MM* ^ it' mm $•$ irtii»!. hi HI !!« ;» • r n • .<^ ■*.'?:*& .■„.*»■.-■ •• *«. .1 ^».¥ii' -** MMwiil-:!?1?'/-!:-;;::-- 1 OPERATIVE SURGERY. A STSTE OPJIRATIYE SURGERY: BASED UPON THE PRACTICE OF SURGEONS IN THE UNITED STATES: AND COMPRISING A BIBLIOGRAPHICAL INDEX AND HISTOR,/cAL RECORD OF MANY OF THEIR OPERAMONS, PERIOD OF TWO RED YEARS. HENRY H. ^MITII, M.D., SURGEON TO THE ST. JOSEPH'S HOSPITAL J ASSISTANT LECTUREK ON DEMONSTRATIVE SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; LECTURER ON THE PRINCIPLES AND PRACTICE OF SURGERY IN THE PHILADELPHIA MEDICAL INSTITUTE, ETC. ILLUSTRATED BY NUMEROUS StE PHILADELPHIA: LIPPINCOTT, GRAMBO- AND CO., SUCCESSORS TO GRIGG, ELLIOT AND CO. 1852. IX \ V V \ % SL5\s \ N x V Entered according to the Act of Congress, in the year 1851, by LIPPINCOTT, GRAMBO AND CO., in the Office of the Clerk of the District Court in and for the Eastern District of Pennsylvania. PHILADELPHIA: T. K. AND P. G. COLLINS, PRINTERS. TO CHARLES A. POPE, M.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY, AND OF CLINICAL SURGEKY, IN THE MEDICAL DEPARTMENT OF THE ST. LOUIS UNIVERSITY, ■&)i fnllutahg $*gia m riBpntfullti E*iu&frir, AS AN ACKNOWLEDGMENT OF HIS DEVOTION TO THE PROGRESS OF SURGEKY IN THE UNITED STATES, AND AS A TESTIMONIAL OF THE RESPECT AND ESTEEM OF HIS SINCERE FRIEND, THE AUTHOR. PREFACE. To the majority of those commencing the study of medicine, few subjects are possessed of greater interest, or surrounded by a more pleasurable excitement, than operative surgery. With some few exceptions, every young man, at an early period of his pupilage, regards the performance of an operation as the highest test of professional acquirements, and under the impression that his knowledge of it is to be obtained by observation, is always anxious to embrace every opportunity of witnessing the efforts of an operator. Whilst, therefore, chemistry displays her secrets, and physiology tenders him in vain the principles of his profession, the surgeon, when limited to the least scientific portion of his duties, is always sure of a numerous audience, who, under the impression that they will be fully prepared to follow in his footsteps, simply by observing his course of proceeding, will readily repeat their visit whenever he can offer them a similar inducement. Having, from long intercourse with medical classes, had many evidences of the existence of this condition of mind, and having, like many others, learned that seeing an operation and performing it are very different acts, the author has wished to lead the reader to a more correct estimate of the means by which operative skill is to be acquired, and sought, in the following pages, to furnish him a guide which might also serve as an instructor, whilst performing for himself the operations which he desires to study. In special anatomy, few have ever acquired a thorough knowledge of the structure of the body until by constant manipulation they have been able to separate each portion for themselves, and, in surgery, the same course must certainly be pursued. Study, observation, and the repeated demon- stration of another are, doubtless, valuable aids to the acquisition of viii PREFACE. knowledge, but, unless seconded by personal practice, they will all pass away as the baseless fabric of a dream. The following pages are, therefore, presented to the Profession, in the hope that they may invite more general attention to the neces- sity of acquiring a knowledge of operative surgery by practicing, upon the subject, such processes as it is desired to master; while, at the same time, drawings have been added in order to facilitate the progress of those who cannot, at the moment, obtain the necessary material for repeating the operation. In many portions of the work, the descriptions furnished will be found to be given in as condensed a form as- seemed compatible with clearness, and have been thus presented in order to prevent the volume becoming too cumbersome for constant use. In addi- tion to which, the author has not desired to go over ground which has so recently been well displayed by writers both in Europe and this country. Many details of history, pathology, physiology, and surgical proceedings which are essential to a complete treatise upon the subject have, therefore, been designedly omitted in this as not coming within the scope of its plan. Although the idea of an instructor cannot be claimed as a novel one, having, in the hands of Messrs. Malgaigne and Fergusson, been most happily illustrated, there has yet been no work issued by the press which has presented the American practitioner with a com- prehensive view of the opinions, operative methods, and instruments of those of his countrymen who have given to American surgery a character of its own. At present, little more than two hundred years have elapsed since the first surgeon stepped upon our shores; yet, during that time, many acts have been performed that will favorably compare with the brightest achievements of the surgeons of Europe. To record these points and save them from unmerited oblivion, has been a pleasant duty in connection with the composition of the volume. In its formation, the author is under many obligations to various sources, which he hopes he has suitably acknowledged. Basing his description of any operation chiefly on the views of his own countrymen, he has yet felt bound to display along with them the opinions of such European authorities as are universally received as sound; and to facilitate a judgment on the part of those whose know- ledge might not be sufficient for the formation of an opinion of the value of the different methods referred to, he has appended to the PREFACE. IX account an estimate of their advantages. This estimate, he wishes it to be distinctly understood, is founded solely upon his own opinion, based upon the experience acquired during a devotion of seventeen years, under auspicious circumstances, to the study and practice of a favorite branch of his profession. To the liberality of the publishers, Messrs. Lippincott, Grambo, & Co., is due the opportunity of presenting a series of. illustrations, that must materially contribute to the reader's comprehension of descriptions, the details of which might otherwise be difficult to follow. For the accuracy and finish of the engravings he is indebted to Mr. John M. Butler, of Philadelphia, who has zealously exerted himself for the perfect execution of his part of the undertaking. To the latter gentleman is also due the author's acknowledgment of the untiring good nature with which all the alterations and renewed criticisms on his work have been received during the progress of the engraving. In selecting the illustrations, various sources have been resorted to, but upon none has the author relied more than on the beautifully finished plates of Messrs. Bernard & Huette. Wherever, in any instance, previous figures did not present such views as were desired, the aid of the Daguerreotype has been invoked, and original draw- ings made with all the accuracy of the scene at the moment. In employing the illustrations of other writers, the effort has been made to credit accurately the original authority; but this having 'often proved a matter of impossibility, the author has merely at- tached the name of the work from which he has taken them. Heister, Froriep, Blasius, Seerig, Dupuytren, Sir Charles Bell, Labat, Gen- soul, Serre, Bourgery, and Jacobson, and Pancoast have all drawn, more or less, from the same sources as Messrs. Bernard and Huette; but most of them have so transferred from work to work the result of their labors, that, with one or two exceptions, it is not easy to trace their origin. For an opportunity of consulting the many works required in connection with the Bibliographical Index, as well as with the mat- ter embodied in the text, the author is indebted to the valuable libraries of the Pennsylvania and New York Hospitals, to the Loganian portion of the Philadelphia Library, and to the private collections of many friends. To the Librarian and Library Com- mittee of the Pennsylvania Hospital he is under especial obliga- X PREFACE. tions for the free use, at all hours, of their valuable and extensive collection. To Dr. John C. Warren, of Boston, and also to his son, Dr. J. Mason Warren, is due the acknowledgment of the aid afforded by an extended manuscript, as well as by a collection of pamphlets which have furnished much valuable information in connection with the surgery of Boston. From the "American Journal of Medical Sciences,'' edited by Dr. Isaac Hays, there has also been gained many scattered facts connected with the doings of the surgeons of this country. In describing the anatomical relations of the various parts con- cerned in the different operations, reliance has been chiefly placed upon the accounts furnished in the " Anatomie Topographique" of Blandin, as well as on that given in the " Special Anatomy and His- tology" of Dr. Wm. E. Horner, of the University of Pennsylvania. In bringing his labors to a close, the author also recalls many acts and suggestions on the part of friends which he cannot properly specify, and which he regrets he did not note at the moment. Hoping, at some future time, to have the opportunity of remedy- ing this, as well as some other omissions connected with the press, he cheerfully submits the volume to the judgment of the Profession in the belief that it will be received as a contribution to facilitate the progress of those who have yet to acquire their surgical experience. That his seniors may find it to embody correct views of practice, whilst recalling by-gone scenes, and his juniors be tempted to refer to it in moments of doubt, is all that is anticipated by THE AUTHOR. Philadelphia, October 1851. TABLE OF CONTENTS. Dedication .... Preface .... History op Surgery Historical Record op American Surgery Bibliographical Index American Journals Papers on Elementary Operations Papers connected with Operations on the Head PAGE v vii xvii xxiii xvii xxii xxvi xxviii PART I. GENERAL DUTIES AND ELEMENTARY OPERATIONS. Introduction 17 CHAPTER I. GENERAL DUTIES OP AN OPERATOR Sect. I. Attention to the patient § 1. Duties of a surgeon before operating § 2. Duties during the operation § 3. Duties after the operation Sect. II. Preparation of instruments § 1. Action and selection of instruments § 2. Preparation and sharpening of instruments § 3. Manipulation of instruments § 4. Preservation of instruments Sect. III. The operator's duties to his assistants . § 1. Selection and instruction of assistants . 20 20 2L 26 28 31 31 32 35 39 39 40 xii TABLE OF CONTENTS. CHAPTER II. ELEMENTARY OPERATIONS Sect. I. Incisions with the scalpel and bistoury Sect. II. Dissections ...... Sect. III. Punctures or incisions with pointed instruments CHAPTER III. MEANS OF ARRESTING HEMORRHAGE . Sect. I. Compression ...... Sect. II. Arrest of hemorrhage by ligatures Sect. III. Styptics, cauteries, and other means of arresting hemor- rhage ...... CHAPTER IV. DUTIES OF A SURGEON IMMEDIATELY AFTER OPERATING Sect. I. Dressings ...... § 1. Closing of parts after an operation § 2. Means employed to favor union PAGE 41 42 46 47 48 48 51 54 55 55 56 61 PART II. OPERATIONS ON THE HEAD AND FACE. CHAPTER I. SURGICAL ANATOMY OP THE HEAD CHAPTER II. OPERATIONS UPON THE HEAD Sect. I. Operations upon the scalp § 1. Encysted tumors § 2. Nervi materni, or erectile tumors § 3. Cephalasmatoma § 4. Division of the supra-orbitar nerve Sect. II. Operations upon the bones of the cranium § 1. Operations for caries and necrosis of the cranium § 2. Trephining the cranium § 3. Puncturing the head for hydrocephalus § 4. Removal of fungoid tumors of the dura mater 65 68 69 69 71 75 75 77 78 78 83 85 TABLE OF CONTENTS. xiii CHAPTER III. OPERATIONS ON THE FACE Sect. I. Anatomy of the face .... § 2. Anatomy of the appendages of the eye § 3. Anatomy of the lachrymal apparatus CHAPTER IV. OPERATIONS ON THE APPENDAGES OF THE EYE Sect. I. Operations practiced on the eyelids § 1. Tumors of the eyelids § 2. Encanthus § 3. Epicanthus § 4. Ankyloblepharon § 5. Symblepharon . § 6. Ptosis . § 7. Blepharoplasty § 8. Ectropium § 9. Entropium Sect. II. Operations on the lachrymal apparatus CHAPTER V. OPERATIONS ON THE EYEBALL Sect. I. Operations on the external parts of the eyeball Sect. II. Operations on the muscles of the eyeball § 1. Anatomy of the muscles concerned in squinting § 2. Operation for strabismus § 3. Extirpation of the eyeball § 4. Tumors in the orbit • . CHAPTER VI. OPERATIONS ON THE HUMORS OF THE EYE Sect. I. Anatomy of the eyeball Sect. II. Operations for cataract § 1. Preliminary treatment . § 2. Dilatation of the pupil § 3. Operations by absorption, couching, and extraction Sect. III. Anatomical relations of the iris § 1. Formation of an artificial pupil PAGE 87 87 88 89 91 91 91 93 93 93 94 95 95 97 100 103 108 108 109 109 111 113 113 114 114 117 119 120 123 129 131 xiv TABLE OF CONTENTS. CHAPTER VII. PLASTIC OPERATIONS ON THE FACE Sect. I. Metoplasty, or restoration of the integuments of the fore- head ...... CHAPTER VIII. OF THE EXTERNAL NOSE Sect. I. Anatomy of the external nose Sect. II. Operations on the external nose Sect. III. Rhinoplasty § 1. Indian or Brahmin method § 2. Taliacotian operation § 3. Restoration of the columna nasi CHAPTER IX. OF THE INTERNAL NOSE Sect. I. Anatomy .... Sect. II. Operations on the nasal cavities § 1. Arrest of hemorrhage from the nostrils § 2. Polypi in the nostrils . • . CHAPTER X. OF THE MOUTH Sect. I. Anatomy of the external portion of the mouth Sect. II. Operations on the lips § 1. Simple hare-lip § 2. Double haredip § 3. Cancer of the lip § 4. Enlargement of the mouth § 5. Cheiloplasty § 6. Genioplasty § 7. Removal of tumors from the cheeks § 8. Salivary fistula Sect. III. Division of the masseter muscle for false anchylosis of the jaw •... CHAPTER XL OPERATIONS PRACTICED WITHIN THE MOUTH Sect. I. Anatomy .... PAGE 136 137 172 174 174 TABLE OF CONTENTS. XV Sect. II. Operations upon the tongue and throat § 1. Cancer of the tongue § 2. Hypertrophy of tongue § 3. Excision of the uvula . § 4. Excision of the tonsils . CHAPTER XII. RESECTION OF THE BONES OF THE FACE Sect. I. Anatomy .... Sect. II. Operation on the jaw-bone § 1. Resection of the upper jaw-bone § 2. Resection of the inferior maxilla § 3. Resection of one side of the jaw Sect. III. Operation on the palate § 1. Staphyloraphy . § 2. Staphyloplasty CHAPTER XIII. OPERATIONS PRACTICED UPON TnE EAR Sect. I. Anatomy of the ear Sect. II. Operations on the ear . § 1. Otoplasty § 2. Foreign bodies in the meatus externus § 3. Polypi in the meatus externus . § 4. Perforation of the membrane of the tympanum § 5. Catheterism of the Eustachian tube TABLE OE CONTENTS. PART III OPERATIONS PRACTICED ON THE NECK AND TRUNK. CHAPTER I. SURGICAL ANATOMY OF THE NECK. Sect. I. The supra-hyoid or glosso-hyoid region of the neck Sect. II. The parotid region ..... Sect. III. The laryngo-tracheal and supra-sternal regions . Sect. IV. The supra-clavicular region .... CHAPTER II. OPERATIONS PRACTICED ON THE PORTION OP THE NECK WHICH IS ABOVE THE OS HYOIDES. Sect. I. Of the diseases of the parotid gland § 1. Extirpation of the parotid gland § 2. Relief of enlargement of the parotid by obstruct- ing the circulation .... Sect. II. Operations practiced on the sub-maxillary gland CHAPTER III. OPERATIONS PERFORMED ON THE LARYNX AND TRACHEA. Sect. I. Surgical anatomy of the larynx and trachea Sect. II. Operations upon the larynx § 1. Cauterization of the larynx § 2. (Edema of the glottis . § 3. Tracheotomy 1. Tracheotomy for croup 2. Tracheotomy for the removal of a foreign body 3. Laryngotomy PAGE 225 227 229 233 235 237 243 244 245 246 246 249 252 252 255 256 XV111 TABLE OF CONTENTS. PAGE § 4. Estimate of the operation . • • 257 § 5. Statistics of the operation of tracheotomy . 260 1. Tracheotomy for croup . • • -61 2. Tracheotomy for removal of foreign bodies . 262 CHAPTER IV. OPERATIONS UPON THE PHARYNX AND OESOPHAGUS. Sect. I. Surgical anatomy of the pharynx and oesophagus . 263 § 1. Of the pharynx . . . .264 § 2. Of the oesophagus . . . .264 Sect. II. Operations upon the pharynx .... 265 § 1. Hypertrophy of the follicles of the pharynx . 265 § 2. Foreign bodies in the pharynx . . . 266 Sect. III. Operations upon the oesophagus . . .267 § 1. Removal of foreign substances from the oesopha- gus and stomach .... 267 1. -Effects of introduction of a foreign body into oesophagus ..... 268 § 2. Extraction of noxious substances from the stomach 271 § 3. Stricture of the oesophagus . . . 273 1. Dilatation of the stricture . . . 275 2. Application of caustic . . .276 3. (Esophagotomy . . . .277 CHAPTER V. OPERATIONS FOR THE RELIEF OF DEFORMITIES OF THE NECK. Sect. I. Deformities from burns . . . 281 Sect. II. Torticollis or wry-neck .... 286 CHAPTER VI. TUMORS OF THE NECK. Sect. I. General pathology of tumors of the neck . 291 § 1. Diagnosis of the character and position of tumors of the neck 1. Character of tumors . 2. Position of tumors Sect. II. Operations for removal of tumors of the neck § 1. Extirpation of lymphatic tumors Sect. IH. Bronchocele or goitre . § 1. Pathology of goitre 293 294 295 298 301 307 307 TABLE OF CONTENTS. XIX § 2. Treatment by compression § 3. Ligature of thyroid arteries § 4. Subcutaneous ligature of goitre 1. Dissection of skin and ligature Sect. IV. Hydrocele of the neck CHAPTER VII. ANEURISMS IN GENERAL. Sect. I. General diagnosis of aneurisms Sect. II. General principles of ligature of arteries CHAPTER VIII. ANEURISM OF THE CAROTID ARTERIES. Sect. I. Anatomy of the bloodvessels of the neck Sect. II. Ligature of the carotid arteries § 1. Ligature of the primitive carotid § 2. Effects of ligature of carotid § 3. Statistics of the operation CHAPTER IX. LIGATURE OF THE INNOMINATA AND SUBCLAVIAN ARTERIES. Sect. I. Surgical anatomy of these arteries § 1. The innominata § 2. The subclavian artery . Sect. II. Ligature of the innominata Sect. III. Ligature of the subclavian artery § 1. Of the subclavian on the first rib § 2. Between the scaleni muscles § 3. Within the scaleni § 4. Ligature of the left subclavian within the scaleni § 5. Statistics of ligature of the subclavian artery CHAPTER X. OPERATIONS UPON THE CHEST. Sect. I. Surgical anatomy of the chest . § 1. Anatomy of portion about the clavicles Sect. II. Operations upon the clavicle . § 1. Extirpation of the clavicle § 2. Resection of the clavicle 1. Resection of sternal end PAGE 310 311 311 312 314 316 317 321 323 324 326 329 330 331 331 334 336 337 338 339 340 343 344 345 346 346 350 350 XX TABLE OF CONTENTS. § 3. Resection of the acromion process of scapula Sect. III. Operations on the parts about the clavicle § 1. Ligature of axillary artery below the clavicle CHAPTER XL OPERATIONS ON THE MAMMARY GLAND OF THE FEMALE Sect. I. Pathology and diagnosis of mammary tumors . § 1. Tumors dependent on hypertrophy § 2. Tumors due to degeneration of tissue 1. Ligneous or wood-like scirrhus 2. Fibro-scirrhous degeneration . 3. Ordinary cancerous tumor of the breast § 3. Abnormal productions . Sect. II. Extirpation of the mammary gland Sect. III. Removal of tumors of the chest 1. Congenital encysted tumor CHAPTER XII. OPERATIONS ON THE WALLS OF THE THORAX. Sect. I. Surgical anatomy of the thorax Sect. II. Operations on the chest § 1. Resection of the ribs § 2. Paracentesis thoracis 1. Statistics of the operation § 3. Effusions in the pericardium CHAPTER XIII. OPERATIONS UPON THE ABDOMEN. Sect. I. Paracentesis abdominis Sect. II. Hepatic abscesses Sect. III. Gastrotomy and enterotomy § 1. Gastrotomy § 2. Enterotomy Sect. IV. Gastric and intestinal fistulas PAGE 351 351 351 TABLE OF CONTENTS. XXI CHAPTER XIV. WOUNDS IN THE ABDOMEN. Sect. I. Wounds causing protrusion of intestines Sect. II. Wounds of the intestine § 1. Sutures employed in longitudinal wounds § 2. Sutures of transverse wounds . CHAPTER XV. HERNIA IN GENERAL. Sect. I. Pathology of hernia § 1. Envelops of hernia § 2. Seat of hernia . § 3. Effects of formation of hernia § 1. Reducible hernia § 2. Irreducible hernia § 3. Strangulated hernia Sect. II. Treatment of hernia . § 1. Reduction of hernia § 2. Means of radically curing reducible hernia CHAPTER XV. STRANGULATED INGUINAL HERNIA. Sect. I. Surgical relations of inguinal hernia . Sect. II. Operations for strangulated inguinal hernia § 1. Taxis.... § 2. Operation for strangulation § 3. Statistics of the operation CHAPTER XVI. STRANGULATED FEMORAL HERNIA. Sect. I. Anatomical relations of femoral hernia Sect. II. Operations for the relief of strangulated femoral hernia § 1. Taxis in femoral hernia § 2. Operation for strangulation § 3. Statistics of the operation PAGE 392 393 395 397 401 403 404 406 407 407 409 410 411 413 417 419 419 422 429 430 434 434 435 439 xxii TABLE OF CONTENTS. CHAPTER XVII. UMBILICAL HERNIA. Sect. I. Surgical anatomy . Sect. II. Operations for umbilical hernia § 1. Strangulated umbilical hernia . § 2. Statistics of operation for umbilical hernia § 3. Summary of the operations for all kinds of hernia ..... CHAPTER XVIII. ARTIFICIAL ANUS. Sect. I. Artificial anus from mortified intestine § 1. Statistics of the operation Sect. II. Formation of an artificial anus. § 1. Anus formed at the groin § 2. Formation of an anus in the lumbar region § 3. Statistics of the operation CHAPTER XIX. LIGATURE OF THE ILIAC ARTERIES. Sect. I. Surgical anatomy .... Sect. II. Operations upon the iliac arteries § 1. Ligature of the external iliac artery § 2. Statistics of the application of a ligature to the external iliac Sect. III. Ligature of the primitive iliac artery . § 1. Surgical anatomy § 2. Operation of ligating the primitive iliac § 3. Statistics .... § 4. Ligature of the internal iliae . CHAPTER XX. OPERATIONS PRACTICED ON THE BACK. Sect. I. Superficial tumors of the back Sect. II. Tumors of the spinal canal, or spina bifida § 1. Operations for the cure of spina bifida PAGE 440 441 441 443 443 444 448 451 451 453 454 455 456 456 460 461 461 462 465 465 467 469 470 TABLE OF CONTENTS. xxiii PART IV. OPERATIONS ON THE GENITO-URINARY ORGANS AND RECTUM. * CHAPTER I. OPERATIONS ON THE MALE GENITO-URINARY ORGANS. Sect. I. Surgical anatomy of the male organs § 1. The penis 1. The urethra § 2. The testicles Sect. II. Operations on the penis § 1. Phymosis 1. Circumcision 2. Incision § 2. Paraphymosis 1. Compression 2. Incision § 3. Division of the frsenum § 4. Amputation of the penis Sect. III. Operations on the urethra § 1. Catheterism 1. Catheters 2. Ordinary operation of catheterism 3. Obstacles to catheterism § 2. Strictures of the urethra 1. Dilatation 2. Internal incisions 3. External incisions 4. Caustic § 3. Fistula in perineo § 4. Hypospadias and epispadias Sect. IV. Operations on the spermatic cord § 1. Ligature of the spermatic artery § 2. Ligature of the spermatic veins Sect. V. Operations on the testicle § 1. Hydrocele 1. Treatment of hydrocele by injection 2. Cure of hydrocele by the seton 3. Treatment by incision . xxiv TABLE OF CONTENTS. PAGE 4. Treatment by excision • • • "07 §2. Castration . . . ■ ■ 508 511 514 514 514 516 517 519 CHAPTER II. » STONE IN THE BLADDER. Sect. I. Surgical anatomy of the male perineum Sect. II. Operation of perineal lithotomy § 1. Preparatory steps 1. Diagnosis of stone in the bladder § 2. Constitutional treatment § 3. Local preparatory means Sect. HI. The lateral operation . § 1. Instruments that may be wanted during the operation 519 § 2. Lateral operation with the cutting gorget . 520 § 3. Operation with the single lithotome cache of Frere Cosme ..... 523 Sect. IV. The bilateral operation .... 524 Sect. V. The median operation .... 527 Sect. VI. Of the supra-pubic operation . . . 528 § 1. The quadrilateral operation . . . 529 Sect. VII. General remarks on perineal lithotomy . . 529 § 1. Extraction of the stone .... 530 § 2. Accidents connected with lithotomy . . 532 1. Ligature ..... 532 2. Plugging ..... 533 3. Wound of the rectum . . . .533 Sect. VIII. After-treatment of the operation of perineal lithotomy 535 § 1. Putting to bed ..... 536 § 2. Treatment of the wound . . . 537 § 3. Constitutional treatment . . 537 Sect. IX. General estimate of the value of the different methods of operating for lithotomy . . 53g CHAPTER III. LITHOTRIPSY, OR CRUSHING OF STONE IN THE BLADDER. CHAPTER IV. OPERATIONS ON THE FEMALE GENITO-URINARY ORGANS. Sect. I. Surgical anatomy of the female perineum . 545 Sect. II. Operations on the external organs of the female 547 § 1. Occlusion of the vulva . . 54- TABLE OF CONTENTS. XXV PAGE § 2. Hypertrophy of the nymphae and clitoris . 547 § 3. Catheterism ..... 549 § 4. Imperforate hymen .... 549 § 5. Imperforation of the vagina . . . 549 Sect. III. Laceration of the perineum . . . .551 § 1. Narrowing of the vagina . . . 554 CHAPTER V. OPERATIONS FOR VAGINAL FISTULA. Sect. I. Vesico-vaginal fistula ..... 555 § 1. Palliative treatment . . . .556 § 2. Operations for vesico-vaginal fistula . . 557 Sect. II. Recto-vaginal fistula ..... 564 CHAPTER VI. OPERATIONS PRACTICED ON THE DEEP-SEATED ORGANS OF THE FEMALE. Sect. I. Lithotomy and lithotripsy in the female . . 567 § 1. Lithotripsy in the female . . . 567 Sect. II. Operations upon the uterus .... 567 § 1. Puncture of the uterus .... 568 § 2. Polypus of the uterus .... 568 1. Ligature ..... 569 Sect. III. Extirpation of the ovary, or ovariotomy . . 569 § 1. The major operation .... 570 1. Are ovarian tumors proper subjects for an operation ? 575 2. Is the removal of the ovarian tumor attended by any extraordinary difficulty or danger during or after the operation ? . . . . 576 Sect. IV. On the Caesarian operation . . . .579 Sect. V. Excision of the neek of the womb . . . 582 Sect. VI. Extirpation of the womb .... 583 CHAPTER VII. OPERATIONS PRACTICED ON THE RECTUM. Sect. I. Surgical anatomy of the rectum . . . 584 Sect. II. Operations on the rectum . . . .586 § 1. Removal of foreign bodies . . .586 § 2. Encysted rectum . . . .587 § 3. Fissure of the anus .... 588 § 4. Imperforate anus .... 589 xxvi TABLE OF CONTENTS. § 5. Prolapsus ani . 1. To restore the prolapsed portion 2. Operation of Dupuytren 3. Excision of a portion of the sphincter 4. Cauterization . 5. Excision or amputation of the tumor Sect. III. Hemorrhoids, or piles § 1. Treatment of hemorrhoids 1. The ligature . 2. Excision 3. Horner's operation Sect. IV. Fistula in ano ... § 1. The ligature § 2. Operation by the knife . TABLE OF CONTENTS. xxvii PART V. OPERATIONS ON THE EXTREMITIES. CHAPTER I. GENERAL OPERATIONS ON THE EXTREMITIES. Sect. I. Of inverted toe nail . § 1. Removal of the nail and its matrix Sect. II. Cure of paronychia, or whitlow Sect. HI. Enlarged bursa § 1. Subcutaneous puncture . § 2. Puncture and injection of iodine § 3. Incision Sect. IV. Painful condition of the nerves Sect. V. Varicose veins Sect. VI. Tenotomy, or division of the tendons . CHAPTER II. LIGATURE OF THE ARTERIES OF THE UPPER EXTREMITY. Sect. I. Ligature of the axillary artery in the axilla Sect. II. Ligature of the brachial artery § 1. Ligature of the brachial artery at the middle of the arm ..... § 2. Ligature of the brachial near the elbow . Sect. III. Ligature of the radial artery .... Sect. IV. Ligature of the ulnar artery .... CHAPTER IH. LIGATURE OF THE ARTERIES OF THE LOWER EXTREMITY. Sect. I. Ligature of the femoral artery 1. Ligature of the femoral artery in the middle of the thigh ..... 2. Ligature of the femoral artery at the upper part of the thigh .... Sect. II. Ligature of the popliteal artery Sect. III. Ligature of the posterior tibial artery . § 1. Ligature of the artery at its middle third § 2. Ligature of the artery behind the malleolus internus PAGE 604 604 605 605 606 606 606 607 607 609 611 614 615 616 617 619 620 621 623 624 625 627 627 XXV111 TABLE OF CONTENTS. Sect. IV. Ligature of the anterior tibial artery . • • § 1. Ligature of the anterior tibial at its middle third § 2. Ligature of the anterior tibial on the dorsum of the foot • CHAPTER IV. OPERATIONS ON THE BONES OF THE UPPER EXTREMITY. Sect. I. Resections in general . Sect. II. Resection of the bones of the upper extremities § 1. Resection of the shoulder-joint . § 2. False joint of the humerus § 3. Resection of the elbow-joint § 4. Resection of the bones of the forearm and hand 1. Resection of the body of the ulna 2. Resection of the inferior extremity of the ulna 3. Resection of the wrist-joint 4. Resection of the metacarpus 5. Resection of the bones of the hand CHAPTER V. OPERATIONS ON THE BONES OF THE LOWER EXTREMITY. Sect. I. Resection of the femur § 1. Resection of the head of the femur § 2. Resection of the femur for anchylosis, and forma tion of a new joint at the hip . Sect. II. Introduction of a seton for a false joint in the femur Sect. III. Resection of the knee-joint § 1. Removal of a portion of the patella, condyles, and articulating surfaces of the tibia § 2. Resection of the bones of the leg Sect. IV. Resection of the ankle § 1. Resection of the inferior extremity of the tibia and fibula .... § 2. Extraction of the fibula . § 3. Resection of the astragalus § 4. Resection of the metatarsal bones and phalanges PAGE 627 628 629 630 631 631 633 633 636 636 637 638 638 639 639 640 640 641 641 644 646 646 646 647 648 648 TABLE OF CONTENTS. xxix CHAPTER VI. GENERAL REMARKS ON AMPUTATIONS. Sect. I. Cases for amputation . § 1. Gunshot wounds § 2. Railroad accidents § 3. The period for amputating Sect. II. Points for the performance of amputations § 1. The place of election Sect. III. The different kinds of amputation § 1. The circular operation § 2. The oval method § 3. The flap operation Sect. IV. Estimate of the different forms of amputation Sect. V. General measures requisite in amputation § 1. Preparatory measures § 2. Duties of assistants § 3. After-treatment . § 4. Accidents that may occur either during or after an amputation .... CHAPTER VII. AMPUTATIONS OF THE UPPER EXTREMITY Sect. I. Amputation at the shoulder Sect. II. Amputation of the arm Sect. III. Amputation at the elbow-joint Sect. IV. Amputation of the forearm Sect. V. Amputation of the fingers CHAPTER Vni. AMPUTATIONS OF THE LOWER EXTREMITY Sect. I. Amputation at the hip-joint . Sect. II. Circular amputation of the thigh Sect. III. Amputation at the knee-joint Sect. IV. Amputation of the leg Sect. V. Amputation of the foot at the tarsus Sect. VI. Amputation of the toes Sect. VII. Organic changes resulting from amputations Sect. VIII. Substitutes for the natural limb HISTORY OF SURGERY. A BRIEF HISTORICAL SKETCH OF SURGERY, COMPILED AND COLLATED FROM THE BEST AUTHORITIES* The origin of surgery, being coeval with that of medicine, dates from the earliest periods of the human race, the reception of injuries naturally requiring that some effort should be made to alleviate them. That surgical operations were performed, at a very remote period, is shown by the laws of Moses, describing minutely the operation of circumcision, which is yet practiced among the Jews according to ancient usage, and by the embalming of Joseph, indicating the pos- session of such surgical knowledge as was necessary for the opening of bodies. The earliest individual, directly spoken of in connection with the practice of surgery, and the reputed originator of the science, is the mythological person of Chiron, the Centaur, supposed to have been born in Thessaly at some unknown period. Next, we find mention made of iEscuLAPius, a son of Apollo, B.C. 1142, who is believed to have been a pupil of Chiron, and then we have more positive information in the account by Homer of the events of the Trojan war, where he describes Podalirius and Machaon as sons of iEscuLAPius, and as surgeons in the war, B. C. 1192. Podalirius is reported to have been the first bleeder, having opened a vein in either arm of the daughter of the King of Caria, and received her hand in marriage as his recompense. The Asclepiades, or reputed descendants of JEsculapius, consti- tute the only surgeons spoken of during the ensuing 500 years, after whom came Pythagoras, B. C. 608; and, after him, the follow- ing may be briefly mentioned in the natural order of time. Damocedes, a cotemporary of Pythagoras, treated King Darius * The facts here stated have been collected from Miller, Richerand, Sharp, Black, Chelius, and from the Dictionary of Antiquities, by William Smith, LL.D. * xviii HISTORY OF SURGERY. for a sprained ankle, and his queen, Atossa, for cancer of the breast; and after him came the great father of medicine and surgery, from whom all the rest may be traced. Hippocrates, B. C. 460, or 357, was among the first of the distin- guished surgeons, and practiced many operations, often claimed as modern. He employed the actual cautery of various shapes; used moxa made of rolls of flax; resorted to issues and tentes as counter- irritants ; operated for calculi in the kidney by incision, but did not cut for stone, lithotomy being then confined to a peculiar class of practitioners. He also reduced dislocations and fractures by means yet resorted to; employed the obstetrical forceps for delivering the foetus; frequently employed the trepan in depressed fractures of the skull; resorted to percussion to prove the presence of fluid in the thorax; and performed empyema, or paracentesis thoracis. He also wrote many excellent surgical treatises. After him, Diocles Carystius invented an instrument for ex- tracting darts, and bandaged the head for wounds, by bandages often employed at the present time. Praxagoras, of Cos, who followed in his footsteps, also proved himself an accomplished surgeon, and some of his operations are yet resorted to. He incised the fauces freely in cases of inflammation; excised the uvula; made an artificial anus, or an opening into the bowels in cases of obstruction in ilius; he also first observed the difference between the arteries and the veins, and noted the pulse, though this fact has also been claimed for Aristotle. Aristotle gave the name to the Aorta, and showed that all the blood-vessels centred in the heart. After him came the anatomist and surgeon, Herophilus, about B. C. 320, though the exact year is unknown, and he was the first who practiced dissections. Erasistratus, his cotemporary, did the same thing, and invented many instruments. This surgeon is reported to have reduced a dis- located humerus for Diodorus Cronus, and by this operation to have convinced him of the possibility of the existence of motion, which he had previously denied. Xexophon, his follower, was the first to arrest hemorrhage from the extremities, by a tourniquet, having recommended the encircling of the extremity with a cord, in order to check the flow of blood. Lithotomy, at this period, as during the time of Hippocrates was avoided by the surgeons, and performed entirely by a peculiar class of individuals who devoted themselves to this one operation. HISTORY of surgery. xix Ammonius, surnamed AiOotofio^ devoted much time to the study of calculous affections, and employed an instrument to crush calculi, being the first surgeon who operated for Lithotripsy.* Cassius, B. C. 96, exhibited considerable knowledge of the phy- siological action of the brain, having described the paralysis of one side of the body as induced by injuries of the opposite portion of the head. Celsus, the cotemporary of Horace, Virgil, and Ovid, practiced surgery at Rome in the beginning of the Christian era, upwards of 150 years before Galen. He was the first to describe Lithotomy, and his mode of performing it (central incision), as well as nume- rous other operations, is yet often resorted to by the surgeons of the present day. He described the operation of Cataract by depres- sion ; mentions the subject of artificial pupil; gave accurate and judicious rules for the application of the trepan; was the first to notice that there might be an effusion and compression within the head without fracture; first recommended the application of liga- tures to wounded arteries; improved the operations of amputation; applied caustics to the treatment of carbuncle; described several species of hernia; and operated for hare-lip, &c, by methods yet in use and often claimed as modern. Aret^eus, A. D. 54, reign of Nero, first employed blisters and re- sorted to cantharides as a vesicating agent. This surgeon condemned the operation for tracheotomy, lest the cartilages should not heal. Rufus, the Ephesian, A. D. 98—117, reign of Trajan, wrote on diseases of the kidneys and bladder, and operated by ligating the brachial artery for varicose aneurism at the bend of the arm. Heliodorus, the physician to Trajan, about A. D. 120, and co- temporary of Juvenal, wrote on injuries of the head. Antyllus, about A. D. 340, recommended tracheotomy, which had been previously practiced by the Asclepiades in threatened suf- focation from diseases of the throat; he practiced arteriotomy in great emergencies, and showed the importance of dividing an artery entirely across, instead of incising it obliquely in order to arrest hemorrhage. In the treatment of aneurism, he tied the artery above and below the sac, and, opening the latter, allowed the wound to heal by granulations; he also alludes to the operation of cataract by ex- traction ; and reports cures of hydrocele by incision. * Smith's Diet. Greek and Roman Antiquity—Art. Chirurgie. XX history of surgery. Claudius Galen, born in the autumn of A. D. 130, wrote upon luxations of the femur backwards, a variety not mentioned by Hip- pocrates; he also described spontaneous luxations of the femur, and trepanned the sternum in empyema. iETius, about A. D. 475, scarified the legs in anasarca; employed the cautery; excised hemorrhoidal tumors; employed lithontriptics to dissolve calculi, and wrote on hernia, diseases of the testicle, and castration. Alexander, of Trallis, a surgeon of the time of Justinian, A. D. 545, wrote on diseases of the eye, and on fractures. Paulus iEGiNETA, about A. D. 670, is reported to have bled freely in cases of gravel. He opened abscesses by caustics; defined the points for paracentesis abdominis; sounded the bladder by the finger in the rectum in cases of stone; cut on the left side of the raphe* (lateral operation) in lithotomy, and believed aneurism to be caused by rupture of the coats of the artery. He also extirpated the breast by a crucial incision; performed laryngotomy, and first performed tracheotomy, but made a transverse incision instead of a longitudinal one, as at present practiced. He practiced the operation for stran- gulated hernia; was the first to treat of fracture of the patella, and originated embryotomy. Caliph Haroun, among the Arabians, had charge of a hospital at Bagdad about A. D. 790, where no fewer than six thousand students, chiefly Christians, are said to have attended the practice of the house. Rhazes, about A. D. 924, first described Spina Ventosa and Spina Bifida; he opposed all operations for cancer when the tumor was not entirely free from the surrounding parts, and cauterized poisonous wounds. Halt Abbas, A.D. 980, advised the application of caustics to hydrocele, and punctured the linea alba a little below the umbilicus in cases of ascites. Avicenna, A. D. 1000, distinguished between closure of the pupil and cataract; preferred depression in cataract to extraction- first resorted to the flexible catheter, and also employed a saw similar to that now named after Hey. Albucasis, A.D. 1100, is supposed to have been the first who noticed the effect of a clot in the arteries in arresting hemorrhage- he described an instrument of his own for curing fistula lachrymalis' and also the cataract needle of his own period. He also reports history of surgery. xxi having operated for hydrocephalus, but with doubtful success; re- moved tumors by the ligature, and first described lithotomy as per- formed on the female; in the male he practiced the lateral operation. He also excised the tonsils and uvula; extracted polypous tumors from the fauces; objected to any attempt at extirpating goitrous tumors; invented the probang; employed sutures in wounds of the intestines; condemned tracheotomy in acute inflammation of the windpipe, and when it had reached the bronchia, and strongly doubted the pro- priety of operating in cancerous tumors; declaring that he never cured, or saw cured, a single case. He also advised the partial eva- cuation of large abscesses, as subsequently practiced in England by Abernethy and others. Pope Innocent II., A. D. 1139, retarded the progress of surgery, by describing its practice as degrading, and forbidding the clergy from pursuing it. Pitard, A. D. 1271, established the College of Surgeons in Paris. Gilbertus Anglicanus and John of Gaddesden, two surgeons of distinction, practiced in England A. D. 1300, 1320. Guy de Chauliac, A. D. 1360, first described the Caesarian operation. John of Arden, A. D. 1370, operated very successfully for fistula; improved the trepan, and added the centre pin. Valasco de Taranta, A. D. 1410, practiced at Montpellier, and first proposed the application of arsenic to the cure of cancer. Germain Colot, surgeon of Louis XI, A. D. 1460, restored the operation of lithotomy to the profession by an act of the law. A. D. 1440—1450 was distinguished by the discovery of Print- ing, which had a marked influence on the progress of the profession. A. D. 1492, Discovery of America. It may, perhaps, specially interest the American student to know that Syphilis was described by Albucasis, Avicenna, Valesco, and John of Gaddesden, nearly 100 years before this period,* and that its origin in connection with the expedition of Columbus