. 199
i. 670

ii. 459
ii. 617
ii. 359
ii. 230

 i. 528
 i. 668
ii. 617
ii. 460
ii.	367
i.	527
i.	199
i.	57
i.	744
ii.	458
ii.	616
ii.  615

ii.  227
ii.  228

ii.  235
 i.  365
ii.  620 
742
ALPHABETICAL  LIST  OF AMERICAN  SURGEONS.
HOOKER,  CHARLES.
    (New Haven.)
  Extracting Foreign Bodies
    from Ear               ii.
HOPTON, ABNER. (North
    Carolina )
  Incisions in Glossitis       ii.
  Laryngotomy and Trache-
    otomy in same Case      ii.
  Trephining in Carious Ster-
    num                   ii.
HORNER, G.  R. B. (U. S.
    Navy.)
  Amputation of Foot       ii.
HORNER, WM. E. (Phila-
    delphia.)
  Hydrocephalus            ii.
  Exostosis of  Nasal Bones   ii.
  Excision of Upper Jaw    ii.
  Immobility of Jaw         ii.
  Ligation of Common Caro-
    tid                     ii.
  Extirpation of  Parotid     ii.
  Hepatic Abscess           ii.
  Artificial Anus            ii.
  Amputation of Penis       ii.
  Fistula in Perineo         ii.
  Extirpation of Testis       ii.
  Lithotripsy                ii.
  Treatment of Lacerated Peri-
    neum                  ii.
  Treatmeut of Hemorrhoids ii.
  Rupture of Tendo-Achillis ii.
  Femoral and Brachial Aneu-
    rism                   ii.
  Aneurism of Femoral Ar-
    tery                   ii.
  Resection of Femur       ii.
  Amputation  at  Shoulder-
    Joint                  ii.
HORTON, J. W.  (Mary-
    land.)
  Imperforate Hymen        ii.
HOSACK, ALEX. E. (New
    York.)
  On Removal of Tonsils    ii.
  Instrument to tie Deep Ar-
    teries                  ii.
HOSACK, DAVID.  (New
    York.)
  Hydrocele                ii.
  On Surgery of the Ancients i.
  Aneurism of Femoral Ar-
    tery                   ii.
  Injection in Hydrocele     ii.
	Ligation of Femoral Artery	ii.	719
	u u >■	ii.	719
	HOSBROUCK, M. C. (New		
238	York.)		
	Vaginal Hysterotomy	ii.	616
	HOUSTON, M. H. (Vir-		
236	ginia.) Piece of Linen in Lungs		
360	Twenty Years HOUSTON, ROBERT.	ii.	369
368	Case of Ovarian Dropsy HOWARD, RICHARD L. (Ohio.)	ii.	618
124	Ovariotomy	ii.	620
	Thimble in Posterior Nares	ii.	237
	Spina Bilida	ii.	464
229	Lithotomy	ii.	613
232	Lateral Operation	ii.	613
233	Ovariotomy—New Plan	ii.	620
234	Amputation at Shoulder-		
	Joint	ii.	725
364	HOWARD, ROBT. (Louis-		
359	ville.)		
458	Paracentesis Capitis	ii.	229
463	HOWE, ZADOC. (Massa-		
608	chusetts.)		
608	Operation of Hare-lip	ii.	232
609	Tracheotomy for a Bean	ii.	360
614	HOYT, MOSES. (Ohio.)		
	Tracheotomy for Bean	ii.	362
615	HOYT, OTIS. (Mass.)		
621	Tumor of Thyroid Gland	ii.	363
717	HUBBARD, THOS. (Con-necticut.)		
720	Ligation of Axillary Artery HUBERT and CULVER.	ii.	366
720	(Georgia.)		
722	Gunshot Wound of Brain HUDSON, A. S.	ii.	228
724	Hydrocele HULLIHEN, S. P. (Wheel-ing.)	ii.	610
614	Muco-Purulent Secretion of		
	Antrum	ii.	233
	Elongation of Lower Jaw,		
237	etc. from Burn HULL, G. A. (New York.)	ii.	235
364	Nature of Hernia, etc. HULSE, ISAAC. (U. S. Navy.)	ii.	459
610	Ununited Fracture of Hu-		
52	merus HUNKLE, G. A. (Indiana.)	i.	670
719	Amaurosis	ii.	230
610	Tracheotomy	ii.	362
 
ALPHABETICAL LIST OF  AMERICAN SURGEONS.        743
HUNT, HENRY.  (Wash-
    ington.)
  Resection of Head of Hu-
    merus                  ii. 721
HUNT, THOS.  (Natchez.)
  Removal of half Lower Jaw ii. 234
HUNTON. ARIEL.  (New
    Hampshire.)
  Hunton's Yoke Splint      i. 668
HURD,  P.  H.   (Oswego.)
  Case of Spina Bifida.      ii. 464
  Division of  Spinal Marrow  ii. 464
I.
i.	409
i.	199
ii.	229
ii.	233
ii.	359
ii.	360
ii.	360
ii.	360
ii.	360
IRWIN, J. D.  (U.S. Army.)
  Amputation  at  Shoulder-
    Joint                  ii. 726
ISAACS, C.E. (New York.;
  Cancer of Caruncula       i. 409
  Removal of half of Lower
    Jaw                   ii. 236
  Ligation of Common Caro-
    tid                     ii. 365 I
  Ligation of Common Carotidii. 365
  Encephaloid Tumor of Va-
    gina                   ii. 616
  Bernard  and  Huette,  Op.
    Surg.                  i.  55
  Anomalous Sac  connected
    with Urethra           ii. 609
  Tumor of Calf of Leg      ii. 719 I
  Cases of Resection        ii. 723 i


                J.

JACKSON, A.  R. (Penn-       .
    SYLVANIA.)
  Hemorrhage from dividing
    Fraenum Linguae        ii
  Urethro-Vesical Calculi    ii
  Resection of Fibula        ii
JACKSON, CHARLES T.
    (Boston.)
  Anaesthetic Agents        i
JACKSON, Dr.   (Boston.)
  Partial Fracture of Femur  i
JACKSON, SAML. (North-
    umberland.)
  On Ectropion             ii
JACKSON, SAML. (Phil-
    adelphia )
  Paracentesis in Effusion into
    Chest.                 »• 369
JAMESON,  H.   G.,  Sr.
    (Philadelphia.)
  Extensive Fistula         ii. 622
JAMESON,  HORACE  G.
    (Baltimore.)
  Naevus
  Traumatic Hemorrhage
  Tumor of Orbit of the Eye ii
  Tumors of Upper Jaw
  Stricture of (Esophagus
  Bronchotomy  for Water-
    melon Seed
  Memoir on Bronchotomy
  Bronchotomy for a Pebble
  Tracheotomy
  Huge Tumor of Submax-
    illary Bone.
  Ligation of Thyroid Arte-
    ries for Bronchocele
  Strangulated Inguinal Her-
    nia
  Ligation of External Iliac
  Perineal Incision in  Stric-
    ture
  Stricture of Urethra
  New Operation for Circocele ii. 609
  Sarcocele                ii. 609
  Amputation of Cervix Uteri ii. 617
  Stricture of Rectum       ii. 621
  Caustic on Tumor of Thigh ii
ii. 233
ii. 362
11.	460
ii.	462
ii.	608
ii.	608
717
720
720
720
721
236
613
723
200

668


229
  Popliteal Aneurism       ii.
  Diffused Aneurism        ii.
  Wound of Ulnar Artery   ii.
  Necrosis                 ii.
JARROTT, RICHARD.
    (South Carolina.)
  Amputation in Gangrene  ii. 724
JEFFRIES,  J.  (Boston.)
  Osseous Formation in Eye ii. 230
  Operation forArtificial Pupil ii. 230
JENNINGS, JNO. C.  (St.
    Louis.)
  Ligation  of  External  Ca-
    rotid                  ii. 365
JENNINGS, ROBERT  G.
    (Virginia )
  Wound of Abdomen      ii. 458
  Polvpus Uteri            ii. 618
JERVEY, J. P. (Charleston.)
  Stricture of Urethra, etc.   i.  54
  Resection of Lower Jaw   ii. 235
JEWETT, CALVIN. (New-
    berg. )
  Tracheotomy for a Bean   ii. 360
  Bronchotomy for Iron Nail ii. 360 
744
ALPHABETICAL LIST OF AMERICAN SURGEONS.
JONES, JAS. (Louisiana.)
  On Imperforate Anus      ii. 622
JONES. JOS. S.  (Boston.)
  Radical Cure of Herniae   ii. 460
JOHNSON,  CARTER  P.
    {Richmond.)
  Resection of Inferior Max-
    illa                   ii. 235
  Tracheotomy             ii. 3(>1
  Amputation of Breast     ii. 367 |
  Lithotomy               ii. 612 i
  Pseudarthrosis            i. 670
  Resection of Ulna        ii. 722
JOHNSON, JNO. G. (New       j
    York. )
  Mammary Abscess        ii. 368
JOHNSON,  WM.  (New
    Jersey.)
  Stricture of  Oesophagus    ii. 359
  Varicose Aneurism        ii. 720
JOHNSON, WM. J. (Geor-
    gia.)
  Double Lithotomy        ii. 612
JUDKINS,  WM.   (Ohio.)
  Trephine  in  Injuries   of
    Brain                  ii. 227
KINLOCK, R. A. (Charles-
    ton.)
  GSdematous Laryngitis    ii. 361
  Rare Form of Fracture of
    Lower Jaw             i. 669
  Pseudarthrosis            i. 670
  Resection of Knee-Joint   ii. 723
KIRKBRIDE, T. S.  (Phil-
    adelphia.)
  Compression in Wounded
    Arteries                i. 199
KISSAM, J. B. (New York.)
  Minor Surgery of Bourgery  i.  53
KNEELAND, S. (Boston.)
  Spina Bifida             ii. 464
KNIGHT, J.  (New Haven.)
  Popliteal Aneurism        ii. 720
     "         "          ii. 721
KRAUSE, W.   (Ohio.)
  Bandage of Gypsum Paste
    in Fractures             i. 668
KAST,  THOS.   (Boston.)
  Aneurism of Thigh        ii. 719
KELLER, WM. (Philadel-
    phia.)
  Tumor of the Nates       ii. 464
KELLY,  JOHN.   (New
    York.)
  Case of Urinary Calculus  ii. 612
KENNARD,  THOS.   (St.
    Lolis. )
  Fracture of Body of  Sca-
    pula                  i.
  Wound of the Lung       ii.
KIMBALL, OILMAN.  (Mas-
    sachusetts.)
  Ligation  of  the  Internal
    Iliac                  ii.
  Extirpation of Uterus      ii.
KING, DANIEL.  (Rhode
    Island.)
  Callous Stricture  of  Rec-
    tum                   ii.
KING,  WM.  NEPHEW.
    (Georgia.)
  Lithotomy               ii.
669
368
462
617
621
613
LANE,   ROBERT.  (New
    Hampshire.)
  Case of Hernia
LATTIMORE, W. P. (Phil-
    adelphia.)
  Ricord's Letters
LAWSON, THOS.   (U.  S.
    Army.)
  Statistics of Military  Sur-
    gery
LEASURE, D.  (Pennsyl-
    vania.)
  Spontaneous Cure of Arti-
    ficial Anus
  Puncture of the Bladder
LEBBY^, ROBERT.
  Water between Cranium and
    Scalp
LEE, T. D.  (New I^ork.)
  Ascites
LEFEVER, ISAAC. (Penn-
    sylvania.)
  Hydrocele
LE1DER,  M. S.   (Ohio.)
  Lithotomy
LENTE, F. D. (New York.)
  Perineal Section for Stric-
    ture of Urethra
  Dangers of  Anaesthesia
  Elkoplasty
ii. 461


i.  56



i. 528
ii.	462
ii.	611
ii.	229
ii.	458
ii.	610
ii.	613
ii.	609
l.	200
l.	289
 
ALPHABETICAL LIST OF AMERICAN SURGEONS.
745
   Remote  Effects  of  Anaes-
     thesia                 i
   Fracture of Spine         i
 LEONARD, W. T. (Balti-
     more.)
   Inguinal Hernia           ii
 LEVERT, HENRY L. (Mo-
     bile.)
   Metallic Ligatures on Ar-
     teries                  i.
   Fungus Haematodes of Knee ii.
 LEVIS, RICH. J.  (Phila-
     delphia.)
   New  Apparatus  for Frac-
     ture of Clavicle         i.
 LEWIS,  GEORGE.  (New
     York.)
   Statistics of Diseases of Ap-
     pendix Vermiformis      ii.
 LEWIS, WINSLOW. (Bos-
     ton.)
   Operation for Carotid Aneu-
      rism                 ii.
 LIGHTFOOT, W. S. (Geor-
     gia.)
   Comminuted  Fracture  of
     Forearm                i.
 LINDSAY, R. W. (District
     of Columbia.)
   Case of Gunshot Wound    ii.
 LINDSLEY,  HARVEY.
     (Washington.)
   Extirpation  of  Cancerous
     Eye
 LITTELL,  S.   (Philadel-
     phia.)
   Treatise on Diseases  of the
     Eye
   Walton on Ophthalmic Sur-
     gery
 LOCKWOOD, JNO. A.  (U.
     S. Navy.)
   Fracture  of  Base  of Cra-
     nium
 LOGAN, THOS. M. (South
     Carolina.)
   Compendium of Operative
     Surgery
LOTZ, J.  R.   (Pennsylva-
    nia.)
   Operation for  Artificial
     Anus
LOVELL, JOS.  (U. S. A.)
  Wounds of Stomach
200
668
461
n.
              M.