is by no means established. Vesalius, in A. D. 1550, taught Anatomy; and Eustachius, in A. D. 1560, did the same. Ambrose Pare, in France, A. D. 1560, created a new period in surgery, both by his practice and writings. He wrote on gunshot wounds, firearms being first introduced at this period; employed See Lectures of Sir A. Cooper, by Lee. xxii history of surgery. ligatures more than the actual cautery, and first resorted to the twisted suture in hare-lip, copying the mode in which the ladies and tailors carried the thread and needle in their cuffs. Taliacotius, an Italian, in A. D. 1597, revived and systematized the class of plastic operations which had previously been practiced in a very irregular manner by empirics. Fabricius ab Aquapendente, A. D. 1610, the preceptor of Har- vey, introduced the modern trephine, or the instrument that is gene- rally resorted to both in England and America; he also invented the curved canula, formerly employed after tracheotomy. Wiseman, A.D. 1676, the surgeon to Charles II, advocated im- mediate amputation in military surgery, and especially before fever set in. James Young, of Plymouth, A. D. 1679, first proposed the flap amputation, since claimed by Verduin and Sabaurin, and first re- commended compression being limited to the artery in amputation. Fabricius Hildanus, A. D. 1653, of Germany, and Scultbtus, each wrote an armamentarium chirurgicum, which includes a large number of surgical instruments illustrative of the practice of their own and preceding periods. Dionis, Belloste, Saviard, and Morel, in France, all practiced during the seventeenth century. Heister, A. D. 1710, was highly distinguished as a surgeon, and wrote a large and excellent work on the Practice of Surgery to which modern surgeons are largely indebted. ' Desault, A.D. 1730, first taught surgical anatomy. This dis- tinguished surgeon made many improvements in surgery; amon* others he changed the curved amputating knife to the present straight one; first suggested the cure of artificial anus, by removal of the septum between the ends of the bowel, and also first proposed lift- ing the distal side of the tumor in aneurism Petit A. D. 1740, did much to advance French surgery; he in- fill, 1 b ST l0""^^' and ™ the firSt wh0 op^ted for fistula lachrymalis by transfixing the sac. Le Drax Sabatier, Garrangeot, Louis, and Frere Cosme were also eminent French surgeons during the eighteenth century. history of surgery^ xxiii AMERICAN HISTORY. HISTORICAL RECORD OF SOME OF THE PRINCIPAL FACTS OF INTEREST CONNECTED WITH THE ORIGIN AND PROGRESS OF MEDICINE AND SURGERY IN THE UNITED STATES, ARRANGED TO FACILITATE REFERENCE* The history of Surgery in the United States is so closely identi- fied with that of Medicine, as to render it impossible to separate them; nor is it advantageous to do so, the existence of surgery, as a separate branch, being only produced by violence, both having naturally a common trunk and one universal root. In the United States, any attempt to separate the practice of the one from that of the other is altogether futile, the most distinguished surgeons having been, and yet being, in many instances, the most accom- plished physicians of their respective localities. The United States, in its earliest periods, being a colony of Great Britain, the medical wants of the settlers were necessarily supplied by the practitioners who emigrated with them from Europe. A large number of these emigrants being also those who left their homes on account of religious persecutions, we find that many of our early physicians united the clerical function with that of medicine, or were the public officers, who undertook the treatment of the complaints of the hardy colonists. The following facts, though mainly of local interest, and specially connected with the origin of the profession in particular towns, are * For the facts and dates furnished in this synopsis, I have drawn upon various authorities, but especially upon the following writers:— American Medical Biography, or Memoirs of Eminent Physicians who have flourished in the United States, by James Thacher, M. D., Boston, 1828. Annual Address (on American Medicine before the Revolution), delivered before the Medical Society of the State of New York, Feb. 1842, by John B. Beck, M. D., President of the Society. A Review of the Improvement of Medicine in the Eighteenth Century, by David Ramsay, M. D., Charleston, 1800. xxiv f ISTORY OF SURGERY. yet deemed worthy of general notice, as showing the condition of the profession during a period of over 200 years. In 1620, the United States of America was a wilderness. In 1850, it had more than 40,000 practitioners of medicine, and a population of 25,000,000 souls. The first record of the presence of a physician, as a resident of the colonies, is found in the settlement of Virginia, where, in 1608, one year after the settlement of the colony, Dr. Walter Russel arrived from England. In 1620, Dr. Samuel Fuller, a deacon in the church of the Rev. John Robertson, arrived at Plymouth in the first ship with the Puritans. In 1635, Dr. Thomas Thatcher came over from England, and subsequently published the first American medical work. In 1637, Dr. John Fisk arrived and settled at Salem as a clergy- man and physician. In 1638, Harvard University, Mass., was founded. Many of its early graduates, after obtaining medical degrees in Europe, returned to practice their profession in their native country, bringing with them the views and practice of their European teachers, thus esta- blishing medicine in this country on the basis of that taught during their pupilage in the European schools. In 1642, Samuel Bellingham and Henry Saltonstall gra- duated at Harvard University, and then took the degree of M. D. in Europe. In 1644, Dr. Thomas Oliver is spoken of, in the Journal of Go- vernor Winthrop, as a skillful surgeon. In 1649, a law was passed in Massachusetts "regulatino- the practice of chirurgeons, midwives, and physicians." In 1650, Dr. John Glover graduated at Harvard, and obtained a medical degree at Leyden. Dr. Howard did the same. In 1651, Dr. Isaac Chauncey graduated at Aberdeen, and settled in Massachusetts. In 1662, Dr. John Winthrop was made Governor of Connecticut He was one of the founders of the Royal Society of England being in London at that time as an agent for the colony. In 1667, Dr. Thomas Thatcher, of Massachusetts, published a medical tract, entitled "A Brief Guide in the Small-pox and Mea sles," being the first medical publication in the country. history of surgery..*, XXV In 1669, Dr. Henry Taylor, of Boston, practiced surgery in that town, and "had his rate remitted for attending the poor." In 1673, Dr. Samuel Fuller was appointed Surgeon-General to the Forces. In 1674, Dr. Edmund Davie, of Harvard, obtained the degree of M. D. at Padua. In 1682, Dr. Thomas Wynn and brother, Welsh physicians, located themselves in Philadelphia, and were the earliest practition- ers in this city. In 1691, William and Mary College, in Virginia, was founded for the education of young men, but without any medical department. In 1700, Dr. John Nicoll, a graduate of Edinburgh, located in New York city. In the same year, Dr. Hamilton, a Scotch physician, settled in Maryland. At the same period, Dr. John Mitchell, of England, settled in Virginia. In 1700, Yale College, Connecticut, was founded. In 1704, the first newspaper was published in the United States, and doubtless had its influence on the profession, in disseminating general information. In 1705, Dr. John Clayton, of England, settled in Virginia. In 1707, Dr. Grosme came over with the governor, and settled in Philadelphia. In 1712, Dr. Gustavus Brown, of Scotland, located himself at Port Tobacco, Maryland, and was the most distinguished practi- tioner of this and the adjoining State. In 1716, Dr. William Douglass, of Scotland, emigrated to New England. In 1718, Dr. Colden, of Scotland, settled in New York. In 1720 or 1730, Dr. Lloyd Zachary, one of the founders of the Pennsylvania Hospital, commenced practice in Philadelphia. In 1720, Dr. Colden wrote an account of the climate and dis- eases of New York city, recommending it especially to consumptive patients. In 1721, Dr. Benjamin Colman, a clergyman of Boston, pub- lished a pamphlet on Inoculation, defending the practice introduced by Dr. Boylston. In 1721, Dr. Cotton Mather introduced inoculation in Boston. Experiments were also made by Dr. Boylston in June, 1721, upon XXVI .history of surgery. his own family. This practice created such inflammatory conduct on the part of the other physicians and the populace as to endanger their lives. The first case, Lady Mary Wortley Montague, was in- oculated in England, in April, 1721. In 1725, Dr. Boylston was handsomely received at court in Lon- don, and was the first American elected a fellow of the Royal So- ciety. The ensuing year, he published in England, at the request of the Royal Society, " An Historical Account of the Small-pox, inoculated in New England." In 1730, Dr. Nath. Williams wrote on the Practice in Small-pox. In 1732, Dr. Walton published an essay on Fever. In the same year, Dr. Thomas Howard published a treatise on Pharmacy. In 1734, Dr. William Bull, of North Carolina, after studying under Boerhaave, graduated at Leyden, and wrote on lead colic. In 1736, Dr. William Douglass published "The History of a new Epidemical Eruptive Fever" which prevailed in New England in 1735, 1736. In 1736, Dr. Douglass employed calomel in the treatment of in- flammation. This practice has been claimed for Dr. Robert Hamil- ton, of England, but his attention, it is well known, was not called to it until 1764. In the same year, Dr. John Tenent, of Virginia, published an account of the Polygala Senega. In 1737, 1741, 1742, Dr. John Mitchell, of Virginia, treated yellow fever by copious bleedings. In 1740, Dr. Magraw, of Scotland, settled in New York city. In the same year, Dr. Thomas Cadwalader, of Philadelphia, published an " Essay on the Iliac Passion," recommending mild purges and opiates instead of the violent treatment previously pur- In 1741, Dr. Colden published an account of the Fever which prevailed in New York ; also a paper on Cancer J\Xl^' ^' J°Rl ^ITCHELL' of Y^™> Polished letters on the lellow Fever of 1741, in Virginia, also on " The Causes of diflerent Colors of People in different Climates." In the same year, Dr. Clayton published the "Flora Virginiana " which was republished by Gronovius, at Leyden, in 176? In 1746, Dr. Colden, Lieut.-Governor of New YorWave Ma deira wine freely in yellow fever, with much success. history of surgery., xxvii In 1746, Princeton College, New Jersey, was founded. In 1748, Dr. John Lining, of Charleston, published a descrip- tion of the American Yellow Fever. In 1749, Dr. John Moultrie, of Charleston, graduated at Edin- burgh, being the first native Carolinian who obtained this honor. In 1750, Drs. John Bard and Peter MiDDLETotf injected and dissected the body of a criminal for the instruction of the students, being the first dissection recorded in the United States. In 1752, the Pennsylvania Hospital was established in Philadel- phia, being the first general hospital in the United States, and has always been noted for the amount of its surgical practice. In the same year, patients were received into its wards. In 1753, Dr. James Lloyd, after enjoying the instruction of Warner, Sharpe, Smellie, and Hunter, of London, settled in Boston, and was the first systematic practitioner of midwifery, &c. in that section. In 1754, Dr. Lionel Chalmers, of Charleston, wrote a paper on Tetanus, then very prevalent in that city, recommending bleed- ing, the warm bath, and opiates. In the same year, Dr. Thomas Bond, of Philadelphia, wrote an account of a worm found in the Liver. At the same period, Dr. Bond was actively engaged in the Penn- sylvania Hospital. In 1755, Drs. Andrew Robinson and James Craik came over as surgeons to Braddock's army, and settled in Virginia. In 1756, Dr. William Shippen, Jr., of Philadelphia, returned from Europe, and commenced practice in his native city. He was elected Professor of Surgery in Philadelphia in 1765, and was the first Pro- fessor of Surgery in the United States. In 1759, inoculation was generally adopted in Philadelphia. In the same year, Dr. John Bard, of New York, published seve- ral papers on Yellow Fever, and on the Pleurisy, which prevailed on Long Island in 1749. In 1759, Dr. Bond wrote on the use of bark in Scrofula. In 1760, the General Assembly of the Province of New York ordained that no person should practice as a physician or surgeon in the city of New York before he had been examined and approved by one of his majesty's council. During the same year, Dr. Wil- liam Douglass published a summary of the progress and planting xxviii history of surgery. of the British settlements in America, which contained a notice of the state of the profession. In 1763, Dr. John Morgan, of Philadelphia, graduated at Edin- burgh, and maintained in his inaugural essay that pus was a secre- tion. The credit of this doctrine has usually been assigned to Mr. John Hunter, but there is no doubt of his having been anticipated by Dr. Morgan.* In 1765, Dr. Morgan delivered an address on the institution of medical schools in America, at the first commencement of the Uni- versity of Pennsylvania. The University was established this year. In 1768, Columbia College, New York (then King's), was founded. In the same year, Dr. Chalmers, of Charleston, published an "Essay on Fevers," and in 1776, "Meteorological Observations taken at Charleston, from 1750 to 1760." In 1769, Dr. Kearsley, of Philadelphia, wrote a paper on An- gina Maligna. In the same year, Dr. Peter Middleton, of New York, delivered an address on the State of Medicine at the opening of King's Col- lege. Dr. John Jones was elected Professor of Surgery this year. In 1769, Dr. Samuel Bard suggested the establishment of the New York Hospital. The building was erected in 1773, but destroyed shortly afterwards by fire when nearly completed, and did not re- ceive patients until 1791. In 1770, 1781, Dr. Bayley, a surgeon of New York, described! the false membrane in croup as the result of inflammation, and treated it by bleeding, tartar emetic, and calomel. The credit of this practice was incorrectly claimed for Dr. Cheyne more than twenty years subsequently to Dr. Bayley's publication. In 1771, Dr. Samuel Kissam, of New York, published an in- augural essay on the anthelmintic virtues of Cowhage. tv*. nDr' Jam7r,CUMy' LeCtUPer a* GUy'S H°Spita1'in referri"S t0 th* Priority of this opinion of Dr. Morgan, says, < M. D. Philadelphia. Medical Examiner, vol. iv. p. 390, 1841. Sub-conjunctival 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. xxxiv BIBLIOGRAPHICAL INDEX. Operation for Artificial Pupil and subsequent section of the Rec- tus 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. Philada. Am. Journ. Med. Sciences, vol. iv. N. S. p. 371, 1842. Two Cases Malignant Ophthalmic Disease, (Colloid Tumor of the Orbit and Melanosis of Globe,) S. R. 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. Philadelphia. Philadelphia Med. Examiner, vol. vi. p. 241, 1850. Dislocation of the Crystalline Lens, beneath the Conjunctiva, ex- traction at the Inner Canthus, by Charles A. Pope, M. D. St. Louis. St. Louis Med. and Surg. Journ., vol. vii. p. 289, 1850. OPERATIONS ON THE FACE. Tic Douloureux (cured by dividing the Infra and Supra-orbitar Nerves), by Dr. Jeremy Stimpson, M. D. Boston. New England Journ. Med. and Surg., vol. vi. p. 14, 1817. Case of Anastomosing Aneurism of the Internal Maxillary Artery, by Granville Sharp Patteson, M. D. Baltimore. Philada. Med. Recorder, vol. v. p. 108, 1822. Cases of Neuralgia, treated by division of the Nerves, (Infra- orbital Submaxillary, Portio Dura, and Supra-orbitar,) by John C Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. i. p. 1, 1825. ^Facial Neuralgia, cured by Acupunctural, by J. Hunter Ewing, North American Med. and Surg. Journ., Philad., vol vi p 77 1826 Cases illustrative of Remedial Effects of Acupunctural, by Franklin Bache, M. D. Philadelphia. North American Med. and Surg. Journ., vol. i. p 311 l8o6 c^:;uTi:::lhz*r(for Tic Douio"e^b*j;h- B°St0n Med- and Sw9- Journ., vol. i. p. 2,1828. Case of Anastomosing Aneurism of the External Maxillary (Tem- poral) Artery successfully treated by tying the Common Caret d, by David L. Rogers, M. D. New York. ' ' Am. Journ. Med. Sciences, vol. xiii. p. 271,1833. BIBLIOGRAPHICAL INDEX. XXXV On Acupuncturation, by Franklin Bache, M. D. Philada. American Cyclopedia of Practical Medicine and Surgery, vol. i. p. 200,1834. Rhino-plasty, Blepharo-plasty, and Cheilo-plasty, in the same pa- tient, by F. H. Hamilton, M. D. Buffalo. Buffalo Medical Journal, vol. iv. p. 549, 1849. A Horn (seven inches long and five broad at the base) excised from the Face, by F. H. Hamilton, M. D. Buffalo. Buffalo Med. Journ., vol. vi. p. 13, 1850. OPERATIONS ON THE EXTERNAL NOSE. Rhino-plastic Operation (being the first successful case in the United States), by J. Mason Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. xvi. p. 69, 1837. Rhino-plastic Operation, by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xx. p. 269, 1837. Rhino-plastic Operation, by Thomas D. Mutter, M. D. Philad. Am. Journ. Med. Sciences, vol. xxii. p. 61, 1838. Rhino-plastic Operations, by J. Mason Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. xxii. p. 264, 1840. Auto-plastic Operations, by J. Mason Warren, M. D. Boston. Boston Med. Journ., vol. xxii. p. 268, 1840. Taliacotian Operation, flap divided seventy-two hours after the operation (successful two years afterwards), by J. Mason Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. xxviii. p. 69, 1843. Also, Rhino-plastic Operations, by J. Pancoast, M. D. Philada. Operative Surgery, p. 345, 1844. ON POLYPI. Inquiry into the Pathology and Treatment of Polypous Tumors of the Nasal Fossae, with Observations on other Tumors in various parts of the Body, by John Watson, M. D. New York. Am. Journ. Med. Sciences, vol. iii. N. S. p. 325, 1842. Case of Gelatinous Polypus, cured with Sanguinaria Canadensis, after Extraction had twice failed, by Lewis Shanks, M. D. Ten- nessee. Am. Journal Med. Sciences, vol. iv. N. S. p. 368, 1842. A Nasal Operation for the Removal of a Large Tumor, filling up XXX VI BIBLIOGRAPHICAL INDEX. the entire Nostril, and extending into the Pharynx, by Valentine Mott, M. D. New York. Am. Journal Med. Sciences, vol. v. N. S. p. 87, 1842. Removal of a large Polypus from the Nose, through the Pharynx (by a tape), by Paul F. Eve, M. D. Georgia. Southern Med. and Surg. Journ., 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 Zadoc Howe, M. D. Massachusetts. Am. Journal Med. Sciences, vol. vii. p. 414, 1831. On the Operation of Hare-lip (within the week two cases success- fully treated), by A. L. Pierson, M. D. 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, occur- ring in the same Family, in which Operations were performed, by Isaac Parrish, M. D. Philadelphia. Am. Journal Med. Sciences, vol. xxii. p. 97,1838. 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. Journal 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. II. Hamilton, M. D. Buffalo. Buffalo Med. Journ., vol. iv. p. 603,1849. Insect Pins in Cases of Hare-lip, by George Hayward, M. D. B°St0n- Boston Med- <™<* Surg. Journ., vol. xix. p. 153. Hare-lip—Nursing during the process of Union (without any strain on the Lip), by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xix. p. 74,1850. BIBLIOGRAPHICAL INDEX. xxxvii OPERATIONS ON THE UPPER JAW. Osteo-sarcoma of the Upper Jaw, with a successful operation for its removal nearly entire, by David L. Rogers, M. D. New York. New York Med. Phys. Journ., vol. iii. p. 301, 1824. Tumor in the Antrum Highmorianum extirpated, by Clarke Wright, M. D. New York. New York Med. Phys. Journ., vol. iv. 1825. Exostosis of the Upper Jaw, treated successfully by B. A. Rod- rigues, M. D. Penna. Am. Journ. Med. Sciences, vol. xxiv. p. 516, 1839. Case of Osteo-sarcoma of Upper Jaw, successfully treated by Extirpation of the whole of the Superior Maxillary and Malar Bones, and portions of the Ethmoid and Sphenoid Bones, with Remarks, 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 successfully performed, by J. C. Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. xxvi. p. 9, 1842. Also, Am. Journ. Med. Sciences, vol. iii. N. S. p. 506, 1842. Removal of the Upper Maxillary Bone for Cephalomatous Dis- ease, by J. C. Warren, M. D. Boston Med. and Surg. Journ., vol. xxvi. p. 9, 1842. On Muco-purulent Secretion of the Antrum Highmorianum, by S. P. Hulihen, M. D. Va. Boston Med. and Surg. Journ., vol. xxvi. p. 94, 1842. Amputation of the Superior Maxillary, Malar, and Palate Bones, by Daniel Brainard, M. D. Chicago. Am. Journ. Med. Sciences, vol. xiii. 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. Journ. Med. Sciences, vol. xiii. p. 340, 1847. Modified Operation for the Excision of Upper Jaw, cured (with- out any incision through the cheek), by W. E. Horner, M. D. Phi- ladelphia. Medical Examiner, vol. vi. N. S. p. 16, 1850. xxxviii BIBLIOGRAPHICAL INDEX. ON IMMOBILITY OF THE JAW. Case of Immobility of the Jaw, successfully treated, by Valentine Mott, M. D. Rutger's College. Am. Journ. Med. Sciences, vol. v. p. 102, 1829. Case of Immobility of the Jaw and Taliacotian Operation, by Va- lentine Mott, M. D. New York. Am. Journ. Med. Sciences, vol. ix. p. 47, 1831. Case of Immobility of the Jaw, successfully treated, by Professor Mott's complicated Lever, and a Modification of his Operation, by Jesse W. Mighels, M. D. Maine. Am. Journ. Med. Sciences, vol. ix. p. 50, 1831. On Immobility or incomplete Muscular Anchylosis of the Jaw, by William E. Horner, M. D. Philadelphia. Am. Cyclopedia 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. New 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. Sciences, vol. vi. N. S. p. 374, 1843. Claims to Priority on the Division of the Masseter Muscle, &c, in immobility of the Inferior Maxilla, by John Murray Carnochan, M. D. New York. Mott's Velpeau by Townsend, vol. ii. p. 20, Appendix, 1847. Immobility of the Jaw, relieved by Mott's Dilator, by Paul F. Eve, M. D. Ga. South. Med. and Surg. Journ., vol. vi. p. 257, 1850. Case of Immobility of the Lower Jaw from adhesions, the result of salivation, relieved by an operation, by P. Calhoun, M. D. Louisiana. Charleston Med. Journ., vol. v. p. 43, 1850. 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. Rogersville, Tenn, (claiming justly to be the first operation of the kind ever performed, being two years before that of Dupuytren). Med. Recorder, vol. vi. p. 516, 1823. Also, Am. Journ. Med. Science*, vol. xiii. p. 521, 1847. BIBLIOGRAPHICAL INDEX. xxxix Case of Fracture of Inferior Maxilla, successfully treated by Se- ton, by P. S. Physick, M. D. July 1822. Chapman's Journal, vol. v. p. 116, 1822. Case of Osteo-sarcoma, in which the right side of the lower jaw was removed successfully after tying the carotid, by Val. Mott, M. D. New York, 1821. * New York Med. and Phys. Journ., vol. i. p. 385, 1822. 2d Case of Osteo-sarcoma, in which the left carotid was tied, and a portion of the lower jaw removed successfully. March, 1823. New York Med. Phys. Journ., vol. ii. p. 157, 1823. 3d Case of Osteo-sarcoma on the right side of the lower jaw, removed at the articulation, the carotid tied—died 5th day, by Val. Mott, M. D. 1823. New York Med. Phys. Journ., vol. ii. p. 401, 1823. Removal of nearly one-half 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. Charleston, 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. Sciences, 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. C. Am. Journ. Med. Sciences, vol. x. p. 315, 1832. Case of Exsection of half of the Lower Jaw (disarticulated), by Geo. W. Campbell, M. D. Tenn. Trans. Journ. Med., vol. vi. p. 400, 1833. xl BIBLIOGRAPHICAL INDIX. Amputation of nearly half of the Lower Jaw, by Paul F. Eve, M.D. Ga. Am. Journ. Med. Sciences, vol. xxiii. p. 261, 1839. Osteo-sarcoma and Excision of a large portion of the Lower Jaw, by J. Wort, M. D. Am. Journ. Med. Sciences, vol. xxiv. p. 260, 1839. Osteo-sarcoma of the Lower Jaw, removed by Dr. Batchelder, June, 1825. Reported by S. W. Williams, M. D. Deerfield. Boston Med. and Surg. Journ., vol. xxii. p. 39, 1840. Case of Excision of a portion of the Inferior Maxillary Bone, by H. H. Toland, M. D. S. C. Am. Journ. Med. Sciences, vol. i. N. S. p. 534, 1841. Osteo-sarcoma of Lower Jaw, Amputation, and Cure, by Charles Bell Gibson, M. D. Baltimore. Am. Journ. Med. Sciences, vol. iv. N. S. p. 277, 1842. Osteo-sarcoma of Lower Jaw, Excision and Cure, by Joseph P. Dewey, M. D. Charleston. Am. Journ. Med. Sciences, vol. viii. p. Ill, 1844. Exsection of Inferior Maxillary Bone, by Val. 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. Pinckney, M. D., U. S. N. Am. Journ. Med. Sciences, vol. xii. p. 335, 1846. Osteo-sarcoma of the Lower Jaw, Resection of Bone, and Cure, by J. Marion Sims, M. D. Alabama. Am. Journ. Med. Sciences, vol. xi. p. 128, 1846. Osteo-sarcoma of 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. Sci., vol. iv. p. 370, 1847. Fibrous Tumor of the Lower Jaw, in which the left half of the bone was successfully removed (disarticulated), by S. D. Gross, M. D. Louisville. Am. Journ. Med. Sci., vol. xvi. p. 344, 1848. Exsection and Disarticulation of the Lower Jaw for Osteo-sar- coma, by Geo. C. Blackman, M. D. Am. Journ. Med. Sciences, vol. xvii. p. 93, 1849. Exsection of three inches Inferior Maxilla for Spina Ventosa, cured by Paul F. Eve, M. D. South. Med. and Surg. Journ., vol. vi. p. 261, 1850. BIBLIOGRAPHICAL INDEX. Xii Case of Elongation of the Lower Jaw, and Distortion of the Face and Neck, caused by a burn ; successfully treated by operations, by S. P. Hulihen, M. D. Wheeling, Va. Med. Examiner, vol. vi. p. 188, 1850. OPERATIONS ON THE FACE. Operation for the Removal of a large Tumor 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 Dieffenbach'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. Sciences, vol. iv. N. S. p. 337, 1842. Plastic Operations, by J. Pancoast, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. v. N. S. p. 99, 1843. Genio-plasty for a Fungous Tumor of the Neck, by George C. Blackman, M. D. New York. Am. Journ. Med. Sciences, vol. x. N. S. p. 327, 1845. A Case of Cheilo-plastic Operation, by Abraham Stout, M. D. Easton, Pa. Med. Examiner, vol. vi. p. 13, 1850. OPERATIONS ON THE TONGUE. t Amputation of the Tongue for Enlargement, (the portion ampu- tated measured, length 2| inches—circumference 7|- inches, thick- ness 1J inches,) cured by H. S. Newman, M. D. Warren county, Penn. Med. Recorder, vol. vii. p. 541, 1824. Case of Glossitis, attended with alarming symptoms of Suffoca- tion, removed by deep incisions made into the Substance of the Tongue, by Abner Hopton, M. D. N. C. Am. Journ. Med. Sciences, vol. iv. p. 533, 1829. Operation for Cancer of the Tongue (cured), by J. C. Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. ii. p. 157, 1829. Chronic Intumescence of the Tongue (very large), treated by amputation (cured), by Thos. Harris, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. vii. p. 17,1830. xiii BIBLIOGRAPHICAL INDEX. Case of Hypertrophy of the Tongue (operated on) by Thomas Wells, M. D. Columbia, S. C. Am. Journ. Med. Sciences, vol. x. p. 21, 1832. Carcinoma of the Tongue, successfully treated with the ligature, by M. Donnellan, M. D. Louisiana. Am. Journ. Med. Sciences, vol. xvii. p. 540, 1835. Case of Congenital Enlargement of the Tongue (Lingua Vitula), by Thos. Harris, 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. 377, 1837. Removal of Cancer of the Tongue, (believed to be rarely success- ful,) treated by Geo. Hayward, M. D. Boston. Boston Med. and Surg. Journ., vol. xix. p. 158,1838. Case of Glossocele, amputated successfully by M. G. Delaney, M. D. U. S. N. Am. Journ. Med. Sciences, vol. xvi. p. 294, 1848. Removal of a Foreign Body (pin) from the Duct of Wharton, by H. F. Campbell, M. D. Am. Journ. Med. Sciences, vol. xv. p. 572, 1848. Observations on Ranula, with Cases, Treatment and Cure, (iodine injected into tumor,) by Jas. M. Gordon, M. D. Ga. Southern Med. and Surg. Journ., vol. v. p. 65, 1849. 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 instru- ment employed for that purpose, and also for excision of Scir- rhous Tonsils, by P.S. Physick, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. i. p. 262, Feb. 1827. Case of Consumption (?) relieved by Truncating the Uvula, by Augustus W. Mills, M. D. Ky. Trans. Journ. Med., vol. xxii. p. 530, 1829. Extraction of a Thimble from the Pterygoid Fossa, by Isaac Par- rish, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvii. p. 540, 1835. Cancer of the Throat—Operation—Recovery—but the patient subsequently died of Peritonitis, by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xix. p. 120, 1836. BIBLIOGRAPHICAL INDEX. xliii OPERATIONS ON THE TONSILS. The Double Canula and Wire Ligature, recommended in Extir- pating Tonsils and Haemorrhoidal Tumors, by P. S. Physick, M. D. Philadelphia. From Phil. Journ. of Med. and Phys. Sciences, vol. i. p. 17, 1820. Treatment of Enlarged and Indurated Tonsils, with a new Mode (ligature) of removing these and Polypous Tumors, by Alex. H. Ste- vens, M. D. N. Y. From N. Y. Med. and Phys. Journ., vol. vi. p. 523,1827. On an Improved Instrument for Excising Tonsils and Uvula, by C. B. Matthews, M. D. Philadelphia. Phil. Med. Recorder, vol xiii. p. 309, 1828. Remarks on the various modes generally adopted for the Removal of the Tonsils, by Alex. E. Hosack, M. D. N. Y. Am. Journ. Med. Sciences, vol. i. p. 262, 1828. Description of a Forceps used to facilitate the Extirpation of the Tonsils, and invented by P. S. Physick, M.\D. Philadelphia. Am. Journ. Med. Sciences, vol. ii. p. 116, 1828. Remarks on Enlarged Tonsils, with a new Instrument for Excision, by Abrm. L. Cox, M. D. N. Y. N. Y. Med. and Phys. Journ., N. S. vol. ii. p. 52, 1830. New Instrument for Excising Tonsils, by David L. Rogers, M. D. N. Y. N. Y. Med. and Phys. Journ., N. S. vol. ii. p. 13, 1831. A new Instrument for Extirpating Tonsils, by J. K. Mitchell, M. D. Philadelphia. North Am. Med. and Surg. Journ., vol. xi. p. 239, 1831. An Essay on Excision of the Tonsils with an Instrument, by Geo. Bushe, M. D. N. Y. Med.-Chirurg. Bulletin, vol. ii. p. 161, 1832. Description of an Instrument for the Excision of the Tonsils, by Wm. B. Fahnestock, M. D. Penn. Am. Journ. Med. Sciences, vol. ii. p. 249, 1832. Instrument for the Excision of Tonsils, by N. R. Smith, M. D. Baltimore. North Am. Archives, Baltimore, vol. i. p. 90, 1835. On the Common Induration of the Tonsils, and a Description of an Instrument for their Excision, by John C. Warren, M. D. Boston. Surg. Obs. on Tumors, with Cases and Operations. Boston, 1839. Xlir BIBLIOGRAPHICAL INDEX. Remarks on the Enlargement of the Tonsils, attended by certain Deformities of the Chest. By J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xxiv. p. 523, 1839. Tonsilotomy—Profuse Hemorrhage—by F. II. Hamilton, M. D. Buffalo. Buffalo Med. Journ., vol. iv. p. 217, 1849. ON STAPHYLORAPHY. Suture of Palate in Infancy, believed to have been successfully performed by Nathan Smith, M. D. Yale College. From 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. N. S. p. 1, 1828. Extensive Division of the Soft Palate (from a wound) sewed with Physick's Needle, &c, by Thos. Wells, M. D. Columbia, S. C. Am. Journ. Med. Sciences, vol. x. p. 21, 1832. Observations on Staphyloraphy with a new Instrument, by N. R. Smith, M. D. Baltimore. North Am. Archives, vol. i. p. 27, 1835. Congenital Fissures of the Palate operated on, by Jas. 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. Boston. " ' 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. BIBLIOGRAPHICAL INDEX. xlv 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 re- sult of 24 cases, by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xv. p. 329, 1848. OPERATIONS ON THE EAR. Extraction of Foreign Substances from the Ear, (by means of a thread attached to the article by glueing with shell lac,) by Charles Hooker, M. D. New Haven. Boston Med. and Surg. Journ., vol. x. p. 317, 1833. Polypi of the Meatus Auditorius Externus removed by Ligature, by E. J. Davenport, M. D. Boston, 1837. Boston Med. and Surg. Journ., vol. xvii. p. 235, 1837. Congenital Absence of Meatus Auditorius Externus of both Ears without much impairing the hearing, by R. D. Mussey, M. D. Fair- field, N. Y. Am. Journ. Med. Sciences, vol. xxi. p. 377, 1837. On the Extraction of Foreign Bodies from the Meatus Auditorius Externus, by J. Marion Sims, M. D. Alabama. Am. Journ. Med. Sciences, vol. ix. p. 336, 1845. Fibrous Tumor removed from the Lobe of the Ear, by Geo. W. Norris, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xx. p. 557, 1850. Maggots, probably 40, in the Ear (from previous entrance of a fly), removed by F. H. Hamilton, M. D. Buffalo Med. Journ., vol. vi. p. 10, 1850. PAET III. 0 PAPERS RELATING TO 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 McClellan, M. D. Philadelphia, 1826. New York Med. and Phys. Journ., vol. v. p. 649, 1826 ; also Am. Med. Review and Journal. Case of Extirpation of the Right Parotid for Melanotic Enlarge- ment, by George McClellan, M. D. Philadelphia, 1829, being his second case. New York Med. and Phys. Journ., vol. ii. N. S. p. 309, 1830. An Account of the Extirpation of the Parotid Gland, by George McClellan, M. D. Philadelphia. 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 (December 14th, 1827, September 16th, 1830, and one not dated), by George Bushe, M. D. New York. Medico-Chirurgical Bulletin, vol. ii. p. 133, 1832. Extirpation of the Parotid Gland, with other Cases, by Nathan R. Smith, M. D. Baltimore. Am. Journ. Med. 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. 517, 1839. C Xlviii BIBLIOGRAPHICAL INDEX. A Case of Extirpation of the Parotid Gland in 1805, by John McClellan, M. D. Franklin County, Pennsylvania. Am. Journ. Med. Sciences, vol. vii. N. S. p. 499, 1844. Extirpation of a Scirrhous Parotid Gland, by H. H. Wheeler, M. D. Pennsylvania. Am. Journ. Med. Sciences, vol. ix. N. S. p. 520, 1845. ON DEFORMITIES OF THE NECK. A Case of Deformity from Burns (on the Face and Neck) relieved by an Operation, by T. D. Mutter, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. iv. N. S. p. 66, 1842. 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 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. OPERATIONS ON THE (ESOPHAGUS. 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 Dr. Monroe, of Edinburgh, had done the same thing), by C. B. Matthews, M. D. Philadelphia. Am. Med. Record., vol. x. p. 322, 1826. Case in which a Copper Coin remained thirteen years in the (Eso- phagus, by John Syng Dorsey, M. D. Philadelphia. New York Med. and Philosoph. Journ., vol. iii. p. 173, 1811; also Philad. Med. Museum, vol. i. N. S. p. 125, 1811. Two Cases in which Poison was removed by the Stomach-Tube by P. S. Physick, M. D. Philadelphia. Eclectic Repert. and Analytical Review, vol. v. p. Ill, 1813. A Case of Stricture of the (Esophagus, cured by Caustic by Charles T. Hildreth, M. D. Haverhill. ' New England Journ. of Med. and Surg., vol. x. p. 235, 1821. Extraction of a Fish-Hook and Line from the Stomach, by slip- ping a Perforated Bullet over the Line and Point of the Hook, by BIBLIOGRAPHICAL INDEX. xlix Dr. Brite. Communicated by S. Brown, M. D., of Lexington, Ken- tucky. Am. Med. Record., vol. vi. p. 581, 1823. A new Instrument for Extracting Coins, &c, from the (Esophagus, by Nathan Smith, M. D. Yale College. Neto York Med. and Phys. Journ., vol. iv. p. 576, 1825. Case of Stricture of the (Esophagus (with a new Instrument for its Relief), by H. G. Jameson. Baltimore. Med. Record., vol. viii. p. 1, 1825. On the Removal of Foreign Bodies from the (Esophagus, by means of Forceps, &c, by Henry Bond, M.D. Philadelphia. North American Med. and Surg. Journ., vol. vi. p. 278, 1828. Description of a new (Esophagus Forceps, by Constantine Weever, M. D. Michigan. Am. Journ. Med. Sciences, vol. xiv. p. Ill, 1834. Description of a new form of Stomach-Pump, by P. B. Goddard, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xv. p. 262, 1834. Practical Observations on Organic Obstructions of the (Esopha- gus, preceded by a case which called for (Esophagotomy, and sub- sequent Tracheotomy, with accompanying illustrations, by John Watson, M. D. New York. Am. Journ. Med. Sciences, vol. viii. N. S. p. 309, 1844. Case of Ulceration and Stricture of the (Esophagus, 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. ON TRACHEOTOMY. Case of Hydrophobia, with the proposal of Tracheotomy, by P. S. Physick, M. D. Philadelphia, 1801. New York 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.. New York Med. Repository, vol. x. p. 250, 1807. 1 BIBLIOGRAPHICAL INDEX. Tracheotomy for Croup (died), by Dr. Thompson. New England 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. New York Med. Repository, vol. xx. p. 79, 1820. Bronchotomy successfully performed for the Removal of a Water- melon Seed, by H. G. Jameson, M. D. Baltimore. Am. Med. Recorder, vol. v. p. 673, 1822. Memoir on Bronchotomy, by H. G. Jameson, M. D. Baltimore. Am. Med. Recorder, vol. vi. p. 151, 1823. Case of a Pebble successfully extracted by Bronchotomy, by H. G. Jameson, M. D. Baltimore. Med. Recorder, vol. vii. p. 36, 1824. Three Cases of Bronchotomy, by S. Annan, M. D. Emmets- burg. Med. Recorder, vol. vii. p. 42, 1824. Case of Tracheotomy (successful) for the Removal of a Water- melon Seed, by Henry S. Waterhouse, M. D. Franklin County, New York. Philadelphia Journ. of Med. and Phys. Sciences, vol. viii. p. 391, 1824. Case of a Bean extracted successfully by Bronchotomy, by Jo- seph Palmer, M. D. Med. Recorder, vol. vii. p. 32, 1824. Two Cases of Bronchotomy (in which one was cured, one died), by Richard Burgess, M. D. Med. Recorder, vol. vii. p. Ill, 1824. Case of Tracheotomy for the Removal of a Bean (cured), by Cal- vin Jewett, M. D. Newberg, Vermont. New England Journ. of Med. and Surg., vol. xiii. p. 237, 1824. Case of Laryngotomy for a Watermelon Seed (cured), by Samuel A. Cartwright, M. D. Natchez. New England Journ. 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, N. H. New England 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 introducing the Forceps into the Trachea, by Enos Barnes, M. D., of Yates Countv New York. ^ New York Med. and Phys. Journ., vol. vi. p. 78, 1827. BIBLIOGRAPHICAL INDEX. Ii Operation of Laryngotomy and Tracheotomy (successfully) per- formed at the same time, on the same Patient, for the Removal of an Extraneous Body (a Grain of Corn) from the Larynx, by Abner Hopton, M. D. North Carolina. Am. Journ. Med. 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. Sciences, 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. Transylv. Journ. of Med., vol. iii. p. 267, 1830. An unsuccessful Case of Cynanche Trachealis, in which Tracheo- tomy was resorted to, by E. Atlee, M. D. Lancaster. West Journ. of Med. and Phys. Sciences, vol. iv. p. 23, 1831. Remarkable Instance of a Brass Nail remaining in the Lungs for more than a year, by Amariah Brigham, M. D. Hartford, Conn. Am. Journ. Med. Sciences, vol. xviii. p. 46, 1836. Case of Bronchotomy for the Removal of an Iron Nail (1 inch and fths long, and weighing 55 grains) from a child three years of age, nine days after it was swallowed, by Calvin Jewett, M. D. St. Johnsburg, Vermont. Boston Med. and Surg. Journ., vol. xvi. p. 91, 1837. Foreign Bodies (a Pipe-stem If inches long) in the Trachea re- moved by Tracheotomy (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 La- rynx, Carpet-Tack, Horse-shoe 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, successfully performed, for Membranous Croup (by J. Pancoast, M. D.), reported by C. D. Meigs, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvi. p. 529, 1848. Case of Membranous Croup of a severe character, and attended with all the symptoms of approaching death, cured without an ope- ration for Tracheotomy, by Isaac Parrish, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvi. p. 530,1848. A Foreign Body (Grain of Corn) in the Trachea, cured by Tra- cheotomy, by William Davidson, M. D. Madison County, Indiana. Am. Journ. Med. Sciences, vol. xvi. p. 263, 1848; also Western Lancet, Mav, 1848. Hi BIBLIOGRAPHICAL INDEX. CEdematous Laryngitis successfully treated by Scarification of the Glottis and Epiglottis, 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-Membranous Croup, in which Tracheotomy was performed (three cured, two died, Operation by J. Pancoast, M. D.), with remarks on the Treatment, and on the Operation, by J. Forsyth Meigs, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvii. p. 307, 1849. Case of Tracheotomy for Laryngitis (died), by Dr. Townsend. Boston. (Reported by Dr. J. B. S. Jackson.) Am. Journ. Med. Sciences, vol. xvii. p. 28, 1849. OPERATIONS FOR TUMORS ON THE NECK. 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. Eatonton, Georgia. Philadelphia Journ. of Med. and Phys. Sciences, vol. vi. p. 130, 1823. Case of (Adipose Sarcomatous) Tumor (weighing eight pounds) extirpated successfully (from the side of the neck), by David L. Ro- gers, M. D. New York. Communicated by P. Cadwallader, M. D. Philadelphia Journ. of Med. and Phys. Sciences, vol. xiii. p. 161, 1826. Case of a large Encysted Tumor, on the Side of the Neck, suc- cessfully removed, by Alexander H. Stevens, M. D. New York. New York Med. and Phys. Journ., vol. v. p. 311, 1826. Case of an Operation for the Removal of a formidable Tumor from the Neck (cured), by John C. Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. i. p. 26, 1828. Case of the Removal of a Tumor of the Neck, in which the Poste- rior 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 Account of the Operation for its Removal, by G. Hayward, M. D. Boston. Am. Journ. Med. Sciences, vol. viii. p. 352, 1831. Case of the Removal of a large Steatomatous Tumor of the Neck, by John C. Brent, M. D. Kentucky. Western Journ. of Med. and Phys. Sciences, vol. iv. p. 487, 1831. BIBLIOGRAPHICAL INDEX. liii Case of Extirpation of a Tumor of the Neck, in which the Carotid Artery and Internal Jugular Vein were tied (died), by William Gib- son, 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. Case of Attempt at Suicide, in which the Internal Jugular Vein was partially divided; 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 Western Lancet, May, 1842. Case of Tumor of the Thyroid Gland successfully extirpated, by Otis Hoyt, M. D. Boston Med. and Surg. Journ., vol. xxxv. p. 297, 1846. On Hydrocele of the Neck, by Thos. D. Mutter, M. D. Phila. Med. Examiner, vol. vi. N. S. p. 257, 1850. ON LIGATURE OF THE CAROTID ARTERY, AND ALSO OF THE ARTERIA INNOMINATA. Case of Carotid Aneurism, cured by an Operation, by Wright Post, M. D. (being the first operation successfully performed on this artery in the United States). Communicated by V. Mott, M. D. New York. Transact, of the New York Phys. Med. Soc, vol. i. p. 367, 1817. Case of Ligature of the Innominata (the Ligature separated on the fourteenth day, and on the twenty-sixth day the patient was attacked with Hemorrhage, and died), by Valentine Mott, M. D. New York, May 11th, 1818. New York Med. and Surg. Register, p. 9, 1818; also Eclect. Repert. and Analyt. Review, vol. ix. p. 1, 1819. Surgical Anatomy of the Arteries, with Rules for the Ligatures of all of them, by George McClellan, M. D. Philadelphia. Med. Recorder, vol. iii. p. 25, 1820. liv BIBLIOGRAPHICAL INDEX. Case of Ligature of the Carotid Artery (cured), by R. D. Mussey, M. D. Hanover. New England Journ. of Med. and Surg., vol. xi. p. 369, 1822. Case of Ligature of the Carotid Artery, for Aneurism (success- ful), by James Sykes, M. D. Dover, Delaware. Philadelphia 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 Ligature of the Carotid Artery, by J. W. Cusack, M. D. Med. Recorder, vol. vii. p. 104, 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 furnished by J. Kearney Rodgers, M. D. New York. New York Med. and Phys. Journ., vol. iv. p. 576, 1825. A Case of Ligature of the Carotid (died), by Mason F. Cogswell, M. D. Hartford, Connecticut. New England Journ. of Med. and Surg., vol. xiii. p. 357, 1824. Three Cases of Ligature of the Carotid Artery, successfully per- formed on children of five, eleven, and sixteen years of age, by George McClellan, M. D. Philadelphia. New York Med. and Phys. Journ., vol. v. p. 523, 1826. Case of an Operation for Carotid Aneurism (cured), by John C. Warren, M.D. Boston. Boston Med. and Surg. Journ., vol. i. p. 42, 1828. Case of an Operation for Carotid Aneurism (cured), by Winslow Lewis, M. D. Boston. Boston Med. and Surg. Journ., vol. ii. p. 371, 1829. Aneurism of the Arteria Innominata, involving the Subclavian and the Root of the Carotid; successfully treated by Tying the Ca- rotid, by Valentine Mott, M. D. New York. Am. Journ. Med. Sciences, vol. v. p. 297, 1829. Case of Ligature of the Carotid, in 1825, for Fungus of the An- trum (died), by Michael A. Finley, M. D. Williamsport, Maryland. Maryland Med. Record., vol. i. p. 97, 1829. Case of Ligature of the Carotid, for Anastomosing Aneurism, in a child three months old (cured), by Valentine Mott, M. D New York. Am. Journ. Med. Sciences, vol. vii. p. 271, 1830; also vol. v. p. 255, idem. BIBLIOGRAPHICAL INDEX. Iv Description of the Circulation of the Head and Neck, in a case in which one Carotid had been tied, by Valentine Mott, M. D. New York. Am. Journ. Med. Sciences, vol. viii. p. 45, 1831. Case of Telangiectasis of Cheek, cured by Ligature of the Common Carotid, by George Bushe, M. D. New York. New York Medico-Chirurgical Bulletin, vol. i. p. 53, 1822. Case of Ligature of the Common Carotid (in a court-room), for Attempted Suicide, by William E. Horner, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. x. p. 403, 1832. Case of Aneurism of the Carotid, treated by Puncture with a Ca- taract-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 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 Surg. Journ., vol. i. p. 125, 1833. Ligature of both Carotid Arteries simultaneously (died in twenty- four hours), by Valentine Mott, M. D. New York. Reported by Dr. Vache. Amer. Journ. Med. Sciences, vol. xiv. p. 530, 1834. Case of Ligation of both Carotids (successful), by R. D. Mussey, M. D. Fairfield, New York. Am. Journ. Med. Sciences, vol. xxi. p. 397, 1837. Case of Gunshot Wound of the Face and Neck; Ligature of Ca- rotid (cured), by Dr. Twitchell, New Hampshire. Am. Journ. Med. Sciences, vol. v. N. S. p. 510, 1843; also New England Quarterly Journal Med. and Surg., Oct. 1842. Case of Subcutaneous Erectile Tumor of Cheek; Ligature of common Carotid Artery (death from phlebitis and pus between meninges of the brain), by A. C. Post, M. D. New York. Am. Journ. Med. Sciences, vol. x. p. 539,1845; also New York Journ. Med., Sept., 1845. Case of Gunshot Wound, Secondary Hemorrhage, Ligature 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. p. 534, 1845 ; also New York Journ. Med., Sept., 1845. lvi BIBLIOGRAPHICAL INDEX. Case of Ligature of the Carotid Artery for Fungous Tumor of the Neck (died), by George C. Blackman, M. D. New York. Am. Journ. Med. Sciences, vol. x. p. 331, 1845. Ligature (successful) of both Carotids (at an interval of near five weeks), for a remarkable Erectile Tumor of the Mouth, Face, and Neck, by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xi. p. 281, 1846. Case of Ligature of Common Carotid for Removal of the Parotid Gland (successful), by A. B. Shipman, M. D. Illinois. Am. Journ. Med. Sciences, vol. xiv. p. 264, 1847. Case of Ligature of the Primitive Carotid Artery (cured), by H. F. Campbell, M. D. Georgia. Am. Journ. Med. Sciences, vol. xiv. p. 542, 1847; also Southern Med. and Surg. Journ., August, 1847. Case of Ligature 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. Sciences, vol. xiv. N. S. p. 13, 1847. Ligature of both Primitive Carotids (successful), by George C. Blackman, M. D. Am. Journ. Med. Sciences, vol. xv. p. 357, 1848. Statistics of Large Surgical Operations (performed in private practice), by Usher Parsons, M. D. Rhode Island. Am. Journ. Med. Sciences, vol. xv. p. 359, 1848. Case of Ligature of the Common Carotid (in two cases, both died), by John P. Mettauer, M. D. Virginia. Am. Journ. Med. Sciences, vol. xviii. p. 348, 1849. Case of Wound of the External Carotid—Ligature to Common Carotid (result unknown), by E. Geddings, M. D. Charleston. Am. Journ. Med. Sciences, vol. xviii. p. 550, 1849. Case of Ligature of the Primitive Carotid Artery, below the Omo- Hyoid Muscle (cured), by George Fox, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xviii. 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. Charleston Med. Journ., vol. iv. p. 585, 1849. BIBLIOGRAPHICAL INDEX. lvii Case of Ligature of the Principal Carotid (successful), by Paul F. Eve, M. D. Georgia. Southern Med. and Surg. Journ., vol. vi. p. 210, 1850. ON LIGATURE OF THE SUBCLAVIAN AND AXILLARY ARTERIES. Observations relative to the Ligature of the Subclavian Artery, by Joseph Parrish, M. D. Philadelphia. Eclectic Repert. and Analyt. Review, vol. iii. p. 229, 1813. Ligature 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 Clavicle, by Wright Post, M. D. New York. Transact. Phys. Med. Society of New York, vol. i. p. 387, 1817. Remarkable Spontaneous Cure of Aneurism, with Observations on Obliteration of Arteries, by William Darrach, M. D. Philadelphia. Phil. Med. and Phys. Journ., vol. xiii. p. 115, 1826. Case of Axillary Aneurism (from the reduction 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 Liga- ture to the Subclavian 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. Case of Axillary Aneurism, in which the Subclavian was success- fully secured by a Ligature, by Valentine Mott, 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. Sciences, vol. xii. p. 354, 1833. Case of Ligature of the Left Subclavian (successfully performed), by Valentine Mott, M. D. New York. Am. Journ. Med. Sciences, vol. xiv. p. 530, 1834. Case of successful Ligature of the Subclavian, by G. H. White, M. D. Hudson, N. Y. Am. Journ. Med. Sciences, vol. xxiii. p. 351, 1839. lviii BIBLIOGRAPHICAL INDEX. Case of Axillary Aneurism—Ligature of the Subclavian (above the Clavicle), death on the thirty-first day, by S. D. Gross, M. D. Louisville. Am. Journ. Med. Sciences, vol. ii. N. S. p. 517, 1841. Case of Wound of the Axillary Artery and Plexus of Nerves, Amputation below the Shoulder, Secondary Hemorrhage, Ligature of the Subclavian (successful), by Alfred C. Post, M. D. New York. Am. Journ. Med. Sciences, N. S. vol. x. p. 263, 1845 ; 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. Philadelphia. Am. Journ. Med. Sciences, vol. x. N. S. p. 13, 1845. Case of Ligature of the Subclavian Artery, between the Scaleni, attended with some Peculiar Circumstances (cured), by John C. War- ren, M. D. Boston. Am. Journ. Med. Sciences, vol. xi. p. 539,1846; also Med. Times, Dec. 6th, 1845. Case of Ligature of the Left Subclavian within the Scaleni Mus- cles (died), by J. Kearney Rodgers, M. D. New York. Am. Journ. Med. Sciences, vol. xi. p. 541, 1846; also New York Journ. of Med., March, 1846. Case of Ligature of the Left Subclavian Artery, for Subclavian Aneurism (cured), Ligature remaining Ninety-six Days, with a Re- markable Deviation of the Vessel and Consequent Change of its Relations, by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xvii. p. 13, 1849. Notice of the Anatomical Phenomena, in a case of Ligature of the Subclavian Artery, four years subsequent to the Operation (showing collateral circulation, &c), by F. S. Ainsworth, M. D. Boston. Am. Journ. Med. Sciences, vol. xix. p. 83, 1850. ON REMOVAL OF THE CLAVICLE. An Account of a Case of Osteo-Sarcoma of the Left Clavicle, in which Exsection of that Bone was successfully performed by Valen- tine Mott, M. D. New York. Am. Journ. Med. Sciences, vol. iii. p. 100, 1828. BIBLIOGRAPHICAL INDEX. lix Case of Removal of the Clavicle in a State of Osteo-Sarcoma (died on the fourth week), by John C. Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xiii. p. 17, 1833. OPERATIONS ON THE BREAST. On Cancer of the Breast, by Joseph Parrish, M. D. Philadelphia. North Amer. Med. and Surg. Journ., vol. vi. p. 293, 1828. History of a Case of Sarcomatous Tumour of the Mamma, extir- pated, by N. Hitt, M. D. Vincennes, Indiana. Transylvania Journ. of Med., vol. iv. p. 508, 1831. Case of Cancerous Breast, with partial Ossification of that Organ, by John Maclellan, M. D. Greencastle. Am. Journ. Med. Sciences, vol. xiii. p. 277, 1833. 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. xii. 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. Sciences, vol. xvii. p. 22, 1849. Statistics of twelve Cases of Fungus Haematodes of the Face, Trunk, Mamma, and Extremities, in which seven were operated upon, and five benefited probably, by Paul F. Eve, M. D. Georgia. Southern Med. and Surg. Journ., vol. vi. p. 577, 1850. OPERATIONS ON THE CHEST. Case of Extensive Caries of the Fifth and Sixth Ribs, and Disor- ganization of the greater part (about two pounds) of the Right Lung, with a Description of the Operation for the same (being its removal, patient living several months subsequently), by Milton Antony, M. D. Augusta, Georgia. (With a Certificate from John Pugsley, M. D., of Jefferson County, Georgia.) Phila. Journal Med. and Phys. Sciences, vol. vi. p. 108, 1823. Ix BIBLIOGRAPHICAL INDEX. 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, New York. Med. Record, vol. viii. p. 236, 1825. On the Pathology of Bones, with a Case of successful Removal of Carious Ribs, by H. McDowall, M. D. Fincastle, Virginia. Med. Record, 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. 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 McClellan, M. D. Philadelphia. Western Journ. of the Med. and Phys. Sciences, vol. iv. p. 479, 1831; also A Report, by J. II. B. McClellan, M. D., Med. Examiner, vol. vi. N. S. p. 75, 1850. Two Cases of Excision of the Ribs, successful, by John C. War- ren, M. D. Boston. Boston Med. Journ., vol. xvi. p. 201, 1837. ON EMPYEMA. Operation for Empyema—Excision of a Piece of the Lung, as large as a Nutmeg (cured), by Isaac Rand, Esq., Vice-President of the Massachusetts Medical Society. 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., of Swanton, Vermont. New York Med. Repository, vol. xx. p. 36, 1820. Case of Paracentesis Thoracis, Life prolonged, by Lemuel W. Briggs, M. D. Bristol, Rhode Island. New England Journ. of Med. and Surg., vol. ix. p. 223, 1820. Case of Empyema successfully treated by Paracentesis Thoracis, by Dr. Craven, of Harrisonburg, Virginia. Med. Record., vol. vii. p. 363, 1824. Case of Effusion into the Chest, in which Paracentesis Thoracis was performed (died), by Samuel Jackson, M. D. Philadelphia. Phil. Journ. Med. and Phys. Sciences, vol. x. p. 119, 1825. BIBLIOGRAPHICAL INDEX. lxi Case of Empyema (cured by Paracentesis), by A. S. Sheldon, M. D. Broome County, New York. Med. Record., vol. ix. p. 273, 1826. History of a Case of Empyema, from protracted Measles and Pleurisy, in which the Operation of Paracentesis gave immediate Relief, by Samuel Merriwether, M. D. Indiana. Western Journ. of Med. and Phys. Sciences, vol. iii. p. 65, 1830. Paracentesis, successfully performed, for Empyema, by Dr. Wol- fley. Lancaster, 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 (Para- centesis 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. Sciences, vol. ix. N. S. p. 342, 1845. Case of Empyema in which Paracentesis Thoracis failed from a cause not generally noticed (a membrane, lining the Pleura Costalis, being pushed before the instrument, and not opened), by John A. Swett, M. D. New York. Am. Journ. Med. Sciences, vol. xiii. p. 518, 1847 ; also New York Journ. of Med., January, 1847. ON OPERATIONS ON THE ABDOMEN. Experiments, to show that the Inflammation which supervenes on the Surface of Wounded Cavities is the Consequence of the Change and Diminution of Temperature caused by the Admission of Air into them, by James Cocke, M. D. (Thesis.) Maryland, 1804. Amer. Med. Record., vol. ii. p. 489, 1819. Case of Incision of the Intestines, and Removal of a Silver Tea- spoon which had been swallowed (cured), by Samuel White, M. D. Hudson, New York. New York Med. Repository, vol. x. p. 367, 1807. A Remarkable Case of Encysted Dropsy and Paracentesis Abdo- lxii BIBLIOGRAPHICAL INDEX. minis (635 pounds being drawn off in eleven months), by Dr. Amos Holbrook. Milton, Massachusetts. Med. Communications and Dissertations of Mass. Med. Soc, vol. ii. p. 29, Boston, 1813. Case of Evacuation of Water from the Abdomen by the Umbili- cus (with a proposal to tap at that point), by Samuel Agnew, M. D. Harrisburg. Philadelphia Med. Museum, vol. i. N. S. p. 159, 1811. Case of a Scirrhous Tumor of the Caecum, mistaken for an Aneu- rism of the Right External Iliac Artery, by Theophilus E. Beezley, M. D. Salem, New Jersey. Phil. Journ. Med. and Phys. Science, vol. vi. p. 350, 1823. Wound of the Stomach (St. Martin), by Joseph Lovell, Surgeon- General U. S. A. Med. Record., vol. viii. p. 14, 1825. Experiments on Digestion (St. Martin), through a Wound in the Stomach, by William Beaumont, M. D. Fort Niagara. Med. Record., 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 Abdomen and Section of the Intestinal Canal, successfully treated on the plan of Ramdohr, with Remarks, by Zina Pitcher, M. D., U. S. A. Am. Journ. Med. Sciences, vol. x. p. 42, 1832. Notes of a Case of Fistulous Opening of the Stomach, success- fully treated (by Pressure, &c), by J. H. Cook, M. D. Am. Journ. Med. Sciences, vol. xiv. p. 271, 1834. Case of Abscess of the Liver; Operation and Recovery, by Chas. A. Savery, M. D. Hopkinton, N. H. Boston Med. and Surg. Journ., 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, Reco- very of the Patient, by A. Brigham, M. D. Utica. Am. Journ. Med. Sciences, vol. ix. N. S. p. 355, 1845. Case of Gastrotomy (successful), by J. E. Manlove M. D. Ten- nessee. Am. Journ. Med. Sciences, vol. x. N. S. p. 532; also Boston Med. and Surg. Journ., July, 1845. BIBLIOGRAPHICAL INDEX. lxiii Sequel to the Case of Removal of seventeen inches of the Intes- tines, and Recovery of. the Patient, by A. Brigham, 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| gallons of water drawn off, by John H. Griffin, M. D. Virginia. Am. Journ. Med. Sciences, vol. xix. N. S. p. 401,1850. ON HERNIA. Case of Strangulated Crural Hernia, operated on according to the method of Don Antonio Gimbernat, with some Observations on the Treatment of Hernia, by Jno. 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 suc- ceeded after the Obstruction had continued ten days, by John Hahn, M. D. Philadelphia. Philad. Med. Museum, vol. iv. p. 26, 1808. Case of Strangulated Hernia, with Observations on the Treatment of Mortified Omentum, by Joseph Parrish, M. D. Philadelphia. Eclectic Repertory and Analytical Review, vol. i. p. 98, 1811. Practical Elucidation of the Nature of Hernia, &c, with an Ex- planation 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. Journ., vol. iv. p. 435, 1825. Case of Strangulated Umbilical Hernia, cured by an Operation, by T. S. Hewson, M. D. Philadelphia. Med. Record., vol. xi. p. 106, 1827. Cases of Hernia, in which the Stricture remained 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 days before the Operation (treated successfully), by John J. Abernethy, M. D. Hartford, Connecticut. Am. Journ. Med. Sciences, vol. xi. p. 31, 1832. On Congenital Hernia (cured by an Operation), 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. lxiv BIBLIOGRAPHICAL INDEX. A Case of Strangulated Inguinal Hernia successfully treated, by , Hunting Sherrill, M. D. Duchess County, New York. New York Medico-Chirurgical Bulletin, vol. i. p. 20, 1832. Case of Strangulated Umbilical Hernia with Removal of the Cyst, followed by a Radical Cure, by J. W. Heustis, 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. Sciences, vol. xvii. p. 368, 1835. Cases of Hernia (with Remarks), by F. H. Hamilton, M. D. Rochester, New York. Boston Med. and Surg. Journ., vol. xxv. p. 57, 1841. Of a new Knife for dividing the Stricture in Cases of Strangu- lated 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 Strangulated 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 Hernia, by including 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, patient operated on while under the influence of Chloroform (died seven days after the Opera- tion), by James D. Trask, M. D. Whiteplains, New York. Am. Journ. Med. Sciences, vol. xviii. N. S. p. 90,1849. ON ARTIFICIAL ANUS. Case in which a new and peculiar Operation 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. Two Cases illustrative of an Operation for the Cure of Artificial Anus, by John Rhea Barton, M. D. Philadelphia. Med. Record., vol. vii. p. 356, 1824. Singular Case of Artificial Anus, successfully treated by George W. Campbell, M.D. Tennessee. Transylvania Journ. of Med., vol. ii. p. 425, 1829. BIBLIOGRAPHICAL INDEX. lxv Account of a successful Operation for Artificial Anus, accom- plished by the Aid of a Novel Instrument, and performed by J. R. Lotz, M. D. New Berlin, Pennsylvania. With Observations on the Apparatus, &c, by Reynell Coates, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xviii. p. 367, 1836. Case of Artificial Anus (at the 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. M. 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. Bush, M. D. Lexington, Kentucky. Am. Journ. Med. Sciences, vol. xix. N. S. p. 275, 1850. ON LIGATURE OF THE ILIAC ARTERIES. LIGATURE OF THE EXTERNAL ILIAC ARTERY. Ligature of the External Iliac Artery (cured), by John Syng Dorsey, M. D. Philadelphia, August, 1811. (This was the first successful operation reported in the United States.) Eclec. Repert. and Analyt. Review, vol. ii. p. Ill, 1811 ; also New England Journ. of Med. and Surg., vol. i. p. 66, 1812. Case of Aneurism of the Femoral Artery (successful), by David Hosack, M. D. New York. Amer. Med. and Philosophical Register, vol. ii. p. 49, 1811. Case of Ligature of the External Iliac (cured), by Alexander H. Stevens, M. D. New York. New York Med. and Phys. Journ., vol. i. p. 112, 1822. A Case of Inguinal Aneurism (successful ligature) of the External Iliac (by means of Physick's needle), by Wright Post, M. D. New York. Am. Med. and Philosophical Register, vol. iv. p. 443, 1814. Ligature of the External Iliac Artery, by J. B. Whitridge, M. D. Sackett's Harbor. New England Journ. of Med. and Surg., vol. iv. p. 318, 1815. Case of Ligature of the External Iliac (cured), by John C. War- ren, M. D. Boston. New England Journ. of Med. and Surg., vol. xii. p. 225,1823. lxvi BIBLIOGRAPHICAL INDEX. Case of Ligature of the External Iliac for Inguinal Aneurism (cured), by Nathan Smith, M. D., of Yale College. Philadelphia Journ. of Med. and Phys. Sciences, vol. i. p. 415, 1820. Ligature of the External Iliac, by 11. G. Jameson, M. D. Balti- more. Med. Recorder, vol. v. p. 118, 1822. Case of Inguinal Aneurism (in which an Empiric plunged a lancet), reported by John Rhea Barton, M. D. Philadelphia. Philadelphia Journ. of Med. and Phys. Sciences, vol. i. N. S. p. 127, 1825. Ligature of the External Iliac (cured), by David L. Rogers, M. D. New York. Communicated by P. Cadwallader, M. D. Med. Recorder, vol. ix. p. 269, 1826. Case of Aneurism of the External Iliac Artery, treated success- fully by tying up the Vessel, by J. Randolph, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. iii. p. 489, 1829; also North Amer. Med. and Surg. Journ., vol. vii. p. 206, 1829. 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, Ligature 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 successfully tied, by William H. Ruan, M. D. St. Croix, West Indies. Am. Journ. Med. Sciences, vol. xviii. p. 43, 1836. Case of Ligature of the External Iliac Artery for Aneurism (cured), by J. M. Boling, M. D. Alabama. Am. Journ. Med. Sciences, vol. vii. N. S. p. 359, 1844. Case of true Inguinal Aneurism ; attempt at Manual Compression of the External Iliac; subsequent Ligature (cured), by William H. Van Buren, M. D. New York. New York Journ. of Medicine, vol. ii. N.S. p. 168, 1849; also Am. Journ. Med. Sciences, vol. xvii. N. S. p. 540, 1849. Case of Inguinal Aneurism, Ligature of the External Iliac (cured), by George Fox, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xviii. N. S. p. 377, 1849. Case of Ligature of the External Iliac (patient died), by Dr. Sted- man. Reported by S. Parkman, M. D. Boston. Am. Journ. Med. Sciences, vol. xix. N. S. p. 73, 1850. BIBLIOGRAPHICAL INDEX. lxvii ON LIGATURE OF THE COMMON ILIAC ARTERY. 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. Med. Record., vol. iii. p. 185,1820. Case of Ligature of the Common Iliac at its origin (cured), by Valentine Mott, M. D. Philadelphia Journ. of Med. and Phys. Sciences, vol. xiv. p. 176, 1827. Case of Ligature of Right Common Iliac Artery in a child six weeks old (died), by George Bushe, M. D. New York. New York Medico-Chirurg. Bulletin, vol. i. p. 55, 1832. Case of Ligature of the Primitive Iliac (cured). The Ligature came away on the thirty-fifth day, by Edward Peace, M. D. Phila- delphia. Med. Examiner, vol. i. N. S. p. 645,1842 ; also Am. Journ. Med. Sciences, vol. iv. N. S. p. 250, 1842. Case of Ligature of the Internal Iliac Artery for a Traumatic Aneurism of the Gluteal (died), by H. J. Bigelow, M. D. Boston. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 29, 1849. Case of Ligature of the Internal Iliac Artery (died), by Gilman Kimball, M. D. Lowell, Massachusetts. Am. Journ. Med. Sciences, vol. xx. N. S. p. 92, 1850. OPERATIONS ON THE BACK. Gunshot Wound, ball lodged in the posterior part of the Neck, and subsequently discharged by stool, by William Hening, M. D., late Surgeon U. S. A. Eclectic Repert. and Analyt. Review, vol. vii. p. 246, 1817. Case of Steatomatous Tumor, weighing twenty-five pounds, re- moved from the upper part of the Back, by J. S. Dorsey, M. D. The circumference of the neck, or narrowest part of the tumor, two feet ten inches. Thickest part vertically, three feet nine inches. " horizontally, three feet one inch and a half. " of waist, after removal of tumor, two feet nine inches. Am. Med. Record., vol. i. p. 400, 1819. lxviii BIBLIOGRAPHICAL INDEX. Case of Gunshot Wound, in which Tetanus was controlled by a Caustic Issue to the Spine, by David M. Reese, M. D. Baltimore. Med. Record., vol. viii. p. 548, 1825. Case of Fistula in the Lumbar Region, communicating with the Bladder, by L. Proudfoot, M. D. Am. Journ. Med. Sciences, vol. i. p. 241, 1827. Case in which portions of three Dorsal Vertebrae were removed with partial success, for the relief of Paralysis from Fracture, by Alban G. Smith, M. D. Danville, Kentucky. North American 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. (Communicated 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 patient recovered, by Eli Hurd, M. D. Ni- agara County, New York. Am. Journ. Med. Sciences, vol. x. N. S. p. 531, 1845; also New York Journ. Med., Sept., 1845. 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 Amasa Trowbridge, M. D., of Watertown, New York. Boston Med. and Surg. Journ., vol. i. p. 753, 1829. Case of Spina Bifida, with Remarks (punctured seventy times without bad consequences, but died ultimately of diarrhoea), by Charles Skinner, M. D. North Carolina. 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 New York Journ. of Med. and Collateral Sciences, No. 2. Case of Spina Bifida treated by Injection of Tincture of Iodine, by Daniel Brainard, M. D. Am. Journ. Med. Sciences, vol. xvi. N. S. p. 262, 1848; also III. and Ind. Med. and Surg. Journ., Jan., 1848. BIBLIOGRAPHICAL INDEX. lxix PART IV. PAPERS ON THE GENITO-URINARY ORGANS AND RECTUM. OPERATIONS ON THE PENIS. New Method of performing the Operation of Phymosis, by George Bushe, M. D. New York. New York Medico-Chirurgical Bulletin, vol. i. p. 224, 1832. Induration and Enlargement of the Penis, with a new Mode of Amputating that Organ, by Thomas L. Ogier, M. D. Charleston. Am. Journ. Med. Sciences, vol. xviii. p. 382, 1836. On Amputation of the Penis, by John P. Mettauer, M. D. Vir- ginia. 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 Pharmacy, Jan. 1847. ON AFFECTIONS OF THE MALE URETHRA. Fistula in Perineo, attended with considerable loss of substance,. cured by Lunar Caustic, by Wm. E. Horner, M. D. Philadelphia. Philadelphia Journ. of Med. and Phys. Sciences, vol. ix. p. 141, 1824. Practical Observations on Stricture of the Urethra, by H. G. Jameson, M. D. Baltimore. Amer. Med. Record., vol. xii. p. 329, 1828. Description of an Instrument (with a Plate), for dividing Stric- tures of the Urethra, by E. R. Chew, M. D. Louisiana. North American Med. and Surg. Journ., vol. v. p. 341, 1828. Operations for Artificial Urethra (successful), by Jno. C. Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. ii. p. 321, 1829. E lxx BIBLIOGRAPHICAL INDEX. On Hypospadias (with Cases), by George Bushe, M. D. New York. New York Medico-Chirurgical Bulletin, vol. ii. p. 1, 1832. Practical Observations on those Malformations 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, 1842. A Case of Stricture of the Urethra cured by bougies of bark of the slippery-elm tree, by Wm. Waters, M. D., Maryland. Am. Journ. Med. Sciences, vol. xxv. p. 321, 1839. Employment of G-utta Percha in the treatment of Strictures, by Henry J. Bigelow, M. D. Boston. Boston Medical Journal, vol. xl. p. 0, 1849. OPERATIONS ON THE TESTICLE AND CORD. New Operation (Ligature of Arteries), for Circocele, cured by H. G. Jameson, M. D. Baltimore. Am. Med. Record., 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. 237,1828. Extirpation of the Testes and Penis affected with Cancerous Dis- ease, by J. C. Hall, M. D. Washington. Am. Journ. Med. Sciences, vol. x. p. 395, 1832. On Tubercles of the Testis (Castration, &c), by Henry II. Smith, M.D., Philadelphia. rhila. Med. Ex., vol. iii. p. 360, 1840. Varicocele and Extirpation of the Testis, by F. H. Hamilton, M. D. Rochester, New York. Boston Med. and Surg. Journ., vol. xxv. p. 153, 1841. Treatment of Diseases of the Testicle, by Compression, in No- vember, 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 Watson, M. D. New York. Am. Journ. Med. Sciences, vol. x. N. S. p. 316, 1845. New Operation (Incision and Ligature), for the Radical Cure of BIBLIOGRAPHICAL INDEX. lxxi Varicocele, performed successfully eight times, by S. D. Gross, M. D. Louisville. Am. Journ. Med. Sciences, vol. xvi. N. S. p. 327, 1848. Castration of Enlarged and Irritable Testis, by M. G. Delaney, M.D., U.S.N. Am. Journ. Med. Sciences, vol. xvi. N. S. p. 292, 1848. ON HYDROCELE. Hydrocele treated by Injection, by David Ilosack, M. D. New York. New York Medical Repository, vol. i. p. 419, 1797. (First Journal of its kind in the United States, though the Transactions of the Mass. Med. Society preceded it seven years. Observations on Hydrocele, by B. Winslow Dudley, M. D. Lex- ington. Transylvania Journ. of Med., vol. i. p. 268, 1828. 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 Hayward, M. D. Boston. Boston Med. and Surg. Journ., vol. xix. p. 154, 1839. Case of Sudden Formation of Hydrocele, unconnected with inflam- mation of Tunica Vaginalis—(operation—cure), by Henry H. Smith, M. D., Philadelphia. Am. Journ. of Med. Sciences, vol. xiii. N. S. p. 85, 1847. OPERATIONS ON THE BLADDER. Preternatural Retention of Urine in consequence of external in- jury. Bladder tapped above the Pubis. Cured. By James Tha- cher, M. D. Plymouth. Med. Communications and Dissertations of Mass. Med. Society, vol. i. p. 35, 1790. Laceration of the Urethra from a fall on the perineum; retention of urine (Bladder punctured above the Pubis), died, by Thomas F. lxxii BIBLIOGRAPHICAL INDEX. Betton, M. D. Philadelphia. (With Observations by Isaac Hays, M. D.) Am. Journ. Med. Sciences, vol. xix. p. 389, 1836. Paracentesis of the Bladder, through the Perineum, by N. R. Smith, M. D. Baltimore. Am. Journ. Med. Sciences, vol. xxiii. p. 03, 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 Operation, by Gurdon Buck, Jr., M. D. New York. Am. Journ. Med. Sciences, vol. viii. N. S. p. 544, 1844; also Neio York Journ. of Med., Sept. 1844. 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. Transactions of the Philadelphia College of Physicians, vol. i. p. 76,1793. An Inaugural Dissertation on Stone in the Bladder (recommend- ing 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 Calculous Matter, extracted by the Operation of Lithotomy, by Joseph Bossuet, M. D. Hing- ham, Mass. New England Journ. Med. and Surg., vol. vi. p. 135, 1817. 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 Operation, both cured), by Lunsford Pitts Yandell, M. D. Lexington. Transylvania Journ. of Med., vol. i. p. 431, 1828. Description of a Remarkable Urinary Calculus, by R. D. Mussey, M. D. New Hampshire. Am. Journ. Med. Sciences, vol. iv. p. 333, 1829. Case of Lithotomy (Lateral Operation, cured), by Hugh H. To- land, M. D. South Carolina. ^Transylvania Journ. Med., vol. iii. p. 139, 1830. BIBLIOGRAPHICAL INDEX. Ixxiii Cases of Lithotomy (Lateral Operation, cured), in which the Stones were dependent on the presence of a spicula of bone in the bladder, by George W. Campbell, 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. Am. Journ. Med. Sciences, vol. ix. p. 537, 1831. Case of Stone, in which the Fundus of the Bladder was coated with Calculous Incrustations, 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 Instru- ments recommended for this Operation), by George Bushe, M. D. New York. New York Medico-Chirurgical Bulletin, vol. i. p. 1, 1832. Lithotomy and extraction of a calculus, measuring nearly twelve inches in circumference, and weighing upwards of seventeen ounces avoirdupois (death, fifth day), by Valentine Mott, M. D. New York. Am. Journ. Med. Sciences, vol. xiv. p. 530, 1834. Supplementary Observations on Lithotomy, with a description of the instruments employed, &c, by N. R. Smith, M. D., Baltimore. Bait. Med. and Surg. Journ., vol. ii. p. 13, 1834. Case of Lithotomy in which the healing process was interrupted by the supervention of an Eruptive Disease, by Jno. P. Mettauer, M. D. Virginia. Boston Med. and Surg. Journ., vol. xii. p. 283, 1835. Observations on the Operation of Lithotomy, illustrated by cases from the practice of Professor B. W. Dudley, by James M. Bush, M. D. Lexington. Am. Journ. Med. Sciences, vol. xxi. p. 535, 1837 ; also Trans, of Med. vol. x. p. 478, 1837. Case of Urinary Calculus in a Girl, successfully removed by Li- thotomy, by T. D. Mutter, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xxi. p. 260, 1837. Lectures on Lithotomy, with an Account of the Bi-lateral Opera- tion, by Alexander H. Stevens, M. D. New York. New York Journ. Med., vol. xi. p. 104, 1838. Remarks on the Propriety and best manner of breaking and ex- lxxiv BIBLIOGRAPHICAL INDEX. tracting 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. Med. Sciences, vol. vii. N. S. p. 504, 1844. On the Bi-lateral Operation for Lithotomy, and on Lithotrity in the Female, by John 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.) Philad. Med. Examiner, November, vol. i. N. S. p. 648, 1845. Lithotomy and Lithotrity (with an Account of Dr. Dudley's Ope- rations), by J. M. Bush, M. D. Lexington, Kentucky. Am. Journ. Med. Sciences, vol. xi. N. S. p. 545, 1846; also Western Lancet, January, 1846. Bi-lateral Operation in Lithotomy, by R. D. Mussey, M. D. Cin- cinnati. Am. Journ. Med. Sciences, vol. xi. N. S. p. 264, 1846. Case of Lithotomy in the Female, with remarks by A. Baker, Jr., M. D. Chenango County, New York. Transactions of Med. Society, Slate of New York, vol. vi. p. 133, 1846. Extraordinary Case of Urinary Calculi, two hundred and twenty- eight in number, 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 months old; patient under influence of Chloroform (cured), by F. H. Hamilton, M. D. Buffalo Med. Journ., vol. iv. p. 735, 1849. Lithotomy in an Adult under the influence of Chloroform (death in two weeks from Purulent Absorption), by F. H. Hamilton, M. D. Buffalo Med. Journ., vol. iv. p. 736, 1849. Lithotomy (Bi-lateral Operation), in a Boy ten years old; Calcu- lus weighing 3xxv; attacked with Dysentery ninth day (died), by Paul F. Eve, M. D. Southern Med. and Surg. Journ., vol. v. p. 596, 1849. Case of Lithotomy in a Child (four years old, cut by the Bi-lateral Section), Anaesthesia (Ether), died forty-five hours after the opera- tion, by James R. Wood, M. D. New York. New York Journ. of Medicine, vol. ii. N.S. p. 326, 1849. Lithotomy, one hundred and seventeen Calculi, weighing four BIBLIOGRAPHICAL INDEX. lxxv and a half ounces, successfully removed by Paul F. Eve, M. D., Georgia. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 539,1849; also Southern Med. and Surg. Journ., March, 1849. Results of fifteen Operations for Lithotomy, by P. G. Spencer, M. D. Petersburgh. Am. Journ. Med. Sciences, vol. xx. p. 103, 1850. Stone in the Bladder, weighing eight ounces;, unpleasant Anchy- losis of the Hip; successful Bi-lateral Operation, by Charles A. Pope, M. D. St. Louis. St. Louis Med. and Surg. Journ., vol. vii. p. 298, 1850; ON LITHOTRIPSY. Lithotripsy, successfully performed by L. Depeyre, M. D., New York. (October, 1830. First successful Case in the United States.) North American Med. and Surg. Journ., vol. xi. p. 492, 1831. Successful Lithotrity, by Alban G. Smith, M. D. Danville, Ken- tucky. North American Med. and Surg. Journ., vol. xii. p. 256, 1831. Lithotrity, successfully performed by P. S. Spencer, M. D. Vir- ginia. Am. Journ. Med. Sciences, vol. xii. p. 554, 1833. Lithotripsy, successfully performed in six Cases, by J. Randolph, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xv. p. 13, 1834. Removal of Calculi from the Urethra, by means of a Wire Loop attached to a Silver Bougie, by A. Leander Uttery, M. D. Provi- dence. Boston Med. and Surg. Journ., vol. xii. p. 237, 1835. Statistical Account of the Cases of Urinary Calculi treated in the Pennsylvania Hospital, 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 Urinary Calculus, in which Dr. J. Randolph successfully performed Lithotripsy, by Isaac Hays, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvii. p. 258, 1835. Sketch of Lithotripsy, with Cases, by William Gibson, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xviii. p. 338, 1836. lxxvi BIBLIOGRAPHICAL INDEX. Seven additional Cases of Stone in the Bladder, successfully treated by Lithotripsy, by J. Randolph, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xix. p. 52, 1836. Report of four additional Cases of Stone in the Bladder, suc- cessfully treated by Lithotripsy, by J. Randolph, M. D. Philadel- phia. Am. Journ. Med. Sciences, vol. xxi. p. 13, 1837. Report of Cases of Lithotripsy, by N. R. Smith, M. D. Balti- more. Am. Journ. Med. Sciences, vol. xxi. p. 25, 1837. Cases of Lithotrity performed by J. Randolph, M. D. Reported by A. 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. Philadelphia Medical Examiner, vol. v. N. S. p. 288,1849. Lithotrity and Lithotomy, with the Use of Ether in those Opera- tions, by J. Mason Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. xviii. p. 47, 1849. Two Cases of Lithotripsy, by the late George McClellan, M. D., in one of which the male b]ade of Heurteloup's instrument broke in the Bladder and was subsequently passed by the Urethra. Reported by J. H. B. McClellan, M. D. Philadelphia. Philadelphia Med. Examiner, vol. v. N. S. p. 513, 1849. Removal of three inches of a Gum Elastic Catheter by means of Heurteloup's Instrument, by J. H. Dillson, M. D. Pittsburg. Am. Journ. Med. Sciences, vol. xx. p. 268, 1850. ON THE EXTERNAL ORGANS OF THE FEMALE. Case of Fistulous Communication between the Vagina, Bladder, and Rectum, by Charles Byrne, M. D., U. S. Army. Am. Journ. Med. Sciences, vol. vi. p. 70, 1830. Observations on Sanguineous Tumors of the Vagina, by Hugh H. Toland, M. D. South Carolina. Transylvania Journ. Med., vol. vii. p. 204, 1834. Case of Medullary Sarcoma of the Labia, &c, by A. B. Ship- man, M. D. New York. Am. Journ. Med. Sciences, vol. v. N. S. p. 368, 1843. BIBLIOGRAPHICAL INDEX. lxxvii On Occlusion of the Vagina (operation by incision and dilatation, relieved), by IT. J. Holmes, M. D. Miss. Ohio Med. and Surg. Journ., vol. ii. p. 540, 1850. A Case of Imperforate Hymen, by William Shultice, M. D. Vir- ginia. Am. Journ. Med. Sciences, vol. vii. N. S. p. 243, 1844. Case of Imperforate Hymen, by John G. Metcalf, M. D. Mas- sachusetts. Am. Journ. Med. Sciences, vol. xii. N. S. p. 139, 1846. Vaginal Hysterotomy and subsequent delivery with the Forceps, with safety to both Mother and Child, by G. S. Bedford, M. D. New York. Am. Journ. Med. Sciences, vol. xv. N. S. p. 348, 1848. A previous successful Case of the same. New York Journal of Medicine, March, 1843. Vaginal Hysterotomy (successful to Mother), by John H. Griffin, M. D. Virginia. Am. Journ. Med. Sciences, vol. xvii. p. 94, 1849. OPERATIONS ON THE FEMALE PERINEUM. Parturient Laceration of the Recto-Vaginal Septum, successfully treated with Metallic Ligatures, by John P. Mettauer, M. D. Vir- ginia. Am. Journ. Med. Sciences, vol. xiii. p. 113, 1833. Extirpation of the Os Coccygis for Neuralgia, by J. C. Nott, M. D. Mobile. Am. Journ. Med. Sciences, vol. viii. p. 544, 1844. Hints on the Treatment of Lacerated Perineum, by William E. Horner, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xx. p. 329,1850. OPERATIONS ON THE VAGINA. Non-Existence 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 Ope- ration, by George Hayward, M. D. Boston. (Numerous others since published in Pamphlet form, from Boston Journal, 1851.) Am. Journ. Med. Sciences, vol. xxiv. p. 283, 1839. lxxviii BIBLIOGRAPHICAL INDEX. Recto-Vaginal Fistula (cured), by J. Rhea Barton, M. D., Phila. Am. Journ. of Med. Sn'cuces, vol. i. N. S. p. 305, 1840. On Vesico-Vaginal Fistula, by John P. Mettauer, M. D. Vir- ginia. Am. Journ. Med. Sciences, vol. xiv. N. S. p. 117, 1847. Vesico-Vaginal Fistula, treated by the ordinary Hare-lip Opera- tion (relieved), by Henry II. Smith, M. D. Philadelphia. Philadelphia Med. Examiner, vol. v. N. S. p. 155, 1849. Case of Imperforate Vagina and Malformation of the Superior Portion. Operation (cure), by A. B. Shipman, M. D. Indiana. Am. Journ. Med. Sciences, vol. xviii. p. 401, 1849. OPERATIONS UPON THE UTERUS. Amputation of the Cervix Uteri for Scirrhus (died), by II. G. Jameson, M. D. Baltimore. Am. Medical Record, 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. Sciences, vol. v. p. 307, 1829. Extirpation of Cancer of the Uterus (died sixth day), bj John C. Warren, M. D. Boston. Am. Journ. Med. Sciences, vol. iv. p. 536, 1829. Complete Extirpation of the Uterus by Ligature after Chronic Inversion of the Organ (successful), by John M. Esselman, M. D. Nashville. Am. Journ. Med. Sciences, vol. vii. N. S. p. 254, 1844. Amputation of the Neck of the Uterus, by N. J. McL. Moore, M. D. New Hampshire. Boston Med. and Surg. Journ., Dec. vol. xxxvii. p. 397, 1847. Excision of the Cervix Uteri for Carcinomatous Disease (died), by Washington L. Atlee, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvi. p. 86, 1848. Case of Excision of the Uterus (died three months after the ope- ration), by Paul F. Eve, M. D. Georgia. Am. Journ. Med. Sciences, vol. xx. N. S. p. 395, 1850. BIBLIOGRAPHICAL INDEX. lxxix ON POLYPUS UTERI. Cases of Uterine Polypus treated by Ligatures, by Thomas Chad- bourn, M. D. New York. Boston Med. and Surg. Journ., vol. xxi. p. 289, 1839. Polypus Uteri, removed by Excision, by C. R. Gilman, M. D. New York. Am. Journ. Med. Sciences, vol. ii. N. S. p. 519, 1841. Cases of Uterine Polypus (new Instrument for Ligature), by John V. P. Quackenbush, M. D. Albany. Am. Journ. Med. Sciences, vol. vii. N. S. p. 241, 1844. Polypus and Inversion of Uterus; Ligature, Excision of a large portion of the Uterus (recovery), by A. L. Peirson, M. D. Salem, Mass. Am. Jottrn. Med. Sciences, vol. xvii. p. 339, 1849. Case of Polypus Uteri, successfully removed by Ligature, by S. B. Philips, M. D. New York. New York Journ. Med. and Collateral Sciences, vol. iv. N. S. p. 199, 1850. OPERATIONS ON THE UTERUS AND OVARY; GASTROTOMY. Three Cases of Extirpation of the Ovaria, successfully performed, by Ephraim McDowell, M. D. Danville, Kentucky, 1809. (The first time in America, and the second ever performed.) Eclectic Repert. and Analyt. Reviev), vol. vii. p. 242, 1817. 