MADISON, R. L. (Peters-
    burg. )
  External and Internal Uses
    of Chloroform
MAJOR, F.  (Ohio.)
i. 200
u.
	Herniae	ii.	461
199	MANLOVE, J. E. (Ten-		
724	nessee.)		
	Gastrotomy	ii.	458
	MANN, JAMES. (Massa-		
	chusetts.)		
668	Sketches of Campaigns ol		
	1812, '13, '14	i.	52
	MANSON, OTIS F. (North		
	Carolina. )		
459	Puncture of Bladder MARCH, ALDEN. (Al-bany.)	ii.	611
	Hernia	ii.	460
364	Coxalgia	i.	718
	Coxalgia	ii.	782
	Lithotomy	ii.	613
	Ovarian Tumor	ii.	619
669	MARKHAM.W.D. (Phila-delphia.)		
	Surgical Practice in Paris	i.	54
724	MARKOE, THOS. M. (New York.)		
	Abscess in Bone	i.	289
	Orchitis	i.	344
230	Ununited Fractures	i.	670
	Abscess in Bone	i.	704
	Dislocation of Hip-Joint	i.	744
	Luxation of Radius	i.	744
53	Manipulation in Luxations	i.	744
	Cancer of the Breast	ii.	367
55	Amputation at the Knee-		
	Joint	ii.	726
	Syme's Amputation through		
	Knee	ii.	726
669	Amputations at the Knee-		
	Joint	ii.	726
	MARTIN, JNO. B. (New		
	Madrid.)		
53	Snake Poisoning MARTIN, JOHN H. (Maine.)	i.	527
	Necrosis	ii.	721
461	MASON, J. K. (Philadel-phia.)		
458	Rupture of Uterus	ii.	617
 
74G        ALPHABETICAL LIST OF AMERICAN  SURGEONS.
MATTHEWS, C. B. (Phila-			M'CLELLAN, JOHN.		
delphia.)			(Greencastle.)		
Instrument to Excise Ton-			Extirpation of Parotid	ii.	358
sils	ii.	237	Cancerous Breast	ii.	367
To Extract Poisons from			M'CLELLAN, JOHN II. B.		
Stomach	ii	359	(Philadelphia.)		
MAXSON, EDWIN M.			Principles of Surgery	i.	55
(New York.)			M'CREARY, CHARLES.		
Poisoned Wounds	i.	527	(Kentucky.)		
Dislocation of Vertebrae	i.	744	Exsection of Clavicle	ii.	367
MAXWELL, R. T. (Cali-			McDANIEL, R. (South		
fornia.)			Carolina.)		
Lithotomy for piece of Bou-			Tapping in Ovarian Dropsy	ii.	620
gie broken in the Bladder	ii.	613	McDOWALL, H (Vir-		
MAY, JNO. FRED.			ginia.)		
(Washington.)			Pathology of Bones, etc.	ii.	368
Tracheotomy	ii.	361	McDOWELL, A. W. (New		
Lithotomy in Female	ii.	613	Jersey.)		
Bilateral Operation	ii.	613	Fracture of Skull	i.	669
Foreign Bodies in Joints	ii.	718	McDOWELL, EPHRAIM.		
Amputation at Hip	ii.	725	(Danville.)		
Amputation of Thigh	ii.	725	Extirpation of Ovaria	ii.	618
Amputation of Thigh for			ii ii	ii.	618
Tetanus	ii.	725	McGILL. (Maryland.)		
Amputation of both Legs	ii.	725	Ligation of both Carotids	ii.	364
Amputation at Shoulder	ii.	725	McELRATH, J. J. (Ar-		
MAYES, J. A. (South			kansas.)		
Carolina.)			Fracture of Cranium	i.	669
Spermatorrhoea Rings	i.	344	Resection of Superior Max-		
MAYNARD, JOHN p.			illa	ii.	233
(Boston.)			Wound of Abdomen	ii.	459
On Collodion	i.	199	Intestinal Wounds	ii.	459
MAYOR, CHARLES. (New	r		xMcEL BRIGHT, T. G.		
York )			Reduction by Reid's Method i.		744
Localization of Baths	i.	199	McGEE, J. C. (Louisiana.)		
M'CALL, JNO. (Utica.)			Wound of Small Intestine	ii.	459
Hemorrhoids	ii.	622	McILVAINE, R. H. (North		
M'CLELLAN, GEORGE.			Carolina.)		
(Philadelphia. )			Tracheotomy in Croup	ii.	361
Principles and Practice of			McKINNEY, J. W. (Illi-		
Surgery	i.	55	nois.)		
Operation for Spina Ven-			Laceration of Cornea	ii.	230
tosa	ii.	227	McPHEETERS, W. W. (St.		
Extirpation of Parotid	ii.	358	Louis )		
Extirpation of Right Pa-			Herniae	ii.	461
rotid	ii.	358	McRUER, D. (Maine.)		
Extirpation of Parotid	ii.	358	Ovariotomy	ii.	619
Surgical Anatomy of Ar-			Ovariotomy	ii.	620
teries	ii.	363	McSHERRY, R. (U.S.N.)		
Ligation of Carotid in Chil-			Castration	ii.	609
dren	ii.	364	Abscess in Tibia	ii.	718
Excision of Cartilages, Ribs,			Amputation of Thigh	ii.	726
and Sternum	ii.	368	MEANS, A. (Georgia.)		
Case of Lithotripsy	ii.	614	New Instrument for Ampu-		
On Fungus Haematodes	ii.	723	tations	ii.	726
 
ALPHABETICAL LIST OF AMERICAN SURGEONS.
747
MEASE, JAMES.  (Phila-
    delphia.)
  Life and Surgical Works of
    John Jones             i.  51
MEEKER, DANIEL.
    (Indiana.)
  Extirpation of Diseased
    Ovary                 ii. 618
MEIER, C.  THEODORE.
    (New York.)
  Carcinoma of Eyelid       ii. 229
MENNINGER,  J.  (New
    Y^ORK.)
  Cystoid Tumor of Ovary   ii. 620
MERCIER,  A.   (New
    Orleans j
  Ligation of External Iliac  ii.
  Hydrocele                ii.
  Ovariotomy              ii.
MERIMAN, WM. H. (Mis-
    sissippi. )
  Caesarean Section         ii. 621
MERRIWETHER, SAML.
    (Indiana.)
  Paracentesis in Empyema  ii. 369
METCALF, JOHN G.
    (Massachusetts.)
  Imperforate Hymen       ii. 615
METCALFE, JNO. T.
    (New York.)
  Paracentesis Thoracis
463
610
620
369
369
METTAUER,   JOHN  P.
    (Virginia.)
  Extirpation of Parotid    ii. 359
  Affections of Female Mam-
    ma                   ii
  Vesico-Vaginal Fistula    ii
  Staphyloraphy            ii
  Ligation  of Common Ca-
    rotid                  ii
  Amputation of  Penis      ii
  Hypospadias and Epispadias ii
  Case of Lithotomy        ii
  New Director and Gorget  ii
  Rupture  of Recto-Vaginal  _
    Septum               ii
  Vesico-Vaginal Fistula    ii
  Polypus Uteri            ii.
MIGHELS, JESSE  W.
    (Maine.)
  Immobility of Jaw
MILLER, H. (Louisville.)
  Ovariotomy              n
  Encysted tumor of  Ovary  ii
367
616
238

365
608
G08
611
612

615
615
618
ii. 233

  618
  620
MILLER, H. V. M. (Geor-
    gia.)
  Gunshot Wound of Head   ii. 228
MILLS,  AUGUSTUS  W.
    (Kentucky.)
  Truncating  Uvula in Con-
    sumption               ii. 237
MILLS,  CHARLES S.
    (Virginia.)
  Caesarean Section         ii. 621
MITCHELL, J. K. (Phila-
    delphia. )
  Instrument to Excise Tonsils ii. 237
MITCHELL, JNO. S.
    (Charleston.)
  Imperforate  Anus         ii. 621
MITCHELL, S. WEIR.
     (Philadelphia.)
  Venom of Rattlesnakes     i. 527
MOORE,  E.  B.   (Boston.)
  Inguinal Hernia          ii. 461
MOORE, FRANCIS. (Con-
    necticut.)
  New Tourniquet          ii. 723
MOORE, N. J. McL.  (New
    Hampshire. )
  Amputation Neck of Uterus ii. 617
MOREHOUSE,  G. R.
    (Philadelphia.)
  Laryngotomy             ii. 361
MORELAND, W. W.
    (Philadelphia.)
  Diseases of Urinary Organs i.  56
MORGAN, JAS. E. (Wash-
    ington.)
  Epidemic Paronychia       ii. 718
MORGAN, JOHN G.
    (Geneva.)
  Ligature in  Division of Ju-
    gular Vein             ii. 363
MORRISON, JOHN. (New
    Orleans.)
  Amputation of Thigh      ii. 726
MORROGH,  C.   (New
    Jersey.)
  Ligation of Carotid        ii. 365
  Resection of Os Calcis     ii. 723
MORTON, WM. T. G.
    (Boston.)
  Effects of Sulphuric Ether  i.  55
MOSES, J.  (Missouri.)
  Military Surgery          i. 528
MOTT, A. B.  (New York.)
  Exostosis of Orbit and Na-
    sal Cavity              ii. 230 
748         ALPHABETICAL LIST  OF AMERICAN  SURGEONS.
MOTT, VALENTINE.
    (New York.)
  Velpeau's Surgery          i.  54
  Treatment  of Injuries  of
    Head                  ii. 227
  Removal of  Tumor from
    Nose
  Immobility  of Jaw
  Taliacotian Operation
  Osteo-sarcoma of Lower Jaw
  Resection of Inferior Max-
    illa
  Extirpation of Parotid
  Tuberculated  Sarcoma
  Ligation of the Innominata
  Ligation of Carotid
     u         ii
     "         "   in Infant
  Circulation of Head after
    Tying Carotid
  Ligation of both Carotids
  Chloroform, importance of
  Case of Axillary Aneurism
  Aneurism of Right Subcla-
    vian
  Ligation of Left Subclavian
      u      (i      ii
    external to  Scaleni
  Osteo-sarcoma of Left Clavi-
    cle
  Ligation of Common Iliac
  Ligation of External Iliac
  Ligation of Internal Iliac
  Diffused Femoral Aneurism
  Diseases of Prostate Gland
  Case of Lithotomy
  Occlusion of Vagina
  Femoral Aneurism
  Amputation at Hip-Joint
MUSCROFT, S.  C.  (Ohio.)
  Operation for Femoral Her-
    nia                    ii.
MUSSEY, B.W. II.  (Ohio.)
  Vesico-Vaginal Fistula     ii.
MUSSEY, R. D.  (Cincin-
    nati.)
  Entrance of Air into Veins ii.
  On Aiujesthesia             i.
  Fracture of Femur          i.
  Aneurism by Anastomosis  ii.
  Exostosis of Frontal Bone ii.
  Excision of Upper Maxillary ii.
  Large Tumor of Neck     ii.
232
233
233
234
234
234

235
358
363
363
364
364
364

364
364
200
366

366
366
366
366

367
462
463
462
463
609
611
616
720
723
461

616
366
200
669
364
227
233
363
  Operation on  Enlarged
    Tongue                ii. 236
  Congenital absence of Ex-
    ternal Meatus           ii. 238
  Excision of large Tumor on
    Neck                  ii. 363
  Ligation of Carotid       ii. 361
  Ligation of both Carotids  ii. 364
                           ii. 364
                           ii. 365
  On Urinary Calculus       ii. 611
  Operation for Lithotomy   ii. 612
  Recto-Vaginal Fistula     ii. 616
  Operation of Ovariotomy   ii. 618
MUSSEY,  WM. II.   (Cin-
    cinnati.)
  Anaesthetic Agents         i. 200
  Tracheotomy'             ii. 362
MUTTER,  THOMAS  D.
    (Philadelphia.)
  Liston's Operations of Sur-
    gery                    i.  55
  Rhinoplastic Operation     ii. 232
  Deformity of  Mouth, and
    Diefl'enbach's Method    ii. 236
  Physick's Needle in Cleft
    Palate                  ii. 238
  Operation  for  Deformity
    from Burns             ii. 359
  Hydrocele of the Neck     ii. 363
  Urinary Calculus in a Girl  ii. 612
  New Instrument for Fistula
    in Ano                 ii. 621
  Stricture of Rectum        ii. 621
  Resection  of Femur        ii. 722
               N.