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 removed by an Incision through the Abdomen, by Nathan Smith, M. D. Yale College. Am. Medical Recorder, vol. v. p. 124, 1822. Account of a Case of successful removal of a Diseased Ovarium, by Alban G. Smith, M. D. Danville, Kentucky. North American Med. and Surg. Journ., vol. i. p. 30, 1826. Case of Ovarian Tumor, successfully extirpated, by David L. Rogers, M. D. New York. New York Med. and Phys. Journ., vol. ii. N. S. p. 285, 1830; also Am. Journ. Med. Sciences, vol. v. p. 549, 1829. lxxx BIBLIOGRAPHICAL INDEX. Uterine Tumor removed by an Operation (died), by Moses Ilib- bard, M. D. New Hampshire. Boston Med. and Surg. Journ., vol. viii. p. 68, 1833. Contributions to Ovarian Pathology, by E. Geddings, M. D., Bal- timore. North Am. Archives, vol. i. p. Ill, 1835. Successful Operation for Ovarian Disease, Adhesion of Wall of Vagina, &c, 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 Dis- eased Ovaria, &c, by John L. Atlee, M. D. Lancaster. Am. Journ. Med. Sciences, vol. vii. N. S. p. 44, 1844. Case of Extirpation of a Fibrous Tumor by the large Peritoneal Section, by Washington L. Atlee, M. D. Pennsylvania. Am. Journ. Med. Sciences, vol. viii. N. S. p. 539, 1844. Case of Congenital Tumor (of the Abdomen) composed of numer- ous Cysts, by Washington 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 Washington L. Atlee, M. D. Lancaster. Am. Journ. Med. Sciences, vol. viii. N. S. p. 43, 1844. Case of successful Extirpation of a Fibrous Tumor from the surface of the Uterus by the large Peritoneal Section, by Washing- ton L. Atlee, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. ix. p. 309, 1845. Case of Extra-Uterine Foetation, Gastrotomy (cure), by Alex- ander H. Stevens, M. D. New York. Am. Journ. Med. Sciences, vol. xii. N. S. p. 279, 1846; also New York Journ. Med., May, 1846. Case of Extirpation of Ovarian Sacs for the cure of Hydrops Ovarii (died), by Joseph A. Gallup, M. D. Vermont. New England Journ. of Med. and Surg., vol. xiv. p. 358, 1825. 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 Daniel Meeker, M. D. In- diana. Boston Med. and Surg. Journ., vol. xxxix. p. 116, 1848. Ovarium, successfully removed, by H. Miller, M. D. Louisville. Am. Journ. Med. Sciences, vol. xvi. N. S. p. 528, 1848. BIBLIOGRAPHICAL INDEX. Ixxxi Ovarian Dropsy cured by the long Abdominal Section in 1701, by Robert Houstoun. Glasgow, Scotland. Reported by Washing- ton L. Atlee, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 534, 1849. Extra-Uterine Fostation, Gastrotomy, successfully performed ten years after Conception, by Alexander H. Stevens, M. D. New York. Am. Journ. Med. Sciences, vol. xii. N. S. p. 279,1846; also New York Journ. of Med., May, 1846. 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. 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. Gastrotomy (for a Uterine Tumor which could not be removed), recovery, by J. Deane, M. D. Greenfield. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 258, 1849; also Boston Med. and Surg. Journ., vol. xxxix. p. 221, 1848. Case of successful Extirpation of an Ovarian Tumor by the large Peritoneal Section, by Washington L. Atlee, M. D. Phila- delphia. Am. Journ. Med. Sciences, vol. xviii. N. S. p. 336, 1849. An Eclectic Essay on the Non-Pediculated Fibro-Scirrhous Tu- mors of the Uterus, by Wm. C. Roberts, M. D. New York. New York Journ. of Medicine, vol. iii. N. S. p. 330, 1849 ; also Ibid., vol. iv. N. S. p. 31, 1850. Solid Ovarian Tumor, extending from the Pubis to the Right Hypochondrium, cured by Incision followed by Suppuration, 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. Transitions of New York Med. Society, vol. viii. p. 201, 1850. Fibrous Tumor of the Left Ovarium successfully removed by the large Abdominal Section, by Wm. H. Van Buren, M. D. New York. Am. Journ. Med. Sciences, vol. xx. N. S. p. 272, 1850. Ixxxii BIBLIOGRAPHICAL INDEX. Two Cases of Ovariotomy (with Statistics), by Washington L. Atlee, M. D. Philadelphia. 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., Sept., 1850. Ovarian Dropsy—removal of the sac (large section) and fatal termination by A. II. Grimshaw, M. D. Delaware. Phila. Med, Ex., vol. vi. N. S. p. 630, 1850. ON THE CESAREAN OPERATION. Caesarean Operation, successfully performed by John L. Rich- mond, M. D. Ohio. (Done without assistance at 1 A. M. with In- struments from a pocket case.) Western Journ. of Med. and Phys. Sciences, vol. iii. p. 485,1830. Observations on the Caesarean Operation (accompanied by an Ac- count of the Operation of Dr. Wm. Gibson), in which both Mother and Child were preserved, by Joseph G. Nancrede, M. D. Phila- delphia. Am. Journ. Med. Sciences, vol. xvi. p. 343, 1835. Case where the Caesarean Section was performed with a fatal ter- mination, by A. Brooke, M. D. Am. Journ. Med. Sciences, vol. xviii. p. 258, 1830. Account of a Case in which the Caesarean Section performed by Professor W. Gibson was a second time successful in saving both Mother and Child, by George Fox, M. D. Am. Journ. Med. Sciences, vol. xxii. p. 13, 1838. Caesarean Section on a Dwarf, by Cyrus Falconer, M. D. Am. Journ. Med. Sciences, vol. vi. N. S. p. 264, 1843; also Western Journ. of Med. and Surg., May, 1843. Caesarean Operation (performed unsuccessfully) by A. B. Ship- man, M. D. Indiana. Am. Journ. Med. Sciences, vol. xviii. p. 122, 1849. Case of Caesarean Section (successful), by Brodie S. Herndon M. D. Virginia. Am. Journ. Med. Sciences, vol. xii. N. S. p. 386, 1846. BIBLIOGRAPHICAL INDEX. lxxxiii ON AFFECTIONS OF THE RECTUM. Fistula in Ano in an Infant, eight months old, cured by Incision, by Felix Pascalis, M. D. New York. Philadelphia Med. Museum, vol. vi. p. 197, 1809. Stricture of Rectum, successfully treated by an operation, by II. G. Jameson, M. D. Baltimore. Am. Med. Record, vol. v. p. 290, 1822. Improved Mode of Operating for Hemorrhoids, by J. C. Rous- seau, M. D. Philadelphia. Am. Medical Record, vol. ix. p. 288, 1825. Fissure of the Rectum, attended with Constriction of the Anus, cured by division of the Sphincter Ani, by Alexander H. Stevens, M. D. New York Med. and Phys. Journ., vol. iv. p. 242, 1825. Case of Prolapsus Ani, in which the entire Rectum was success- fully extirpated, by J. W. Brite, M. D. New Castle, Kentucky. Am. Medical Record, vol. x. p. 311, 1826. Case of Blind Hemorrhoids, cured by Use of Setons, by Ransom M. Collins, M. D. Louisiana. Transylvania Med. Journ., vol. ii. p. 139, 1829. Prolapsus Ani (cured by Ligatures and Needles), by George Hay- ward, M. D. Boston. Boston Med. and Surg. Journ., vol. xix. p. 156, 1838. Callous Stricture of Rectum (died), by Daniel King, M. D. Charlestown, Rhode Island, Sept., 1830. Boston Med. and Surg. Journ., vol. iii. p. 525, 1830. Case of Prolapsus Recti, successfully treated by excision, by J. W. Heustis, M. D. Alabama. Am. Jovrn. Med. Sciences, vol. xi. p. 411, 1832. New Instrument for Fistula in Ano, by T. D. Mutter, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xiv. p. 80, 1834. Remarks on the Pathology and Treatment of Hemorrhoidal Tumors, by N. R. Smith, M. D. Baltimore. North American Archives, vol. ii. p. 10, 1835. Remarks on the Treatment of Hemorrhoids (suggesting a new mode of operating), by Wm. E. Horner, M. D. Philadelphia. Amer. Journ. Med. Sciences, vol. iv. N. S. p. 358, 1842. lxxxiv BIBLIOGRAPHICAL INDEX. On Strictures of the Rectum, by Thomas D. Mutter, M. D., Phi- ladelphia. Philadelphia Med. Examiner, vol. i. N. S. p. 77, 1845. Description of a new Operation for Hemorrhoids, by Amussat, translated by Henry Selden, M. D. Virginia. Am. Journ. Med. Sciences, vol. xi. N. S. p. 346, 1846. Extraction of a Glass Goblet from the Rectum, by W. S. W. Ruschenberger, M. D., U. S. N. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 409, 1849. BIBLIOGRAPHICAL INDEX. lxxxv PART V. PAPERS ON OPERATIONS ON THE EXTREMITIES. GENERAL OPERATIONS ON THE EXTREMITIES. On the Arrest of the Progress of Whitlow, by means of Caustic, by Dr. Perkins. Philadelphia. Am. Medical Record, vol. ii. p. 490, 1819. On the Best Method of Removing Contractions in the Limbs from Burns, by Wm. G. Nice, M. D. Virginia. Am. Medical Record, vol. iii. p. 341, 1820. Hydrops Articuli in the Shoulder, by James Kent Piatt, M. D. Plattsburg. Am. Medical Record, vol. iv. p. 209, 1821. Case in Proof of Efficacy of the Actual Cautery in Deep Sinuses, by N. R. Smith, M. D. Burlington, Vermont. Philadelphia Journ. Med. and Phys. Sciences, vol. vi. p. 128, 1823. Removal of a large indolent Tumor on the Thigh, by the Applica- tion of Caustic, by H. G. Jameson, M. D. Baltimore. Am. Med. Record, vol. vi. p. 59, 1823. An Operation for Inverted Toe-Nail, by John D. Godman, M. D. Philadelphia. Philadelphia Journ. Med. and Phys. Sciences, vol. iii. p. 338, 1826. Traumatic Hemorrhage, illustrated by Experiments on Living Animals, by H. G. Jameson, M. D. Baltimore. Am. Medical Record, vol. xi. p. 3, 1827. Case of Wounded Nerve from Bleeding in the Forearm just be- low the Elbow, cured by Division of the Nerve, by T. Nelson, M. D. New York. New York Med. and Phys. Journ., vol. iii. p. 62, 1824. Cases of Neuralgia or Painful Affections of the Nerves from In- jury, &c, by Jno. C. Warren, M. D. Boston. Boston Med. and Surg. Journ., vol. ii. p. 98, 1829, F lxxxvi BIBLIOGRAPHICAL INDEX. 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 Phys. Journ., vol. ii. N. S. p. 37, 1830. An Inquiry into the Pathology and Treatment of Secondary Ab- scesses, &c, resulting from Injuries and Surgical Operations, by Jno. Watson, M. D. New York. Am. Journ. Med. Sciences, vol. xxi. p. 17, 1837. Abnormal Elongation of the Tibia consequent on extensive Ulcer- ation of the Leg, by Alexander Baron, M. D. South Carolina. North American Archives, vol. ii. p. 290, 1834. 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. Am. Journ. Med. Sciences, vol. xxii. p. 525, 1838. On the Treatment of Varicose Veins, by Henry II. Smith, M. D. Philadelphia. Phila. Med. 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 England Quarterly Journ., July, 1842. On the Pathology and Treatment of Varices, by John Watson, M. D., New York. Am. Journ. of Med. Sciences, vol. v. N. S. p. 36,1843. ON CLUB-FOOT. Report of several Cases of Club-Foot successfully treated by dividing the Tendo-Achillis, by W. Detmold, M. D. New York. Am. Journ. Med. Sciences, vol. xxii. p. 105, 1838; also Phil. Med. Examiner, vol. i. 198, 1838. On Division of the Tendo-Achillis in Club-Foot, by James H. Dickson, M. D. New York. Am. Journ. Med. Sciences, 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. BIBLIOGRAPHICAL INDEX. lxxxvii Case of Talipes Equinus, cured by Stromeyer's Operation, by James H. Dickson, M. D. New York. Am. Journ. Med. Sciences, vol. xxiii. p. 96, 1839. Successful Club-Foot Operations (ten), by A. G. Walton, M. D. Pennsylvania. Am. Journ. Med. Sciences, vol. xxiii. p. 259, 1839. Club-Foot Division of Tendo-Achillis, by Thomas J. Garden, M. D. Virginia. Am. Journ. Med. Sciences, vol. xxiv. p. 257, 1839. Cases of Deformed Feet treated by Mechanical Means alone, with a Description of the Apparatus, by Heber Chase, M. D. Philadel- phia. 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. Med. Sciences, vol. vii. N. S. p. 256, 1844. ON ANEURISMS AND LIGATURE OF ARTERIES IN THE EXTREMITIES. Aneurism of the Thigh, cured by an Operation (two Ligatures), and Use of the Limb preserved, by Thomas Kast, A. M. Boston. Communications and Dissertations of Massachusetts Med. Society, vol. i. p. 96, 1790. Case of Varicose Aneurism at the Bend of the Arm, cured by Ligature of the Brachial Artery, by P. S. Physick, M. D., Phila- delphia. Philadelphia Med. Museum, vol. i. p. 65, 1805. Ligature of the Femoral Artery for a Wound, by John C. War- ren, M. D. Boston. Communications and Dissertations of Massachusetts Med. Society, vol. i. p. 40, 1806. Ligature of the Femoral Artery (cured), by David Hosack, M. D. New York. New York Med. Repository, vol. xii. p. 105, 1809. 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 Ligature 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 lxxxviii BIBLIOGRAPHICAL INDEX. above the Clavicle, by Wright Post, M. D. New York. Commu- nicated by J. C. Bliss, M. D. Transactions of New York Physico-Med. Society, vol. i. p. 367, 1817. Case of Popliteal Aneurism, &c, by Horatio Gates Jameson, M. D. Baltimore. Am. Medical Record, vol. iv. p. 94, 1821. On the Utility of Tying Large Arteries in Preventing Inflamma- tion in Wounds of the principal Joints, with Cases, by David L. Rodgers, M. D. New York. New York Med. and Phys. Journ., vol. iii. p. 453, 1824. Case of Aneurism of the Brachial Artery cured by Compression, by W. B. Fahnestock, M. D. Pennsylvania. Philada. Journ. Med. and Phys. Sciences, vol. ii. N. S. p. 363,1825. Spontaneous Cure of Aneurism, with Observations on the Obli- teration of Arteries, by W. Darrach, M. D. Philadelphia. Philada. Journ. Med. and Phys. Sciences, vol. iv. N. S. p. 115, 1826. Case of Femoral Aneurism of the Left Thigh and Popliteal Aneurism of the Right Leg, successfully treated, by Valentine Mott, M. D. (The Femoral was tied first for Popliteal, and the Ex- ternal Iliac fourteen days subsequently, both successful.) Am. Journ. Med. Sciences, vol. i. p. 483, 1828. Case of Aneurism of the Brachial Artery, cured by Compression, by J. W. Heustis, M. D. Alabama. Am. Journ. Med. Sciences, vol. ix. p. 261, 1831. 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. 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, success- fully treated by Compression after the Ligature had failed, by H. G. Jameson, M. D. Baltimore. Maryland Med. Record, vol. iii. p. 40, 1832. Ligature of the Femoral Artery for Popliteal Aneurism, Hemor- rhage 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., vol. ii. p. 61, 1834. Two Cases of Aneurism (Femoral and Brachial), exhibiting the BIBLIOGRAPHICAL INDEX. lxxxix Necessity of a Ligature both Above and Below the Tumor, by Wm. E. Horner, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. i. N. S. p. 74, 1841. Ligature of the Femoral Artery for Popliteal Aneurism (cured), also of the Brachial (cured), by A. W. Shipman, M. D. New York. Philadelphia Med. Examiner, vol. iv. p. 441, 1841. Inguinal Aneurism, treated successfully by Ligature of the Ex- ternal Iliac, by Edward Peace, M. D. Philadelphia. Philadelphia Med. Examiner, vol. i. N. S. p. 224, 1842. Femoral Aneurism, Ligature of the External Iliac, death on the fifth day, by W. Power, M. D. Baltimore. Am. Journ. Med. Sciences, vol. iv. N. S. p. 511, 1842; also Maryland Med. and Surg. Journ., Sept. 1842. Aneurism of the Femoral Artery, showing the Importance of Ap- plying a Ligature Below as well as Above the Sac, by Wm. E. Hor- ner, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. iv. N. S. p. 332, 1842. Aneurism of the Femoral Artery from Fracture of the Femur, Ligature of the External Iliac Artery (cured), by Daniel Brainard, M. D. St. Louis. Am. Journ. Med. Sciences, vol. vi. N. S. p. 359, 1843. Ligature of the External Iliac Artery for Aneurism of the Femo- ral Artery, cured, by W. M. Boling, M. D. Alabama. Am. Journ. Med. Sciences, vol. vii. N. S. p. 359, 1844. Varicose Aneurism, successfully treated by Pressure, by William Johnston, M. D. New Jersey. Am. Journ. Med. Sciences, vol. xii. N. S. p. 378, 1846. Ligature of the External Iliac Artery (for Aneurism of the Fe- moral, died), by A. J. Wedderburn, M. D. New Orleans. Am. Journ. Med. Sciences, vol. xiii. N. S. p. 249, 1847; also New Orleans Med. and Surg. Journ., Sept. 1846. Table, 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. Ligature of the External Iliac of one side, and soon after of the Femoral of opposite Limb (both successful), by C. Bell Gibson, M. D. Baltimore. Am. Journ. Med. Sciences, vol. xiv. N. S. p. 535, 1847. Popliteal Aneurism, successfully treated by Compression, by J. Knight, M. D. New Haven. Am. Journ. Med. Sciences, vol. xvi. N. S. p. 255, 1848; also Boston Med. and Surg. Journ., vol. xxxviii. p. 293, 1848. XC BIBLIOGRAPHICAL INDEX. 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 Ligature 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. Med., vol. iv. N. S. p. 199, 1850. Ligature of the Femoral Artery for Popliteal Aneurism (success- ful), by Charles A. Pope, M. D. St. Louis. St. Louis Med. and Surg. Journ., vol. vii. p. 292, 1850. ON PSEUDARTHROSIS, &c Fracture of the Os Humeri, in which from False Joint the Cure was effected by means of a Seton, by Philip S. Physick, M. D. Philadelphia. (Operation 18th Dec. 1802.) Medical Repository, vol. vii. p. 122, 1804. Two Cases of Tardy Union in Fractures, cured by Caustic Issues in Integuments, by Joseph Hartshorne, M. D. Philadelphia. Eclectic Repert., vol. iii. p. 114, 1813. Ununited Fracture of the Humerus, cured by Seton, by Robert , Thaxter, M. D. Dorchester. New England Journ. of Med. and Surg., vol. vii. p. 150, 1818. Case of False Joint, treated by the Seton, by Nicholas Worthing- ton, M. D. District of Columbia. Philada. Journ. of Med. and Phys. Sciences, vol. ii. p. 317, 1821. The Seton, successfully applied in Pseudarthrosis of the Forearm, by John Baxter, M. D. New York. Am. Med. Record, vol. vii. p. 30, 1824. Application of Caustic, and Cure of Pseudarthrosis, by John Rhea Barton, M. D. Philadelphia. Am. Med. Record, vol. ix. p. 275, 1826. Ununited Fracture of the Humerus, successfully treated by Re- section after Failure of Seton, by J. Kearney Rogers, M. D. New York. New York Med. and Phys. Journ., vol. vi. p. 521, 1827. Mechanism of Preternatural Joints, and Means of Cure, by Tho- mas T. Hewson, M. D. Philadelphia. North American Med. and Surg. Journ., vol. v. p. 1, 1828. BIBLIOGRAPHICAL INDEX. Xci Ununited Fracture of the Os Humeri, successfully treated by the Injection of a Stimulating Fluid (sol. cupri sulph.)into the Wound, by Isaac Hulse, M. D., U. S. N. Am. Journ. Med. Sciences, vol. xiii. p. 374, 1833. Case of Ununited Fracture, successfully treated by Friction, by Isaac Parrish, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xiv. p. 372, 1834. Pseudarthrosis of both Bones of the Leg, treated by Excision and Caustic, and again by Resection (failed in both instances from Menorrhagia), by Henry H. Smith, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xv. N. S. p. 84, 1848. Ununited Fracture of the Femur (of one year's standing), suc- cessfully treated by Resection, Denudation, and retaining Ends of Bone by means of Wire, by D. Brainard, M. D. Illinois. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 256, 1849. 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. Medical Record, vol. i. p. 365, 1818. Resection of nearly the whole of the Ulna, successfully, by Ro- bert B. Butt, M. D. Virginia. Philada. Journ. Med. and Phys. Science, vol. i. N. S. p. 115, 1825. Successful Extirpation of the Astragalus after Compound Luxa- tion, by Alexander H. Stevens, M. D. New York Med. and Phys. Journ., vol. v. p. 560, 1826. Treatment of Anchylosis of the Hip-Joint by the Formation of an Artificial Joint, a new Operation, devised and executed by John Rhea Barton, M. D. Philadelphia. North American Med. and Surg. Journ., vol. iii. pp. 279, 400, 1827. Successful Removal of the Astragalus in Compound Dislocation, by Wm. A. Gillespie, M. D. Virginia. Am. Journ. Med. Sciences, vol. xii. p. 552, 1833. xcii BIBLIOGRAPHICAL INDEX. A Case of Excision of Elbow-Joint (being the first in the United States), by Thomas Harris, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xix. p. 341, 1836. A new Treatment in a Case of Anchylosis of Knee (a V incision), by J. Rhea Barton, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xxi. p. 322, 1837. Successful Operation to remedy a Deformed Fracture of the Leg, by Charles Parry, M. D. Indiana. Am. Journ. Med. Sciences, vol. xxiv. p. 334, 1839. Case of Excision of the Elbow-Joint, by Gurdon Buck, Jr., M. D. New York. Am. Journ. Med. Sciences, vol. ii. N. S. p. 249, 1841; also New York Med. and Surg. Journ., April, 1841. Case of Complete Anchylosis, in which the Knee-Joint was per- manently 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. Ruschenberger, M. D. 1842. Philadelphia Med. Examiner, vol. i. N. S. p. 17, 1842. Case of False Anchylosis of the Knee-Joint treated by mechanical means alone, without the aid of Tenotomy, with a Description of the Apparatus, by Heber Chase, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. iii. N. S. p. 101, 1842. Excision of the Elbow-Joint (cured), by J. Pancoast, M. D. Philadelphia. Philadelphia Med. Examiner, vol. i. N. S. p. 609, 1842. Excision of the Olecranon Process for Anchylosis of the Elbow- Joint, by Gurdon Buck, Jr., M. D. New York. Am. Journ. Med. Sciences, vol. v. N. S. p. 297, 1843. Anchylosis of the Knee, successfully treated by Barton's Opera- tion, by J. Piatt Burr, M. D. Louisiana. Am. Journ. Med. Sciences, vol. viii. N. S. p. 270, 1844. The Knee-Joint Anchylosed at a Right Angle. Restored nearly to a straight position, after the Excision of a wedge-shaped portion of Bone consisting of the Patella, Condyles, and Articulating Sur- face of the Tibia, by Gurdon Buck, Jr., M. D. New York. Am. Journ. Med. Sciences, vol. x. N. S. p. 277, 1845. BIBLIOGRAPHICAL INDEX. xciii Removal of a Third of the Head of the Humerus, by N. Pink- ney, M.D., U.S.N. Am. Journ. Med. Sciences, vol. xii. N. S. p. 330, 1846. Excision of the Elbow-Joint for Caries of the Articular Extremi- ties of the Bones, by Gurdon Buck, Jr., M. D. New York. Am. Journ. Med. Sciences, vol. xii. N. S. p. 544, 1846. ON AMPUTATIONS. Amputation at the Shoulder, by Jno. Warren, M. D. Boston, 1781. (First in the United States.) Boston Med. and Surg. Journ., vol. xx. p. 210, 1839. Amputation of the Arm at the Shoulder, together with the Acro- mion Process of Scapula for Fungus Hematodes after the Ligation of the Subclavian Artery (died), by Dr. Wm. C. Bowen. Providence. New England Journ. of Med. and Surg., vol. iii. p. 314, 1814. New Tourniquet, by Francis Moore, M. D. Connecticut. New England Journ. of Med. and Surg., vol. iv. p. 209, 1815. Amputation at the Shoulder-Joint (died), by J. B. Whitridge, M. D. South Carolina. New England Journ. of Med. and Surg., vol. v. p. 21, 1816. Amputation of part of the Foot (cured), by George Hayward, M. D. Boston. New England Journ. of Med. and Surg., vol. v. p. 338, 1816. Report of Extraordinary Cases of Amputation, by Amasa Trow- bridge, M. D. Watertown. New York Med. Repository, vol. xix. p. 20, 1819. Case of Fungus Hematodes, Amputated, by George McClellan, M. D. Philadelphia. Am. Med. Record, vol. v. p. 634, 1822. Remarks on Amputation, by Nathan Smith, M. D., of Yale Col- lege. New York Med. and Phys. Journ., vol. iv. p. 303,1825. Successful Amputation at the Hip-Joint, by Valentine Mott, M.D. New York. Philada. Journ. Med. and Phys. Sciences, vol. v. N. S. p. 101,1827. Amputation at the Elbow-Joint (Flap, first in United States), cured, by J. Kearney Rogers, M. D. New York. New York Med. and Phys. Journ., vol. vii. p. 85, 1828. xciv BIBLIOGRAPHICAL INDEX. Case of Encephaloid Degeneration (Fungus Hematodes) of the Knee and Lower Part of the Thigh, in which Amputation was per- formed, by E. Geddings, M. D. Baltimore. 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. Med. Sciences, vol. xiii. p. 370, 1833. Dislocation and Fracture of the Astragalus, Unsuccessful Efforts at Reduction, Extirpation, Amputation (death), by G. W. Norris, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xx. p. 378, 1837. Amputation of the Foot, by G. R. B. Horner, M. D., U. S. N. Am. Journ. Med. Sciences, vol. xxi. p. 255,1837. Statistical Account of the Cases of Amputations performed at the Pennsylvania Hospital from January, 1831, to January, 1838, by George W. Norris, M. D. Philadelphia. Am. Journ. Med. Sciences, vol. xxii. p. 356,1838. Amputation at the Hip-Joint (died in forty-eight days), by Daniel Brainerd, M. D. Illinois. Am. Journ. Med. Sciences, vol. xxii. p. 372, 1838. Amputation at the Shoulder-Joint (died), with a Description of a new Instrument for securing deeply-seated Arteries, by Wm. E. Horner, M. D. Philadelphia. Philadelphia Medical Examiner, vol. iii. p. 540,1840; also Am. Journ. Med. Sciences, vol. i. N. S. p. 266,1841. Case of Gunshot Wound of the Hand, Forearm, and Arm, with a Fracture of the Humerus, successfully treated (without Amputa- tion), by R. W. Lindsay, M. D. District of Columbia. Am. Journ. Med. Sciences, vol. i. N. S. p. 117,1841. Fungus Hematodes of the Knee, Amputation (cured), by Henry L. Levert, M. D. Mobile. Am. Journ. Med. Sciences, vol. vi. N. S. p. 56,1843. Amputation at the Shoulder-Joint, byN. Pinkney, M.D., U.S.N. Am. Journ. Med. Sciences, vol. xii. N. S. p. 332,1846. Amputation of the Foot, excessive Hemorrhage from the Stump (over forty Ligatures applied), by J. C. Butler, M. D. Virginia. Am. Journ. Med. 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. BIBLIOGRAPHICAL INDEX. XCV Statistics of Amputations in the New York Hospital, from January 1, 1839, to January 1, 1848 (ninety-one cases, twenty-six deaths), by Henry W. Buel, M. D. New York. Am. Journ. Med. Sciences, vol. xvi. N. S. p. 33, 1848. Successful Amputation of the Shoulder-Joint, patient under Chlo- roform, by Paul F. Eve, M. D. Georgia. Am. Journ. Med. Sciences, vol. xvii. N. S. p. 257, 1849. Also, Buffalo Medical Journal, vol. v. 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 Medical Journal, vol.iv. p. 301, 1849. Case of Secondary Hemorrhage after Amputation at the Shoulder- Joint (cured by Pressure), by Charles S. Tripler, M. D., U. S. A. New York Journ. of Med., vol. iii. p. 40, 1849. Amputations and Compound Fractures, with Statistics, by John 0. Stone, M. D. New York. New York Journ. of Med., N. S. vol. iii. 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 sustained Fifteen Years previously, by Wm. Byrd Page, M. D. Philadelphia. Philadelphia Med. Examiner, vol. v. N. S. p. 451, 1849. Amputation of the Thigh, successful. Leg, Thigh, cured in two weeks, by Paul F. Eve, M. D. Georgia. Southern Med. and Surg. Journ., vol. vi. pp. 261, 264, 1850. ALPHABETICAL LIST OF AMERICAN SURGEONS, WITH THE TITLES OF THEIR PAPERS AS QUOTED IN THE BIBLIOGRAPHICAL INDEX. The difference that may be noted in the variety of papers assigned to the Surgeons quoted in the preceding Index must not be regarded as indicating the entire number of their publications, but only the fact that their articles were so published as to be accessible to the Author. ABERNETHY, JOHN J. (Con- necticut.) Case of Inguinal Hernia lxiii AGNEW, SAM'L. (Harrisburg.) Evacuation of Water, by the Um- bilicus lxii AINSWORTH, F. S. (Boston). Anatomical Phenomena in Liga- ture of Subclavian Artery Iviii ALLEN, JONATHAN A. (Ver- mont.) Excision of Fungus Cerebri xxxi ANDERSON, W. W. (Charles- ton.) Osteo-Sarcoma of Lower Jaw xxxix ANDERSON, "WM. (New York.) System of Surgical Anatomy xviii ANNAN, S. (Emmetsburg.) Three Cases of Bronchotomy 1 ANTONY, MILTON. (Georgia.) Removal of part of Right Lung, &o. lix ATLEE, E. (Lancaster.) Tracheotomy in Cynanche Tra- chealis li ATLEE, JOHN L. (Lancaster.) Operation for Diseased Ovaria ATLEE, WASH. L. (Lancaster.) Excision of Cervix Uteri lxxviii Extirpation of Fibrous Tumor lxxx * Case of Congenital Tumor of Abdomen ib. Bi-locular Ovarian Cyst ib. Removal of Tumor from Uterus ib. Extirpation of Ovarian Tumor lxxxi Two Cases of Ovariotomy lxxxii B BACHE, FRANKLIN. DELPHIA.) On Acupuncturation (Phila- xxxiv xxxv BAKER, Jr. A. (New York.) Lithotomy in the Female lxxiv BARNES, ENOS. (New York.) Foreign Bodies in the Trachea 1 BARNWELL, WM. (Philadel- phia.) Diseases of Warm and Vitiated Atmosphere xvii BARON, ALEX. (South Caro- lina.) Elongation of Tibia Ixxxvi BARTON, BENJ. S. (Philadel- phia.) Memoir on Goitre xvii xcviii ALPHABETICAL LIST OF PAGE BARTON, JOHN RHEA. (Phil- adelphia.) Artificial Joint in Anchylosis xix Operation for Tumor of Lower Jaw xxxix Operation for Artificial Anus lxiv Inguinal Aneurism lxvi Recto-Vaginal Fistula _ lxxviii Caustic in Pseudarthrosis xc Treatment of Anchylosis of Hip xci " " Knee xcii Deformity from Fracture of Leg ib. BATCHELDER, Dr. Osteo-Sarcoma of Lower Jaw xl BAXTER, JOHN. (New York.) Seton in Pseudarthrosis xc BAYARD, ROBERT. Brunswick.) Diseased Sciatic Nerve (New Ixxxvi BEAUMONT, WM. (Fort Ni- agara.) Experiments on Digestion, through a Wound in Stomach lxii BEDFORD, G. S. (New York.) Vaginal Hysterotomy lxxvii Sarcomatous Tumor of Uterus lxxxi BELL, JOHN. (Philadelphia.) Averill's Operative Surgery xviii BENNETT, E. S. (Charleston.) Tumor on Occiput xxix BENNETT, E. P. (Connecticut.) Ligature of Femoral Artery xc BETHUNE, S. R. (Boston.) Malignant Ophthalmic Disease xxxiv BETTON, THOS. F. (Philadel- phia.) Lacerated Urethra from a Fall lxxi BEEZLEY, THEOPHILUS E. (New Jersey.) Scirrhous Tumor of Caecum lxii BIGELOW, HENRY J. (Bos- ton.) Manual of Orthopedic Surgery xxii Gutta Percha in Strictures lxx Ligature of Internal Iliac lxvii BLACKMAN, GEO. C. (New York.) Genio-plasty xii Ligature of Carotid ^ lvi " both Primitive Caro- tids ib. Osteo-Sarcoma of Lower Jaw xl BOLING, WM. M. (Alabama.) Ligature of External Iliac Ixxxix BOND, HENRY. (Philadel- phia.) Forceps for Bodies in Oesopha- gus xlix BOSSUET, JOSEPH. (Massa- chusetts.) Lithotomy for Extra-Uterine Foetus lxxii BOWDITCH, HENRY J. (Bos- ton.) Maunoir on Cataract xx BOWEN, WM. C. (Providence.) Amputation for Fungus Hema- todes xciii BRAINARD, DANL. (Chicago.) Plastic Operation for Ectropion xxxii Amputation of Super-maxillary, &c. xxxvii Collodion in Erectile Tumors xxviii Immobility of Lower Jaw xxxviii Iodine in Spina Bifida lxviii Ununited Fracture of Femur xci Amputation at Hip-Joint xciv Aneurism of Femoral Artery Ixxxix BRENT, JOHN C. (Kentucky.) Removal of Tumor from Neck Iii BRIGGS, LEMUEL W. (Rhode Island.) Paracentesis Thoracis lx BRIGHAM, AMARIAH. (Con- necticut.) Brass Nail in Lungs for a year li Removal of seventeen inches of Intestine lxii Sequel to do. do. lxiii BRITE, J. W. ^ (Kentucky.) Prolapsus Ani lxxxiii Extraction of Fish-Hook from Stomach xlviii BROOKE, A. On Caesarian Section lxxxii BROWN, J. B. (Boston.) On Club-Foot lxxxvii Myotomy in Torticollis xlviii BYRNE, CHARLES. (U. S. Army.) Fistula between Vagina, Blad- der, and Rectum lxxvi BUCK, GURDON, Jr. (New York.) Researches on Hernia Cerebri xxxi AMERICAN SURGEONS. xcix PAGE CEdematous Laryngitis treated Hi Operation for Closure of Urethra lxxii Excision of Elbow-Joint xcii " Olecranon Process ib. Anchylosis of Hip-Joint ib. Excision of Elbow-Joint xciii BUCKNER, P. J. (Georgetown.) Ovariotomy Ixxxii BUEL, HENRY W. (New York.) Statistics of Amputations xcv BURGESS, RICHARD. Two Cases of Bronchotomy 1 BURR, J. PLATT. (Louisiana.) Anchylosis of Knee xcii BUSH, J. M. (Lexington.) Amussat's Operation for Arti- ficial Anus lxv Operation of Lithotomy lxxiii Lithotomy and Lithotrity lxxiv BUSHE, GEORGE. (New York.) On Diseases of the Rectum xx Torsion of Arteries xxvi Telangiectasis xxviii Scirrhus of Lachrymal Gland xxxii Excision of Tonsils xliii Removal of Parotid Gland xlvii Telangiectasis of Cheek lv Aneurism of Carotid ib. Ligature of Right Common Iliac Ixvii Operation for Phimosis Ixix On Hypospadias lxx Congenital Hydrocele lxxi Bilateral Operation for Stone lxxiii On Popliteal Aneurism lxxxviii BUTLER, J. C. (Virginia.) Amputation of Foot xciv BUTT, ROBERT B. (Virginia.) Resection of Ulna xci C CAIN, J. C. (Charleston.) Nutritive Enemata to sustain Life xlix Imperforate Prepuce . Ixix CALHOUN, P. (Louisiana.) Immobility of Lower Jaw xxxviii CAMPBELL, GEO. W. (Ten- nessee.) Exsection of half Lower Jaw xxxix Case of Artificial Anus lxiv Operation of Lithotomy lxxiii page CALDWELL, CHARLES. (Phil- adelphia.) Translation of Bichat on the Bones xvii CAMPBELL, H. F. (Georgia.) Ligature of Primitive Carotid lvi Removal of Pin from Duct of Wharton xiii CARNOCHAN, JNO. MURRAY. (New York.) Priority in Division of Masseter xxxviii CARTWRIGHT, A. (Natchez.) Laryngotomy for Watermelon Seed 1 CATHRALL, ISAAC. (Phila- delphia.) Case of double Harelip xxxvi CHASE, HEBER. (Philadel- phia.) Cases of Deformed Feet lxxxvii False Anchylosis of Knee-Joint xcii CHADBOURNE, THOS. (New York.) Cases of Uterine Polypus Ixxix CHEW, E. R. (Louisiana.) Instrument to divide Stricture of Urethra Ixix COATES, REYNELL. (Phila- delphia.) Cases of Urinary Calculi lxxv COCKE, JOSEPH. (Maryland.) Admission of Air into Wounds lxi COGSWELL, MASON F. (Con- necticut.) Ligature of Carotid liv COLLINS, RANSOM M. (Louis- iana.) Case of Blind Hemorrhoids Ixxxiii COOK, J. H. Fistulous Opening in Stomach lxii COOPER, SAMUEL. (Philadel- phia.) Properties and Effects of Stra- monium xvii CORNELL, EDWARD. (New York.) Intestines through Diaphragm, &c. Ix COX, ABRAHAM L. (New York.) Instrument to Excise Tonsils xliii c ALPHABETICAL LIST OF CRAVEN, Dr. (Virginia.) Paracentesis in Empyema lx CUSACK, J. W. Ligature of Carotid, Hemor- rhage, &c. liv D DALE, THOS. F. (Pittsburg.) Depressed Fracture of Cranium xxx DARRACH, WM. (Philadel- phia.) Spontaneous Cure of Aneurism lvii Drawings of Anatomy of Groin xix DAVENPORT, E. J. (Boston.) Encysted Tumors of Eyelids xxxii Operation for Artificial Pupil xxxiii " Strabismus ib. Polypi of Meat. Audit. Ext. xiv Spontaneous Cure of Aneurism lxxxviii DAVIDSON, WM. (Indiana.) Tracheotomy for Grain of Corn li DAVIS, EDWARD G. (Phila- delphia.) Beck on Ligature of Arteries xx DAVIS, N. S. (New York.) Congenital double Harelip xxxvi DEADERICK, W. H. (Ten- nessee.) Osteo-Sarcoma of Lower Jaw xxxviii DEANE, JAMES. (Greenfield.) Congenital Fissures of Palate xliv Case of Gastrotomy Ixxxi DEAS, E. H. Ligature of Common Carotid lvi DELAFIELD, EDW. (New York.) Artificial Pupil xxxiii DELANEY, M. G. (U. S. Navy.) Castration of Enlarged Testis lxxi Amputation in Glossocele xiii DEPEYRE, L. (New York.) Case of Lithotripsy lxxv DETMOLD, WM. (New York.) Abscess in Substance of Brain xxxi Cases of Club-Foot lxxxvi DEWEY, JOS. P. (Charleston.) Osteo-Sarcoma of Lower Jaw xl DICKSON, JAMES H. (New York.) Division of Tendo-Achillis lxxxvi Case of Talipes Equinus ib. page DILLSON, J. H. (Pittsburg.) Gum-Elastic Catheter in Blad- der lxxvi DIX, J. H. (Boston.) On Strabismus xxxiii DIXON, E. H. (Boston.) Interrupted Suture in Cleft Pa- late xliv DOANE, A. SIDNEY. (New York.) Dupuytren's Surgical Clinic xx Blandin's Topographical Ana- tomy xx Surgery illustrated from Cut- ler, Hind, Velpeau, and Bla- zius xx DONNELLAN, M. # (Louisiana.) Ligature in Carcinoma of Tongue xiii DORSEY, JOHN SYNG. (Phil- adelphia.) Elements of Surgery xviii Cooper's Surgical Dictionary xviii Trephining in Fractured Skull xxx Copper Coin in OEsophagus xlviii Ligature of External Iliac Ixv Steatomatous Tumor from Neck lxvii DUDLEY, BENJ'N WINSLOW. (Lexington.) Bandage in Gunshot Wounds, &c. xxvi Injuries of the Head xxx Trephine in Epilepsy ib. On Hydrocele lxxi DUGAS, L. A. (Georgia.) Tapping in Hydrocephalus xxix E ELLIS, JOHN. (Michigan.) Ligature of both Carotids lv ESSELMAN, JOHN L. (Nash- ville.) Extirpation of Uterus lxxviii EWING, J. HUNTER. Acupuncturation in Neuralgia xxxiv EVE, PAUL F. (Georgia.) Anaesthesia'in Operations xxvii Compound Fracture of Cranium xxxi Removal of large Polypus Na- rium through Pharynx xxxvii Immobility of Lower Jaw xxxviii Amputation of half of Lower Jaw xl Spina Ventosa in Lower Jaw ib. AMERICAN SURGEONS. CI PAGE Foreign Body passing from Pha- rynx to Larynx xlix Ligature of Primitive Carotid lvii Fungus Ilaematodes of Face, &c. lix Bilateral Operation for Stone lxxiv Case of Lithotomy ib. Case of " Ixxv Excision of Uterus lxxviii Amputation at Shoulder-Joint xcv " " " ib. " " " ib. " of Leg and Thigh ib. F FAHNESTOCK, WM. B. (Penn- sylvania.) Instrument to Excise Tonsils xliii Aneurism of Brachial Artery lxxxviii FAHNESTOCK, P. (Pennsyl- vania.) Strangulated Umbilical Hernia lxiv FALCONER, CYRUS. Cesarean Section lxxxii FINLEY, MICHAEL A. (Mary- land.) Ligature of Carotid liv FLINT, JOSHUA B. (Philadel- phia.) Druitt's Modern Surgery xxi FOLTZ, J. M. (U. S. Navy.) Enormous Steatoma from Side lix FOX, GEORGE. (Philadelphia.) Compressed Comminuted Frac- ture of Skull xxxi Ligature of Primitive Carotid lvi Inguinal Aneurism lxvi FRICKE, G. (Baltimore.) Operations for Cataract xxxiii " Artificial Pupil ib. G GAITHER, N. (Kentucky.) Bandage in Wounded Arteries xxvi GALLUP, JOSEPH A. (Ver- mont.) Extirpation of Ovarian Sacs lxxx GARDEN, THOMAS J. (Vir- ginia.) Division of Tendo-Achillis lxxxvii GEDDINGS, E. (Charleston.) Ligature of Common Carotid lvi Ovarian Pathology lxxx Encephaloid Degeneration xciv PAGE Sanguineous Tumors on Head xxix Practice of Surgery xviii GIBSON, CHAS. BELL. (Balti- more.) Osteo-Sarcoma of Lower Jaw xl Ligature of External Iliac Ixxxix GIBSON, JOHN MASON. (Bal- timore.) Anatomy, &c. of the Eye xix GIBSON, WM. (Philadelphia.) Operation on Tumor in Neck liii Axillary Aneurism lvii Wound of Common Iliac lxvii Sketch of Lithotripsy lxxv Operation for Anchylosed Knee- Joint xcii Caesarean Section lxxxii GILBERT, DAVID. (Pennsyl- vania.) Amputation above Shoulder- Joint xciv GILLESPIE, WM. A. (Vir- ginia.) Removal of Astragalus xci GILMAN, C. R. (New York.) Polypus Uteri lxxix GODDARD, P. B. (Philadel- phia.) Curling on Diseases of Testis xxi New Stomach-Pump xlix GODMAN, JOHN D. (Phila- delphia.) Coster on Surgical Operations xviii Inverted Toe-Nail lxxxv GODMAN, J. (Philadelphia.) Pediculis pubis on Tarsi Carti- lages xxxii GORDON, JAMES M. (Georgia.) Cases of Ranula xiii GRIFFIN, JOHN H. (Virginia.) Tapping in Ascites lxiii Vaginal Hysterotomy lxxvii GRIMSHAW, A. H. (Delaware.) Ovarian Dropsy lxxxii GROSS, SAMUEL D. (Louis- ville.) Diseases of Bones and Joints xix Liston's Elements of Surgery xxi Fibrous Tumor of Lower Jaw xl GUILD, JAMES. (Alabama.) Trephining in Epilepsy xxx G cii ALPHABETICAL LIST OF PAGE Ligature of Subclavian for Axil- lary Aneurism lviii Congenital Tumor on Chest, (Encysted) lix On Varicocele lxxi H HAIIX, JOHN. (Philadelphia.) Strangulated Femoral Hernia lxiii HALL, CHARLES A. (Ver- mont.) Tracheotomy for Foreign Bodies li Inability to raise Upper Eyelid xxxii Paracentesis Thoracis lx HALL, J. C. (Washington.) _ Extirpation of Testes and Penis lxx Ligature of External Iliac lxvi HALL, RICHARD WILMOT. (Baltimore.) Aneurism of Right Subclavian lv Larrey's Military Surgery xviii HAMILTON, F. H. (Rochester.) Varicocele and Operation lxx Lithotomy in a Child lxxiv Operation of Lithotomy ib. Rhino-plasty, Cheilo-plasty,&c. xxxv Horn Excised from Face ib. Three Cases of Hare-lip xxxvi Tonsilotomy xliv Maggots removed from Ear xiv Cases of Hernia lxiv HAMILTON, ROBERT. Stone in the Female lxxii HARDY, JOS. F. E. (North Carolina.) Laryngotomy for Watermelon Seed li HARLAN, R. (Philadelphia.) Medical and Physical Researches xx HARRIS, THOMAS. (Philadel- phia.) Amputation of Enlarged Tongue xii Congenital Enlargement of do. xiii Excision of Elbow-Joint xcii HARTSHORNE, JOS. (Phila- delphia.) Tardy Union in Fractures xc Boyer on Diseases of the Bones xvii HASTINGS, JOHN. (Philadel- phia.) Practice of Surgery xxii HAXALL, ROBERT W. (Vir- ginia.) On Fistula Lachrymalis xxxii page HAYS, ISAAC. (Philadelphia.) American Cyclopedia xix Lawrence on Diseases of Eye xxi Anchylo-blepharon xxxii Plastic Operation in Symblepha- ron ib- Extraction of Foreign Bodies from Eyes xxxiii Operation for Artificial Pupil xxxiv HAYWARD, GEO. (Boston.) Needles, &c. in Naevi Materni xxviii Trephining in Epilepsy xxxi Insect Pins in Hare-lip xxxvi Removal of Cancer from Tongue xiii Operation for Tumor in the Neck Hi Ligature of Carotid lvi On Hydrocele lxxi Vesico-Vaginal Fistula Ixxvii Prolapsus Ani lxxxiii Enlarged Bursa over Patella lxxxvi Amputation of part of Foot xciii HEATON, J. (Boston.) Strangulated Femoral Hernia lxiv IIENING, WM. (U. S. Army.) Gunshot Ball discharged by Stool lxvii HERBERT, WILLIAM II. (New York.) Ducamp on Strictures xviii HERNDON, BRODIE S. (Bos- ton.) Caesarean Section lxxxi HEUSTIS, J. W. (Mobile.) Compression in Wound of Bra- chial Artery xxvi Hernia Cerebri xxxi Strangulated Umbilical Hernia lxiv Prolapsus Recti lxxxiii Aneurism of Brachial Artery lxxxviii HEWSON, THOS. T. (Philadel- phia.) On Preternatural Joints xc Strangulated Umbilical Hernia lxiii HIBBARD, MOSES. (New Hamp- shire.) Operation on Uterine Tumor lxxx HILDRETH, CHAS. T. (Haver- hill.) Caustic in Strictured CEsopha- gus xlviii HILL, JOHN. (South Carolina.) Artificial Pupil xxxiii AMERICAN SURGEONS. cm HITT, N. (Indiana.) Extirpation of Tumor of Mam- ma lix HOLBROOK, AMOS. (Massa- chusetts.) Paracentesis Abd. in Dropsy Ixi HOLMES, H. J. (Mississippi.) Occlusion of Vagina lxxvii HOLSTON, J. G. F. (Ohio.) Trephining in Epilepsy xxxi HOOKER, CHAS. (New Haven.) Extracting Foreign Bodies from Ear xiv HOPTON, ABNER. (North Carolina.) Incisions in Glossitis xii Laryngotomy and Tracheotomy in same Case li Trephining in Carious Sternum lx HORNER, G. R. B. (U. S. Navy.) Amputation of Foot xciv HORNER, WM. E. (Philadel- phia.) Excision of Upper Jaw xxxvii Immobility of Jaw xxxviii Ligature of Common Carotid lv Fistula in Perineo Ixix Treatment of Lacerated Peri- neum lxxvii Treatment of Hemorrhoids lxxxiii Femoral and Brachial Aneurism Ixxxix Aneurism of Femoral Artery ib. Amputation at Shoulder-Joint xciv HOSACK, ALEX. E. (New York.) On Removal of Tonsils xliii Instrument to tie Deep Arteries liv HOSACK, DAVID. (New York.) Aneurism of Femoral Artery Ixv Injection in Hydrocele lxxi Ligature of Femoral Artery lxxxvii On Surgery of the Ancients xviii HOUSTON, ROBERT. Case of Ovarian Dropsy lxxxi HOUSTON, M. H. (Virginia.) Piece of Linen in Lungs twenty years Ixi HOWE, ZADOC. (Massachu- setts.) Operation of Hare-lip xxxvi Tracheotomy for a Bean li HOYT, OTIS. (Massachusetts.) Tumor of Thyroid Gland liii HUBBARD, THOMAS. (Connec- ticut.) Ligature of Axillary Artery lvii HULIHEN, S. P. (Wheeling.) Muco-Purulent Secretion of An- trum xxxvii Elongation of Lower Jaw, &c. from Burn xii HULL, G. A. (New York.) Nature of Hernia, &c. lxiii HULSE, ISAAC. (U. S. Navy.) Ununited Fracture of Humerus xci HUNT, THOMAS. (Natchez.) Removal of half Lower Jaw xxxix HUNT, HENRY. (Washington.) Wounded Shoulder-Joint xci HURD, P. H. (Oswego.) Case of Spina Bifida Ixviii Division of Spinal Marrow Ixviii JACKSON, SAMUEL. (Phila- delphia.) Paracentesis in Effusion into Chest lx JACKSON, SAMUEL. (North- umberland.) On Ectropion xxxii JAMESON, HORACE G. (Bal- timore.) Traumatic Hemorrhage xxvi Tumor of Orbit of the Eye xxxii Stricture of QEsophagus xlix Bronchotomy for Watermelon Seed 1 Memoir on Bronchotomy ib. Bronchotomy for a Pebble ib. Taking up Thyroid Arteries for Bronchocele Hi Ligature of External Iliac lxvi Stricture of Urethra Ixix New Operation for Circocele lxx Amputation of Cervix Uteri lxxviii Stricture of Rectum lxxxiii Caustic on Tumor of Thigh lxxxv Popliteal Aneurism Ixxxviii Wound of Ulnar Artery ib. JARROTT, RICHARD. Amputation for Gangrene xcv JEFFRIES, J. (Boston.) Osseous Formation in Eye xxxiii Operation for Artificial Pupil xxxiii JEWETT, CALVIN (Newberg.) Tracheotomy for a Bean 1 Bronchotomy for Iron Nail li civ ALPHABETICAL LIST OF JOHNSTON, WM. (New Jersey.) Varicose Aneurism Ixxxix JUDKINS, WM. (Ohio.) Trephine in Injuries of Brain xxx K KAST, THOMAS. (Boston.) Aneurism of Thigh lxxxvii KELLY, JOHN. (New York.) Case of Urinary Calculus lxxiv KIMBALL, GILMAN. Ligature of Internal Iliac lxvii KING, DANIEL. (Rhode Island.) ^ Callous Stricture of Rectum lxxxiii KIRKBRIDE, T. S. (Phila- delphia.) Compression in Wounded Arte- ries xxvi KNIGHT, J. (New Haven.) Popliteal Aneurism Ixxxix LEBBY, ROBERT. Water between Cranium and Scalp ^p;x LEVERT, HENRY S. (Mobile.) Metallic Ligatures on Arteries xxvi Fungus Hematodes xciv LEWIS, WINSLOW. (Boston.) Operation for Carotid Aneurism liv LINDSAY, R. W. (District of Columbia.) Case of Gunshot Wound xciv LINDSLEY, HARVEY. (Wash- ington.) Extirpation of Cancerous Eye xxxiii LITTELL, S. (Philadelphia.) Treatise on Diseases of the Eye xx LOTZ, J. R. (Pennsylvania.) Operation for Artificial Anus lxv LOVELL, JOSEPH. (U. S. Army.) Wounds of Stomach lxii M McCLELLAN, GEO. (Phila- delphia.) Principles and Practice of Sur- gery • xxii Operation for Spina Ventosa xxix Extirpation of Parotid xlvii Right Parotid ib. Parotid ib. Surgical Anatomy of Arteries liii Ligature of Carotid in Children liv page Excision of Cartilages, Ribs, and Sternum lx Case of Lithotripsy lxxvi On Fungus Hematodes xciii McCLELLAN, JOHN. (Green- castle.) Cancerous Breast lix McCLELLAN, JOHN H. B. (Philadelphia.) Extirpation of Parotid Gland xlviii McDOWALL, H. (Virginia.) Pathology of Bones, &c. lx McDOWELL, EPHRAIM. (Dan- ville.) Extirpation of Ovaria lxxix ib. McGILL. (Maryland.) Ligature of both Carotids liv MANLOVE, J. E. (Tennessee.) Gastrotomy lxii MANN, JAMES. (Massachu- setts.) Sketches of Campaigns of 1812, '13, '14 xviii MARCH, ALDAN. (Albany.) Ovarian Tumor lxxxii MARTIN, JOHN II. (Maine.) On Necrosis xci MATTHEWS, C. B. (Phila- delphia.) Instrument to Excise Tonsils xliii To Extract Poisons from Sto- mach xlviii MARKHAM, W. D. (Philadel- phia.) Surgical Practice in Paris xxi MAYNARD, JOHN P. (Boston.) On Collodion xxvii MEASE, JAMES. (Philadel- phia.) Life and Surgical Works of John Jones XyiJ MECKER, DANIEL. (Indiana.) Extirpation of Diseased Ovary lxxx MERRIWETHER, SAMUEL. (Indiana.) Paracentesis in Empyema Ixi METCALF, JOHN G. (Massa- chusetts.) Imperforate Hymen lxxvii METTAUER, JOHN P. (Vir- ginia.) Staphyloraphy xliv Ligature of Common Carotid lvi Amputation of Penis Ixix AMERICAN SURGEONS. CV Hypospadias and Epispadias lxx Case of Lithotomy lxxiii New Director and Gorget lxxiv Rupture of Recto-Vaginal Sep- tum lxxvii Vesico-Vaginal Fistula lxxviii MIGHELS, JESSE W. (Maine.) Immobility of Jaw xxxviii MILLER, H. (Louisville.) Ovariotomy lxxx MILLS, AUGUSTUS W. (Ken- tucky.) Truncating Uvula in Consump- tion xiii MITCHELL, J. K. (Philadel- phia.) Instrument to Excise Tonsils xliii MOORE, FRANCIS. (Connecti- cut.) New Tourniquet xciii MOORE, N. J. McL. (New Hampshire.) Amputation Neck of Uterus lxxviii MORGAN, JOHN G. (Geneva.) Ligature in Division of Jugular Vein liii MOTT, VALENTINE. (New York.) Velpeau's Surgery xxi Ligature of Carotid xxviii Treatment of Injuries of Head xxx Removal of Tumor from Nose xxxv Immobility of Jaw xxxviii " ib. Osteo-sarcoma of Lower Jaw xxxix " ib. ib. Resection of Inferior Maxilla xl Extirpation of Parotid xlvii . " ■ Tuberculated Sar- coma liii Ligature of the Innominata ib. Aneurism liv Anastomosis and Aneurism of Carotid ib. Circulation of Head after Tying Carotid lv Ligature of both Carotids ib. Case of Axillary Aneurism lvii Aneurism of Right Subclavian ib. Ligature of Left ib. Osteo-sarcoma of Left Clavicle lviii Ligature of Common Iliac lxvii Case of Lithotomy lxxiii Femoral Aneurism Ixxxviii page Diffused Femoral Aneurism Ixxxviii Amputation at Hip-Joint xciii MUSSEY, R. D. (Cincinnati.) Entrance of Air into Veins xxvi On Anaesthesia xxvii Excision of Upper Maxillary xxxvii " Large Tumor on Neck liii Aneurism by Anastomosis xxviii Exostosis of Frontal Bone xxix Operation on Enlarged Tongue xiii Congent. absence of External Meatus xiv Ligation of both Carotids lv Ligature of Carotid liv Operation of Ovariotomy lxxx . On Urinary Calculus lxxii Operation for Lithotomy lxxiv MUTTER, THOMAS D. (Phi- ladelphia.) Liston's Operations of Surgery xxii Rhinoplastic Operation xxxv Deformity of Mouth, and Dief- fenbacn's Method xii Physick's Needle in Cleft Palate xliv Operation for Deformity from Burns xlviii Hydrocele of the Neck liii Urinary Calculus in a Girl lxxiii New Instrument for Fistula in Ano lxxxiii Stricture of Rectum lxxxiv N NANCREDE, JOS. G. (Phila- delphia.) On the Caesarean Operation lxxxii NELSON, T. (New York.) Wounded Nerve from Bleeding lxxxv NEWMAN, H. S. (Philadelphia.) Amputation of Enlarged Tongue xii NEWMAN, JOHN. (North Carolina.) Tracheotomy for Lead Bullet xlix NICE, W. G. (Virginia.) On Contractions in Burns lxxxv NORRIS, GEORGE W. (Phila- delphia.) Liston's Practical Surgery xx Ferguson's " xxi Chelius's System of " xxii Report of Cases of Injuries of Head xxx Fibrous Tumor on Lobe of Ear xiv CV1 ALPHABETICAL LIST OF PAGE Statistics of Mortality following the tying of Carotid and In- nominata lvi Statistics of Ligature of Subcla- vian Iviii Congenital Club-Foot lxxxvi Statistics of Ligature of Iliacs Ixxxix Statistics of Ligature of Femoral xc Fracture of Astragalus xciv Statistics of Amputations at Pennsylvania Hospital ib. NOTT, J. C. (Mobile.) Radical Cure of Hernia lxiv Extirpation of Os Coccygis lxxiv Large Stones in Lateral Opera- tion lxxvii 0 OGIER, THOS. L. (Charleston.) Amputation of Penis Ixix ONDERDONK, HENRY U. (New York.) On Stone in Bladder Ixxii Popliteal Aneurism lxxxvii Ligature of Femoral Artery ib. PAGE, WM. BYRD. (Philadel- phia.) Amputation at Shoulder-Joint xcv PALMER, JOSEPH. Bronchotomy for a Bean 1 PANCOAST, JOSEPH. (Phila- delphia.) On Operative Surgery xxi Operation for Strabismus xxxiii Rhinoplastic Operations xxxv Plastic Operations xii ib. Staphyloraphy xliv Tracheotomy in Croup li (Meigs) Iii Empyema cured by Operation Ixi Excision of Elbow-Joint xcii PARK, AND'W. (Eaton, Ga.) Trephining in Fractured Skull xxx Encysted Tumor of Neck Iii PARKMAN, SAMUEL. (Boston.) Velpeau on Diseases of the Breast xxi Extirpation of Uterine Tumor lxxx PARRISH, ISAAC. (Philadel- phia.) Anaesthetic Agents and Statis- tics xxvii PAGE Congenital Division of Lip and Palate xxxvi Thimble in Pterygoid Fossa xiii Croup cured without Operation li Case of ununited Fracture xci PARRISH, JOSEPH. (Phila- delphia.) Surgical Observations xx Ligature of Subclavian Artery lvii Case of Strangulated Hernia lxiii Cancer of Breast lix PARRY, CHARLES. (Indiana.) Deformed Fracture of Leg xcii PARSONS, USHER. (Rhode Island.) On Cancer of Mammae xx Statistics of Surgical Operations lvi PASCALIS, FELIX. (New York.) Fistula in Ano lxxxiii PATTESON, GRANVILLE SHARPE. (Baltimore.) Burns' Anatomy of Head and Neck xviii Aneurism of Internal Maxillary xxxiv PEACE, EDWARD. (Philadel- phia.) Ligature of External Iliac lxvii " Primitive ib. Inguinal Aneurism Ixxxix PEIRSON, A. L. (Massachu- setts.) Polypus and Inversion of Uterus lxxix Operation for Harelip xxxvi PERKINS. (Philadelphia.) Arrest of Progress of Whitlow lxxxv PHILIPS, S. B. (New York.) Case of Polypus Uteri lxxix PHYSIC, PHILIP SYNG. Employment of Animal Liga- tures xxvi Tapping in Hydrocephalus xxix Nitrate of Silver in Wart on Ad- nata xxxiii Seton for Fracture of Inferior Maxilla xxxix Cough, caused by Elongated Uvula, &c. xiii Double Canula and Wire Liga- ture ' xliii Forceps for Removing Tonsils xliii Stomach Tube in Poisoning xlviii Tracheotomy in Hydrophobia xlix New Operation for Artificial Anus lxiv AMERICAN SURGEONS. cvii page Diseases of Testicle lxx Operation of Lithotomy lxxiii Ligature of Brachial Artery lxxxvii Fracture of Os Humeri xc PINCKNEY, N. (U. S. Navy.) Excision of Portion of Lower Jaw xl Removal of one-third of Head of Humerus xciii Amputation at Shoulder-Joint xciv PITCHER, ZINA. (U. S. Army.) Penetrating Wound of Abdomen lxii PLATT, JAMES KENT. (Pitts- burg.) Hydrops Articuli in Shoulder lxxxv POPE, CHAS. A. (St. Louis.) Fracture of Cranium xxxi Dislocation of Crystalline Lens xxxiv Stone in Bladder lxxv Ligature of Femoral Artery xc POST, ALFRED C. (New York.) Blepharoplastic Operation for Ectropion xxxii Subcutaneous Erectile Tumor of Cheek, &c. lv Ligature of Subclavian, &c. lviii POST, WRIGHT. (New York.) Operation on Carotid Aneurism liii Ligature of Subclavian for Bra- chial Aneurism lvii Ligature of External Iliac Ixv Case of Brachial Aneurism lxxxvii POWELL, W. B. (Kentucky.) Excision of part of Spleen lxii POWER, W. (Baltimore.) Femoral Aneurism Ixxxix PRINCE, DAVID. (St. Louis.) Ovarian Tumor lxxxi PROUDFOOT, L. Fistula in Lumbar Region Ixviii Q QUACKENBUSH, J. V. P. (Al- bany.) Uterine Polypus lxxix R RAMSAY, DAVID. (Charles- ton.) Improvements in Medicine in Eighteenth Century xvii RAND, ISAAC. (Massachu- setts.) Operation for Empyema lx PAGE RANDOLPH, J. (Philadel- phia.) Osteo-sarcoma of Lower Jaw xxxix Extirpation of the Parotid xlvii Aneurism of External Iliac lxvi Cases of Lithotripsy lxxv Stone in Bladder lxxvi " " ib. Cases of Lithotripsy ib. " Lithotrity ib. Case of Lithotripsy lxxv REESE, DAVID M. (Balti- more.) Cooper's Surg. Diet. xix Tetanus controlled by Issues to Spine Ixviii RICHMOND, JNO. L. (Ohio.) Caesarean Section lxxxii RIVINUS, E. F. (Philadelphia.) Larry on Wounds xix ROBERTS, WM. C. (New York.) Tumors of Uterus lxxxi ROBERTS & KISSAM. (New York.) Minor Surgery of Bourgery xx RODRIGUES, B. A. (Pennsyl- vania.) Exostosis of Upper Jaw xxxvii ROGERS, DAVID L. (New York.) Trephining in Epilepsy xxx Ligature of Common Carotid xxxiv Osteo-sarcoma of Upper Jaw xxxvii " " Lower Jaw xxxix Excising Tonsils xliii Excision of Tumor from Neck Iii Ligature of External Iliac lxvi Operation for Fractured Spine Ixviii Ovariotomy t lxxix On Tying Large Arteries Ixxxviii ROGERS, J. KEARNEY. (New York.) Ununited Fracture of Humerus xc Amputation at Elbow-Joint xciii Operation for Artificial Pupil xxxiv Ligature of Left Subclavian lviii ROUSSEAU, J. C. (Philadel- phia.) Operation on Hemorrhoids lxxxiii RUAN, WM. H. (West Indies.) Ligature of Right External Iliac lxvi RUSCHENBERGER, W. S. W. (Philadelphia.) Marshal on Enlisting, &c. of Soldiers xxi Glass Goblet in Rectum lxxxiv Cviii ALPHABETICAL LIST OF SAVERY, CHARLES A. (New Hampshire.) Abscess of Liver lxii SARGENT, F. W. (Philadel- phia.) Druitt's Surgery xxi On Bandaging, &c. xxii SCHMIDT, J. W. (New York.) Morbid Erectile Tissue xxix Division of Masseter Muscle xxxviii SELDEN, HENRY. (Virginia.) On Hemorrhoids lxxxiv SHANKS, LEWIS. (Tennessee.) Treatment, &c. of Cephalaema- toma xxix Bloodroot in Gelatinous Polypus xxxv SHELDON, A. S. (New York.) Paracentesis in Empyema Ixi SHERRERD, JOHN B. (New Jersey.) Injection in Ascites lxii SHERRILL, HUNTING. (New York.) Strangulated Inguinal Hernia lxiv SHIPMAN, A. B. (Indiana.) Injury of Head xxxi ib. ib. Ligature of Common Carotid lvi Imperforate Vagina lxxviii Caesarean Operation lxxxi Medullary Sarcoma of Labia, &c. lxxvi SHIPMAN, A. W. (New York.) Ligature of Femoral Artery Ixxxix SHULTICE, WM. (Virginia.) Case of Imperforate Hymen lxxvii SIMS, J. MARION. (Alabama.) Removal of Super-Maxillary xxxvii Osteo-Sarcoma of Lower Jaw xl " , " " ib. Extraction of Foreign Bodies from Ear xiv SKINNER, CHARLES. (North Carolina.) Case of Spina Bifida Ixviii SMITH, ALBAN G. (Ken- tucky.) Successful Lithotrity lxxv Removal of Diseased Ovarium lxxix Vertebrae Removed Ixviii SMITH, HENRY II. (Philadel- ■ PHIA.) Civiale on Stone and Gravel xxi Minor Surgery ib. Tubercles of Testis lxx Sudden Formation of Hydrocele lxxi Vesico-Vaginal Fistula lxxxiii Case of Varicose Veins lxxxvi Treatment " " _ ib. Excision and Caustic in Pseu- darthrosis xci SMITH, J. AUGUSTINE. (New York.) Bell's Principles of Surgery xviii SMITH, NATHAN. (Yale Col- lege.) Suture of Palate in Infancy xliv To Extract Coins, &c. from Oesophagus xlix Ligature of External Iliac lxvi Operation for Ovarian Tumor lxxix Remarks on Amputations xciii SMITH, NATHAN R. (Balti- more.) On Diseases of Internal Ear xix Medical and Surgical Memoirs ib. Surgical Anatomy of Arteries ib. Caustic Threads in Vascular Naevus xxviii Observations on Staphyloraphy xliv Extirpation of Parotid xlvii Tumors on Neck liii Tonsils xliii Actual Cautery in Deep Sinuses lxxxv Paracentesis of Bladder through Perineum lxxii Instruments, &c. in Lithotomy lxxiii Cases of Lithotripsy lxxvi Hemorrhoidal Tumors lxxxiii Division of Tendo-Achillis lxxxvi Case of Popliteal Aneurism Ixxxviii SNEAD, N. (Virginia.) Cases of Hernia lxiii SNEED, W. C. (Kentucky.) Paracentesis in Empyema Ixi SPENCER, P. C. (Pittsburg.) Results of Lithotomy lxxv Case of Lithotrity ' lxxv SQUIBB, E. R. U. S. Navy.) Advantages of Simple Dressings in Surgery xxvii STEDMAN. Ligature, External Iliac lxvi STERLING, JOHN W. (New York.) Velpeau's Surgical Anatomy xix AMERICAN SURGEONS. C1X STEVENS, ALEX. H. (New York.) On Encysted and other Tumors xxix Osteo-Sarcoma of Upper Jaw xxxvii Treatment of Enlarged and In- durated Tonsils xliii Staphyloraphy xliv Encysted Tumor on Side of Neck Iii Congenital Hernia lxiii Ligature of External Iliac lxv Puncture in Spina Bifida Ixviii Lectures on Lithotomy lxxiii Extra-Uterine Fcetation lxxx lxxxi Case of Fissure of Rectum lxxxiii Extirpation of Astragalus xci Translation of Boyer on Surgi- cal Diseases xviii Cooper's Practice of Surgery ib. " " xix STEWART, F. CAMPBELL. (New York.) Knife to divide Strictures in Hernia lxiv STIMPSON, JEREMY. (Boston.) Tic Douloureux cured xxxiv STONE, JOHN 0. (New York.) Amputations and Compound Fractures xcv STOUT, ABRAHAM. (Easton, Pennsylvania.) Cheiloplasty xii STRACHN, JOHN B. (Virginia.) Excision of Cervix Uteri lxxviii SWETT, JOHN A. (New York.) Paracentesis in Empyema Ixi SYKES, JAMES. (Delaware.) Ligature of Carotid liv TALIAFERRO, W. T. (Ken- tucky.) Congenital Tumor of Eyeball xxxiii THACHER, JOS. (Plymouth.) Bladder Tapped above Pubis lxxi THAXTER, ROB'T. (Dorches- ter.) Ununited Fracture of Humerus xc THOMPSON, GEORGE. Ten- nessee.) Compression on Wounded Ar- teries xxvii Tracheotomy for Croup 1 TOLAND, H. H. (South Caro- lina.) Congenital Hypertrophy Upper Eyelid xxxii Excision part Inferior Maxilla xl Case of Lithotomy lxxii Sanguineous Tumors of Vagina lxxvi TOLEFREE, R. (New York.) On Circular and Flap Opera- tions xciv TOWNSEND. (Boston.) Tracheotomy for Laryngitis Iii TRASK, JAMES D. (New York.) Ligature of Primitive Carotid, &c. xxviii Strangulated Inguinal Hernia lxiv TRIPLER, CHARLES S. (U. S. Army.) Secondary Hemorrhage xcv TROWBRIDGE, AMASA. (New York.) Operation of Lithotomy lxxiii Extraordinary Cases of Ampu- tation xciii Three Cases Spina Bifida Ixviii Tracheotomy for a Bean 1 TWITCHELL. (New Hamp- shire.) Ligature of Carotid in Gunshot Wound lv U UTTERY, A. LEANDER. (Providence.) Calculus in Urethra lxxv VAN BUREN, WM. H. (New York.) Malignant Polypus Nose, &c. xxxvi True Inguinal Aneurism lxvi Tumor of Left Ovary lxxxii W WAGNER, JNO. (Charleston.) Amputation of part Lower Jaw ex ALPHABETICAL LIST OF WALTON, A. G. (Pennsylva- nia.) Operations for Club-Foot lxxxvii WARREN, JOHN. (Boston.) Amputation at Shoulder xciii WARREN, JOHN,C. (Boston.) Operations on Tumors xx Etherization, with Surgical Re- marks xxii Effects of Chloroform ib. Air in Veins xxvi Cold Water Dressing xxvii Etherization ib. Ether and Chloroform ib. Use of Anaesthetics ib. Division of Nerves in Neuralgia xxxiv Excision of Submaxillary Nerve ib. Double Harelip xxxvi Removal of Upper Maxilla xxxvii " " " ib. Removal of half Lower Maxilla xxxix Operation for Cancer of Tongue xii Induration of Tonsils xliii Natural Fissure of Soft Palate xliv Operation for Tumor of Neck Iii " Carotid Aneurism liv Ligature of Subclavian Artery lviii Removal of Clavicle lix Excision of Ribs lx Strangulated Crural Hernia lxiii Ligature of External Iliac lxv Aneurism of External Iliac lxvi Artificial Urethra Ixix Omental Hernia lxx Bi-lateral Operation for Stone lxxiv Non-Existence of Vagina lxxvii Cancer of Uterus lxxviii Cases of Neuralgia lxxxv Ligature of Femoral Artery lxxxvii WARREN, JOHN MASON. (Boston.) Inhalation of Ether xxvii Ligature of Both Carotids xxviii Trephining for Old Depression xxxi Blepharoplastic Operations xxxii Rhinoplastic " xxxv << «< ib. i< d ib. Autoplastic " ib. Taliacotian " ib. Nursing after Operating for Hare-lip xxxvi Cancer of Throat xiii Enlargement of Tonsils xliv Fissures, Hard and Soft Palate xiv Fissures, Hard and Soft Palate xiv Division of Sterno-C.-Mastoid xlviii Foreign Bodies in Air Passages li Ligature of both Carotids lvi " Left Subclavian lviii Operation for Artificial Anus lxv Lithotomy and Lithotrity lxxvi WATERHOUSE, HENRY S. (New York.) Tracheotomy for Watermelon Seed 1 WATERS, NICHOLAS B. (Phi- ladelphia.) Bell's System of Surgery xvii WATERS, WM. (Maryland.) Strictures of Urethra lxx WATSON, JOHN. (New York.) Nature, &c. of Telangiectasis xxviii Anaplastic Operation on Os Frontis xxix Polypi in Nasal Fossae, &c. xxxv Organic Obstructions of OEso- phagus xlix Treatment of Varicocele lxx On Secondary Abscesses lxxxvi On Varices ib. WEBSTER, JAMES. (Phila- delphia.) Removal of Tumor from Face xii WEDDERBURN. (New Orleans.) Ligature of External Iliac Ixxxix WEEVER, CONSTANTINE. (Michigan.) New Oesophagus Forceps xlix WELLS, EDWARD W. Ligature, Subclavian lvii WELLS, THOMAS C. (South Carolina.) Hypertrophy of Tongue xiii Extensive Division of Soft Palate xliv WEST, FRANCIS. (Philadel- phia.) Dislocation of Crystalline Lens xxxiv WHARTON, R. G. (Mississippi.) Artificial Anus lxv WHEELER, H. H. (Pennsyl- vania.) Extirpation Parotid xlviii WHINERY, EDWARD. (Iowa.) Extra-Uterine Pregnancy lxxxi WHITE, SAMUEL. (New York.) Teaspoon Removed from Intes- tine Ixi AMERICAN SURGEONS. CXI WHITRIDGE, J. B. (Charles- ton.) Tapping in Hydrocephalus xxix Ligature of External Iliac lxv Amputation at Shoulder-Joint xciii WILLDAY, JOHN Cold Water in Calculus lxxii WOLFLEY. (Ohio.) Paracentesis in Empyema Ixi WOOD, JAS. R. (New York.) Lithotomy in a Child lxxiv WOODBURY, PETER P. (New Hampshire.) Tracheotomy for Bean 1 WORT, J. Osteo-Sarcoma of Lower Jaw xl WORTHINGTON, NICHOLAS. (District of Columbia.) Case of False Joint xc WRAGG, W. T. Sutures in Surgery xxvii WRIGHT, CLARKE. (New York.) Tumor in Antrum xxxvii YANDELL, LUNSFORD PITTS. (Kentucky.) Two Cases of Lithotomy lxxii YARDLEY, THOS. (Philadel- phia.) Removal of Extra-Uterine Foetus lxxxi OPERATIVE SURGERY, PART I. GENERAL DUTIES AND ELEMENTARY OPERATIONS. OPERATIVE SURGERY. PART I. GENERAL DUTIES AND ELEMENTARY OPERATIONS. INTRODUCTION. Operative Surgery, in the usual acceptation of the term, has been so long regarded as designating that department of medicine in which diseases are treated by means of cutting instruments, that the importance to an operator of other qualifications than those of manual dexterity is liable to be overlooked. Although every medi- cal man is presumed to know that a successful surgeon must neces- sarily be also a good physician, yet as the absence of reference to this fact may lead the inexperienced to place too much confidence in mere mechanical measures, it seems right, in this portion of the work, to call the attention of the reader to the value of constitu- tional treatment, in connection with surgical operations of a hazard- ous kind. The human system, upon which a surgeon acts mechanically, is a combination of organs, so mutually dependent on each other, that the removal of any portion, or even the partial division of the tegu- mentary membrane which encases and protects the whole, frequently creates derangement which nothing but judicious medical treatment can remedy. Appropriate constitutional measures are therefore often as essential to the success of an operation as anatomical knowledge is necessary to its performance; and the happiest results will uspally be obtained by those who closely attend not only to the local, but also to the general management of the cases on which they operate. For this reason, a successful surgeon must not only be a judicious practitioner of medicine, but also a devoted nurse and careful observer of the varying conditions of the system, under all 2 18 INTRODUCTION. circumstances. In every operation he should feel that he is largely indebted to nature; without her aid he can neither anticipate nor obtain success, whilst with it, especially as exhibited in the processes of adhesion, or reproduction of tissue, he possesses a power that seems almost divine. Admitting the necessity of thus combining medical skill with operative dexterity, there yet remain to be noticed two special duties which are essential to a correct appreciation of the extended quali- fications requisite in an operator, to wit, tact in diagnosis and a correct knowledge of surgical pathology. By diagnosis, the various mental and physical processes which ennoble and augment the value of operative proceedings, are brought into play. In the practice of medicine, the power to diagnosticate disease is universally esteemed a test of skill, but in surgery it is occasionally apparent that its acquisition is deemed easy and of less value, than that assigned it in the kindred branch of the profession. In surgery, it is also often deemed of little difficulty, because the duties of the surgeon being limited to external complaints, their characteristics are regarded as more tangible, and therefore supposed to present peculiarities which can be more readily recognized by the senses. Slight practice will, however, convince those entertaining such an opinion that the mere acquisition of the nice sense of touch, which is essential to the development of this power, is of itself suffi- ciently difficult, to say nothing of the experience necessary to regu- late the mental impressions which touch creates. The consequences of diagnostic error in operative surgery are also such, that heavy and prompt responsibility is connected with its exercise by an operator, as his means of treatment may in a moment destroy life, or produce irreparable mutilation before he recognizes his mistake. A correct diagnosis is, therefore, always presumed to precede every attempt at the use of instruments. Surgical pathology, as demonstrating the peculiarities of diseased structure, together with the other phenomena of abnormal action, is also a necessary qualification in a surgeon. On the perfection of the knowledge possessed by him in this department rests the neces- sity of submission by the patient to any operative proceeding. If it is requisite to remove a tumor, he is supposed fully to recognize its characters and probable progress before recommending its extir- pation ; while his decision as to the propriety of amputation may involve not only the serious question of loss of limb, but also of life GENERAL DUTIES. 19 if the operation is unnecessarily delayed. While then for the ad- vantages of methodical arrangement, the ensuing pages are mainly limited to mechanical details, let it be remembered that the author has no intention of giving them any other value than that of being one of the means of treatment occasionally demanded for the relief of disease. With this explanation, the subject may be divided into two parts: 1st. Minor Operative Surgery, or simply Minor Surgery, in which there is usually but little danger to the life of the patient, from the means employed; and, 2d, Major Surgery, or Operative Surgery proper, where, from the more free use of instruments, risk to life may reasonably be anticipated. To show the various modes of operating, and especially such as are resorted to by surgeons in the United States, is the object of the present volume. For the exposition of the duties of Minor Surgery, the reader is referred to the various treatises upon the subject, among which may be found the third edition of that published by the author of these pages.* In the arrangement of the work, five divisions may be advantage- ously made : 1st. General Duties and Elementary Operations. 2d. Operations on the Head and Face. 3d. Operations on the Neck and Trunk. 4th. Operations on the Genito-Urinary Organs ; and, 5th. Operations on the Extremities. In adopting this order, the author has been guided by the opinion that the natural relation of parts is that in which one desiring in- formation in respect to an operation, would almost intuitively seek it. Thus, the treatment of Hare-Lip would be looked for in connec- tion with operations on the lips, and not among those for malforma- tions of the soft parts, or for disorders of the skin or muscles ; while the process of Trephining would properly be sought under injuries of the cranium, and not under that of affections of the bones. With the same views, the details of each subject will be presented in the order in which the operator should attend to them. Thus, before operating, a surgeon naturally thinks of the anatomical relations of the region upon which he is to act; then of the methods of operating; then of the instruments that may be required; then of the dress- ings; and, lastly, of the adjuvants necessary either to local or gene- ral measures of treatment. * Minor Surgery, or Hints on the Every-day Duties of the Surgeon, 3d edi-. tion, Phila. 1850. 20 OPERATIVE SURGERY. CHAPTER I. OF THE GENERAL DUTIES OF AN OPERATOR. By the general duties of an operator, are understood all such acts as may be required in connection with his mechanical proceedings. These duties may be classed under three heads: 1st. Attention to the patient; 2d. Preparation of instruments ; and 3d. Selection of assistants. SECTION I. ATTENTIONS TO THE PATIENT. The attentions to the patient, as a portion of the general duties of an operator, may be subdivided into three periods: those which are required before the operation; during its proceedings; and subse- quent to its performance. As every operation in surgery is undertaken solely with the view of benefiting the patient, the duties of an operator necessarily com- mence with the establishment of a correct diagnosis. Certainty, or a cautious examination of the nature of the disorder, should in all instances be a sine qud non to any operation. Without it, every application of the knife becomes barbarous and unjustifiable. The Prognosis of an operation, or the opinion that the result to the patient will be preferable to his condition before it, should in like manner be firmly settled; but as all men are liable to error, even when caution is largely exercised, it becomes the duty of an operator, in every case where it is possible, to demand a consulta- tion with one or more of his professional brethren, not only in order to render the necessity of the operation certain, but also to secure his own reputation as to its correctness. The propriety of ampu- tations has been subsequently doubted; lithotomy has been per- formed when a calculus did not exist; whilst the removal of hemor- rhoids, the cure of fistula in ano, or the performance of plastic DUTIES BEFORE OPERATING. 21 operations have all left the patient in a worse condition than he was previously. The result, also, is by no means the same, even under apparently similar circumstances. Death has ensued from the ope- ration for piles; a greater deformity been created by operating for strabismus; and new noses have not always proved so handsome as the old. The issue should, therefore, be carefully weighed by every surgeon, before an operation is undertaken, if only on account of his own reputation. But when, after due deliberation, the affair has been decided, let him immediately, with perfect confidence, assume his position as the operator, and give his attention to such general and local measures as will facilitate the accomplishment of his object. § 1.—Duties of a Surgeon before Operating. Among the first of the general measures required at this period, may be placed the employment of such means as are occasionally necessary to induce the patient to consent to the performance of the operation. Sometimes it happens that an individual is timid, fear- ful of pain, and requires strong inducements to lead him to suffer that which is requisite for his cure. Under such circumstances, the surgeon will be obliged to promise largely, or present a lively de- lineation of the benefits that may result from its performance; but, on the other hand, if his patient is over-bold, or has obtained too exalted an idea of the advantages that will accrue to him from its execution, it may become necessary to diminish his anxiety to submit, and point out the risks to which he will be exposed; lest, anticipating too much, and being disappointed, he throw the blame upon his surgical attendant. Especially is this requisite in the case of females. A young girl is annoyed by a squint, and hopes to improve her beauty; or, she has been disfigured by a burn, or deformed from a fracture, and, full of the accounts of friends and neighbors, almost insists upon an operation ; and in these cases it is imperatively the duty of the surgeon to display the darker tints of the picture, and limit the anticipations that hope and vanity have so readily created. In this, which has been termed the moral preparation of the patient, much of the means required must be decided by that indefi- nite quality of the mind known as "tact;" and the best mode of ac- complishing it must consequently be left to the judgment of him who 22 OPERATIVE SURGERY. operates. Nor are these measures only of importance in respect to the comfort of the patient; they are also often closely allied to the result of the case. Fear depresses the vital powers, but hope en- livens and elevates them; and their undue excitement may, there- fore, either prove a serious obstacle, or a powerful lever to the attain- ment of the surgeon's object.* From the extensive sympathies of one organ with another, it also becomes the operator's duty at this stage of his proceedings to look not only at the mental, but also to the general condition of his patient. Let him see that the digestive organs are as far as is possible free from disease, and active in the performance of their functions; that the secretions of the liver and kidneys are not obstructed; that the lungs and heart are in a proper condition for the circulation of the blood, and that the head is free both from mental and physical disorders; in other words, let him satisfy himself before the operation that his patient is possessed of the mens sana in corpore sano, or, in other words, that he is, as far as may be, sound both in body and mind. After fully attending to the general preparation of the patient, the surgeon should next turn his attention to such means as will facilitate his own movements, and save the patient unnecessary suf- fering. In some few instances, the production of pain, and the development of the patient's sensibility, are the object of the opera- tion, as is seen in the use of stimulants for the cure of hydrocele, or the excitement of vital action in the treatment of un-united frac- ture. But, in the majority of cases, the creation of pain by any operation can only be regarded, at the present time, as both unne- cessary and injurious. The surgeon should therefore prevent it, and endeavor to save his patient the excitement arising from suffering, by resorting to the use of Anaesthetics or of Opiates. Let him, especially before severe operations, blunt the nerves of sensation either by partial or entire Etherization; and as its safety has been widely tested, philanthropy and that desire to ameliorate the suf- ferings of mankind, which is the true basis of sound practice, demand that neither prejudice nor ignorance of its effects should longer prevent its employment by every operator. If experience as to its power and mode of administration has not * For many excellent details on the moral preparation of the patient, see Pathologie Externe, par Vidal du Cassis, torn. 1.; also Velpeau's Surgery, by Drs. Mott & Townsend, vol. i., New York, 1847. ANESTHETICS. 23 yet been gained, let him at once resort to books, (of which there are many,) or to the schools, or even travel to distant points, until by study and observation he be satisfied fully of its propriety, and enabled yet further to extend the benefits of this admirable agent for the relief of suffering. Five years have now elapsed since its suggestion by Dr. Morton, of Boston, and its application to surgery by Dr. John C. Warren, of the same city, excited the attention of the world. The best surgeons throughout the globe have employed it, and the most ignorant have not hesitated to resort to its influence. Yet, out of the thousands thus indiscriminately exposed, few have suffered from its effects, whilst numbers have passed through the most severe operations without being "conscious of anything more than a pleasant dream." In my hands, pure ether has been widely administered during the last four years; but for some months past, I have resorted to it mixed with Chloroform in the proportion of one part of the latter to five of the Ether, and I have yet to see the first patient in whom evil has undoubtedly resulted from its use. But in addition to the individual experience of many of our coun- trymen,* every surgeon now possesses the firmly grounded evidence of the large European hospitals. In St. Bartholomew's Hospital, in London, upwards of nine thousand cases have been recorded, in not one of which, including young and old, the healthy and the infirm, has the employment of the anaesthetic (chloroform) left the least stain upon its character as an agent for good.f But although this success is very marked, personal experience, and that of many professional friends, have created such doubts of its safety that in this locality ether, or the compound of ether and chloroform before mentioned, is more frequently employed. In the administration of Anaesthetics, almost any article will answer for the application of the vapor to the mouth of the patient, such as a hollow sponge, towel, or handkerchief. But, as these agents are exceedingly volatile, much is wasted when they are thus employed; in addition to which, I have myself been affected by extreme lassitude from breathing the atmosphere around the patient when administering them in this manner during a prolonged etheri- zation. I prefer, therefore, the use of a tin cone, like Plate II. Fig. * See Bibliography. f Skey's Op. Surg., Phila. edit., 1851, p. 31. 24 OPERATIVE SURGERY. 1, as it prevents this waste, and yet furnishes quite enough fresh air to obviate any inconvenience to the patient. A simple and good contrivance employed by Dr. Horner, of Philadelphia, is the old-fashioned powder horn, or a nicely-dressed cow's horn; the sponge being placed in its largest extremity, while the smaller end is inserted in the mouth of the patient. The effects of anaesthetic inhalation have been described by Dr. Warren as follows:— "On inhaling Ether the respiration is at first short and quick; and apt to be followed by a cough or gasp which induces the patient to refuse the inhalation." When the ether is combined with chloroform in the proportions above mentioned, this temporary irritation is less frequently noticed. " The bronchia becoming ac- customed to the vapor, the respiration becomes fuller and slower, till at last the inspiration is taken to the fullest extent, when, as etherization is induced, it becomes slower and comparatively feeble. " The pulse at first is quickened, but soon begins to diminish in frequency, and ultimately becomes slow, till it counts even as low as forty or fifty in the minute. "As soon as the pulse begins to diminish in frequency, the inhala- tion may be checked and the soporific effect of the vapor care- fully noted. The face and neck will soon be seen to become flushed and heated, and the action of the heart to be strong and vibrating. The conjunctiva is also apt to become temporarily injected; the eye vacant and listless, and the patient soon loses all control over vision. "The muscles are often excited at first, and their increased action sometimes makes the patient troublesome until perfect etherization is induced."* But with the mixture referred to above, this muscular excitement is less frequent. In either case, however, a serious opera- tion should not be commenced until this stage has passed, and a slight continuation of the inhalation will soon remove it. "Dr. Simpson has observed that to produce the full and perfect effects of etherization, certain conditions are necessary. First, the patient ought to be left in a state of absolute quiet and freedom from mental excitement, both during the induction of etherization and during his recovery from it. All talking and questioning should be strictly prohibited. Secondly, the primary stage of exhilaration should be entirely avoided, or at least reduced to the slightest pos- * Etherization, by John C. Warren, M. D., Boston. DUTIES BEFORE OPERATING. 25 sible limit, by impregnating the respired air as fully with the ether vapor as the patient can bear, and by allowing it to pass into the lungs both by the mouth and nostrils, so as to superinduce rapidly its anaesthetic effect."* A concordance in the correctness of these views is also another reason why I prefer the use of the cone to the simple sponge, as the current of a very volatile agent is thus more readily circum- scribed, whilst the proper amount of atmospheric air is not ex- cluded. As the detailed effects of anaesthetics, and especially its physiological relations, would, however, take more space than can be here accorded them, the reader is referred for further information to the treatises above cited, as well as to several others now generally circulated. To Dr. John C. Warren, to whose judgment in its first trial the world is indebted for the recommendation of it in surgery, I would especially refer for the details of its administra- tion ; whilst the treatise of Dr. Simpson will be found to present ex- tended statistics and a special description of its application to obstetrics as well as surgery. The local arrangements requisite for the performance of the opera- tion should next claim attention—such as the preparation of the parts to be operated on, and the means that may be likely to facilitate its performance. These measures may be summed up in two rules: 1st. To remove everything that can impede the operative proceed- ings. 2d. To employ such means as will especially facilitate them. In observing the first rule, the operator must necessarily be directed by the peculiar circumstances of the operation: thus, a contracted pupil will interfere with the operation for cataract; a distended rectum increase the dangers of lithotomy; whilst the pre- sence of hair about the part may render the dressing difficult, cause irritation from discharges, or possibly lead to erysipelas. Under the second head, or the direct efforts proper to facilitate the accomplish- ment of the operation, may be placed the removal of all unneces- sary clothing, and especially of any that is tight at the neck—as close-fitting jackets or shirts; the cleansing of the part from plasters and poultices; and the employment of such"means as will tend to secure the safety of adjoining organs, or render those operated on more prominent—as the injection of the bladder in lithotomy and lithotripsy, or the retention of urine in similar cases. Attention to * Simpson on Anaesthesia, p. 27. 