NANCREDE, JOS. G. (Phil-
    adelphia.)
  On the C;t^arean Operation ii. 621
NEILL, JNO.  (Philadel-
    phia.)
  Pirrie's Surgery            i.  55
  Obstruction  of  Eustachian
    Tube                  ii. 238
  Tracheotomy in Epilepsy  ii. 362
NELSON, HORACE. (New
    York.)
  Ligation of  Spermatic Ar-
    tery                   ii. 609
NELSON, T.  (New York.)
  Wounded Nerve from Bleed-
    ing                    ii. 717 
ALPHABETICAL LIST OF AMERICAN SURGEONS.        749
NEWMAN, H. S.   (Penn-
    sylvania.)
  Amputation  of  Enlarged
    Tongue
NEWMAN, JOHN. (North
    Carolina.)
  Tracheotomy for Lead Bul-
    let
NICE, W. G.   (Virginia.)
  On Contractions in Burns
NOEGGERATH, E.  (New
    York.)
  Epicystotomy
NORRIS,   GEORGE  W.
    (Philadelphia.)
  Fracture of  Humerus
  Non-union of Fractures
  Liston's Practical Surgery
  Fergusson's Practical Sur-
    gery
  Chelius's System of Surgery
  Report of Cases of Injuries
    of Head
  Fibrous Tumor on Lobe of
    Ear
  Statistics  of Mortality fol-
    lowing the tying of Caro-
    tid and  Innominata
  Statistics of Ligation of
    Subclavian
  Congenital Club-Foot
  Statistics of Ligation of
    Iliacs
  Statistics of Ligation of
    Femoral Artery
  Fracture of Astragalus
  Statistics of Amputations at
    Pennsylvania Hospital
  Second Statistics of Ampu-
    tations
  Amputation of Astragalus
  Statistics of Amputations
NOTT, J. C.  (Mobile.)
  Testicle containing Hair
  Wire Splints
  Cataract
  Necrosis of Lower Jaw
  Radical Cure of Hernia
  Excision of  Spina  Bifida
  Vesical Calculus
  Radical Cure of Hernia
  Large  Calculi  in Lateral
    Operation
  Extirpation of the Os Coc-
    cygis
ii. 236
360

717
ii.  614
668
670
 53

 54
 55

227

238
ii. 365
366
719
ii. 720
Orthopaedic Institutions    ii. 719
Mortification of Lower Ex-
  tremities                ii. 726
               o.

OGIER, THOS. L. (Charles-
    ton.)
  Compendium  of Operative
    Surgery                i.   53
  Amputation of Penis       ii.  608
  Compression in  Orchitis    ii.  610
  Pulsating Tumors         i.  409
  Occlusion of Vagina       ii.  616
  Uterine Tumor            ii.  617
ONDERDONK, HENRY U.
    (New York.)
  On Stone in Bladder       ii.  611
  Popliteal Aneurism        ii.  720
  Ligation  of Femoral Ar-
    tery                    ii.  720
OTIS,  GEORGE  A.  (Rich-
    mond. )
  Extirpation of part of Thy-
    roid                    ii.  363
OWEN, D. F. (Charleston.)
  Caesarean Section         ii.  621
OWENS, J. A  (Arkansas.)
  Osteo-sarcoma of the  Clav-
    cle                    ii.  367
P.
721
724
ii. 724
724
724
725

610
668
231
236
461
464
614
460

612

615
PACKARD, JNO. H. (Phil
    adelphia.)
  Haematocele
  Malgaigne on Fractures  '
  Fractures and Concussions
  Ligation of the Carotid Ar-
    tery
  Aneurism  of the  Thoracic
    Aorta
  Secondary Hemorrhage
PAGE, WM.BYRD. (Phil-
    adelphia.)
  Amputation at  Shoulder-
    Joint
PALLEN, M. A. (St. Louis.
  Wounds of the Brain
  Artificial Pupil
  Traumatic Arthritis
PALMER, JOSEPH.
  Bronchotomy for a Bean
ii. 610
 i.  56
ii. 228

ii. 365

ii. 721
ii. 726
 ii. 724
)
 ii. 228
 ii. 231
 ii. 718

 ii. 360 
750        ALPHABETICAL  LIST  OF AMERICAN SURGEONS.
 PANCOAST,  JOSEPH.
     (Philadelphia.)
   Operative Surgery
   Operation for Strabismus
   Rhinoplastic Operations
   Plastic Operations
     11       ii
   Staphyloraphy
   Tracheotomy in Croup
        u           11
        "         Laryngitis
   Cystic Goitre
   Cancerous Mammae
   Empyema cured by Opera-
     tion
   Vaginal Fistula
   Resection of Elbow-Joint
 PARK, ANDREW. (Eaton-
     ton, Georgia.)
   Trephining  in  Fractured
     Skull
   Encysted Tumor of Neck
 PARKER,  WILLARD.
     (New York.)
   Trephining,  etc.,  in  Epi-
     lepsy
   Polypus Laryngis
   Strangulated Femoral Her-
     nia
   Lunar Caustic in Hydrocele
   Stone in Female
   Laceration of Perineum and
     Sphincter Ani
   Amputation at Knee-Joint
   Osteo-Aneurism
 PARKMAN,  SAMUEL.
     (Boston.)
   Velpeau on Diseases of the
    Breast
   Excision of Inferior Maxil-
    lary Nerve
  Tracheotomy
  Extirpation of Uterine Tu-
    mor
   Ovarian Cyst
PARRISH, ISAAC.  (Phil-
    adelphia. )
  Anaesthetic Agents and Sta-
    tistics
  Congenital Division of Lip
    aud Palate
  Thimble in Pterygoid Fossa
  Croup cured without Oper-
    ation
   Case of Ununited Fracture
i	54
ii.	230
ii.	232
ii.	236
ii.	236
ii.	238
ii.	361
ii.	361
ii.	362
ii.	363
ii.	367
ii.	369
ii.	615
ii.	722
ii.	227
n.	362
ii.	228
ii.	361
ii.	461
ii.	610
ii.	613
ii.	615
ii.	725
ii.	725
i.  54
231
361

618
619
i. 200
 51
 53

366
367
459
720
232
237

361
670
 PARRISH,  JOSEPH.
     (Philadelphia.)
  Treatise on Ruptures       i.
  Surgical Observations       i.
  Ligation of Subclavian Ar-
     tery                   ii.
  Cancer of Breast          ii.
  Caseof Strangulated Hernia ii.
  Aneurism of Femoral      ii.
 PARRY, CHARLES.  (In-
     diana.)
  Deformed Fracture of Leg  ii. 722
 PARSONS,  USHER,
     (Rhode Island.)
  On Cancer of Mammae     i. 53
  Statistics of Surgical Oper-
     ations                  ii.
  Amputation of Uterus     ii.
  Battle on Lake Erie.       ii.
 PASCALIS, FELIX. (New
     York.)
  Fistula in Ano            ii.
PATTESON, GRANVILLE
     SHARPE. (Baltimore.)
  Burns's Anatomy  of Head
     and Neck               i.
  Aneurism of Internal Max-
    illary                  ii.
PEACE, EDWARD. (Phil-
    adelphia.)
  Ligation of External Iliac  ii.
      "     Primitive       ii.
PEASLEE,  E.  R,   (New
    YrORK. )
  Double Ovariotomy        ii.
  Ovarian Tumor  with  As-
    cites
  Hemorrhage from Tapping
     Ovarian Tumor
  Amputation  at  Shoulder-
    Joint
  Extirpation of Uterus
PEELE, J. J.  (Tennessee.)
  Ranula  treated  by Lead
    Ligature                ii. 236
PEET, DUDLEY.   (New
    York. )
  Remote Causes of Deafness ii. 238
PEIRSON, A. L.   (Massa-
    chusetts.)
  Operation for Hare-lip      ii. 232
  Early Operation for Hare-
    lip                     ii. 232
  Polypus and  Inversion  of
    Uterus                  ii. 618
n.
365
617
717
621



 52

231
463
462
619

620

620

725
617 
ALPHABETICAL LIST OF AMERICAN SURGEONS.         751
 PENDLETON, EM. (Geor-
     gia.)
   Spina Bifida
 PENNOCK, CASPAR W.
     (Philadelphia.)
   Cupping-Olasses   in  Poi-
     soned Wounds
 PEPPER, WM. (Philadel-
     phia.)
   Empyema                ii.
   Hydrocephalus            ii.
 PERKINS. (Philadelphia.)
   Arrest of Progress of Whit-
     low                   ii
 PHILLIPS, S.B. (N.York.) '
   Case  of Polypus Uteri     ii.
 PHYSICK, PHILIP SYNG.
     (Philadelphia.)
   Employment of Animal Lig-
     atures                 i.
   Fracture of Humerus      i.
   Tapping in Hydrocephalus ii.
   Nitrate of Silver in Wart on
     Adnata                ii.
   Seton for Fracture  of Infe-
     rior Maxilla            ii.
   Cough, caused by Elongated
     Uvula, etc.             ii.
   Double  Canula and  Wire
     Ligature               ii.
   Forceps for removing Ton-
     sils                    ii.
   Stomach Tube in Poisoning ii.
   Tracheotomy  in Hydropho-
     bia                    ii.
   New Operation for Artificial
     Anus                  ii.
   Diseases of Testicle       ii.
   Operation of  Lithotomy    ii.
   Ligation of  Brachial  Ar-
     tery                   ii.
   Pseudarthrosis            i.
PIM, LOUIS T. (St. Louis.)
   Tumor of  Orbit           i.
PINKNEY,  N.  (U. S.
     Navy.)
  Excision of Portion of Lower
     Jaw                   ii.
   Removal  of  one-third of
     Head of Humerus       ii.
  Amputation   at  Shoulder-
     Joint                  ii-
PIPER,  R. U.  (Rhode
     Island.)
   Operative  Surgery         i.
ii. 464
i. 527
369
229
717

618
199
669
229

230

234 j

237

237 |

237
359

360

461
609
611

719
669

409
235

722

724


 55
PITCHER,  ZINA.  (U.S.
    Army.)
  Penetrating Wound of Ab-
    domen                ii. 458
PITNEY, JOSEPH T. (New
    Jersey.)
  Tracheotomy             ii. 361
PLATT,  JAMES  KENT.
    (Pittsburg.)
  Hydrops  Articuli  in
    Shoulder              ii, 717
POPE,  CHAS.  A.  (St.
    Louis.)
  Excision of Superior Max-
    illa                   ii. 233
  Strangulated Inguinal  Her-
    nia                   ii. 461
  Rupture of  Perineum in-
    volving  Sphincter  Ani
    and Recto-Vaginal  Sep
  turn
Vesico-Vaginal Fistula
615
616
616
620
227

230
612
719

721
  Ovariotomy
  Fracture of Cranium
  Dislocation of  Crystalline
    Lens                  ii.
  Stone in Bladder         ii.
  Deformity of Knee        ii.
  Ligation  of  Femoral  Ar-
    tery                   ii.
PORCHER,  F.  PEYRE.
    (Charleston.)
  Horn on Head            i. 409
PORTER, JOHN B. (U. S.
    Army. )
  Campaign in Mexico       i. 528
POST, ALFRED C. (New
    York. )
  Blepharoplastic  Operation
    for Ectropion           ii. 229
  Subcutaneous  Erectile  Tu-
    mor of Cheek, etc.      ii. 364
  Ligation of the Subclavian,
    etc.                   ii. 366
  Congenital Hernia        ii. 460
POST,  WRIGHT.   (New
    York.)
  Operation on Carotid Aneu-
    rism                  ii. 363
  Ligation of Subclavian for
    Brachial Aneurism      ii. 366
  Ligation of  the  External
    Iliac                  ii. 462
  Case of Brachial Aneurism ii. 720 
752        ALPHABETICAL LIST OF AMERICAN SURGEONS.
ii. 620
ii. 620
POTTER,  II.  A.   (New
    York. )
  Extirpation of both Ova-
    ries
  Ovariotomy
POWELL,   W. B.   (Ken-
    tucky.)
  Excision of Part of Spleen  ii. 458
POWER, W. (Baltimore.)
  Femoral Aneurism         ii. 463
PRINCE, DAVID.  (St.
    Louis.)
  Ovarian Tumor           ii. 619
PROUDFOOT, L.
  Fistula in Lumbar Region  ii. 464
PURPLE,  SAMUEL S.
    (New York.)
  New Trephine            ii. 228
  Wounds of the Heart      ii. 368
PUSEY, II. K. (Kentucky.)
  Fracture of Bones of Hand i. 668
  Salivary Calculus          ii. 231
PUTNAM, C. G. (Boston.)
  Removal of Uterus        ii. 617
QUACKENBUSH, J. V. P.
    (Albany.)
  Uterine Polypus          ii. 617
              R.

RAMSAY,  DAVID.
    (Charleston.)
  Improvements in Medicine
    in Eighteenth Century   i.
RAND,  ISAAC.  (Mass.)
  Operation for Empyema    ii.
RANDOLPH, J.  (Phila-
    delphia )
  Osteo-Sarcoma  of  Lower
  Jaw
Extirpation of the Parotid
Aneurism of External Iliac
Stone in Bladder
  ii       ii
Cases of Lithotripsy
                          ii
  Case of Lithotripsy        ii
RAPHAEL, B. J. (Louisville
  Rhin.oplastic Operation    ii
 51

369
 234
 358
 463
 614
 614
 614
 614
 614
 614
)
 232
REESE, DAVID M.  (New
    York.)
  Cooper's Surg. Diet.       i.  52
  Tetanus controlled by Issues
    to Spine               ii. 463
RE ID, W. W.  (Rochester )
  Dislocation of Femur       i. 744
REILLY', JOHN 0.   (New
    York. )
  Case of Varus            ii. 719
REYNOLDS, H.  W.  (Illi-
    nois.)
  Gunshot Wound          ii. 718
REYNOLDS,  JAMES   B.
    (New York.)
  Case of Ilvdrophobia       i. 527
REYNOLDS, J  W.   (Mo.)
  Wound of External Carotid ii. 365
RICH,  JNO.  S.  (South
    Carolina.)
  Wound of Ulnar Artery    ii. 718
RICHARDSON,  SAMUEL
    B.  (Kentucky.)
  Varicocele               ii. 610
RICHARDSON,  T.  B.
    (Kentucky.)
  Rupture of Right  Rectus
    Abdominis Muscle      ,ii. 459
  Hemorrhoids             ii. 622
RICHARDSON,  T.  G.
    (New Orleans.)
  Inter-Cranial Suppuration  ii
  Inguinal Entero-Epiplocele ii
229
461
608
616
  Gangrene of Penis        ii.
  Vesico-Vaginal Fistula    ii.
RICHMOND,  JOHN   L.
    (Ohio.)
  Caesarean Section         ii.  621
RIVINUS, E. F.  (Phila-
    delphia. )
  Larrcy on VVounds         i.   53
ROBERT,  WILLIAM  H.
    (Alabama.)
  Singular Hernia          ii.  460
  Injection for Cure of Herniae ii.  461
ROBERTS, WILLIAM C.
    (New York.)
  Minor Surgery of Bourgery  i.   53
  Tumors of Uterus         ii.  617
ROBERTSON,  F.  M.
    (Charleston.)
  Strangulated Inguinal Her-
    nia                   ii.  461
  Lithotomy in Child        ii.  612
  Laceration of Perineum    ii.  615 
ALPHABETICAL LIST OF  AMERICAN SURGEONS.
753
ROBERTSON, T.T. (South
    Carolina.)
  Artificial Anus
RODGERS,  J.  KEARNY.
    (New York.)
  Ununited Fracture of Hu-
    merus
  Operation  for  Artificial
    Pupil
  Ligation of Left Subclavian
  Amputation at Elbow-Joint
  Anchylosis  of Hip
RODRIGUE,  ARISTIDE.
    (Philadelphia.)
  Cupping-Glasses and  Liga-
    tures in Poisoned Wounds
RODRIGUES,  B   A.
    (Pennsylvania.)
  Exostosis of Upper Jaw
ROGERS, DAVID  L. (New
    York.)
  Trephining  in Epilepsy
  Ligation  of Common Ca-
    rotid
  Osteo-Sarcoma  of Upper
    Jaw
  Osteo-Sarcoma  of Lower
    Jaw
  Excising Tonsils
  Excision  of  Tumor  from
    Neck
  Ligation of External Iliac
  Operation  for  Fractured
    Spine
  Ovariotomy
  On Tying large Arteries
ROMER, B.  (Virginia.)
  Iodine in  Ulcers
  Iodine in  Ovarian Tumors
ROUSSEAU, J. C.  (Phila-
    delphia.)
  Operation on Hemorrhoids
RUAN,  WM.  H.   (West
    Indies.)
  Ligation of Right  External
    Iliac
RUSCHENBERGER, W. S.
    W. (Philadelphia.)
  Marshal on Enlisting, etc.
    of Soldiers
  Glass Goblet in Rectum
RYER, WM. M.  (Cali-
    fornia.)
  Dislocation  of Vertebrae
    vol. n.—48
ii. 462
i. 670
230
366
724
722
i. 527
ii. 233
227

364

233

234
237

362
463

464
618
720

289
620
ii. 621
ii. 463
 54
621


745
RYLAND, KIRTLEY. (St.
    Louis.)
  Chloroform in its Effects on
    Hemorrhage            i. 200
  Phosphoric Necrosis       ii. 233
s.
SABAL, A. M. (Georgia.)
  Experiments on Bibron's
    Antidote                i. 527
SANBORN, E. K (Lowell.)
  Pseudarthrosis             i. 670
  Amputation at Shoulder   ii. 725
SANFORD, J. F.  (Iowa.)
  Deformity of Face        ii. 231
  Operation for Labial Fis-
    sures                  ii. 232
  Immobility of Jaw        ii. 234
SARGENT, F. W. (Phila.)
  Druitt's Surgery           i.
  On Bandaging, etc.         i.
  Miller's Principles of Surgery i.
         Practice
SAVERY, CHARLES A.
    (New Hampshire.)
  Abscess of Liver
SAWYER,  A. F.   (Cali-
    fornia.)
  Fractures of Hyoid and In-
    ferior Maxillae
  Osteoid Growth
SAYRE, LEWIS A.   (New
    York. )
  Report on Hip Disease
  Perforation of Rectum
  Resection  of Head  of Fe-
    mur
SCHMIDT
    York.)
  Morbid Erectile Tissue     i
  Division of Masseter Muscle ii
SCHNECK.B. F.  (Lebanon.)
  Fracture  of Clavicle  and
    Humerus               i
SELDEN, HENRY.   (Va.)
  On Hemorrhoids
SHANKS, LEWIS.   (Ten-
    nessee.)
  Treatment, etc. of Cephalae-
    matoma
  Bloodroot   in  Gelatinous
    Polypi
54
55
55
55
J.  W.  (New
ii. 458
668
719
 i. 7*2
 i. 622

ii. 723
409
234
669
ii. 621
i. 409
ii. 232 
754
ALPHABETICAL LIST OF AMERICAN  SURGEONS.
SHARP, S.  (Cincinnati.)
  Gesophagotomy
  Cystotomy
SHELDON,  A.  S.   (New
    York. )
  Paracentesis in Empyema
SHERRERD, JOHN  B.
    (New Jersey.)
  Injection in Ascites
SHERRILL,  HUNTING.
    (New York )
  Strangulated Inguinal Her-
    nia
SHIPMAN, A. B. (Indiana.)
  Injury of Head (3 papers)  ii
  Extirpation of Parotid     ii
  Ligation  of Common Ca-
    rotid
  Medullary Sarcoma of La-
    bia, etc.               ii.
  Imperforate Vagina       ii.
  Caesarean Operation       ii.
SHIPMAN,  A.  W.   (New
    York)
  Ligation  of Femoral Ar-
    tery                   ii.
SHRADY, G. F. (New York.)
  Fracture of Thigh          i.
  Trephining               ii.
  Eight Cases of Amputation ii.
SHULTICE, WILLIAM.
    (Virginia.)
  Case of Imperforate Hymen ii.
SHUPPERT,  M  (New
    Orleans.)
  Resection of Superior Max-
    illa
SIMS,  J. MARION.   (New
    York.)
  Removal of Superior Max-
    illa
  Osteo-Sarcoma of  Lower
    Jaw
  Osteo-Sarcoma of  Lower
    Jaw
  Extraction  of  Foreign
    Bodies from Ear
  Vesico-Vaginal Fistulae
360
613
Successful Lithotrity
Removal of Diseased
Ova-
ii. 369
ii. 458
ii.  460

   227
ii.  359

ii.  365
615
615
621
720

669
229
726
615
ii. 233
SKINNER, CHAS.  (North
    Carolina.)
  Case of Spina Bifida
SMITH, ALBAN G. (Ken-
    tucky.)
  Operation on Vertebrae
ii.	233
ii.	235
ii.	235
ii.	238
ii.	616
ii.	616
614

618


359

722
ii. 464
ii. 464
    num  •                 ii.
SMITH, A.  CLARKSON.
    (Pennsylvania.)
  Auto-plastic Operation     ii,
SMITH, CHAS. (New York.)
  Aneurism of Bone         ii.
SMITH, CHARLES  II.
    (U. S.  Army.)
  Poisoning by Chloroform   i. 200
SMITH, HENRY H. (Phil-
    adelphia.)
  Molluscum                i. 409
  On Ununited Fractures     i.  56
  Artificial  Limbs  in Pseu-
    darthrosis              i. 670
  ^ew Method of Manipulat-
    ing in Reducing Luxations
  Hydrocele
  Ovariotomy
  Civiale on Stone and Gravel
  Minor Surgery
  Splint for Pseudarthrosis
  Resection of Upper Jaw
  Operative Surgery
  Tracheotomy
  Amputation of Breast
  Tubercles of Testis
  Very large Hydrocele
  Sudden Formation  of Hy-
    drocele
  Lithotomy, Lateral
  Lithotomy in Child
  Vesico-Vaginal Eistula
  Case of Varicose Veins
  Hemorrhoids
  Treatment of Varicose Veins ii.
  Double Club-Foot         ii.
  Excision  and  Caustic  in
    Pseudarthrosis
  Resection of Elbow-Joint
  Amputation of Thigh
      "       "  Arm
              " Leg
SMITH,  J.  AUGUSTINE.
    (New York)
  Bell's Principles of Surgery i.  51
SMITH, J. LEWIS.   (New
    York.)
  Statistics of Hydrophobia   i. 527
  Analysis of Cases of "      i. 527
SMITH, J. WASHINGTON.
    (New York.)
  Foreign Body in Joint     ii. 718
745
610
620
 54
 54
670
233
 55
361
367
609
610

610
612
613
615
718
622
718
719

670
723
724
724
724 
ALPHABETICAL  LIST  OF AMERICAN SURGEONS.        755
 SMITH,   JAMES  M.
     (Massachusetts.)
   Pseudarthrosis
 SMITH, NATHAN.  (Y^ale
     College.)
   Suture of Palate in Infancy
   To Extract Coins, etc. from
     (Esophagus
   Ligation of External  Iliac
   Operation  for   Ovarian
     Tumor
   Remarks on Amputation
 SMITH,  NATHAN  R.
     (Baltimore.)
   On Diseases of Internal Ear
   Medical  and Surgical Me-
     moirs
   Surgical  Anatomy of Arte-
     ries
   Caustic Threads in Vascular
     Nasvus
   Extirpation of Tonsils
   Observations on  Staphy-
     loraphy
   Extirpation of Parotid
   Extirpation  of  Tumors on
     Neck
   Extirpation   of Thyroid
     Gland
   Stricture of Urethra
   Extirpation of Testis
   Paracentesis  of  Bladder
     through Perineum
   Instruments, etc. in Lithot-
     omy
   Case of Lithotomy
   Lithotomy
   Cases of Lithotripsy
   Fungus near Vagina
   Hemorrhoidal Tumors
   Actual  Cautery in  Deep
     Sinuses
   Division of Tendo-Achillis
   Case of Popliteal Aneurism
   Ligation  of Femoral
      "    "  Brachial
   Resection of Astragalus
   Amputation of Leg
SMITH, STEPHEN.  (New
     York.)
   Report of Surgical Practice
     in Bellevue Hospital
   Statistics of  Trephining by
     American  Surgeons
   Polypus Laryngis
i. 670
ii.  237
11	359
11.	462
ii.	618
n.	723
i.	52
i.	53
i.	53
i.	409
ii.	237
ii.	238
ii.	358
ii.	363
ii.	363
ii	608
ii.	609
ii.	610
ii.	611
ii.	611
ii.	611
ii	614
ii.	615
ii.	621
ii.	717
ii.	7191
ii.	720
ii.	720
ii.	720
ii.	722
ii.	724
i. 669
228
362
  Statistics of Amputation at
    Hip-Joint             ii. 725
  Statistics of Amputation at
    Shoulder  and   Elbow-
    Joints
SNEAD, N.  (Virginia.)
  Cases of Hernia
SNEED, W. C. (Kentucky.)
  Paracentesis in Empyema
SPENCER, P. C.  (Peters-
    burg.)
  Results of Lithotomy
  Tumor of Neck
  Case of Lithotrity
  Occlusion of Vagina
SQUIBB, E. R.   (U.  S.
    Navy.)
  Advantages of Simple Dress
    ings in Surgery
STE DM AN.
  Ligation of External Iliac
STEPHENSON, M.   (New
    Y^ORK.)
  Sarcomatous Tumor
  Exostosis of Orbit
  Cheiloplastic Operation
STEPHENSON,   W.  D.
    (Alabama.)
  Tracheotomy             ii. 361
STERLING,  JOHN  W.
    (New York.)
  Velpeau's  Surgical  Ana-
    tomy                   i.  52
STEVENS, ALEX. H. (New
    York.)
  Translation of Boyer on Sur-
    gical Diseases           i.  52
  Cooper's Practice of Sur-
    gery                   i.  52
  On Encysted and other Tu-
    mors                   i. 409
  Osteo Sarcoma  of  Upper
    Jaw                  ii. 233
  Treatment  of Enlarged and
    Indurated Tonsils       ii. 237
  Staphyloraphy            ii. 237
  Encysted Tumor on Side of
    Neck                  ii. 362
  Congenital Hernia        ii. 460
  Ligation of External  Iliac  ii. 462
  Puncture of Spina Bifida   ii. 464
  Lectures on Lithotomy     ii. 612
  Extra-Uterine Foetation    ii. 618
ii.	725
ii.	459
ii.	369
ii.	612
ii	613
ii.	613
ii.	363
ii.	614
ii.	616
i.	199
ii.	463
ii.	718
n.	228
ii.	232
 