26 OPERATIVE SURGERY. such a position of the part as will tend to drain it of blood, will also occasionally be required—as in large pendulous tumors or diseases of the extremities, where elevation of them often prevents much unnecessary depletion. § 2.—Duties during the Operation. The duties of a surgeon during an operation embrace two distinct portions: first, those which are requisite for himself, and which, as he acts solely for the benefit of the patient, may be justly placed in the front rank; and, second, those requisite for the comfort and safety of the individual operated on. Among the first of the surgeon's duties to himself, during an operation, is certainly a perfect degree of preparation for that which he is to execute. In addition to his professional acquirements, as a knowledge of structure, or of mechanical skill as an operator, he should also in capital operations, or those of great delicacy, give some atten- tion to the state of his own system. Without a sound condi- tion of his own body, no surgeon can be fully prepared to operate upon that of another. Let him, therefore, at least for some hours previous to an operation, abstain from every act, article of food or drink, that can in any way tend to derange his nervous system. Let him secure a proper amount of sleep on the previous night, and, if he desires to have the most perfect control of his fingers, let him also abstain from anything like violent muscular effort immediately before his appointment. The mere exertion of lifting the patient, or of driving a hard-mouthed horse, will in some persons be quite sufficient to impair the entire command of their muscles, though others of a coarser mould may possibly find such attention to per- sonal details perfectly unnecessary. It may also, perhaps, be thought useless to refer to the propriety of abstinence by medical men from nervous stimulants, on all occasions ; but, as steadiness of hand is peculiarly important to a sur- geon, attention to such a point is especially necessary, previous to an important operation. While operating, the surgeon should endeavor to have his eyes and ears, as well as his hands and brain, fully ready for every event; and so intent will a good operator be upon that which he DUTIES DURING THE OPERATION. 27 has to perform, that it often happens that he is perfectly unaware of the patient's cries, or of the affairs which are passing around him, until he has accomplished his object. In the event of any unex- pected change either in the tissues through which he is cutting, or va- riation in the character of the complaint which he intended to treat, every operator should endeavor to remain perfectly self-possessed. If a large vessel suddenly springs, let him remember that it is only neces- sary to compress it with his finger until it can be tied with a ligature. If a tumor has deeper attachments than was anticipated, he has only to free it from these parts, instead of those for which he commenced his operation ; if it proves to be of a different character from what it was supposed to be, let him think that he can accomplish this as readily as that which was at first proposed. If his hydrocele prove to be a sarcocele, let him, if necessary, at once proceed to the extirpation of the testis; but under no circumstances let him for a moment sup- pose that anything has occurred which his skill and coolness cannot remedy. If the patient faints, he knows that it is a simple matter, and that lowering the head and stimulants will soon revive him. If convulsions supervene, as in trephining, is it not an additional reason for the more prompt application of his remedial measures? If, un- fortunately, air enters into a large vein, will not the prompt pressure of the thumb arrest its progress to the heart, and subsequent manipu- lation expel it from the vessel, or prevent serious injury ?* In fact, let what will occur, the surgeon who undertakes an operation is totally unfit for his duty if he cannot, by these or similar views of serious difficulties, preserve sufficient equanimity to meet them. Although he may not be able to acquire the entire philosophy of the Stoics, some cultiva- tion of it is certainly desirable, and such stoicism is not rashness, nor yet total indifference, but only that state of mind which the French have justly termed "sang froid," a phrase which presents us with a most apt expression of the consummate coolness that always characterizes a good operator. How to gain it, cannot be told. In some men it is intuitive; but it may also be most certainly acquired by practice; and nothing within my experience is more conducive to it than the fact of an operator duly weighing before- * See case reported by Dr. R. D. Mussey of Cincinnati, in which the effects of the entrance of air into the subclavian vein was relieved by the application of stimulants to the nostril, &c.—Am. Journ. Med. Science, vol. xxi. p. 392, Phila. 1837. 28 OPERATIVE SURGERY. hand every accident that can possibly, not probably, happen. When prepared for danger, it loses more than half its paralyzing power; and when a young surgeon is so situated as to be able to avail himself of the lessons furnished by observation of the habits and course of action of his seniors, let him embrace them as hours full of value, and of an importance which naught but subsequent experi- ence will enable him justly to estimate. Another portion of the surgeon's duties, during the operation, will be found in the various positions and manoeuvres he will be required to execute, all of which should be duly settled before he commences. But as these points vary much under different circumstances, the details can be best given under their proper head. The credit attached to certain operators, in reference to the rapidity of their operations, presents another point to which, at this period, attention may well be directed. " If it were done when 'tis done, then 'twere well it were done quickly," is the rule apparently of some who enter the surgical arena, and who think only of that portion of the sentence in which reference is made to time. But though this may suit the spirits of those who, in true Shakspearian style, look upon an operation as a dramatic exhibition, it is certainly not adapted to those of others who, with a more reasonable view of responsibility, regard the interests of the patient as paramount to everything else. Safely at all events, quickly if you can, is the constant motto of a considerate operator; and the slow and sure will very often prove the quickest in the end. During the operation, the surgeon's duties to the patient are very much limited to those just enumerated in connection with himself. The Assistants must necessarily do much towards relieving the wants of the patient; they should give him drink, and revive or restrain his irritability according to circumstances ; but the operator should leave such duties to them, and confine himself strictly to his own acts, or simply encourage his patient by voice and manner as he proceeds. The duties of assistants will be detailed hereafter. § 3.—Duties after the Operation. Notwithstanding the possession of all the qualifications and skill which have been detailed as essential to an operator, the best ope- rations will be likely to fail, unless the surgeon is also equal to the DUTIES AFTER THE OPERATION. 29 performance of the duties which ensue upon its completion. The pro- per application of the dressings ; the judicious employment of reme- dies to counteract the violence necessarily caused by the operation; the arrangement of the bed, the position of the patient, and of the part operated on ; the resort to stimulants, the encouragement of san- guine anticipations; the calm of sleep, together with diet, &c, are but a few of the points to which his attention must now be given. To the well educated surgeon, reference to such details may seem to be a work of supererogation. But to the less accomplished or experienced operator, or to practitioners whom circumstances compel to act the part of a surgeon, the recapitulation may not be without its value. As a general rule, most of these duties may be summed up under one direction, to wit: the observance of such a course of treatment as any good physician would naturally direct, even if not possessed of surgical experience. A few of them, however, embracing matters essentially surgical, seem to demand a closer examination, especially the resort to stimulants, diet and exercise. In respect to stimulants and diet, as all rules must be dependent on the object to be attained by the operation, it becomes difficult or impossible to establish any one law which will be applicable to all cases; and yet a mistake in relation to this most important part of the after-treatment may cause the failure of all previous arrange- ments. It may, however, be said that, generally, an operator will not err in this part of his duty, if he bears in mind the great prin- ciples of all ^ound practice, viz., Inflammation. Is the wound to heal by the first intention, or by granulation? Is the object of the operation to be attained by exciting inflammation, or will its deve- lopment destroy the result ? Is the action to proceed simply to effusion of lymph, or to suppuration? Is the exercise of the part operated on essential to its cure, as in strabismus, or is its perfect rest necessary to success, as in false joint ? These and similar inter- rogatories will soon settle the doubts of any well-trained medical mind in these details. As respects the proper diet of a patient after an operation, much will of course depend upon the replies made to the above questions; but in many operations, such as amputations, removal of tumors, and re-sections, where moderate vascular excitement is not likely to result in hemorrhage, a surgeon may err by placing a patient upon a restricted diet, either before or after an operation. In some instances, the change from ordinary food to a strict diet is alone 30 OPERATIVE SURGERY. sufficient to disorder the digestive organs, affect the circulation, and derange the nervous system, even where no other cause is liable to act on the patient's general health. How likely, then, is it to do harm, when, in addition to change of diet, the shock of the operation is conjoined with the other perturbating causes. In most instances, and especially where common prudence does not demand it, the operator should therefore make no other change in the previous diet of the patient than simply to restrict the quantity. Indeed, in many instances even this will do harm, especially if it is combined with purging. An increase both in the quality and quantity of the nutriment often proves not only useful, but absolutely necessary, especially if strict attention is at the same time paid to the regular daily alvine and urinary evacuations. In many instances I have known patients to become feverish, irritable, and with a furred tongue whilst on a diet or purged, who were promptly relieved by quinine, porter, and beefsteak; but much judgment is requisite in this part of the surgeon's duty. A full diet will not answer as a universal rule; but, with attention to the state of the system before the operation, to the wasting effects of the disease or of the wound, and especially to the purely local disorder caused by a certain class of operations, good diet will prove most useful, and the continuance of nutritious food after an operation be more serviceable than the routine practice of depletion before, and low diet for three or five days subsequently. A routine practice in any complaint is always bad, and in this respect American surgeons have perhaps followed too closely the precepts of their European brethren, forgetful of the different habits of our people, and of the daily developments of science. Meat, and that often in large quantities, is the daily food of all the laboring classes, as well as of many others, in the United States, whilst thin soup, salad, and wine is the diet of most of the same class on the continent. Low diet is, therefore, not so great a change to them as it would be to patients in this country, and the American surgeon may in many instances advantageously pursue a practice more in accordance with his own locality. In recommend- ing a fair or even full diet, that is, a moderate allowance of meat and ordinary food after operations, I do not wish to do more than sug- gest its value; circumstances must restrict its application, and in some instances do this very rigidly, as after trephining, in cataract and in hernia. But in-operating for the removal of tumors in the breast or PREPARATION OF INSTRUMENTS. 31 extremities, or in the case of patients who whilst in full health are suddenly injured, and especially in operations consequent on chronic diseases, a moderate amount of ordinary animal food for the first three days, and then a tolerably full diet, will often prove most con- ducive to a successful result, particularly when employed with judg- ment. SECTION II. PREPARATION OF INSTRUMENTS. Although a good operator can doubtless accomplish his object with any instrument that he can obtain, yet few would, therefore, desire to neglect, or be justified in neglecting, the attentions referred to under this head. A common instrument with a skillful workman will do more than the best one that can be placed under the direc- tion of an ignoramus; but even a skillful workman will obtain a more perfect result by collecting and preserving such as are requisite for his daily wants. In this division of his general duties, the surgeon's attention should, therefore, be bestowed on the selection, preparation, manipu- lation, and preservation of his "mechanical therapeia." § 1.—Action and Selection of Instruments. In selecting his instruments, every operator must be mainly guided by the wants of his own position. As a general rule, his attention should be first bestowed upon the character of the steel, its temper, finish, and shape. Very many of those who begin life in expectation of devoting themselves to surgery, commit the mistake of purchasing a cheap article instead of a good one, and soon have reason to repent of their bargains. Poor steel cannot be made to keep an edge, and constant sharpening, independently of the diffi- culty arising from want of skill, soon renders it useless. Good steel is a more costly article at first, but the cheapest in the end, and, like a true friend, never fails in the hour of need. Attention to this fact is the more necessary in the United States from the great number of surgical instruments now hawked over the country, and 32 OPERATIVE SURGERY. which, like Peter Pindar's razors, are only made to sell. Every operator should, therefore, exercise some caution in the selection of his cutler, and even with the best makers, he will find some exer- cise of judgment necessary in obtaining his instruments. Fashion often perverts the utility of a knife as well as of other articles, and a knowledge of the action requisite in the instrument will, therefore, materially aid in its choice. To assist the decision of this matter, special care has been bestowed on the delineation of those hereafter represented, so that any one, by consulting the plates, can see a specimen of such as are at least capable of performing their duty;* but in selecting all instruments, the observation of the quality of the steel, and not the brilliant appearance of the work, will tend to pre- vent most errors of this kind. § 2.—Preparation and Sharpening of Instruments. Where an operator is so situated as to be able to avail himself of the services of a cutler, this portion of his duty may be advantage- ously placed in other hands; but, under different circumstances, or where he desires to save expense, he will soon find it an easy matter to accomplish perfectly the sharpening of the greater por- tion of his own instruments, and especially those which are in most constant use. Preparatory to attempting the sharpening of any instrument, it is necessary that the principle of its action should be thoroughly un- derstood and that a good stone be obtained, as well as a strop or piece of soft leather. The action of every knife is beyond doubt the same as that of a saw. No matter how fine the edge of a knife may be, a magnifying glass will show points corresponding with the teeth of a saw; and a saw, to cut well, must be set so as to act chiefly in the reverse direc- tion to that in which it is drawn, seldom cutting both up and down with equal facility. The teeth in the scalpel being intended to cut by being drawn over the tissue in a manner similar to the upward motion * To add to the value of these drawings, they have generally been made in accordance with the patterns of Mr. Chas. Schively, cutler, of South Eighth Street, Phila., a gentleman long identified with the operative surgery of the country, and to whom many of our most distinguished surgeons are indebted for the means by which they have accomplished their most important operations. PREPARATION AND SHARPENING OF INSTRUMENTS. 33 of the saw, their edge should be set forwards in sharpening, or from the heel to the point. In the application of the blade to the stone, such motion must, therefore, be given to it as will draw its cutting surface in this direction, the blade being kept at an angle of from 5° to 15° with the surface of the stone, so as to create the proper edge, and yet preserve the polish of the instrument. Every knife being also more or less wedge-shaped, that is, thick upon its bad»and tapering to its edge, the sharpness of the wedge will con- stitute the keenness of the blade. The flatter, therefore, the blade is placed, provided it is not below 5° with the surface of the stone, the more delicate will be the angle produced in the friction of sharpening, whilst the more elevated the back, the greater the pressure on the edge; so that, after this elevation passes an angle of 20°, it will be apt to result in a blunt, rounded or dull surface. When, then, with a good stone (and in the United States there is nothing superior to those of Arkansas or Missouri), the operator wishes to give his scalpel a keen edge, let him proceed as follows:— Place the blade very nearly flat upon the surface of a stone, which has a smooth and well ground face, after it is lubricated with oil, and, holding the handle with the hand in a state of semi-pronation, push the blade, with its edge forwards, across the stone (Plate I, Fig. 12); then turning the hand into semi-supination, draw it from heel to point with its edge towards the operator, over to the point of de- parture, bearing on lightly or heavily, according to the amount of grinding to be accomplished (Plate I, Fig. 13). As a general rule, the harder and closer the grain of the stone, the flatter the blade is applied to it, provided it is not below 5°; and the lighter the pressure, the keener and smoother will be the edge. After repeat- ing these movements until an edge is obtained, as may be tested by shaving the thick skin on the palm of the hand, draw the blade upon the strop or leather in the same manner as razors are sharpened for daily use, and in the reverse manner to that employed on the stone —that is, with the back of the blade presenting to the most distant end of the strop. In sharpening pointed instruments, such as cataract needles, tro- cars, and gorgets, the same principles hold good, although some extra attention to the shape and character of their cutting surface will be required in order properly to adapt them to the stone. As a trocar acts very much on the principle of the chisel, the mode in which that instrument is sharpened by the carpenter will answer, provided the 3 34 OPERATIVE SURGERY. PLATE I. A SIDE VIEW OF SOME OF THE INSTRUMENTS EMPLOYED IN MAKING INCISIONS AND DISSECTIONS, IN THE EXTIRPATION OF TUMORS AND THE LIGATURE OF ARTERIES. These drawings are from the instruments, and about one-third of the natural size. Fig. 1. Tumor Forceps. Schively's Pattern. Fig. 2. Artery Forceps, the blades closed by a spring. " " Fig. 3. Liston's Forceps or "bull-dog." " " Fig. 4. Ordinary Dissecting Forceps. " " Fig. 5. Savigny's Tenaculum for carrying a ligature around deep-seated arteries. " " Fig. 6. Ordinary Tenaculum for taking up arteries after operations. The curve of this instrument is often incorrectly made, and the present one has therefore been carefully selected. Fig. 7. A Silver Director. Charriere's Pattern. The advantage of silver over steel will occasionally he found in its being flexible, and thus adapting itself more readily to tortuous sinuses. Fig. 8. Operating Scalpel, medium size. Schively's Pattern. Fig. 9. Operating Scalpel, small size. " . " Fig. 10. Sharp-pointed Straight Bistoury. " « Fig. 11. Sharp-pointed Curved Bistoury. " « Fig. 12. Position of the scalpel in the first motion of Sharpening. Fig. 13. Position of the scalpel in the second motion of Sharpening. MINOR CASE OF INSTRUMENTS. A complete and compact case of the instruments required for most opera- tions, exclusive of lithotomy, trephining, cataract, or amputation, may be formed by combining the following: 1 Probe-pointed Curved Bistoury; 1 Sharp-pointed ditto; 2 Scalpels curved on the flat, one of which should have a double edge; 4 Operating Scalpels (1 large, 1 medium, and 2 smaller); 1 Tenaculum; 1 Savigny's Tenaculum; 1 Pair of Dissecting Forceps; 1 Eyed Probe;—all in a movable tray. 1 Physick's Forceps and Needle; 1 Polypus or Shot Forceps; 1 Tumor Forceps; 1 Pair of small Bone Nippers; 2 Curved Spatula}; 2 coils of Silver Annealed Wire; 3 Straight and 3 Curved Needles of different sizes; 1 dozen wire Hare-Lip Pins;—in the bottom of the case. 1 Pair Straight sharp-pointed Scissors; 1 Director; 1 large Double Canula of Levret, for Polypus; 1 small Canula for Hemorrhoids;—in the top of the box. These instruments will be sufficient for the operations of Hernia, Polypus, Fistula in Ano, Hemorrhoids, Hare-Lip, Ligature of Arteries, and the Extir- pation of Tumors. MANIPULATION OF INSTRUMENTS. 35 point is kept flat to the stone—and the same manoeuvres will be applicable to cataract needles and gorgets when the edges have be- come very round: but under other circumstances it will be better to manipulate with them in the manner described in sharpening the scalpel. When an instrument has acquired a rounded and blunt edge, grinding will generally be found necessary, and, in most instances, this should be confided to the cutler, though the surgeon may ap- proximate the same end, by steadily rubbing the blade upon a coarse stone, and then proceeding to finish its edge by using one that is finer, or even a strop. § 3.—Manipulation of Instruments. Few of the qualities of an operator are more quickly noticed by a spectator than the facility or even grace with which his movements are executed. But although this ease in manipulating is highly advan- tageous to the patient and a valuable accomplishment to an operator, directions in regard to it would be out of place at present, and can be more readily comprehended in connection with each operation. The principles which should govern the movement of cutting instruments in all operations, may, however, be briefly noticed. Scalpels, bistouries, and amputating knives, acting simply as saws, will be found to cut with the greatest facility when drawn regularly, and with moderate but steady pressure, over the part to be divided. When, therefore, in using a scalpel, it is desirable to make a clean and smooth cut, the motion given to the instrument should be one of simple traction, effected by flexing and extending the thumb and fingers in very much the same manner that a pen is moved in writing, any great amount of motion in the wrist being unnecessary. Indeed, as a general rule, the wrist joint should never participate in the motion of a scalpel, except when it is requisite to change the course of an incision, or make it of extraordinary length, and even under these circumstances a neat manipulator will seldom feel the necessity of moving it. If the wrist is permitted to take part in the movement of dissecting, chopping or hacking of the tissue will usually result, or such a division of parts as might be effected by an axe, but not by a saw. 36 OPERATIVE SURGERY. Scissors, being formed of two blades, are designed to act like two scalpels pressed together; consequently, in dividing very dense structures, a slight drawing motion enables them to cut better and with less contusion of tissue, than the exercise of any great amount of force in closing the blades. Instruments specially required for punctures are fortunately few in number. Like the chisel, they necessarily compress or contuse the parts at their point of entrance, and should, consequently, always possess a keen edge and be introduced gradually. The stabbing motion sometimes given to trocars or gorgets is usually indicative of ignorance of these principles on the part of the ope- rator, and nearly always induces more or less sloughing at the point punctured. A sudden elevation of the operating hand from the surface on which it should be supported is also an error occasionally apparent in operators when using the scalpel, and especially of such as study the art of manipulating with a view to the gracefulness of the movement, rather than as an auxiliary to the perfect action of the instrument. Like a similar motion on the part of pianists, it may be deemed captivating, but as it necessarily draws the knife from the portion on which it is acting, it is worse than useless, and should be avoided. A neat operator may be characterized as a good dissector, who accomplishes his task with certainty and mode- rate quickness, and the motions of a good dissector are certainly not of the jumping order, but, on the contrary, result from the regu- lar movements of his fingers in flexion and extension. All manipu- lation of cutting instruments, to be well executed, should therefore be entirely accomplished by these motions of the fingers, or by those of a hand which moves as if balanced at the wrist. The motion of the elbow can never be required in using a scalpel, and seldom with any other instrument, except the saw or amputating knife. Great flexibility of the fingers, and the power of causing three or four of those of the same hand to perform different acts at the same moment, will also add much to the neatness of a surgeon's manipulation. Thus, the thumb, and first and second fingers, may hold the scalpel in dissection; the little finger serve as a point of support; and the third finger be made to stretch a tissue, hold back a flap, or serve as a fulcrum at the same moment—the difference of power possessed by some operators over others being often shown in the facility with which they accomplish these movements. A thick, clumsy, and heavy hand can never make a neat operator, though study of its motions, together with constant MANIPULATION OF INSTRUMENTS. 37 practice, may do much to remedy it. The ability to use the left hand nearly as well as the right is also occasionally not only an accomplishment, but also a most useful qualification in an operator, and a little practice in the daily acts of life, as in carving or dressing, will soon enable any one to acquire it. In order to facilitate his manipulations, the operator will also find it advantageous to arrange his instruments upon a waiter or tray in the order in which they will be required for service, previous to commencing an operation. In doing this, he should pass in review the different steps of his operation, so as to note immediately the absence of any one that may be required. By placing a napkin upon the tray, so as to pre- vent the blades touching any hard substance, he will also do much towards the preservation of their edges, and be prepared to act with them in the most advantageous manner. In hospital service, a board is usually kept prepared for this purpose, and will al- ways be found to answer very well. Upon this the operator should spread a napkin, and then, if about to perform a circular ampu- tation, place upon it his tourniquet and bandage, with a pin and scis- sors ; then the amputating knife; then a scalpel to dissect back the skin; then a small catlin for the interosseous space, if the limb has two bones; next, a retractor to protect the soft parts when sawing the bones; then the saw; next, the bone nippers, and then the te- naculum and ligatures. It is also a good rule to have at least two of all such instruments as are liable to be injured or rendered unfit for service during the operation. Some surgeons, especially in public institutions, very properly confide the arrangement of their instruments to an assistant; but, when this is done, they should carefully overlook the tray before commencing the operation. Another tray, containing the anaes- thetic, the bandages and other portions of the dressings, as sponges, basins, and stimulants, should also be close at hand; and if the room admits of it, one tray may be placed so near the operator that he can help himself to his instruments: but, if this is not desired, a special assistant may hand them to, and receive them from him according to directions which should always be given previously, and no other person should be allowed to touch either board, after the commencement of the operation, lest confusion be created by several persons attempting to reach them at the same moment. 38 OPERATIVE SURGERY. PLATE II. DRAWINGS OF INSTRUMENTS FOR ARRESTING HEMORRHAGE, EXTRACTING POLYPI, ETC. Drawn from the instruments, and about one-third the natural size. Fig. 1. A silver plated or tin Cone for Inhalations. Fig. 2. A Compressor for deep-seated arteries, or Signoroni's Tourniquet. Fig. 3. Physick's Artery Forceps and Needle, invented in 1800. Schively's Pattern. Fig. 4. Straight Needles of different sizes. " " Fig. 5. Curved " " " " " Fig. 6. Small Bone Nippers, for excising the ends of the steel hare-lip pins. " " Fig. 7. A silver Hare-lip Pin with the movable steel point. " " Figs. 8, 9. Steel Hare-lip Pins, made of wire sharpened at the point. " " Fig. 10. A side view of a Curved Spatula, made of copper and plated. The two curves are intended for wounds of different depths. This is a most useful instrument for holding back the sides of a wound when operating for the ligature of arteries, or removing deep-seated tumors. Schively's Pattern. Fig. 11. Levret's Double Canula, with the wire ligature employed by Dr. Physick for the removal of nasal polypi. A smaller canula, which should be only two inches long, was employed by the same surgeon for the strangula- tion of hemorrhoids. Schively's Pattern. Fig. 12. Polypus and Shot Forceps. " " Figs. 13, 14. Cauteries of different shapes, intended for operations on the bones of the face. These cauteries should only be heated to a red heat, and applied very lightly to the bleeding surface, so as to produce shrinking of the vessels, but not a deep eschar. I'liltl- -i THE OPERATOR'S DUTIES TO HIS ASSISTANTS. 39 § 4.—Preservation of Instruments. A few words in relation to this apparently simple portion of an operator's general duties may, perhaps, save the younger surgeon some vexation. No matter how finely polished instruments may be, as received from the cutler, unless an operator is attentive to this minor point, he will soon find them out of order. Thorough cleansing after operating is, of course, essential to their preservation, and every surgeon should, therefore, either wipe and thoroughly dry his instruments himself before putting them away, or examine them closely, if the duty is performed by another. In keeping instruments ready for use, attention to the place of deposit is also necessary, as sometimes there is a slight dampness in a closet, which will soon tell even when the cases are closed per- fectly, and which will be certain to create rust when instruments are put away without a case. Even in a warm and apparently dry room, I have known my eye instruments to be so affected by moisture as to become rusty. A practice which is pursued to some extent in the preservation of instruments, is also one which frequently destroys or impairs their utility, viz., oiling or greasing them when replaced in the case. This custom, as well as that of anointing the blades with mercurial ointment, may serve a good purpose on board ship or near the sea shore if very lightly done; but, under ordinary circumstances, the development of acid in the chemical change of the article, especially when it becomes rancid, will soon do quite as much towards rusting a blade as a damp atmosphere. The most certain preservative in my experience has been, first, to render each instrument perfectly dry; second, to keep it well wrapped in soft paper or cotton; and third, to place it in a close box, and wrap this thoroughly in hardware or thick brown paper. These precau- tions, however, can only be required by such instruments as are not in constant use. SECTION III. THE OPERATOR'S DUTIES TO HIS ASSISTANTS. In every important operation, the value to the patient of the services rendered by good assistants may be regarded as nearly 40 OPERATIVE SURGERY. equal to those of the operator, the responsibility of the surgeon being much increased, and his labor greatly augmented, when com- pelled to act by himself. In addition to their ordinary duties, the necessity for one of them taking the principal part occasionally occurs, as in the event of cramp or embarrassment in the operator ; and under such circumstances a good assistant is essential to the welfare of the patient. Every operator should, therefore, thoroughly reflect upon the cha- racter and qualifications of those whom he selects to assist him, as well as upon the duty they may have to perform, choosing them not only with reference to the physical, but also to the moral, support that they can furnish him. A doubt may arise as to the character of the tissue operated on, or as to the propriety of continuing the operation, and in all such cases the decision of the question may depend on the skill and judgment of the assistants, if they happen to be medical men. § 1.—Selection and Instruction of Assistants. In selecting assistants, every surgeon will of course be guided by his peculiar position; but if he can obtain the services of his pro- fessional brethren, and especially of those with whom he is on inti- mate terms, he will doubtless select them. Where, on the contrary, this is not the case, and he is compelled to resort to strangers, and especially if, in addition, they are to be selected from the friends of the patient, he should be especially cautious in his choice. Many who are very brave before an operation, find their sang-froid fail them after a little blood is lost. Others are sickened by smells or by the flow of blood, and rendered worse than useless, by requiring for themselves the attentions that are due to the patient. Others, again, even among medical men, are so little conversant with the details of operative surgery as to require instruction, or, when this is not necessary, are so clumsy in the use of their fingers as to put them constantly in the wrong place. Very few physicians are able to tie a ligature quickly, simple as it appears to be; and an operator should, under such circumstances, anticipate extraordinary difficul- ties, and prepare himself to meet them. As, however, it is impossi- ble to give more than general directions on this subject, the surgeon must regulate his action according to the wants of the moment. ELEMENTARY OPERATIONS. 41 One rule may certainly be laid down as applicable to all cases, even where the surgeon is fortunate enough to be aided by the pre- sence of those on whom he can rely, and that is, always to explain to those who are to participate in the operation the method to be pursued, and the special duty that will be assigned to each, before commencing to operate. Few operations in surgery are so limited in their character as to be amenable to any universal law, and the peculiar views of each operator should therefore be distinctly express- ed, even to his colleagues, before the operation is commenced. After informing each assistant of his duty, the surgeon should subsequently endeavor so to arrange his own movements as not to encroach upon the parts previously assigned to others. Occasionally, good surgeons err in this manner, and delay their operations by endeavoring to do everything themselves, instead of relying upon their assistants for the performance of the duty previously assigned them. When good assistants are to be obtained, let them by all means be trusted, and the patient will be sure to benefit by the division of labor. The instructions and special duties required of assistants will be referred to in connection with each operation. CHAPTER II. ELEMENTARY OPERATIONS. Under this head are embraced such general manipulations as constitute the primary portion of every operation, and especially of those necessitating a division of the integuments, such, for example, as Incisions and Dissections, arrest of Hemorrhage, together with the closing of the part and its Dressing. Although every surgeon, in passing through his anatomical studies, necessarily acquires a certain degree of skill in making incisions and dissections, yet a re- capitulation of the ordinary rules required for their proper perform- ance may correct such faults, either of carelessness or ignorance, as have been unwittingly acquired. The details of each act, and the varying positions of the knife usually described by French writers, have, however, little of sufficient value to justify their repetition, except that the employment of a numerical system in the position 42 operative surgery. of the scalpel is advantageous by saving repetition in the description of the same act in different operations. SECTION I.' INCISIONS WITH THE SCALPEL OR BISTOURY. The Scalpel usually employed in operating resembles, in most points, that generally found in the dissecting case. Its function is, indeed, the same in both instances, though there is a difference of opinion as to the best shape of its blade, some surgeons preferring one that is somewhat angular towards the point, and others liking it better when made with a greater degree of convexity. In either case, the blade should be firmly fastened to the handle, and the latter made plain and tolerably smooth, not only because this is more favorable to accuracy of touch, but also because it can be more readily cleansed. On the latter account, the serrated handles some- times placed on scalpels are objectionable. The most common positions of the scalpel, in operating, are the six following, as employed by the French surgeons:— First Position.—Hold the scalpel in the position of a carving knife, that is, with the handle in the palm of the hand and the fore- finger pressed upon the back of the blade, and make the incision by bearing firmly on the blade with the forefinger (Plate III, Fig. 1). This position gives the operator an opportunity of exerting consider- able force, and is well adapted to the first incisions in dense tissues, as in excising a scirrhous breast, or in the removal of an osseous or fibrous tumor, or in the division of ligaments or tendons and mus- cles, as in disarticulating joints. Second Position.—Hold the scalpel with its edge upwards, and, puncturing a fold of the skin, incise it from within outwards, by ele- vating the point with the thumb and finger, pressing the handle against the palm with the other fingers (Plate III, Fig. 2). Pre- vious to employing the scalpel or bistoury in this position, an assist- ant should be directed to raise a fold of the skin so as to free it from the subjacent parts. When the integuments are thus divided, there is but little risk of injuring deep seated parts, and also less pain caused to the patient than when the incision is made from without inwards, as in ordinary dissection. incisions with the scalpel or bistoury. 43 Third Position.—Hold and move the scalpel very much like a pen, the point and edge being pressed downwards with sufficient firmness to enable them to divide the parts to the desired extent. In com- mencing an incision, the point of the blade should be inserted into the tissue by a perpendicular pressure of the fingers in an extended position, and then drawn firmly towards the operator by strongly flexing the fore and second fingers (Plate III, Fig. 3), the incision being terminated by a perpendicular pressure of the blade at the point where it is wished to stop, in order to prevent the irregular scratch of the skin, or that mark which the French call "a tail." Fourth Position.