756        ALPHABETICAL LIST OF  AMERICAN SURGEONS.
  Case of Fissure of Rectum ii. 621
  Extirpation of Astragalus ii. 721
STEVENS,  J.  P.  (New
    York.)
  Resection of Head of  Fe-
    mur                   ii. 723
STEWART, F. CAMPBELL.
    (New York.)
  Scoutetten on Club-Foot    i.  54
  Knife to divide Strictures in
    Hernia                ii. 460
STILLMAN, J. B. D. (New
    York. )
  Use of Liquid Caoutchouc  i. 199
  Caoutchouc in Burns       i. 527
STIMPSON,   JEREMY.
    (Boston.)
  Tic Douloureux cured      ii. 231
STONE, JOHN 0.  (New
    YrORK.)
  Occlusion of Vagina
  Resection of Elbow
  Ulcers of  Patella
  Statistics  of Amputation
615
722
718
724
725
STONE, WARREN.  (New
    Orleans.)
  Trephine in Epilepsy      ii. 229
  Tracheotomy             ii. 362
  Heruiae                  ii. 461
  Ligation of Common Iliac ii. 462
             Gluteal Artery ii. 462
  On Inflammation           i. 289
  On Amputations          ii. 726
STONER, E. R. (Illinois.)
  Hydrophobia              i. 527
STOUT,  ABRAHAM.
    (Easton, Pa.)
  Cheiloplasty             ii. 236
STRACHN,JOHNB. (Vir-
    ginia.)
  Excision of Cervix Uteri   ii. 617
STRONG, Dr.   (Boston.)
  Pus in Tibia             ii. 723
SWEAT, MOSES. (Maine.)
  Three Parotids Removed   ii. 359
  Division of Nerves in Teta-
    nus                   ii. 718
SWETT, JOHN A.   (New
    York.)
  Paracentesis in Empyema   ii. 369
SYKES, JAMES.    (Dela-
    ware.)
  Ligation of Carotid       ii. 364
T.
TALIAFERRO,  W.   T.
    (Kentucky.)
  Congenital  Tumor  of Eye-
    ball                    ii. 230
TAYLOR, B. F.  (Louisi-
    ana.)
  Chloroform in Hernia      i. 200
TAYLOR, C. F.   (Phila-
    delphia.)
  On Localized Movements   i.  57
TAYLOR,  O.  H.   (New
    Jersey.)
  Atresia Vasrinae           ii. 616
TAYLOR, WM. T. (Phila-
    delphia. )
  Castration                ii. 610
THACHER,  JAS.   (Ply-
    mouth.)
  Bladder Tapped above Pu-
    bis                     ii. 610
THAXTER, ROBT.   (Dor-
    chester.)
  Ununited Fracture  of  Hu-
    merus                  i. 669
THOMAS, S. D. (Pennsyl-
    vania.)
  Vesico-Vaginal Fistula     ii. 616
THOMPSON, Dr.  (Massa-
    chusetts.)
  Tracheotomy for Croup     ii. 360
THOMPSON, GEO.   (Ten-
    nessee.)
  Compression in  WTounded
    Arteries                i. 199
THOMPSON, J. E.   (Mis-
    souri.)
  Encysted Tumor of  Head   i. 409
  Inflammation, etc. of Female
    Breast                 ii. 368
TOLAND, H.  H.   (South
    Carolina.)
  Persulphate of  Iron        i. 199
  Tumors of Neck           ii. 363
  Congenital Hypertrophy of
    Upper Eyelid           ii. 229
  Immobility of Jaw         ii. 234
  Excision of Part of Inferior
    Maxilla                ii. 235
  Extirpation of  Parotid     ii. 359
  Case of Lithotomy         ii. 611
  Sanguineous Tumors of Va-
    gina                   ii. 615
i 
ALPHABETICAL LIST OF  AMERICAN SURGEONS.
757
  Reproduction of Bones and
    Joints                 ii. 719
TOLEFREE,  R.  (New
    York.)
  On Circular and Flap Oper-
    ations                  ii. 724
TOWNSEND.   (Boston.)
  Tracheotomy for Laryngitis ii
                F.  (Ken-
UTTERY, A. LEANDER.
    (Providence.)
  Calculus in Urethra       ii.
614
V.
(New
TRABUE,  B
     TUCKY.)
  Tracheotomy
TRACEY, WM. A
     Hampshire.)
  Paracentesis Thoracis      ii
TRASK,  JAS.  D.  (New
     York. )
  Ligation of Primitive Ca-
     rotid, etc.               ii
  Strangulated Inguinal Her-
     nia                    ii
TRIPLER, CHARLES  S.
     (U. S. Army.)
  Secondary Hemorrhage after
     Amputation of Shoulder ii
  Inspection of Recruits      i
  Ligation of Gluteal and In-
     ternal Iliac             ii
TROWBRIDGE, AMASA.
     (New York.)
  Tracheotomy for a Bean    ii
  Three Cases Spina Bifida  ii.
  Operation of Lithotomy    ii,
  Lithotomy                ii.
  Extraordinary Cases of Am-
     putation
TRUGIEN, J. W. H. (Vir-
     ginia. )
  Trephining in Compression ii.
TURNBULL, LAURENCE.
     (Philadelphia.)
  Occluded Os Uteri         ii.
  Defects of Sight and Hear-
    ing                    .!■
  Ophthalmoscope          n.
TWITCHELL. (New Hamp-
    shire.)
  Ligation of Carotid in Gun-
    shot Wound            ii.
361


362


369



231

460
724
 56

462
360
464
611
613
H.
VAN  BUREN,  WM.
    (New York)
  Simultaneous Dislocation
  Bernard and Huette's Sur-
    gery
  Malignant Polypus  Nose,
    etc.
  Ligation of Subclavian, with
    Statistics
  Rare Hernia
  Ligation of External Iliac
  Lithotomy
  Tumor of Left Ovary
  Ovariotomy
  Popliteal Aneurism
  Amputation at Hip-Joint
  Amputation of Thigh
  Amputation  at  Shoulder-
    Joint
VAN INGEN, JAMES  L.
    (New York )
  Trephining in Infancy
ii.  723
228
616

 57
231
364
 i. 745

 i.  55

ii. 232

ii. 367
ii. 460
ii. 463
ii. 613
ii. 619
ii. 619
ii. 722
ii. 726
ii. 725

ii. 726


ii. 228
               u.

UPSHUR, GEO. L.  (Vir
    GINIA.)
  Occlusion of Vagina       ii.  61
              W.

WAGNER, JNO. (Charles-
    ton.)
  Amputation of part of Lower
    Jaw
WALKER, E. M.  (Texas.)
  Bibron's Antidote
WALTON,  A. G.  (Penn-
    sylvania.)
  Operations for Club-Foot
  Resection of Femur
WARREN, JNO.  (Boston.)
  Amputation at  Shoulder
WARREN, JOHN C. (Bos-
    ton.)
  Observations on Tumors
  Etherization, with Surgical
    Remarks
  Effects of Chloroform
  Air in Veins
  Cold Water-Dressing
  Etherization
  Ether and Chloroform
ii. 234
i. 527
719
723
ii. 723
i.  55
i.	55
i.	55
n.	363
i.	199
l.	200
i.	200
 
7oS
ALPHABETICAL LIST OF  AMERICAN  SURGEONS.
  A Death from Chloroform
  Use of Anaesthetics
  Division of Nerves in Neu-
    ralgia
  Excision of  Submaxillary
    Nerve
  Double Hare-lip
  Removal of Upper Maxilla

  Removal of half of Lower
    Maxilla
  Operation   for  Cancer  of
    Tongue
  Induration of Tonsils
  Natural Fissure  of  Soft
    Palate
  Operation   for  Tumor  of
    Neck
  Excision of Jugular
  Air in Veius
  Operation for Carotid Aneu-
    rism
  Ligation of Subclavian Ar-
    tery
  Removal of Clavicle
  Excision of Ribs
  Strangulated Crural Hernia
  Ligation of External Iliac
  Aneurism of External Iliac
  Artificial Urethra
  Omental Hernia
  Bilateral Operation for
    Stone
  Non-Existence of Vagina
  Cancer of  Uterus
  Cases of Neuralgia
  Ligation of Femoral Artery
WARREN, JNO. MASON.
    (Boston.)
  Cold as an  Anaesthetic
  Hydrophobia
  Dislocations of both Thighs,
    with Fracture
  Dislocations of both Thighs,
    with Fracture
  Tic Douloureux
  Trephine iu Neuralgia
  Inhalation  of Ether
  Ligation of both Carotids
  Trephining for Old Depres-
    sion
  Blepharoplastic Operations
  Rhinoplastic       "

  Autoplastic        "
1.	200
i.	199
ii.	231
ii.	231
ii.	232
ii.	233
ii.	233
ii.	234
ii.	236
ii.	237
ii.	237
ii.	363
ii.	363
ii.	363
ii.	364
ii.	366
ii.	367
n.	368
ii.	459
ii.	462
ii.	463
ii.	608
ii.	609
ii.	612
ii.	615
ii.	617
ii.	717
ii.	719
i.	200
i.	527
i	745
i.	745
11.	231
ii	231
i	200
ii.	365
ii	228
n	229
ii	232
n	2:^2
ii	232
  Excision of Tonsils         ii. 237
  Tumors in Parotid Regions ii. 359
  Taliacotiau Operations     ii. 232
  Section  of  Infra-Orbital
    Nerve                  ii. 231
  Nursing after Operating for
    Hare-lip                ii. 232
  Cancer of Throat          ii. 237
  Enlargement of Tonsils     ii. 238
  Fissure of Palate          ii. 238
  Fissures,  Hard  and  Soft
    Palate                  ii. 238
  Fissures,  Hard  and  Soft
    Palate                  ii. 238
  Extirpation of Parotid     ii. 359
  Division  of  Sterno-Cleido-
    Mastoid                ii. 359
  Foreign Bodies in Air-Pas-
    sages                   ii. 361
  Laryngotomy              ii. 361
  Ligation of both Carotids  ii. 365
  Ligation of Left Subclavian ii. 366
                            ii. 366
  Operation for Artificial Anus ii. 461
  Lithotomy and Lithotrity   ii. 614
  Occlusion of Vagina        ii. 616
  Three Cases of Occlusion of
    Vagina                 ii. 615
  Three Cases of Occlusion of
    Vagina                 ii. 616
  Amputation  at  Shoulder-
    Joint                   ii. 725
  Resection of Knee-Joint   ii. 723
  Barton's Operation for Knee-
    Joint                   ii. 723
  Amputation at Hip-Joint   ii. 726
WATERHOUSE, HENRY S.
    (New York.)
  Tracheotomy  for  Water-
    melon  Seed              ii. 360
WATERMAN, L. D. (Ohio.)
  Empyema                 ii. 369
WATERS, NICHOLAS B.
    (Philadelphia.)
  Bell's System of Surgery   i.   51
WATERS,  WM.   (Mary-
    land)
  Elm Bougies              ii. 608
WATSON,  JOHN.   (New
    York.)
  Anaplasty in Ulcers,        i. 289
  Fracture of Os Brachii     i. 668
  Nature, etc. of Telangiectasis i. 409
  Anaplastic Operation  on Os
    Frontis                 ii. 231 
ALPHABETICAL LIST OF AMERICAN SURGEONS.        759
  Polypi in Nasal Fossae, etc. ii.
  Organic Obstructions of
    Oesophagus            ii
  Radical Cure of Herniae   ii.
  Treatment of Varicocele   ii.
  On Secondary Abscesses   ii.
  On Varices              ii.
  Cases of Pseudarthrosis     i.
WATSON, JNO. M.  (Ten-
    nessee.)
  Foreign Bodies in Air-Pas-
    sages                 ii.
WEBER, G.  C.  E.   (New
    York.)
  Plaster  of  Paris Bandage
    for Fractures            i.
  On Stone in the Bladder of
    Females               ii.
  On Stone iu the Bladder of
    Females               ii.
WEBER, J. M. (New York.)
  Ou Inguinal Hernia       ii.
  Hydatids of Liver         i.
                           ii.
WEBSTER,  JAS.  (Phil-
    adelphia.)
  Removal of Tumor from
    Face
WEDDERBURN, A. J.
    (New Orleans.)
  Removal of Parotid        ii.
     "     " Clavicle        ii.
  Ligation of Primitive Iliac  ii.
     "     " External Iliac  ii.
  Resection of Femur        ii.
WEDERSTAUL, Dr. (New
    Orleans.)
  Tracheotomy             ii.
WEE YE R, CONSTANTINE.
    (Michigan.)
  New Oesophagus Forceps  ii.
WEIR, ROBERT F.  (New
    Y'ORK.)
  Hernia Cerebri            ii.
WELLS, EDWARD  W.
  Ligation of Subclavian     ii.
WELLS, THOMAS. (South
    Carolina.)
  Hypertrophy of Tongue    ii.
  Extensive Division of Soft
    Palate                 ii.
WELLS, W. LEHMAN.
    (Philadelphia.)
  Case of Fracture connecting
    with Frontal  Sinus       i.
232

359
460
609
718
719
670
362
668

613

613

461
 55
459
ii. 236
359
367
462
463
722
361
359
229
366
236
237
668
WEST, FRANCIS.  (Phil-
    adelphia. )
  Dislocation  of Crystalline
    Lens                  ii. 230
WHARTON, R. G.   (Mis-
    sissippi.)
  Artificial Anus           ii. 461
WHEELER,  II. H.  (Penn-
    sylvania. )
  Extirpation of Parotid     ii. 359
WHINERY,  EDWARD.
    (Iowa.)
  Extra-Uterine Pregnancy  ii. 618
WH1TAKER,  J.  (New
    York.)
  Fracture of Pelvis         i. 668
WHITE, G.H.  (NewYork.)
  Ligation of Subclavian    ii. 366
WHITE, JAMES C.   (Mas-
    sachusetts.)
  Analysis of Urinary Calculi ii. 613
WHITE, S. POMEROY.
    (New York.)
  Ligation of Internal Iliac  ii. 462
WHITE, SAMUEL.   (New
    York. )
  Teaspoon removed from In-
    testine                ii. 458
WHITRIDGE, J. B.
    (Charleston.)
  Tapping iu Hydrocephalus ii. 229
  Ligation of External Iliac ii. 462
  Amputation  at  Shoulder-
    Joint                 ii. 7 23
WILLDAY, JOHN.
  Cold Water in Calculus    ii. 611
WILLIAMS, A. V   (New
    York.)
  Spontaneous  Rupture  of
    Bladder
  Vesico-Vaginal Fistula
WILLIAMS,  HENRY W.
    (Boston.)
  Cataract
  Extirpation of Eyeball
  Extraction of Cataract when
    etherized
  Empyema
WILLIAMS,  J.  (Massa-
    chusetts. )
  Paracentesis Thoracis     ii. 369
WILLIAMS, STEPHEN W.
    (Massachusetts.)
  American Medical  Biogra-
    phy                     i.  54
ii.	611
ii.	616
ii.	231
n.	229
ii.	230
ii.	369
 
760        ALPHABETICAL LIST OP AMERICAN SURGEONS.
 WILLIAMS, W. G. (Ohio.)
   Pseudarthrosis            i. 670
 WINCHELL, M. E.  (New
     York.)
   Trephining              ii. 228
 WINTON, NELSON.  (New
     York.)
   Ovariotomy              ii. 620
 WOLFLEY, T.  (Ohio.)
   Paracentesis in Empyema  ii. 369
 WOOD, J. A.   (Boston.)
   Apparatus for Curvature of
     Spine                 ii. 464
 WOOD,  JAS.   R.   (New
     York.)
   Division of Masseter in Im-
     mobility of Jaw
   Lithotomy in a Child
   Procidentia Uteri
   Two Cases of Popliteal
     Aneurism
WOOD, T.  (Cincinnati.)
   Cold as an Anaesthetic
   Fracture of Os Hyoides
  Plastic Operation
  Lithotomy in Infants
   Strangulated Herniae
  Chase's Truss  in Herniae
WOODBURY,  PETER  P.
    (New  Hampshire.)
  Tracheotomy  for  Removal
    of a Bean              ii. 360
11.	234
ii.	612
ii.	615
ii.	721
i.	200
i.	668
ii.	359
ii.	613
ii.	460
ii.	460
WORT, J.  (Indiana.)
   Osteo-Sarcoma  of Lower
    Jaw                  ii. 235
WORTHINGTON, NICHO-
    LAS.  (District of Co-
    lumbia.)
   Case of False Joint        i. 669
WRAGG, J A.  (Georgia.)
   Impermeable Stricture     ii. 608
WRAGG, W. T.   (South
    Carolina.)
   Sutures in Surgery         i. 199
   Dislocation of Patella       i. 744
WRIGHT, CLARKE. (New
    York.)
  Tumor in Antrum         i. 233
WRIGHT,  THOMAS  H.
    (Baltimore. )
  Reunion of Fractured Bones  i. 670
               Y.

YANDELL,  LUNSFORD
    PITTS.  (Kentucky.)
  Two Cases of Lithotomy   ii. 611
YARDLEY, THOS.  (Phil-
    adelphia.)
  Removal  of Extra-Uterine
    Foetus                 ii. 618
YORK, J. II.  (Boston.)
  Imperforate Anus         ii. 621 
INDEX   TO   VOL.   II.
                    A.
                                     PAGE
 Abdomen, tapping of....................... 371
      Physick's operation for.............. 372
 Abdomen, wounds of....................... 382
 Abscess, hepatic............................ 373
 Abscess of antrum.......................... 173
 Abscess of septum narium............... 144
 Abscess, retro-pharyngeal................ 280
 Absorption of cataract..................... 117
 Adenoma of neck........................... 301
 Alae nasi....................................... 141
 Albugo.........................................  98
 Amputation................................... 666
 Amputation, after-treatment of......... 674
 Amputation, accidents after.............. 680
 Amputation, assistants in................ 678
 Amputation at knee-joint................. 702
     Bauden's operation................... 703
     Parker's operation.................... 703
     Smith's operation..................... 702
 Amputation at shoulder-joint............ 682
 Amputation, circular......................  674
 Amputation, flap...........................  675
 Amputation in railroad accidents......  669
 Amputation of ankle-joint...............  709
     Pirogotf's operation.................  709
     Syme's operation.....................  709
     Velpeau's operation..................  709
 Amputation of arm..........................  686
     Alanson's operation.................. 686
     Teale's operation..................... 687
 Amputation of elbow-joint............... 689
     Velpeau's operation.................. 689
 Amputation of fingers..................... 693
 Amputation of foot......................... 710
 Amputation of forearm.................... 691
 Amputation of hip-joint.................. 693
 Amputation of leg.......................... 705
 Amputation of lower extremity......... 693
 Amputation of neck of uterus............ 577
 Amputation of penis....................... 471
 Amputation of thigh....................... 699
 Amputation of toes......................... 731
Amputation of tongue..................... 167
Amputation, oval...........................  675
Amputation, period for.................... 670
Anaplasty..................................... 129
Anatomy of chest...........................  333
 Anatomy of eyeball........................  92
 Anatomy of larynx.......................... 255
 Anatomy of rectum......................... 586
 Aneurisms  of Scalp.....................  58
     Dudley's operation....................  58
 Ankle-joint amputation................... 709
 Ankle, resection of......................... 664
     Roux's operation..................... 664
 Ankyloblepharon...........................  79
 Anterior tibial artery,  ligation of...... 648
 Anteversio  uteri.............................. 573
 Antidotes for poisons...................... 285
 Antrum, abscess of......................... 173
 Antrum, etFusions into..................... 171
 Antrum, polypus of........................ 173
 Anus, artificial..... ........................ 433
     Dupuytren's operation for.......... 434
     Lotz's  operation for.................. 435
     Physick's operation for.............. 434
     Warren's operation for.............. 438
 Anus, disorders of.......................... 587
 Anus, eczema of.............................. 588
 Anus, fissure of.............................. 591
 Anus, imperforate.......................... 591
 Anus, prolapse of.......................... 593
     Cheselden's operation............... 596
     Dupuytren's operation............... 595
     Ricord's operation.................... 596
     Robert's operation.................... 596
 Appendages of eyes........................ 72
 Arm, amputation of......................... 686
 Arteries of extremities..................... 632
 Arteries of the lower extremity......... 641
 Arteries of the neck, ligation of........ 310
 Artificial anus................................ 433
 Artificial anus, formation of............. 439
     Amussat's operation for............  440
     Littre's  operation for................. 439
 Artificial eyes................................ 127
 Artificial limbs..............................  716
 Artificial pupil..............................  123
     Hays' operation.......................  125
     Pancoast's operation.................  125
     Physick's operation..................  124
    Scarpa's operation.................... 125
Artificial tympanum........................ 222
Assistants in amputation................. 678
                        (761) 
762                          index to  vol. ii.
                                    PAGE
Astragalus, resection of.................. 665
Atresia oris................................... 156
Aural catheterism........................... 224
Axilla.......................................... 633
Axillary artery, ligation of.........  341, 633
B.
Back, operations on........................ 451
Bellocque's canula.......................... 145
Bertrand's suture........................... 385
Bilateral lithotomy.......................... 527
    Dupuytren's operation................ 527
    Eve's operation........................ 530
    Fergusson's operation............... 529
    May's operation....................... 530
    Mussey's operation................... 529
    Ogier's operation..................... 529
Bladder, puncture of....................... 487
Bleeding from the nostril................. 145
Blepharoplasty...............................  82
    Dieffenbach's operation..............  83
    Graefe's operation....................  83
    Jones' operation.......................  82
Blows on eye................................  75
Bond's forceps.............................. 281
Bones of hand, resection of............... 057
Bones of leg, resection of................. 663
Borkell on amputation....'................. 710
Brachial artery, ligation of.............. 636
Brahmin method of rhinoplasty......... 133
Breast,  amputation of..................... 332
Bronchocele................................. 305
Burns.......................................... 293
     Mutter's operation.................... 293
Burns,  deformities from.................. 293
Caesarean operation........................ 585
Calculus....................................... 511
Cancer of lip................................. 156
Cancer of tongue........................... 165
Caries of cranium...........................  60
Caries of sternum........................... 353
Carotid  artery, ligation of................ 315
Cases for amputation...................... 667
Castration.................................... 501
Cataract....................................... 110
Cataract, extraction of..................... 119
Catarrhal deafness.......................... 219
Catheterism.................................. 473
Catheterism in the female................ 552
Catoptric test................................. 112
Cauterization of the larynx............... 258
    Green's operation..................... 258
Cavity of tympanum...................... 197
Cephalaematoma.............................  59
Chase's truss................................. 406
Cheeks, tumors of........................... 161
                                    PAGE
Cheiloplasty.................................. 157
    Hamilton's operation................. 159
    Pancoast's operation................. 157
    Taliacotian operation................ 157
Chemosis......................................   95
Chest, anatomy of.......................... 333
Chest, effusions into........................ 3)3
Chest, tumors of............................. 350
Chew's stylet catheter..................... 480
Choroiditis................................... 101
Circular amputation........................ 674
Circumcision................................. 468
    Cloquet's operation for.............. 468
    Cullerier's operation for............ 468
Clavicle, resection of....................... 334
Clitoris, hypertrophy of.................. 551
Club-foot...................................... 623
Club-foot, treatment of.................... 630
Colic, nephritic.............................. 514
Columna nasi................................ 141
Conjunctivitis................................   94
Corectomia.................................... 124
Coredialysis.................................. 125
Coretomia.....................................  124
Corneitis.......................................   98
Cranium, caries of..........................   60
Cranium, spina ventosa of...............   61
    M'Clellan's operation................   61
Cranium, trephining of...................   61
Croup, tracheotomy in....................  262
Crural herniae...............................  421
Cysticercus...................................  103
Cystine.........................................  510
Cystoma of scalp............................   54
D.
Dacryocystitis...............................  89
Deafness....................................... 215
Deafness, catarrhal........................ 219
Deafness, nervous........................... 220
Deformities from  burns.................... 293
Dilatation of pupil.......................... 115
Dislocation of the lens..................... 123
Disorders of anus........................... 587
Disorders of eyeball........................  92
Disorders  of head...........................  51
Disorders  of neck........................... 276
Disorders  of rectum......................... 589
Disorders  of the ear....................... 195
Disorders  of the  throat.................... 274
Disorders of the uterus.................... 571
Displacements of the uterus............. 573
Distichiasis..................................  78
Distortion of pupil.......................... 126
Division of masseter........................ 162
     Mott's operation....................... 162
     Schmidi's operation..................  162
Division of supra-orbitar nerve.........  60
     Warren's operation...................  60
Drum of ear, inflammation of............ 207
Dryness of the ear.......................... 217
Dura mater, tumors of....................   69 
INDEX TO VOL. II.
763
                   E.
                                    EPAGE
  ar, anatomy of............................. Kir,
Ear, disorders of............................ 195
Ecraseur in amputation of penis........ 472
Ecraseur in hemorrhoids.................. 601
Ectropion.....................................   83
    Adams' operation....................   84
    Brainard's operation.................   81
    Dosmarres' operation................   84
    DiefFenbach's operation..............   84
    Horner's operation...................   84
Eczema of  anus.............................. 588
Eczema of  vulva............................. 549
Edema of glottis............................. 259
Edema of larynx........................... 259
    Buck's operation for.................. 260
    Green's operation..................... 260
    Lisfranc's operation.................. 260
Effusions into chest........................ 353
Effusion into pericardium................. 357
    Warren's operation for.............. 358
Elbow-joint, amputation of............... 689
Elbow, resection of......................... 0'>4
    Harris' operation...................... 654
Elephantiasis of scrotum.................. 496
    Picton's operation for............... 496
Encanthus....................................   79
Encysted rectum............................ 590
Encysted stone.............................. 535
Encysted tumors of scalp.................   54
Enlargement of  clitoris.................... 551
Enlargement of mouth..................... 156
Enterotomy................................... 378
    Manlove's operation for............. 379
    White's operation for................ 380
Enterotomy or gastrotomy............... 376
Entropion.....................................   85
    Crampton's operation................   87
    Dorsey's operation....................   85
  *  Guthrie's operation..................   87
    Janson's operation....................   85
    Key's  operation........................   87
    Walton's operation....................   87
Envelopes  of herniae........................ 389
Epicanthus....................................   79
Epilepsy, tracheotomy for................ 265
Epiphora......................................   88
Episoraphy................................... 575
Epispadias.................................... 491
Erectile tumors of scalp...................   55
Eustachian tube, catheterism of......... 224
Eversion of eyelids.........................   83
Excision of tonsils.......................... 169
    Physick's operation.................. 170
Excision of uvula........................... 168
External nose, anatomy of............... 131
External nose, operations on............ 131
External otitis............................... 20-5
Extirpation of eyeball.................... 109
    Mettauer's operation................. 109
Extirpation parotid gland................ 248
    Horner's operation.................... 251
    M'Clellan's operation................ 248
    Mott's operation...................... 250
    Randolph's operation................ 231
Extirpation of mammary gland......... 342
Extirpation of uterus ..................... 578
Extraction of cataract..................... 119
Extraction of the stone.................... 534
Extremities, operations on................ 623
Eyeball, extirpation of.................... 109
Eye, blows on................................  75
Eye, foreign bodies in.....................  75
Eyelids, tumors of..........................  76
Eyelids, wounds of.........................  76
P.
Face, surgical anatomy of...............   71
Facial artery, ligation of..................  321
Falling of eyelid............................   81
Falling of the body........................  593
False anchylosis of jaw....................  162
Female perineum...........................  548
Femoral artery, ligation of...............  643
    Hunter's operation ...................  643
    Mott's operation......................  643
    Scarpa's operation....................  643
Femoral hernias..............................  421
Femoral trusses.............................  425
Femur, resection of........................  657
    Barton's operation....................  659
Fibula, resection of.........................  664
Fingers, amputation of....................  693
Fissure of anus..............................  591
    Boyer's operation for................  591
Fissure of the palate.......................  187
Fistulae gastric..............................  380
    Cook's operation for..................  381
Fistulae, vesico-vaginal....................  559
    Hayward's operation.................  560
Fistula in ano................................ 605
    Gibson's operation....................  605
Fistula in perineo...........................  487
Fistula lachrymalis........................   88
Fistula of parotid duct............".........  161
Fit. of the stone..............................  515
Flap amputation............................  675
Foot, amputation of........................  710
    Chopart's operation..................  711
     Hey's operation.......................  711
    Lisfranc's operation..................  711
Forearm, amputation of..................  691
Forearm, resection of.......................  655
Foreign bodies in eye.....................   75
Foreign bodies in nostril.................  144
Foreign bodies in oesophagus............ 281
    Bond's operation......................  281
    Rice's operation.......................  283
    Weever's operation...................  281
Foreign bodies in rectum................. 590
Foreign bodies in the ear.................  200
Foreign body in trachea..................  264
Formation of  artificial anus.............. 438
Fraenum penis...............................  471
Frontal sinus, trephining of.............   66
Fungoid of dura mater.....................   69
    J. C.  Warren's operation............   69
Fusible calculi............................... 512 
764
INDEX TO VOL. II.
                   G.
                                    PAGE
Gastric fistulae............................... 380
Gastrotomy or enterotomy............... 376
General pathology of herniae............ 389
Genioplasty.................................. 160
    Dieffenbach's operation.............. 160
    Mott's operation....................... 160
    Mutter's operation.................... 160
Genito-urinary organs..................... 465
Gland, parotid........................ 241, 248
Glosso-hyoid  region........................ 240
Glottis, edema of............................ 259
Glover's suture.............................. 384
Goitre.......................................... 305
    Ballard and Rigal's operation..... 308
    Dwight's operation................... 307
    Jameson's operation.................. 308
    Warren's operation................... 308
Gonorrhceal ophthalmia...................  95
Gorget......................................... 523
Gravel.......................................... 502
Gravel, constituents of....................  503
H.
 Haematocele..........................
 Hare-eye..............................
 Hare-lip..............................
 Head disorders and operations..
 Head, surgery and anatomy of..
 Hemorrhoids.........................
 Hepatic abscess......................
  .   Begin's operation for..........
     Savery's operation for.......
 Herniae.................................
 Herniae, femoral.....................
 Herniae. inguinal....................
 Herniae, ischiatic....................
 Herniae, lumbar......................
 Herniae, perineal....................
 Herniae, phrenic.....................
 Herniae, pudendal....................
 Herniae, radical cure of...........
 Herniae, reducible....................
 Herniae, reduction of................
 Herniae, scrotal.......................
 Herniae, strangulated...............
 Herniae, thyroidal...................
 Herniae umbilical....................
 Herniae, vaginal......................
 Herniae, ventro-inguinal..........
 Herniae, inguinal....................
 Hernial sac............................
 Herniotomy  in femoral herniae...
 Herniotomy  in inguinal herniae..
 Herniotomy  in umbilical herniae.
 Heyward's suture....................
 Hip-joint,  amputation of...........
    Ashmead's operation..........
    Buchanan's operation........
    Lalouette's operation..........
    May's operation................
    Van Buren's operation........
Hodge's pessary......................
, 499
.  82
 152
  51
  51
 596
 373
 373
 375
 388
 391
 390
 390
 390 j
 390
 390
 391 j
 403
 400
 398
 391 j
 395
 390
 429
 390
 391
 409
 389
 425 ;
 415
 432 I
 384
 693
 697
 697
 694
 695 I
 694 I
 575 i
                                    PAGE
Hordeolum....................................  77
Hydatids of liver........................... 375
Hydrocele..................................... 497
Hydrocele of the neck.............. 277, 309
Hydrocephalus..............................  67
Hydrorachis.................................. 453
    Brainard's operation for............ 456
    Skinner's  operation for.............. 455
    Stevens' operation for............... 456
    Trowbridge's operation for......... 453
Hymen, inflamed........................... 551
Hymen, imperforate........................ 552
Hymen, warts  of............................ 551
Hypertrophy of tongue............~...... 167
Hypopion..................................... 100
Hypospadias................................. 491
I.
 Iliac arteries, ligation of..................  442
    Abernethy's operation...............  443
    Bogros' operation.....................  445
    Cooper's operation....................  444
    Dorsey's operation....................  443
    Mott's operation.......................  414
    Peace's operation.....................  448
    Post's operation.......................  443
Immobility of jaw...........................  162
Imperforate anus............................  591
Imperforate hymen.........................  552
Imperforate vagina..........................  552
Incision of puncta...........................  88
    Bowman's operation..................  88
Inguinal herniae.............................  409
Inguinal herniae, herniotomy for........  415
Innominata, ligation of....................  323
Internal otitis................................  102
Intestinal sutures...........................  384
Intestines, wounds of......................  3B3
Iritis............................................  99
Inversion of eyelids........................  85
J.
Jaw, anchylosis of.......................... 162
                  K.