—Hold the knife nearly in the same position as a pen, but with its cutting edge upwards, so as to cut from the ope- rator (Plate III, Fig. 4). Both this and the third positions are constantly required in every operation in which dissection is neces- sary, as in the removal of tumors, ligature of arteries, &c. Fifth Position.—Hold the scalpel by placing the thumb on one side of the handle while the four fingers are approximated on the other, like the position of a fiddle-bow (Plate III, Fig. 5). This position is well calculated for incisions requiring delicate touches of the knife, as in the division of tissues over large vessels and other important parts. Sixth Position.—Hold the scalpel or bistoury with its edge to the palm of the hand, so as to cut towards the operator, the tissue, if near important parts, being raised upon a director (Plate III, Fig. 6). The multiplication of these positions of the scalpel may be carried to any extent, but those most frequently required will be found to be such as have just been detailed. In every case where dissection is requisite, it is important that the parts to be divided should be kept upon the stretch, either by holding them with the forceps, or, where the portion is of sufficient size, by seizing them with the thumb and fingers of the hand opposite to that which holds the scalpel. Wherever, in incising the skin, it is desirable to make a regular and smooth cut, the integuments in the neighborhood should be kept quite smooth or prevented from yielding before the pressure of the scalpel, either by the operator placing his thumb on one side, of the line of incision, and his fingers on the other, or by em- ploying the hands of assistants. In limited incisions, the left hand of the operator is sufficient; but in those of greater extent, as in the removal of a breast or large tumor, those of assistants will be 44 operative surgery. PLATE III. THE SIX positions of the scalpel employed in INCISIONS AND dissections. Modified and drawn from Bernard and Huette. Fig. 1. First Position. The Scalpel held as a carving knife, and cutting from without inwards. In this position, the thumb and radial side of the second finger should be placed at the rivets in the handle; the ring and little finger shut the back of the handle into the palm of the hand, and the fore- finger rest upon the back of the blade. The farther this finger is extended upon the blade, the greater will be the amount of force that can be displayed by the operator. Fig. 2. Second Position. The reverse of the preceding. In this position, the thumb and forefinger should be placed at the sides of the handle near it3 junction with the blade, and the middle, ring, and little finger press the belly of the handle against the palm. The blade being thus turned upwards, the surgeon can readily divide the most resisting tissues from within outwards, a fold of the skin having been raised in the fingers of an assistant previous to its puncture. Fig. 3. Third Position. The Scalpel held as a pen, being the ordinary position of the instrument in dissecting. The tissues to be divided are represented as being stretched by the forceps. Although this position is designated as that of the pen in writing, the scalpel should not be held by its blade, but by its handle, or rather at the line of junction of the two; and the motion of flexion in the fingers is the only one that causes the knife to cut in this position. Fig. 4. Fourth Position. The Scalpel held as a pen, but cutting from the operator. This position is therefore the reverse of the preceding. Fig. 5. Fifth Position. The Scalpel held as a fiddle-bow; the pulps of the four fingers being extended in a line along one side of the handle, and the thumb placed on the opposite side so as to correspond with the position of the point of the second finger. This position is a very easy one, and admirably adapted to the execution of light incisions, as in dividing the tissues over important parts. Fig. 6. Sixth Position. The Scalpel or Straight Bistoury, as employed upon a Director. In this position, the left hand generally holds the director, and the incision results from the joint movement of the two hands, or the left hand is kept stationary and the fingers of the right strongly flexed. i'late ^^ 6 / I incisions with the scalpel or bistoury. 45 necessary. As the first incision generally causes the flow of blood, one of these assistants may, at the same time, sponge the part so as to facilitate the operator's view of the structure. Incisions may be made of various shapes, thus: a single line con- stitutes what has been termed a simple incision, and that formed by two or more lines a compound one. These compound incisions may be modified to any extent, but usually they are formed by the arrange- ment of straight lines, so as to form cuts like the letters V, L, T, or H, or [, or as a -f, or of curved lines, as the crescent -^s or ellipse 0> or double crescent ^^ (Plate V, Fig. 1). By these, and similar incisions, the skin may be divided into various flaps, which, being subsequently freed from the subjacent parts by dissection, will enable the operator to act according to his pleasure. An important rule in all these incisions is to make them sufficiently long, or even too free at the first cut, as the skin usually heals readily, and a free primary incision facilitates very much the subsequent dissection. Another useful rule in connection with incisions, especially in parts where the cicatrix will afterwards be apparent, as in the face, or on the neck and shoulders of young females, is to make them so that the scar may come in the course of the contractions of the fibres of the neighboring muscles, by which means the cicatrix will be hid in the natural folds of the skin; thus, on the forehead, the incision in the skin should, if possible, be transverse, so as to correspond with the wrinkles created by the occipito-frontalis ; on the cheeks in the line of the levator anguli oris or levator labii superioris alseque nasi; and on the neck in front of, or behind, but in the line of the sterno- cleido-mastoid muscle. Incisions, or the division of parts by the Scissors, require but a few words, as the necessity for employing them is rarely met with. Whenever scissors are to be used for incising parts concerned in operations, they should be held by placing the last joint of the thumb through one ring, and that of the second or third finger through the other, the index or second finger being placed on the side or above the blades. The preference should, however, be given, in most in- stances, to incisions made by the scalpel, where there is a sufficient basis of support, as the latter will generally make a cleaner cut, being susceptible of a keener edge than scissors, which, in the United States, are often imperfectly made even by the best cutlers. The incisions of bone by the saw or bone nippers may be classed under 46 operative surgery. those of the scalpel and scissors, but will be again referred to in connection with the operations on the bones. SECTION II. DISSECTIONS. Dissections, as performed by a surgeon, constitute the greater portion of his operative manoeuvres ; but, as they do not vary from those employed upon the dead subject, the same general rules are applicable" both to them and to the ordinary dissections of the anatomical rooms. 1st. Stretch the part to be divided, and render it perfectly tense. 2d. Incise it by a long steady sweep of the scalpel in the third position, with a motion similar to that made in forming large letters with a pen. 3d. Kemove the blade of the knife as seldom as possible from the line of incision ; so as to avoid scratching, digging, piercing, jerking, or notching the tis- sue. 4th. Obtain in the case of tumors a good hold upon them, before commencing their dissection. This may be accomplished either by passing a needle and ligature deeply through the part, and then forming a loop and removing the needle; or by seizing them with the forceps known as Liston's Bull Dog (Plate I, Fig. 3), or with the tumor forceps (Plate I, Fig. 1), or with a tenaculum, or with the ordinary dissecting forceps, according to the size and structure of the portion to be excised. The looped ligature, being the firmest, will in most instances prove the best adapted to this purpose. If, in the course of a surgical dissection, the tissues to be divided in- volve parts of delicacy and importance, it will be better to employ the director and bistoury, as is shown in the sixth position of the scalpel (Plate III, Fig. 6), for their incision, than to trust to the ordinary motion of the knife, unless the operator is very sure of a steady and light hand. The support of the hand to be obtained by resting the ring and little finger upon surrounding parts, in the third position of the scalpel, will, in these dissections, prove of great service. When, in the course of an operation, small arteries are divided, it becomes a question whether the operator should stop in order to take them up, or whether he should not proceed rapidly to accomplish his object. In deciding this question, much must depend upon circum- PUNCTURES, OR INCISIONS WITH POINTED INSTRUMENTS. 47 stances; but, as a general rule, if the part is superficial and the arte- ries of no great size, as is the case in most operations on the breast, the surgeon may finish his dissection before attending to the hemor- rhage, or may direct an assistant to compress or twist the vessels as they spring, or put his finger on them, and often before the termina- tion- of the dissection, the contraction and retraction caused by the stimulus of the air, or the effect of the latter on the liquor sanguinis, will be sufficient to arrest the hemorrhage. If, in the dissection of complicated or deep-seated parts, the first assistant can not by sponging keep the part free from blood, or if the patient will not be benefited by the depletion, then the operator had better stop and ligate the vessels before proceeding with his dissection. SECTION III. PUNCTURES, OR INCISIONS WITH POINTED INSTRUMENTS. When tissues are divided by the direct pressure of a pointed in- strument, it constitutes a puncture. Punctures may be made with a scalpel, but more frequently they are created by the use of the lancet, sharp-pointed bistoury, or trocar. In making punctures with either of these instruments, the depth may, if requisite, be regu- lated by seizing the blade near the point, between the forefinger and thumb. On introducing either the lancet or bistoury in making a puncture, the blade may simply be withdrawn by a movement which is the reverse of that which introduced it, or the handle depressed towards the surface, and the point made to cut its way out by incising the structures from within outwards. The trocar should be held with the handle supported against the palm of the hand, and then forcibly pressed through the tissue that it is in- tended to perforate. As every trocar is usually surrounded by a canula or tube for the evacuation of the fluid, attention should be given to the free motion of this tube upon the blade previous to operating, lest, after its introduction, it be found impossible to separate the trocar from the canula. 48 OPERATIVE SURGERY. CHAPTER III. MEANS OF ARRESTING HEMORRHAGE. After every application of the knife in operating, the necessary division of vessels gives rise to hemorrhage, which, when of sufficient amount to debilitate the patient, requires that some means should be employed to arrest it. These means may be classified as those which are proper before commencing the operation or before any incision is made, and those demanded subsequent to or during its perform- ance. Among the first and simplest may be placed such a position of the part as will prevent the afflux of blood (as has been already detailed); second compression, and third the employment of ligatures, cauteries, and styptics. SECTION I. COMPRESSION. The prevention of hemorrhage by means of compression is a purely mechanical result, which may be accomplished either by applying the thumb or fingers over the course of the main artery supplying the part, a mode of compression that, with good assistants or with a skillful surgeon, may be pursued with perfect success; or by the use of tourniquets. In practicing compression with the hand, the thumb should be placed directly upon the vessel, and pressure made against a bone, by placing the thumb over the artery on one side of the limb whilst the fingers grasp the other; or by placing one thumb on the vessel, and pressing upon it with the other, as seen in Plate IV, Fig. 1. Where the artery is so situated as to render the application of the thumb difficult, as in the subclavian or external iliac, pressure may be applied by means of a common door key, well wrapped around its handle with muslin or flannel, and then placed over the artery, the wards of the key being held in the hand. The advantages claimed COMPRESSION. 49 for arterial compression as thus practised, is the non-interruption of the general venous circulation of the part, the course of the blood in the artery being alone obstructed. The next means of arresting the circulation is by the Garrot or Spanish windlass (Plate IV, Fig. 2), a contrivance which, from its simplicity, has much to recommend it. It may be formed at a mo- ment's notice, by twisting a handkerchief into a cord, tying a knot in its middle, applying the latter over the course of the artery, and then tying the free ends loosely together, introducing a stick into the loop of the handkerchief, and twisting it tight. An additional recommendation of this instrument is, that patients may be taught to employ it themselves, a matter of importance in military sur- gery. The tourniquet of Petit (Plate IV, Fig. 3), or Bsllingham's compressor (Plate IV, Fig. 4), also answer very well when ap- plied to the extremities, and will be again referred to under the head of amputations. At present, the Figures explain themselves sufficiently well. A very simple method of compressing only the arteries of a limb, and one easily practised, will be found in the plan proposed by Dr. Physick, in the case of hemorrhage from the foot. A compress was first applied over the anterior tibial artery, and another over the posterior tibial, about two inches above the ankle; over these a strip of sheet copper (or tin) was passed round the leg, and then a tourniquet applied over the copper. By tightening the tourniquet the arteries were compressed, and the bleeding arrested, whilst the rest of the circulation was not inter- rupted.* A special tourniquet or Compressor, as it has been named, has lately been brought forward by some one in the Eastern States, and is a useful instrument for the compression of deep arteries. It is figured in Plate II, Fig. 2, but is evidently a repetition of Signoroni's tourniquet, or of that of Dupuytren. It is especially applicable to the axillary and iliac arteries, or where it is desirable to compress only two points of a limb. It consists of two semicircular sections, jointed at one end, and made to move upon each other by means of a racket piece which is acted on by a key. Pads are attached to the oppo- site ends of each section, and they are thus made to press directly upon the points to which the instrument is applied. Compression for the arrest of hemorrhage either previous to, or during an opera- * Elements of Surgery, by John Syng Dorsey, M. D., vol. i. p. 61, Phil. 1823. 4 50 OPERATIVE SURGERY. PLATE IV. ARREST OF HEMORRHAGE BY THE COMPRESSION AND LIGATURE OF ARTERIES. Fig. 1. Compression of a main arterial trunk (femoral) by means of the thumbs of an assistant. Drawn from Nature. Fig. 2. The G-arrot or Spanish Windlass, made by twisting a stick in a pocket handkerchief. Drawn from Nature. Fig. 3. The application of the Tourniquet of Petit. A pad should be placed on the artery, and a bandage carried over it and around the limb in the course of the strap of the tourniquet, so as to prevent the latter from chafing the integuments; the plates of the tourniquet, closely screwed to- gether, should then be placed over the pad, the strap buckled tight, and the plates separated by turning the screw, the lower plate being thus made to press directly upon the pad, and through it upon the artery. The pad under the buckle is intended to preserve the soft parts from being contused by the latter. As it is directly acted on by the strap, it is liable to be drawn from its position, and the compression from its pad cannot therefore be relied on. Drawn from Nature. Fig. 4. A Ring Tourniquet, or Bellingham's Compressor. Drawn from the Instrument. Fig. 5. Ligature of an Artery on a Stump. 1. The open mouth of the artery. 2. The point of the tenaculum transfixing it. 3, 3. The two knots of the ligature as passed around the tenaculum: they should both be firmly tied previous to its removal from the vessel. After Bernard and Huette. Fig. 6. The result of the application of a Ligature. 1. One of the anas- tomosing arteries enlarging in order to transmit the proper amount of blood. 2. The conical formation of the clot in the vessel, rising to the first anasto- mosing branch. After Bernard and Huette. Fig. 7. The effects of a ligature upon the coats of the artery. 1. The ligature as applied. 2, 3. The internal and middle coats ruptured by its application. 4, 5. The external coat which sustains the ligature after the other coats are ruptured, as is seen all round the vessel. After Bernard and Huette. Fig. 8. The effects of Torsion. 2, 2. The internal and middle coats of the vessel, lacerated by twisting. 3. The external coat uninjured. After Bernard and Huette. Fig. 9. A view of the enlarged condition of the anastomosing arteries, and of the contraction in the main trunk after the application of a ligature. The figure represents the cure of a popliteal aneurism. 1, 1, 1. The main artery below the ligature. 2, 2, 2. The anastomosing branches, enlarging. After Bernard and Huette. Plate 4 ARREST OF HEMORRHAGE BY LIGATURES. 51 tion, should, however, be applied only for a limited time, lest it induce mortification. When more permanent means are necessary, the surgeon should resort to direct applications to the wounded vessels, and employ the ligature or torsion. SECTION II. ARREST OF HEMORRHAGE BY LIGATURES. In no instance, after a severe operation, can a surgeon feel him- self secure against the risks of hemorrhage, unless he has taken care to ligate each vessel thoroughly. To accomplish this, it is necessary that he should resort to some means of seizing the bleeding orifice, such as a tenaculum (Plate I, Fig. 6), artery forceps (Plate I, Fig. 2), or curved needle (Plate II, Fig. 5). The tenaculum is intended to hook and draw out the vessel from surrounding parts, and is the instrument most frequently employed in this country. The artery forceps perform the same office, but are not so much valued on this side of the Atlantic, as on the continent of Europe. The curved needle is applied to vessels that shrink in among surrounding parts, or where the bleeding orifice cannot be readily found, or where the portions immediately around the point of hemorrhage must be in- discriminately ligated in order to control the bleeding. Without entering into the physiological effects of the applica- tion of ligatures to arteries, it may suffice to say, that it is ne- cessary, as established by Dr. J. F. D. Jones,* that the ligature should be drawn with sufficient firmness to cut through the internal and middle coat of the vessel (Plate IV, Fig. 7), and that sufficient inflammatory action be established within the artery to glue its sides together, and render the channel impervious. If the artery is dis- eased, care must be exercised lest the force thus applied cause the ligature to cut through the vessel before adhesion has occurred; and to obviate such an event, it has been advised to employ a broad liga- ture, or, as Manec suggested, to introduce a piece of bougie into the vessel in order to diminish the pressure upon the coats, or to employ a portion of the adjacent muscle, as has been done by Dr. Mutter, of Philadelphia. * Treatise on Hemorrhage and the Use of the Ligature, with Observations on Secondary Hemorrhage. London, 1805. 52 OPERATIVE SURGERY. When an artery in the healthy condition is to be tied, the sur- geon should proceed as follows: seize the open end of the vessel with a tenaculum, by inserting the point of the instrument into its coats, draw it out of its sheath, and separate it as much as possible from the surrounding tissue, especially from the accompanying nerves. (Plate IV, Fig. 5.) If the latter are included, it may give rise to violent neuralgic pains, or create neuromatous tumors, or, by causing the ligature to remain for a long period in the wound, inter- fere with the process of cicatrization. Then let an assistant pass the middle of the ligature beneath the tenaculum, and, bringing its two ends around the vessel, form a loop, and drawing upon the ends with his fingers, tighten the knot with the points of his thumbs, in the same manner that a cobbler draws his ends, taking care that the knot passes below, and not above the point of the tenaculum, and that it is drawn with sufficient firmness to accomplish the division of the arterial coats recommended by Dr. Jones. A second knot being then tied in like manner, one end of the ligature should be cut off within about an eighth of an inch of the knot; the other brought out at an angle of the wound, and the tenaculum removed. Some surgeons remove the tenaculum before the second knot is formed, but it is a dangerous practice, exposing the patient to the risks of secondary hemorrhage from the ligature being imper- fectly applied. Subsequently, on closing the wound, all the free ends of the ligatures should be brought out at the lowest point, where they will favor the escape of pus, and thus prevent the forma- tion of abscesses. Various knots have been recommended for tying ligatures, but the ordinary double knot is all that is absolutely necessary in most instances. The advantage of cutting off one end of the ligature will be found in the diminished amount of foreign matter necessarily left in the wound until the ligatures separate, and is now the general custom of sur- geons in the United States. "The practice of removing both ends close to the knot, published by Haire, of England, in 1786, was adopted by Hennen in 1813, at the suggestion of one of his asso- ciates, who believed it to have been an American invention;''* but if this were so, it was probably at the period when animal ligatures were used, as the practice revived by Veitch in 1806 has long been the only one employed in this country. * South's Chelius, vol. i. p. 339, Phila. edition. ARREST OF HEMORRHAGE BY LIGATURES. 53 The ligature, thus applied, closing the vessel, arrests the passage of the blood beyond it, and a clot is formed (Plate IV, Fig. 6), which, gradually rising as high as the first anastomosing branch above the ligature, causes the blood to pursue a winding course around it, by dilatino- the collateral branches until at last it enters the main trunk •it a distance below the ligature. This clot contracting adhesions to the sides of the artery, its more liquid portions are absorbed, and the vessel closing upon it, is soon converted into a ligamentous cord, the amount of blood formerly transmitted through the artery being now carried by the enlarged anastomosing vessels. (Plate IV, Fig. 9.) The substance of which the ligature should be made, and its mode of action, were formerly points of great interest to operators, and, under peculiar views, it was deemed necessary that they should be made of chamois skin, kid, buckskin, the tendon of the deer, catgut, parchment, or lead, as suggested by Drs. Physick, Hartshorne, and Dorsey of Philadelphia, and Jameson of Baltimore.* But, of late years, the simple silk or hemp thread has been found to answer every purpose, and is now almost universally resorted to.f Torsion is effected by seizing the end of the artery in forceps, and twisting it by rotating the instrument between the fingers and thumb, until the internal and middle coats are lacerated. (Plate IV, Fig. 8.) Torsion is a favorite means of arresting hemorrhage among the French surgeons, but much observation has convinced me that it cannot be relied upon except in the case of small arteries. The credit of suggesting torsion for the arrest of hemorrhage has generally been assigned to Amussat, of Paris, who published his iccount of it in August, 1829.J Dr. Bushe, of New York, has, however, disputed this claim, assigning the origin of it to Guy de Chauliac, and quoting cases of his own where, in December 1826, April 1827, June 1827, and July 1828, he employed torsion "by twisting the cut extremities of the vessels in a square-beaked for- ceps, furnished with a sliding bar, and two nuts."§ The credit of priority in reviving the operation seems, therefore, to belong to him. * Dorsey's Surgery, vol. i. p. 53, Philadelphia, 1823. f For the manufacture of ligatures, see Smith's Minor Surgery, 3d edition, 1850. X Archives Generates, tome xx. p. 606 (quoted from South's Chelius). I New York Medico-Chirurgical Bulletin, vol. ii. p. 212. 54 OPERATIVE SURGERY. SECTION III. STYPTICS, CAUTERIES, AND OTHER MEANS OF ARRESTING HEMORRHAGE. Among the older surgeons, much confidence was placed in the employment of styptics for arresting hemorrhage; but, at present, American surgeons seldom resort to them, except in cases where the ligature cannot be applied, as in oozing from- a general surface, or in bleeding from the cancellated structure of bone. Among the articles occasionally employed as styptics are the nitrate of silver, sulphate of copper, alum, tannic acid, tinctura ferri chloridi, and matico, either in leaf or tincture, nearly all of which act by constricting the vessel. Hemorrhage may also be arrested by the application of fine sponge, or dry lint, so as to favor the formation of a clot at the end of the vessel, and when combined with pressure occasionally answers a good purpose. The heated iron, or Actual Cautery, though seldom resorted to, may be demanded in operations upon the bones of the face, or in other positions where the bleeding point cannot be seen. In order to adapt the cautery to these surfaces, a great variety of shapes has been given to it, but those figured in Plate II, Figs. 13, 14, are all that are generally necessary. When a cautery is to be employed, it may be heated either to a white or red heat by fire, or kept plunged in boiling water. White heat will form an eschar which, on separating, is likely to bring on secondary hemorrhage; but the red heat will only produce contraction of the vessels and tend to produce adhesive inflammation. The propriety of using the actual cautery in either of the conditions referred to may, however, be regarded as doubtful. The nitrate of silver, or tincture of iron, or plugging the part with dry lint, is all that is generally found neces- sary, surgeons generally preferring to apply a ligature, or resort to cold for a temporary arrest of the more serious bleeding, or by leaving the wound exposed to the air for one or two hours, as sug- gested many years since by Dr. Joseph Parrish, of Philadelphia, to favor the closure of the minute vessels by the effused liquor san- guinis.* * Elements of Surgery, by John Syng Dorsey, M. D., vol. ii. p. 350, Phila- delphia, 1823. DRESSINGS. 55 CHAPTER IV. DUTIES OF A SURGEON IMMEDIATELY AFTER OPERATING. After accomplishing his object, and arresting the hemorrhage, the subsequent duties of the surgeon may be classed under the general head of the Dressing. SECTION I. DRESSINGS. The object to be attained in operating being very different in each case, it follows that the dressing must also be varied, and special directions may therefore be reserved until the consideration of each operation. Certain general remarks are, however, applicable to every operation requiring division of the skin; thus, attention must be given to the means of cleansing the part, of favoring its cicatriza- tion, and of preventing the recurrence of hemorrhage, in all which, although various opinions exist, yet certain general rules of prac- tice are universally admitted. In this portion of the surgeon's duty even good operators occasionally appear to be deficient, and show a degree of carelessness that is apparently due to the belief that the great object of the operation ceases when they lay aside their instruments. The education also of many of our students is very defective on this point, it being no uncommon event to see a class leave the operating room before the dressing is commenced, with as much indifference as they would show if this stage of the operation really had no value. Any surgeon, however, who has been long engaged in practice will, it is thought, sustain the assertion that the first and subsequent dressings of an operator are the real tests of his surgical skill. In making them he first proves his claims to the high position of a surgeon, and rises above the grade of the "cutter." Before this the surgeon was limited to the mechanical portion of his profession, but in the dressing and after-treatment • 56 OPERATIVE SURGERY. he has an opportunity of showing his judgment and the resources of his science. This subject should, therefore, receive special at- tention from every one. The dressing after an operation may be divided into two portions : 1st, the cleansing and uniting of the wound, and its protection from external or internal irritation; and 2d, the selection of such means as are requisite to aid in the union. § 1.—Closing of Parts after an Operation. The decision of the question of union by the first or second in- tention, being in a great measure settled in the United States, by the almost universal practice of healing or attempting to heal by the process of adhesion, the first dressing should generally be made with this object; an effort to close the part by granulation being an excep- tion to the rule. In attempting union by the first intention, the removal of all foreign matter is of great consequence. This may be effected either by squeezing a stream of water from a sponge upon the surface to be united, or by the direct application of the sponge itself. Of course it is requisite that the sponge employed in this, or in other instances directly to a wound, should be as soft and free from sand as possible, and the selection of a proper article is, therefore, a measure of some importance. Sponge may usually be rendered entirely free from grit, by pounding it when dry, soak- ing it in a mixture of muriatic acid and water, and subsequently washing it in a solution of soda; but as the proper preparation and method of employing it belong to Minor Surgery, the reader is referred to the volume on that subject for the details. The mode of uniting parts becomes, therefore, the first point in the dressing. To close a wound after an operation, resort may be had to strips of adhesive plaster, about a half inch wide; to the application of collodion; to the suture, or simply to the bandage; but in all cases of extensive wounds, before closing the skin by any of these means, it will be found useful to introduce a morsel of lint or linen between its edges, as suggested by Dr. Physick, in order to prevent union of the surface before the deeper parts have adhered, as this would tend to create an abscess. In employing adhesive plaster, the strips should be first warmed by wrapping them around a bottle filled with boiling water, taking care to place the unspread side of the strip • CLOSING OF PARTS AFTER AN OPERATION. 57 next to the bottle. After the plaster is thus softened, one end of a strip should be placed upon the integuments about one or more inches from the edge of the wound, and whilst its sides are approxi- mated by the fingers and thumb of one hand, the strip may be stretch- ed across it with the other so as to draw the two sides together. In this application, the strip should also be applied to the most depend- ing portion first—a short interval being left between each piece, in order to favor the escape of any discharge from the wound. (Plate V, Fig. 2.) In using collodion, strips of muslin should be moistened with it, and then applied in a similar manner. Though occasionally resorted to with satisfaction, as a substitute for adhesive plaster, I do not think it likely to supplant the use of the former article. Sutures or stitches are employed to unite such parts as, from their flaccid or movable condition, cannot be accurately held together by other means. For the formation of the suture various needles are employed (see Plate II, Figs. 4, 5), any of which may be selected, according to the taste of the surgeon. The only matter of consequence in their selection is to see that they have good points, keen sides, and sufficient temper to prevent their yielding to the force necessary for their introduction. The sutures at present resorted to for the union of wounds are the Interrupted, the Twisted or Hare-lip, and occa- sionally the Quilled. The Continued suture and others recommended by the older surgeons, are now seldom employed. The interrupted suture will be found of service whenever it is desirable to approximate large flaps, or those which present angles, as after crucial incisions and others of a similar character. In making these sutures, the operator should seize the side of the wound nearest to him, or its most depending portion, with the thumb and forefinger of his left hand, so that the latter will be on the inner side of the skin, and then introducing the needle, with its convexity downwards and its point directed upwards, pass it from without inwards through the flap, or side of the wound, and from within outwards through the other part, seizing this portion with the thumb below and the finger above the surface of the skin. Then whilst the two sides are approximated by the fingers of an assistant, let the operator tie the ligature by a double knot, so as to place it on either side of the line of union, and cut off both ends of the ligature, close to the wound (Plate V, Fig. 5). When the knots of sutures are permitted to press directly upon the line of union, they are liable to induce such irritation as results in suppuration; whilst 58 OPERATIVE SURGERY. PLATE V. INCISIONS AND MODES OF UNITING WOUNDS. Fig. 1. A front view of various incisions, as made upon the abdomen of a subject. Drawn from Nature. 1. The V-shaped incision, to form a simple flap. The first incision being made, the second should commence at the base and terminate like the first. 2. The T-shaped incision, to form double lateral flaps. The horizontal cut being made, the vertical one should commence at the proper distance and terminate at the centre of the former. 3. A modified L incision. A horizontal or perpendicular cut being first made, two others of any length are made to terminate at its ends so as to form one large and broad flap. 4. An incision in the shape of the letter H. The middle cut being first made, the two vertical incisions should be carried across its ends, so as to form two broad flaps. 5. The crucial incision, formed either by making several cuts in V, or by making an incision in T, and then continuing its perpendicular cut. 6. A crescentic incision, made by cutting from left to right, if the right hand is employed, or the reverse direction if made by the left. 7. An elliptical incision, intended to remove superabundant integument. One incision should commence at the proper point, and the other be drawn from the same point to the termination of the first. Fig. 2. Union of a wound by adhesive strips, with the intervals left for the escape of pus. After Bernard and Huette. Figs. 3, 4. The Hare-lip or Twisted Suture. " " 1. The pin as introduced, showing the amount of tissue to be included. 2. The ligature twisted around it in the form of a figure 8. 3, 4. The ends of the pins removed, and the integuments protected by adhesive strips placed underneath them. Fig. 5. Several points of the Interrupted Suture, showing the proper posi- tion of the knots, which should always be at the side of the wound. After Bernard and Huette. Fig. 6. A peculiar form of the Continued Suture, occasionally useful in deep muscular wounds. After Bernard and Huette. Fig. 7. The Quilled Suture. " « Plal< T iar-^i-^V l*K 94*r Q™"^*^I 1 ^ H \ V -# » tfl c "* ' ^ <- f^Ssi" € •vtPTvaaam CLOSING OF PARTS AFTER AN OPERATION. 59 if tied as directed near either the point of exit or entrance of the needle, they may sometimes be removed without a sign of inflam- mation. In making the points of a suture, the operator should remember not to pass the needle deeper than the integuments, if possible; to include enough tissue to sustain any strain that it may have to encounter; to avoid pricking nerves or tendons, and to place the first stitch in the middle of a longitudinal wound, the remainder being closed by as many points as may be requisite, intervals being left between each. In angular wounds the first point of the suture should be made at that part where all the free ends of the flap will come together, and subsequently elsewhere, according to circum- stances. These sutures, as well as all others, should be aided by the application of adhesive strips or uniting bandages, in order to diminish the strain upon the thread, and its tendency to create ulceration. In about three days the stitches may be removed by seizing the knot with the dissecting forceps, elevating it slightly from the integuments, cutting the ligature beyond it, and drawing the thread carefully out; but in large deep wounds, or in parts of a loose and movable character, the union should be maintained for several days subsequent to the removal of the thread by the continued use of adhesive strips. If sutures are allowed to remain in a part longer than four days, except where they are passed so deeply as to'include a large amount of tissue (as in the perineum), they will generally tend to prevent union by adhesion, and lead to suppura- tion or ulceration. The twisted or hare-lip suture is especially applicable to ope- rations in which there has been considerable loss of integument, and where the strain upon the thread would probably cause it to tear out of the tissue ; or to cases where the parts are very movable, as in the lips, cheeks, &c. In its application, a straight pin or needle should be held between the thumb and right forefinger, and, com- mencing at the lowest or free edge of the wound, passed as deeply through the tissue as is consistent with safety, on the right side from without in, and on the left from within outwards, the entrance and exit of the pin being favored by sustaining the parts with the thumb or forefinger of the left hand. Then, whilst the wound is well ap- proximated by pressure from the fingers of an assistant, let the operator surround the pin with a thread, and, twisting it around the pin in the shape of the figure 8, tie the ends together over the 60 OPERATIVE SURGERY. line of the wound. After introducing as many other pins as may be necessary (Plate V, Fig. 3), their points should be removed or the surrounding parts protected from injury, either by a strip of plaster (Plate V, Fig. 4), or by a pellet of wax on each end of the pin, and then the whole strengthened, if necessary, by adhesive strips. Various opinions are entertained by operators as to the best mate- rial for the pins employed in this suture. Silver pins with movable steel points were, at one time, much used, and deemed especially suited to this mode of union; but large well silvered pins, or the straight steel needle advised by Heister, or pieces of wire, sharp- ened at the point, as recommended by Dr. Dorsey, of Philadelphia, or the insect-pins proposed by Dieffenbach, can be more readily obtained, answer quite as well, and, in my opinion, better than those with movable points. Where the solid pins are resorted to, their points should be cut off with the scissors or bone-nippers, in order to protect the soft tissues. The quilled suture is, at present, seldom employed, being limited to those cases where it is desirable to unite very thick tissues, as in operations, lacerations, &c, of the perineum. In making this suture, several needles should be threaded by passing both ends of the thread through the eye of the needle, so as to form a loop on the middle of the ligature. Then whilst the parts are held as directed in the interrupted suture, let the operator pass the first needle through the left side of the part from without inwards, as deeply as may be necessary, commencing at the middle of the wound and bring- ing it out on the right side from within outwards. On removing this needle, let him next apply a small piece of waxed bougie, quill, or soft wood, on the left side of the wound, passing it through the loop; then placing a similar piece between the free ends of the ligature on the right side, tie the ends of the thread loosely upon the quill; and on placing two or more stitches at equal distances from the centre and drawing them into firm knots upon the quills, the parts will be thoroughly closed by the pressure thus made upon them. (Plate V, Fig. 7.)- Such modifications of these sutures as may be required in spe- cial operations will be referred to under the appropriate head. MEANS EMPLOYED TO FAVOR UNION. 61 § 2.