Keratonyxis.................................. 118
Knee-joint, resection of................... 659
Kolbe's artificial limbs.................... 716
L.
Laceration of perineum.................... 555
Lachrymal apparatus................... 7^1, 88
Lagophthalmus..............................  82
Laryngoscope................................ 257
    Czermak's............................. 257
Laryngotomy................................. 266
    Buck's operation...................... 266 
INDEX TO VOL. II.
765
 Laryngotomy, Desault's operation.....
 Laryngotracheal region..................
 Larynx, anatomy of........................
 Larynx, polypi in...........................
 Lateral lithotomy..........................
 Ledran's loop  suture......................
 Leg, amputation of.........................
     Circular operation...................
     Flat operation ........................
     Lenoir's operation....................
     Teale's operation.....................
     Verduin's operation..................
 Lembert's suture............................
 Leucoma.......................................
 Ligation anterior tibial artery...........
 Ligation of arteries of  lower extremity
 Ligation of arteries of neck..............
 Ligation of arteries, rules for...........
 Ligation of axillary artery...............
     Lisfranc's operation..................
     Malgaigne's operation...............
 Ligation of brachial artery...............
 Ligation of facial artery..................
 Ligation of femoral artery................
 Ligation of iliac arteries..................
 Ligation internal iliac  artery.............
     Bigelow's  operation for..............
     Kimball's  operation for...............
     Stevens' operation for..............
     White's operation for................
 Ligation of magna pollicis...............
 Ligation of popliteal artery..............
     Lisfranc's operation..................
 Ligation posterior tibial artery.........
     Lisfranc's operation..................
     Malgaigne's operation...............
     Velpeau's operation..................
 Ligation of radial artery..................
 Ligation of spermatic artery.............
 Ligation of the axillary artery..........
    Lisfranc's operation..................
 Ligation of the carotid artery...........
    Mott's operation.......................
 Ligation of the innominata artery.....
    Mott's operation.......................
 Ligation of the lingual artery...........
    Malgaigne's operation...............
 Ligation of the subclavian artery......
    Dupuytren's operation...............
    Kearny Kodgers' operation........
    Mott's operation.......................
    Parrish's rule for.....................
Ligation of ulnar artery...................
Linear extraction  of cataract..........
Lingual artery, ligation of..............
Lingua Vitula................................
    Harris' operation.....................
Lip, cancer of................................
Lipoma of nose..............................
Lips, operations on.........................
Lithectasy....................................
Lithectasy in female .......................
Litholiby......................................
    Denamiel's operation for............
Lithotomy, after-treatment of...........
PAGE
266
243
255
261
522
384
705
705
707
7U8
707
708
385
 98
648
641
310
312
633
633
635
636
321
643
442
449
450
450
449
450
640
644
644
645
647
647
647
639
501
341
341
315
316
323
324
321
321
325
329
330
329
328
640
123
321
167
167
156
131
152
532
569
547
547
537
                                    PAGE
Lithotomy, median......................... 531
    Allarton's operation.................. 531
    Vacca's operation..................... 531
Lithotomy, quadrilateral.................. 534
Lithotomy, recto vesical.................. 532
    Sanson's operation.................... 532
Lithotomy, statistics of................... 540
Lithotomy, vaginal......................... 569
Lithotripsy.................................... 542
    Randolph's operation for........... 543
Lithotripsy in female......... ............ 570
Liver, hydatids of........................... 375
    Weber's operation for............... 376
Loop suture of Ledran .................... 384
Loop suture of Palfyn..................... 384
Lower extremity, amputation of........ 693
                  M.

Magna pollicis, ligation of............... 640
Maisonneuve's stylet catheter........... 481
Male genito-urinary organs.............. 465
Male perineum.............................. 517
Mammary gland extirpation of.......... 342
Masseter muscle, division of............. 162
Median lithotomy........................... 531
Membrana tympani........................ 196
Metacarpus, resection of.................. 657
Meiatarsal bones, resection of.......... 666
Metoplasty................................... 128
    Watson's operation................... 129
Morgagnian cataract....................... Ill
Mouth, anatomy of................... 151, 163
Mouth, enlargement of.................... 156
Myotomy in torticollis..................... 295
Myringitis.................................... 207
                   N.

Naevi, or erectile tumors..................  57
    Barton's operation...................  57
    Brainard's operation................  58
    Bushe's operation.....................  57
    Fawdington's  operation.............  57
    Gibson's operation....................  58
    N. R. Smith's operation............  57
    Physick's operation..................  58
    Stevens'  operation....................  57
Nasal cavities................................ 142
Nebtila.........................................  98
Neck, disorders of.......................... 276
Neck, hydrocele of......................... 277
Neck, operations on........................ 247
Neck, surgical anatomy  of............... 239
Neck, tumors-of............................. 297
Nephritic colic.............................. 514
Neuralgia.....................................  60
Nervous  deafness........................... 220
Nostril, bleeding from .................... 145
Nostril, bodies in........................... 144
Nostril, polypi in........................... 145 
766
INDEX TO VOL. II.
                  o.
                                    PAGE
Occlusion of vagina........................ 552
    Randolph's operation................ 553
Occlusion of vulva.......................... 551
OEsophagotomy.............................. 2911
    Watson's operation................... 291
(Esophagus forceps........................ 281
    Bond's................................... 2S1
    Weever's................................. 281
Oesophagus, stricture of.................. 288
Operation on penis.......................... 467
Operations on  exterior  of eyeball...... 104
Operations on  head........................  51
Operations on  oesophagus  ........ 277, 280
Operations on  neck for tumors.......... 298
Operations on  palate....................... 187
Operations on  scalp........................  54
Operations on  the back..................... 451
Operations on  the ear..................... 199
Operations on  the neck.................... 247
Operations on  urethra..................... 472
Ophthalmia  tarsi............................  77
Ophthalmoscope............................. 101
Orbit, tumors  in............................. 110
Organic changes in amputation......... 713
Os calcis, resection of..................... 665
    Greenhow's operation.............. 665
    Hancock's operation................. 665
Os unguis, perforation of................  91
Os uteri....................................... 571
Otoplasty...................................... 199
    Dieffenbach's operation.............. 200
Otorrhoea.................................... 213
Otoscope, Toynbee's........................ 219
Oval amputation........................... 675
Ovariotomy................................... 578
    Atlee's operation...................... 579
    McDowell's operation................ 579
Ovariotomy, statistics of.................. 582
Oxalate of lime.............................. 509
Ozaena ......................................... 143


                   P.

Palate, operations on...................... 187
Palatoplasty................................. 193
Palfyn's  suture.............................. 384
Pannus........................................  98
Paracentesis abdominis .................. 371
Paracentesis capitis........................  69
Paracentesis thoracis...................... 353
Paraphymosis................................ 469
Parotid fistula............................... 161
Parotid gland............................... 241
Parotid gland, extirpation of........... 249
Parotid region............................... 241
Parrish's needle............................. 313
Penis, amputation of...................... 471
Penis, operations on........................ 467
Perforation  membrana tympani......... 223
    Cooper's  operation......... .......... 223
    Horner's  operation................... 224
Perforation  of os unguis..................  91
Perforation of tympanum................. 223
                                    PAOE
Pericardium, effusions into............... 357
Perineal fistula.............................. 489
    Horner's operation for............... 490
Perineum, female............................ 548
Perineum, laceration of.................., 555
    Brown's operation.................... 556
    Dieffenbach's operation.............. 556
    Horner's operation................... 556
    Mettauer's operation................. 556
Period for amputation..................... 670
Periosteum, preservation of.............. 650
Pes calcaneus............................... 628
Pes equinus................................... 624
Pes plantaris................................. 630
Pessaries...................................... 574
Pes talus....................................... 630
Phalangeal pes equinus................... 627
Pharynx, foreign bodies in............... 274
Pharynx, tumors in ....................... 279
Philadelphia needle........................ 313
Phosphates.................................... 506
Photophobia.................................   96
Phrenic herniae.............................. 390
Phymosis...................................... 467
Physick's bougie catheter................ 476
Physick's stylet  catheter.................. 480
Piles............................................ 596
    Chassaignac's  operation............. 602
    Harris' operation...................... 600
    Horner's operation.................... 601
Place of election............................. 673
Plastic operations  .......................... 128
Plastic suture................................ 135
Points for amputation..................... 673
Poisons, antidotes  for..................... 285
Poisons in the stomach.................... 283
Polypi, enucleation of..................... 576
Polypi in larynx............................ 261
    Green's operation..................... 262
Polypi in the ear............................ 205
    Fabrizji's operation.................. 205
Polypi of nostril............................. 145
Polypi of uterus............................. 575
Polypus of antrum......................... 173
Popliteal artery, ligation of.............. 644
Posterior tibial artery, ligation of...... 645
Preservation of periosteum............... 650
Primitive carotid artery, ligation of...  316
Prolapsus ani................................  593
Prolapsus uteri..............................  573
Psorophthalmia..............................   77
Pterygium....................................   97
Ptosis..........................................   81
     Hunt's operation.....................   81
Puncture of bladder....................... 487
Puncture of uterus..........................  575
Puncturing the cranium..................   67
     Brainard's  operation.................  68
     Dugas' operation......................   67
     Peace's operation.....................   68
     Physick's operation..................   67
     Whitridge's operation...............   67
Pupil, dilatation of.........................  115
Pupil, distortion of.........................  126
Purulent conjunctivitis....................   94 
INDEX TO VOL. II.
767
                   Q.
                                     PAGE
Quadrilateral lithotomy................... 534


                   R.

Radial artery, ligation of................. 639
Radical cure of  herniae.................... 403
     Bowman's operation for........... 404
     Gerdy's operation for................ 403
     Jameson's operation for............ 405
     Nott's operation for.................. 405
     Roberts' operation for............... 405
     Watson's operation for............... 404
     Wood's operation for................. 404
Radical cure of  umbilical herniae...... 431
     Desai>lt's operation................... 431
     Physick's operation.................. 431
Radius and ulna, resection of............ 655
Ramsdohr's suture.......................... 385
Reclination of cataract..................... 118
Recto-vaginal fistulae...................... 567
     Barton's operation.................... 567
     Mussey's operation.................... 568
     Roux's operation..................... 568
     Velpeau's operation.................. 568
Recto-vesical lithotomy................... 532
Rectum, anatomy of........................ 586
Rectum, disorders of....................... 589
Rectum, encysted........................... 590
     Physick's operation.................. 590
Rectum, foreign bodies in................ 590
Rectum, stricture of........................ 607
Rectum, wound  of......................... 536
Reducible herniae........................... 393
Reducible herniae, treatment of......... 400
Reduction of herniae....................... 398
Regional disorders..........................  49
Region, laryngotracheal................. 243
Region, supra-clavicular.................. 245
Resection for false joint.................. 653
Resection of ankle.......................... 664
Resection of astragalus.................... 665
Resection of bones of hand............... 657
Resection of bones of leg................. 663
     Cooper's operation................... 663
Resection of bones of upper extremi-
  ties.......................................... 649
Resection of both jaws..................... 174
Resection of elbow......................... 654
Resection of femur.......................... 657
Resection of fibula.......................... 664
Resection of forearm...................... 655
Resection of knee joint................. ... 659
     Barton's operation.................... 660
     Buck's operation...................... 6j1
     Watson's operation................... 662
Resection of lower jaw..................... 182
     Barton's operation.................... 184
     Deaderick's operation............... 182
     J. M  Warren's operation......... 185
     M'Clellan's  operation................ 185
Resection of metacarpus.................. 657
Resection of metatarsal bones........... 666
Resection of os calcis...................... 665
                                    PAGE
Resection of shoulder-joint............... 651
Resection of the clavicle.................. 334
    Davy's operation...................... 339
    Mott's operation....................... 335
    Velpeau's operation.................. :^38
    Warren's operation................... 336
    Wedderburn's operation............ 337
Resection of the ribs....................... 352
    M'Clellan's operation................ 352
Resection of the scapula.................. 339
    Gross' operation....................... 339
    Hayman's  operation.................. 339
    Luke's operation...................... 340
Resection of upper jaw.................... 174
    Heyfelder's operation............... 181
    Horner's operation.................... 178
    Maisonneuve's operation............ 181
    Mott's operation....................... 179
    Stevens' operation................... 179
    Warren's operation................... 177
Retinitis....................................... 101
Retro-pharyngeal abscess................ 280
Retro-versio uteri............................ 573
Rhinolithes................................... 144
Rhinoplasty.................................. 132
    Warren's operation................... 133
Ribs,  resection of........................... 352
Rupture....................................... 388


                   S.

Sac ofherniae................................ 389
Salivary fistula.............................. 161
    Horner's operation................... 161
Scalp, aneurism of..........................  58
Scalp, cystoma of...........................  54
Scalp, erectile  tumors of..................  55
Scalp, operations on .......................  54
Scalp, venous  tumors of..................  59
Scapula, resection of....................... 339
Scissors for uvula........................... 169
Sclerotitis.....................................  97
Scoop.......................................... 535
Scooping of bone ........................... 650
Scrofulous conjunctivitis..................  96
Scrotum, operations on.................... 496
Sensitive tumors of urethra.............. 551
Septum  narium, abscess of............... 144
Seton in false joint......................... 653
    Physick's operation.................. 653
Shoulder-joint amputation............... 682
    Gilbert's operation.................... 683
    Larrey's operation.................... 685
    Lisfranc's  operation................ 683
    M'Clellan's operation................ 683
    Peaslee's operation ................. 685
Shoulder-joint, resection of.............. 651
    Lisfranc's  operation.................. 651
    Syme's operation..................... 651
    White's operation..................... 651
Simpson's tables of ovariotomy......... 582
Single lithotome............................. 526
Solarscope................................... 208
    Grant's................................... 208 
768                         INDEX  TO  VOL. II.
                                    PAGE
 Solarscope, Hutchinson's................. 208
     Young's................................. 208
 Sounding..................................... 519
 Speculum for ear........................... 196
 Speculum vaginae............................ 572
 Spermatic artery, ligation of............ 601
 Spina bifida................................... 453
 Squint........................................... 105
 Staphyloma..................................  99
 Staphyloplasty.............................. 193
     Velpeau's operation.................. 194
     Warren's operation.................. 193
 Staphyloraphy.............................. 187
     Mettauer's operation................. 192
     Ronx's operation ..................... 189
     Warren's operation................... 191
 Statistics of lithotomy..................... 540
 Statistics of ovariotomy.................. 582
 Statistics of shoulder amputation...... 686
 Statistics of tracheotomy.................. 270
 Stomach, opening of....................... 377
     Bell's operation for ..................  378
     Shoval's operation for............... 377
 Stomach, poisons in........................  283
 Stomach-pump,.............................. 287
 Stone.................................... 502, 511
 Stone, encysted........................      535
 Stone, extraction of......................... 534
 Stone in the female........................ 568
 Strabismus.................................... 107
     Tavignot's operation................ 108
 Strangulated herniae....................... 395
 Stricture of oesophagus.................... 288
Stricture of rectum.........................  607
 Stricture of urethra........................  477
 Stye............................................   77
Subclavian artery, ligation of...........  325
Subconjunctival fascia.....................  105
Submaxillary gland........................  254
Supraclavicular region..................  245
Supra-orbital  nerve........................   60
Supra-pubic lithotomy....................  533
     Home's operation.....................  533
Surgical anatomy of face.................   71
Surgical anatomy of the neck............  239
Suture, Bertrand's..........................  385
     Heyward's............................... 384
    Jobert's..................................  385
    Lembert's................................  385
    Ramsdohr's.............................  385
 Suture of transverse wounds............  385
Sutures for intestines.....................  384
Symblepharon.............................   79
Syme's division of strictures.............  481
Synechia...................................... 100
T.
Taliacptian operation...................... 138
Tapping of abdomen....................... 371
Taxis.......................................... 398
Thigh, amputation of...................... 699
    Alanson's operation................... 700
                                    PAGE
 Thigh,  amputation of,  Teale's opera-
          tion................................  700
     Vermale's operation..................  702
 Thoracentesis..........................353,  355
     Metcalfs operation for..............  355
     Wyman s operation for..............  356
 Thorax, anatomy of.......................  351
 Thorax, operations on.....................  352
 Throat, disorders of........................  274
 Toes, amputation of........................  713
 Tongue, amputation of....................  167
 Tongue, cancer of.................  ........  165
 Tongue, hypertrophy of..................  167
 Tonsillotome  ................................  170
 Tonsillotomy.................................  170
 Tonsils, excision of........................  169
 Torticollis....................................  295
     Brown's  operation................... 296
     Warren's operation................... 296
 Tour de maitre.............................. 475
 Toynbee's otoscope......................... 219
 Tracheal fascia.............................. 257
 Tracheotomy................................. 263
     Liston's operation..................... 265
 Tracheotomy, statistics of................ 270
 Treatment of club-foot..................... 630
 Trepanning...................................  61
     Dorsey's  operation ...................  63
 Trephining....................................  61
 Trephining cranium........................  61
 Trephining frontal sinus..................  66
 Trichiasis.....................................  78
 Truss, Chase's............................... 406
Trusses........................................ 400
Trusses, femoral..............,............. 425
Tumors  in orbit.............................. 110
Tumors  in pharynx........................ 279
    Dugas' operation...................... 279
Tumors  of back............................... 452
    Dorsey's operation for............... 452
Tumors  of cheeks .......................... 161
Tumors  of dura mater.....................  69
 Tumors  of eyelids...........................  76
 Tumors  of neck.............................. 297
     Mott's operation....................... 301
    Warren's operation................... 302
Tympanum, perforation of............... 223
                  U.

Ulnar artery, ligation of................... 640
Ulna, resection of........................... 655
    Butt's operation....................... 655
Umbilical herniae........................... 429
Upper extremities, resections of........ 649
Upper jaw, anatomy of.................... 171
Upper jaw, disorders of................... 171
Upper jaw, resection of.................... 174
Uranoplasty.................................. 193
Urates......................................... 503
Urethra, female, polypi of............... 552
Urethra, operations on.................... 472
Urethra, strictures of...................... 477 
INDEX TO VOL. II.
769
                                    PAGE
Uric acid...................................... 503
Uric acid diathesis.......................... 505
Uric oxide.................................... 511
Uterus, disorders of........................ 571
Uterus, displacement of................... 573
Uterus, extirpation  of..................... 578
     Esselman's operation................ 578
     Eve's operation........................ 578
Uterus, neck of amputated................ 577
     Chassaignac's operation............ 577
     Lisfranc's operation.................. 577
     Sims' operation........................ 577
Uterus, polypi of........................... 575
Uterus, puncture of....................... 575
Uvula, excision of.........................., 168
Uvula scissors................................ 169
                  V.

Vagina, imperforate........................ 552
Vaginal lithotomy........................... 569
Vagina, occlusion of....................... 552
Valgus......................................... 630
Varicocele.................................... 492
    Breschet's operation for............ 495
    Ricord's operation for............... 495
    Velpeau's operation for.............. 495
    Vidal de Cassis' operation for..... 495
    Watson's operation for............... 493
Varus.......................................... 629
Venous tumors of scalp..................   59
                                    PAGE
! Vesico-utero-vaginal fistulie..............  567
 Vesico-vaginal fistulae.....................  561
     Agnew's operation....................  565
     Bozeman's operation.................  565
     Mettauer's operation.................  561
     Sims' operation........................  563
,     Smith's operation......................  561
j Vesico-uterine fistulae.....................  566
j Vesico-vaginal fistulae.....................  559
I Vitreoushumor................ .............  103
I Vulva, eczema of...........................  549
| Vulva, occlusion of.........................  551
                  W.

Washing of auditory canal...............  201
Wax in ear....................................  216
Weever's forceps............................  281
Wounds of abdomen .......................  382
    Ashby's operation for...............  383
Wounds of eyelids.........................   7t'.
Wounds of intestines......................  383
Wrist-joint resection.......................  656
     Velpeau's operation..................  656
Wry-neck.....................................  295
Xanthic oxide................................ 513
Xerophthalmia..............................  88
VOL. II.—49 
:&- ? * 
if. ■ i
■1: 1 I
■s t '
~<-i 
NLM041392319