—Means employed to favor Union. In the second portion of the duties of dressing, or the selection of such means as are requisite to facilitate the efforts of nature in heal- ing the wound, lies the great skill of the operator. Unless the sur- geon is well grounded in the principles of surgery, or unless he unites in himself the knowledge requisite for a good physician, he may now mar the whole proceeding, as all his mechanical dexterity or anatomical knowledge will prove of little avail if he is deficient in a knowledge of the great principles of inflammation. Now it is that judgment may be shown, even in apparently neglecting the case, too much anxiety and officiousness preventing the success of the operation nearly as readily as want of skill. The constitutional treatment at this period is also often essential to success; the efforts of nature may require to be restrained or stimulated; rest or motion may prove useful or injurious; loss of blood, or purging, or a full or a low diet after a capital operation, may be the means of saving or destroying the patient, and nothing but a knowledge of the treat- ment of inflammation, together with the practical tact that experi- ence alone can furnish, will enable an operator to conduct himself correctly in this most important portion of his duty. In the third portion of the dressing, or that which has for its object the protection of the part from external agents, the subse- quent steps usually will consist in the application of spread cerate, or of lint wet with cold water, or of compresses and bandages; but as this portion of the subject belongs to Minor Surgery, the reader is referred to the treatises on this subject for further details. As connected with the dressing, the operator should next bear in mind the occurrence of secondary hemorrhage, the changes requi- site in the articles subsequently employed, as well as the varied con- stitutional treatment rendered necessary by a change of action. Whenever, in later dressings, he desires to remove ligatures, let him seize the end of the thread between his thumb and fore- finger, and make very slight traction upon it. If the ulceration of the vessel is completed, the ligature will readily separate by the least force, but if it is not, it should be left to nature. Occasion- ally, however, it happens, that it will remain attached to' the part an unusual length of time, extending sometimes to fifty or seventy days, either in consequence of the employment of too large or too 62 OPERATIVE SURGERY. flat a ligature, or occasionally from adhesions forming around its course, or from too much of the surrounding tissue having been in- cluded with the vessel. Under these, or other circumstances, when the operator is fully satisfied that time is being lost, he may re- sort to the expedient suggested by Dr. Physick, and twist it slightly from day to day; or pass it over a compress placed at a short dis- tance from the wound, and then fastening the free end to a sound part of the limb, by a portion of adhesive plaster, favor ulceration by the gentle strain thus exercised upon the ligature. If the tension thus exercised is moderate, it will enable the knot to separate from the artery, but if it is sudden or violent, it will be liable to induce hemorrhage; judgment as to its employment is therefore necessary. In fastening the free end of the ligature, the position of the part to which it is attached and its motions should be noted; thus, if a ligature coming from the thigh should be thoughtlessly made fast to the leg whilst flexed, the patient, in extending the limb, would be likely to tear the thread off the vessel; so also in the arm and fore- arm. The point to which the ligature from an artery in either extremity is attached, should, therefore, always be above the first joint. OPERATIVE SURGERY. PART II. OPERATIONS ON THE HEAD AND FACE. PART II. OPERATIONS ON THE HEAD AND FACE. CHAPTER 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 which is occupied by the Brain ; the other the Face, or the region bounded above by the supercilise, 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, and usually called the Base. With the Base of the cranium an operator has but little to do, it being so situated and connected with vital parts of the nervous system as to forbid the application of instruments to it, except in its lateral and infe- rior 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 consequence of the relations existing between the bones which com. pose it and the internal parts. The bones forming it are arranged so as to form a cavity which is accurately filled by the brain. Being of the class known as flat bones, they consist of two layers of compact matter with an intermediate diploe or reticulated struc- ture, contain a large number of veins or sinuses, and are covered and nourished by an internal periosteum, being the outer lamina of the dura mater, as well as by an external membrane known as the pericranium. The Dura Mater or fibrous covering of the brain is attached to the internal table of the bones both by fibrous and vascular adhe- sions, and may be regarded as necessary to the nourishment of this table of the skull. In its duplicatures are found several large veins 66 OPERATIVE SURGERY. PLATE VI. INSTRUMENTS EMPLOYED IN OPERATING UPON THE BONES OF THE HEAD. Fig. 1. A strong Scalpel, for incising the scalp, previous to the application of the saw or trephine. A lever is attached to the end of the handle. Schively's Pattern. Fig. 2. A Trephine of large size. " " Fig. 3. A small Trephine, capable of being attached by a screw to the handle of No. 2. 1. The crown. 2. The slide moving the centre pin. " " Fig. 4. A short stiff Brush to clean the Trephine. " " Fig. 5. An Elevator, for raising depressed bone. " " Fig. 6. Hey's Saw; occasionally used in depressed fracture of the cranium instead of the Trephine. " " Fig. 7. A Raspatory or Scraper, useful in caries. " " Fig. 8. A Lenticular Knife for the removal of spicula from the opening made by the Trephine. " " Fig. 9. A Chain Saw, with the needle for passing it around a bone, and the two handles for moving it. Charriere's Pattern. (Drawn from the Instruments.) Fig. 10. The Circular Saw of Martin, of Paris. " " This most useful instrument consists of a shaft, to which circular or mush- room-shaped saws may be adapted by a screw. These saws may be made to revolve rapidly, by means of the brace, Fig. 13. In consequence of the double joint, at the end of the shaft opposite the saw, the latter will 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 directly at right angles. The surgeon holds the heavy handle (1) with both hands, and directs the saw through its shaft, whilst an assistant causes it to revolve by turning the brace, Fig. 13, when attached to it at (2). I have found this saw useful in many- cases. Fig. 11. Another Circular Saw, larger size. Charriere's Pattern. Fig. 12. A Mushroom-shaped Saw, which cuts like a gouge. (These instruments are now made by Schively.) " " Fig. 14. Liston's strong Bone-Nippers. " « Fig. 15. Strong Forceps for cutting fragments of bone. " " Fig. 16. A steel Hammer or Mallet. « it Fig. 17. A steel Chisel, with the shaft running through a wooden handle. u a Fig. 18. A steel Gouge made like the chisel. " « Fig. 19. Bone Forceps for removing sequestra. After Bernard and Huette. Plate li SURGICAL ANATOMY OF THE HEAD. 67 or sinuses, the principal of which, on its upper part, is the Superior Longitudinal Sinus (Plate VIII, Fig. 1). This sinus runs from before backwards in the median line of the cranium, and is liable to be injured if a trephine is applied in its course. Several arterial branches are also found on 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 arteries 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, whence it ramifies in numerous anastomosing branches (Plate VIII, Fig. 1). This vessel is also liable to be wounded in the operation of trephining, and from its deep position in the bone is sometimes ligated with difficulty, though cases are recorded in which hemorrhage from it and from the superior longitudinal sinus has been arrested by pressure with lint.* The Pericranium, or proper 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 occipito-frontalis muscle, the fibres of which run nearly ver- tically, and the course of which should direct the line of all incisions in this region, a transverse cut being occasionally difficult to heal, from the retraction caused by the action of the muscle. The cel- lular tissue between the occipito-frontalis tendon and the pericra- nium is freely developed, and attaches these two parts so loosely to- gether that the tendon and muscle move with great facility upon the pericranium. The cellular substance between 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 cellular 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 * See Trephining. 68 OPERATIVE SURGERY. effusions occur in its dense and unyielding structure. Its character will also be noticed in any attempt to place a ligature upon a divided vessel in the scalp, the difficulty of drawing it out being due to the peculiarity just referred to. The skin immediately above this layer presents the hairs and other appearances known to every one. In studying the structure of the scalp from the surface to the bones, we have, therefore, 1st, the skin with its hairs and fol- licles; 2d, a dense cellular structure closely adherent to surround- ing parts, and containing the fat, together with most of the blood- vessels and nerves; 3d, the occipito-frontalis muscle and tendon; 4th, a loose cellular substance permitting 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 adhesions; but, as the tegumentary vessels usually remain in the flap, it is generally only necessary to replace the latter in its proper position in order to enable the parts to heal. The density of the tissue and the tend- ency of suppurations to travel in the cellular structure between the tendon of the occipito-frontalis and the pericranium, should always be borne in mind in injuries or operations on this region. Sutures employed to unite these parts should only pass to the tendon, and not beneath it. The anatomical relations of the Face will be referred to hereafter. CHAPTER II. OPERATIONS UPON THE HEAD. The operations required for the relief of surgical affections of this region consist of those necessary in disorders 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 mea- sure to shave the part freely before commencing his operation, except in extirpating small encysted tumors, when the presence of the hair will be useful as a means of promoting the adhesion of the incisions. ENCYSTED tumors. 69 SECTION I. OPERATIONS UPON THE SCALP. Among the diseases of the integuments most frequently requiring surgical interference, are Encysted Tumors, and Naevi, or Vascular Tumors. § 1.—ENCYSTED TUMORS. Encysted tumors are of various kinds, and when found in the scalp are usually situated in some portion of it exterior to the occipito-frontalis tendon. Pathology.—The variety called Atheromatous or Melicerous contain cheesy or more liquid matter, and are generally believed to be obstructed and enlarged sebaceous follicles, as suggested by Sir A. Cooper. They are most frequently placed immediately beneath the skin; consist of a perfect sac, having a smooth and shining sur- face internally, but rougher externally; and are, more or less, filled with cheesy or a similarly unorganized matter. Unless of long standing and of some size, these tumors do not adhere to the peri- cranium; but, when more fully developed, they sometimes induce such inflammatory action in this membrane as often results in adhe- sion, and, in some instances, in cartilaginous degeneration of that portion of the pericranium next to the sac. No blood-vessels enter the tumor, the organization of which is low. 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. Ordinary Operation.—If the tumor is small, the surgeon should pass a sharp-pointed, narrow bistoury, with the back to the cranium, directly through its middle, and cut it open from within outwards. Then, after evacuating the contents, let him reflect the edge of the skin retain it in one pair of forceps, and, seizing the divided edge of the sac in another pair, draw it out from its cellular attachments. If the adhesions are strong, careful dissection will be necessary to free the tumor from the pericranium, lest the latter membrane be injured and necrosis supervene. 70 OPERATIVE surgery. PLATE VII. OPERATIONS UPON THE SCALP AND BONES OF THE HEAD. Fig. 1. A front view of a Naevus Maternus upon the forehead of a child, showing a combination of the operations of incision and strangulation, as recommended by Liston. A crucial incision simply through the skin, and without entering the tumor, has enabled the operator to turn back four flaps; two needles armed with double ligatures have been passed at right angles to each other through its base, and the loops of each ligature cut so as to form eight ends, two of which, 1, 2, and 3, 4; 5, 6, and 7, 8, being tied firmly together, strangulate the structure in four sections. After Liston. Fig. 2. The removal of a large tuberculated Exostosis from the posterior portion of the left parietal bone, by Hey's saw. The integuments have been divided over the tumor by a crucial incision; the four flaps dissected back from its base; the tumor sawed through vertically, and represented as being removed from the bone in sections by the saw, which is seen cutting through half of its base. After Bourgery and Jacob. Fig. 3. The removal of a necrosed portion of the Os Frontis. The integu- ments have been dissected off from the head, and the necrosed portion of the bone, after being slightly raised by the elevator, is about to be removed by the strong bone forceps. After Bourgery and Jacob, Fig. 4. A comminuted fracture of the Cranium; a small fragment has been removed by the forceps, and the elevator is in the act of raising the remainder of the depressed bone to its proper level. When a fracture is thus comminuted, the employment of Hey's saw across an angle of the fracture, or the application of a perforator, forceps, or similar instrument through the fissure, will often enable the surgeon to make room for the entrance of the elevator, without applying the trephine. Whenever the latter instrument can be dispensed with, the danger of injuring the dura mater is much diminished. After Bourgery and Jacob. NMVI MATERNI, OR ERECTILE TUMORS. 71 In large tumors, it will sometimes be found necessary to make an elliptical incision through the skin, so as to remove such portions of it as would prove superabundant; then puncturing the sac, proceed as before; but encysted tumors of a size requiring this mode of operating are rare, as any excess of skin usually disappears soon after the removal of the sac, or causes 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 hairs together over the wound in order to close it, or, if the incision has been free, apply a compress and bandage. The hemor- rhage seldom requires attention, or maybe easily arrested by pressure. § 2.—N^EVI MATERNI, OR ERECTILE TUMORS. Pathology.—A class of tumors formed chiefly by enlarged capil- laries united together by cellular substance, called by Mr. John Bell, Aneurism by Anastomosis, or Mothers' Marks—and by Graeffe, Telangiectasis (t*a.oj, far; ayysiov, a vessel; ex^a^;, dilatation)—are sometimes found on the scalp as well as in other portions of the body, and will be now referred to as a class, the operations for their cure being nearly the same wherever they may be developed. 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 direct vascular connection with the skin of adjacent parts. Most frequently nsevi will be found of small size, though they occa- sionally attain the dimensions of a small orange. Being composed almost entirely of enlarged capillaries, the hemorrhage from them will be free when the diseased structure is incised, though it is gene- rally amenable to pressure. Operations.—When seated in the scalp, various means of treat- ment may be resorted to, the object of all being to interrupt the supply of blood to the tumor, or to remove it entirely from the surrounding tissues. In small tumors, the development of moderate inflammation in the diseased part will often suffice to produce obliteration of its cir- culation, after which, the structure will either slough out or waste away; but in other instances, construction of the tumor by ligatures 72 OPERATIVE SURGERY. 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 nsevi, it is important to operate at an early period, as their growth is often rapid, and the hemorrhage in proportion to their size. I. 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 opera- tion for protection from small-pox. The resulting inflammation has in some instances been quite severe without resulting in a cure, and the practice is now seldom resorted to. Heated Needles.—Dr. Bushe, of New York, induced obliteration of the vessels and sloughing of the diseased structure by introducing numerous needles, twenty or thirty, heated to a white heat, through different parts of the base of the tumor.* Dr. Valentine Mott and others have also employed this method with success. Operation.—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 production of a scar. Caustic Threads.—Dr. Nathan R. Smith, of Baltimore, has fre- quently 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 without causing any troublesome symptoms.f Seton.—Dr. A. H. Stevens, of New York, following the sug- gestion of Fawdington, of Manchester, of introducing a seton, has operated successfully by the following modification of his proceed- ing : A blunt-pointed needle, armed with several silk threads, being passed from one edge of the swelling, completely 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 suffi- * See Bibliography, under Naevus Maternus. t American Journal of Medical Sciences, vol. vi. N. S. p. 260, 1843. operation by excision. 73 ciently numerous to fill up the track of the needle; but suppuration ensues—and, in one case reported by Dr. John Watson, a cure fol- lowed in which the cicatrix was only observable on minute exami- nation.* 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, they are liable to excite intense pain and violent inflammation of the surrounding parts, and in children may, therefore, 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, or, when the latter is but slightly or not at all affected, to turn it back by a careful dissection, so as not to open the tumor. Then two curved needles, armed with double liga- tures, being passed through the base of the tumor, the loops of each thread may be cut, and the eight ends tied together so as to strangu- late it, and cause its removal by sloughing. (Plate VII, Fig. 1.) Dr. J. Rhea Barton, of Philadelphia, has operated successfully with the ligature, by passing 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, strangulated all the portions included between the pins and the liga- ture ; the object of the pins being to confine the ligature about the attachment of the nsevus, as well as to compress the structure upon them. Dr. Brainard, of Chicago, has employed Collodion in small tumors, and reported cases of cure. As a simple remedy acting by constricting the structure, it may be resorted to in cases of a limited character. It is to be applied to the surface of the skin over the tumor by means of a brush. n. operation by excision. A careful examination of many of these tumors having shown that they are not, in most instances, intimately connected with the * See Bibliography—Watson on Telangiectasis. .# 74 operative surgery. surrounding parts, the practice of excision, as originally recom- mended by Mr. Bell and Dr. Physick, 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 its elevation from subjacent parts—then, making an elliptical incision around its base, dissect it out without cutting into its structure. In the scalp, the loss of integument and the hemor- rhage 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 con- genital neevus which covered nearly the whole of the right side of the head, Dr. Wm. 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 be- tween 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 afterwards re- moved the tumor.* Dr. Physick, in a similar case, cut round the tumor, tied up the vessels as they sprung, suffered the parts to remain with lint inter- posed to prevent immediate union, and the tumor soon afterwards wasted away.f In a few instances, ligature of the carotid arteries has been resorted to, and the tumors subsequently excised.| Remarks on the Value of these Methods of Operating.— In cases 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, excision will, I think, be found preferable to the other operations, the hemorrhage being in most instances, according to my experience, readily controlled by ligature or by pressure, particularly when care is taken to incise only the healthy structure, and not to open the tumor. Dr. Warren, of Boston, has long favored the operation of exci- sion, especially when the tumor was seated near the eyes, nose, mouth, or other natural apertures.§ In his practice, three cases * Dorsey's Surgery, vol. ii. p. 272, 1823. f Dorsey, loc. cit. *See Bibliography, on Naevus. \ AWarren on Tumors, p. 416. division of the supra-orbitar nerve. 75 were treated by caustic applied externally so as to cause a slough, eight by ligature, and eighty-five by excision, all successfully.* Where the tumor is very vascular and large, or so situated as to create deformity by a cicatrix, the seton, as employed by Drs. Ste- vens and Watson, will be found to answer a good purpose, or caute- rization by the heated needles may effect a cure, especially if the needles be made large. Vaccination is hardly worth the trial. 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 Drs. Physick and Gibson will, it is thought, answer better than the ligature of the carotids. In the cases reported by Drs. Mussey and Warren, the cure of large vascular tumors on the scalp did not ensue upon the ligature of the arteries of the neck.f § 3.—Cephal^ematomata. Cephalgematomata (zW*>i, head; atpa, blood), or the bloody tu- mors occasionally found on the heads of very young infants, may perhaps require the attention of the surgeon. 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 extent, it may become necessary to evacuate it 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.^ § 4.—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 neuralgic pain resulting from the condition referred to. In such cases the object may be easily accomplished by a subcutaneous section. * Cooper's Surg. Dict.-Appendix by Reese of New York, article Naavus. t See Bibliography, under Nsevus. X See Bibliography, on Cephalaamatomata, by E. Geddings, M. D., of Charies- ton. 76 OPERATIVE surgery. PLATE VIII. A SIDE VIEW OF THE,. STRUCTURE OF THE- HEAD, AND OF THE OPERATION OF TREPHINING. Fig. 1. A lateral section of the Head, showing several portions of the scalp and bones, together with the exterior surface of the Dura Mater. 1. The skin of the head after the hair has been shaved off. 2. The tendon of the occipito-frontalis muscle. 3. The divided edge of the bones, showing the outer and inner tables, with the diploic structure. 4. The shining ex- ternal surface of the dura mater. 5, 5, 5. The great or longitudinal sinus of the dura mater, extending from the crista 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. 8. Its posterior branch. 9, 9. The lateral sinus of the dura mater in its course along the occipital and temporal bones, to empty into the internal jugular vein. After Bernard and Huette. Fig. 2. A lateral view of the application of the Trephine to the right parietal bone. The patient is represented as comatose from a depressed frac- ture, and lies with his head firmly supported and steadied upon a hard pillow, placed well under the neck. The integuments over the depression have been incised, dissected back sufficiently far to expose the fracture; and the surgeon, holding the handle of the trephine firmly against his palm with the forefinger extended upon its shaft, is just commencing to pronate and supinate his hand, so as to work the saw or crown of the instrument, and cause it to excise a portion of the skull, sufficient for the introduction of the elevator, or the evacuation of a clot. Drawn from Nature. Fig. 3. After the removal of the disc cut by the trephine, a small spicula left in the opening is about to be removed by the Lenticular, in order to protect the Dura Mater from injury during the pulsations of the brain. 1. The lenticular as applied in the opening, and the position of the hand hold- ing it. Modified from Bernard and Huette. Plate 8 OPERATIONS UPON THE BONES OF THE CRANIUM. 77 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, down to the bone, on the external or temporal side of the foramen, passing it a few lines towards its inner side. Then turning its edge towards the integuments and its back to the bone, let him divide all the tissues from behind forwards until sensation is destroyed, taking care not to cut through the skin; then turning the bistoury again flatwise, with- draw it at the point of entrance, closing the orifice immediately with adhesive plaster. Should a return of the disease lead to the suspi- cion of re-union 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 Dr. John C. Warren, of Boston.* Dr. Warrenf informs me he has divided the three branches of the fifth pair many times with suc- cess. He has also operated on other nerves, as will be hereafter referred to. SECTION II. OPERATIONS UPON THE BONES OF THE CRANIUM. The operations included in this section are those required by dis- eases or injuries of one or both tables of the skull, as, for instance, in caries, necrosis, exostosis, fractures, or bloody or serous effu- sions within the cavity of the cranium. In the treatment of all of these, the operator will find it advantageous to shave the scalp at the point to be operated on, and to have at hand one or more of the instruments referred to, and shown in Plate VI. In most cases, he will also find it necessary to incise the scalp; the incisions required under such circumstances being either in the +, L, V, or N— , and being so arranged, if possible, that the angles, by their dependent position, may favor the escape of subsequent collections of pus. * Boston Med. and Surg. Journal for 1825. Also Bibliography-Tic Dou- loureux, &c. f Dr. Warren in MS. 78 OPERATIVE SURGERY. § 1.—OPERATIONS FOR CARIES AND NECROSIS OF THE CRANIUM. In operating upon the skull for either of these diseases, the scalp should be dissected back from the bones to the necessary extent, care being taken to disturb the pericranium as little as possible, and then by means of the raspatory, saw, trephine, or elevator, such portions of the outer table, or of the diploic structure, removed with the forceps (Plate VII, Fig. 3), as the circumstances of the case may require. In attempting to remove an Exostosis from the cranium, such an incision should be made through the integuments as will freely expose the tumor, and enable the operator to divide it by Hey's saw, either cutting through its centre down to its base (Plate VII, Fig. 2), or by sawing through the base, to free it at once from the skull. Dressing.—Replace the integuments loosely; apply poultices or the warm water dressing until granulations are abundant, and then favor cicatrization. These dressings may be retained on the part by any of the ordinary bandages for the head. § 2.—TREPHINING THE CRANIUM. 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 constitutes the operation of Trephining. The French surgeons, like those of the time of Hip- pocrates,* employ a somewhat similar saw, but one which, like the antique instrument, is fitted to a brace, and worked like a brace and bit. This instrument retains the old name of Trepan (t^ertaa, I per- forate), and the operation is hence called trepanning. The trephine differs from the trepan chiefly in the shape of the saw, and in its being made to act somewhat like a gimlet. 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 alone employed in the United States, whenever it is * Hippocrates on Wounds of the Head, translated by Riollay, London, 1783. INSTRUMENTS FOR THE OPERATION OF TREPHINING. ' 79 necessary to perforate the cranium, but is much less resorted to at the present period than it was formerly, when every possible affec- tion of the brain was deemed sufficient cause for its application. In addition to the trephine, the instruments hereafter named will occasionally prove useful in perforating or elevating the bone. When from a depressed fracture or effusion of blood outside the dura mater the brain is compressed, and the operation demanded, the surgeon should prepare for it as follows: Preparation.—1st. Shave the patient's head and arrange the following 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, and yet take care that the bed or table is not too high, as this may also create difficulty, and fatigue the surgeon in tne manipulation of his instruments. INSTRUMENTS THAT MAY BE REQUIRED FOR THE OPERATION OF TREPHINING.* 1. A large scalpel, to incise the scalp if necessary. 2. A pair of dissecting forceps, to raise the flap. 3. A tenaculum or forceps, to seize the arteries in the scalp. 4. Ligatures and needles. 5. One large or one smaller trephine to perforate the skull, with a brush to clean the teeth of the saw, and a probe or tooth-pick to test the depth of the furrow. 6. A pair of forceps, to remove the disk of bone. 7. A lenticular, to remove splinters in the opening. 8. An elevator. 9. A sharp-pointed bistoury or lancet, if compelled to puncture the dura mater. 10. Hey's saw, to be employed instead of the trephine if a perfo- ration already exists. 11. Sponges and dressings. Ordinary Operation.—If the scalp is uninjured, and an incision is necessary in order to get at the bone, make it either croscentic, * See Plate VI. 80 operative surgery. as advised by Pott and Velpeau, or V-shaped, or crucial +, as re- commended by Dr. Physick, and let it extend through the scalp, over the part upon which it is proposed to operate, dissecting the flaps free from the pericranium, but disturbing the latter as little as possible. If a wound already exists, it may be enlarged to the necessary extent. Then taking the trephine in the right hand, with the centre pin projecting, and holding it as seen (Plate VIII, Fig. 2), apply the crown either upon the edge of the depressed bone, or sufficiently near to permit its being raised by the elevator, when inserted through the opening cut by the trephine. Then turning the hand steadily and slowly from pronation 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; then removing the instrument, draw up^r take out the centre pin—test the depth of the track of the saw with a tooth-pick, and re-applying the instru- ment, renew the sawing until the diploe is reached. This may often be told by the bloody character of the saw-dust, 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 this is often but sparsely developed. 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, as may be told by gently acting in the furrow with the forceps or lever, and endea- voring to raise the piece. When the disc 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 piece, the dura mater will be seen perfectly exposed, and if the case is a depressed fracture, the operator should introduce the elevator very cautiously between this membrane and the cranium, keeping the point of the instrument close to the latter; then using the thumb, or the sound part of the adjoining bone as a fulcrum, let him elevate the fractured portion to its proper level, moulding 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 en- able the operator to turn it out without injuring the membrane, as this is generally depressed and separated from the inner table of the skull by the effusion. If, however, the blood is evidently be- neath the membrane, it may be questionable whether the danger instruments for the operation of trephining. 81 from its puncture is not greater than that which would ensue if the effusion were left to nature. The judgment of the surgeon, 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 ope- rator would deem such a result a precedent except in cases of great emergency. If by the application of the trephine any of the blood-vessels of the dura mater are accidentally cut, the bleeding may be arrested by pressure, or by ligature; Dr. Dorsey, of Philadelphia, having re- ported the arrest of hemorrhage from a wound in the superior longi- tudinal sinus by the application of a dossil of lint, as well as the stoppage of that from the middle artery of the dura mater by the use of the ligature, in the hands of Dr. F. Dorsey, of Maryland.* In the case of an intimate friend, Mr. B----, of Chestnut Street, I also saw hemorrhage from the same artery, which was deeply im- bedded in its channel in the bone, arrested by the operator (Dr. Mutter) plugging the vessel in its bony canal with a small piece of soft wood, as recommended by Dr. Physick. Bleeding from the integuments may be readily checked by a needle and ligature, or by the latter applied in the usual manner, with the tenaculum. Dressing.—After the operation, the parts should be cleansed; the flap loosely applied over the perforation, covered by a poultice, and the case treated as a suppurating wound until the skin has healed; care being taken to secure the free exit of pus from beneath the integuments, and attention given to any signs of meningeal inflammation. In all cases, the strictest diet should be rigidly observed until all risks of inflammation have 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, until liga- mentous matter closes the perforation in the bone. Remarks.—The propriety or impropriety of trephining, in cases of injury or other disorders of the head, is a question which at all times has had able advocates on both sides. That the application of the trephine was at one period unnecessarily resorted to, our present knowledge of the structure of the cranium leaves but little doubt, especially as we find it was employed in cases of concussion of the brain under the supposition that blood had been effused at * Dorsey's Surgery, by Randolph, vol. i. p. 323, 1823. 6 82 operative surgery. particular points of the head, merely because the bone was disco- lored or seemed too vascular, as is recorded by some of the older surgeons. 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 sink 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. To facilitate a decision in cases where the experience of the operator may be limited, the following statistics, collected with care, are pre- sented ; and though not perhaps sufficiently numerous to settle definitely the propriety of the operation, they will yet tend to show its value. Statistics.—Out of 77 cases of compound fracture of the head, reported by MM. Laurie and King, 29 were cured and 48 died. Twenty-six of the seventy-seven were not trephined. Of these 18 were cured and 8 died, that is, more than two-thirds of those not trephined recovered. Of the remaining fifty-one cases which were trephined, 11 were cured and 40 died, or not quite one-fifth were cured.* Of forty-two cases of trephining after injuries of the head, that I have collected from various sources, 28 were cured and 14 died, or two-thirds of those trephined were cured. Of fourteen trephined for epilepsy, 1 died and 13 were cured. Summary.—Trephined 107—cured 52—died 55, or nearly one- half of those trephined were cured, including epileptic cases, in which disease the use of the trephine appears to have been espe- cially successful. trephining the frontal sinus. Operation.—In the rare cases in which it may be deemed neces- sary to apply a trephine upon the frontal sinus, the operator should proceed precisely as in the application of the instrument upon the vault of the cranium, recollecting, however, that an opening in the outer table of the skull, which at this point is often quite thin, is all that is necessary. * Mott's Velpeau, vol. ii. p. 942. PUNCTURING THE HEAD FOR HYDROCEPHALUS. 83 § 3.—PUNCTURING THE HEAD FOR HYDROCEPHALUS. An effusion of serum within the brain or its membranes being usually the result of serious organic disease, but little benefit can be anticipated from an operation which simply looks to the removal of the effect, instead of the cause of the difficulty. When, however, medical treatment has failed, or as a last resort, and with a view of prolonging life, tapping the head for the removal of the fluid may be deemed worthy of trial, although the post-mortem examination in most instances leaves but little reason to anticipate the general adoption of this operation. In the United States, it has been per- formed by Dr. Physick,* by Dr. Glover of Charleston,f by Dr. L. A. Dugas of Georgia, and Dr. J. B. Whitridge of South Caro- lina.;); Dr. Dugas tapped his patient seven times, and drew off sixty-three ounces of liquid, the patient living from June 25th to Oct. 18th. When the effect of the heat of 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 Dr. Whitridge, the child lived from August 31st to October 31st ensuing. An account of a cure effected by tapping, performed by Dr. James Vose, of Liverpool, may also be found in the Medico- Chirurgical Transactions, vol. ix. Operation.—Introduce a needle and canula, or a fine trocar, at any point of the fontanels or other opening in the head, not likely to interfere with the sinuses, and after evacuating the fluid slowly and cautiously, make moderate compression upon the cranium either by the turns of a roller, or by strips of adhesive plaster tightly applied. A proper medical treatment should then be persevered in. The finer the instrument, provided it is capable of evacuating a liquid, the less, of course, will be the irritation from puncturing the membranes. Among other measures which may be tried in these almost hope- less cases, and especially those which are chronic, is the injection of iodine, as suggested by Velpeau in diseases of the serous cavities generally. Dr. D. Brainard, of Chicago, has recently tried this method, and employed a solution of iodine gr. T'g th; iodide of pot- ash gr. Jth; water f3ss, gradually increased to iodine grs. xii; * Phil. Medical Journal, vol. iv. p. 316. -j- Ibid., p. 403. t Am. Journ. Med. Sciences, vol. xx. p. 536,1837. 84 OPERATIVE SURGERY. PLATE IX. EYE INSTRUMENTS. Fig. 1. Adams's Forceps, modified by Charriere. After Bernard and Huette. Fig. 2. Desmarres's ring Forceps, for holding the upper lid during the removal of tumors. " Fig. 3. Desmarres's bifurcated Forceps, for holding the skin during the passage of a suture. " " Fig. 4. Charriere's rat tooth Forceps. " " Fig. 5. Fine Forceps for pterygium. " " Fig. 6. Charriere's Forceps, with curved points. " " Fig. 7. Horner's modification of Anel's Probe for dilating the lachrymal canals. From the Instrument. Fig. 8. Anel's Syringe. " " Fig3. 9, 10. Anel's Points adapted to the Syringe, when injecting the puncta. " " Figs. 11, 12. Front and side views of Ware's Styles. " Fig. 13. Spring Speculum. " " Fig. 14. Strabismus Scissors. " " Figs. 15, 16, 17, 18. Fine Scissors of different shapes, both sharp and probe pointed, for various operations on the eye. After Bernard and Huette. Fig. 19. Elevator of Comperat. " " Fig. 20. Forceps for artificial pupil. From the Instrument. Fig. 21. Pterygium Scissors. " " Fig. 22. One form of Strabismus knife. " " Fig. 23. Hook of Dr. I. Hays, for seizing the muscle in Strabismus; the curve is adapted to the convexity of the eyeball. From the Instrument. Plat. V i-i i^ r i \ removal of fungoid tumors of the dura mater. 85 iodid. potas. grs. xxxvi, and water 3j; all of which was injected, and with apparent benefit at the time of the report.* But further experience in its use is necessary, though analogy seems to present a probability of success. § 4.—REMOVAL OF FUNGOID TUMORS OF THE DURA MATER. The development of fungoid tumors upon the dura mater some- times leads to absorption of both tables of the skull, and the appear- ance 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 disease as hopeless ; but as successful operations have been performed, and as the result of post-mortem examinations have often shown that the disease is fre- quently limited to the dura mater, or rather does not encroach upon the brain, the propriety of operating under these as in other dangerous circumstances is a question which the operator should decide for him- self. Among the cases reported, one out of three of an almost hope- less operation has succeeded, and the surgeon may therefore deem a repetition of it advisable, although his prognosis should be guarded. In a case reported by Dr. J. C. Warren, of Boston,f a lady, 22 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 discolored, somewhat elastic, not painful nor tender, and never had been. Nothing like a depres- sion could be discovered in the central part. In 1847, the skin became ulcerated, with a fungus about the size of an egg; was of a red color, without sensation to the touch, without pain or intellectual disturbance, bled readily, and a probe penetrated the substance of the tumor to the depth of three inches, yet the patient recovered. Operation of Dr. John C. Warren.—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 pos- sible ;^ the soft and cerebriform mass 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. * Transact. Am. Med. Assoc, for 1850, p. 371. f Ibid., p. 403. 86 OPERATIVE SURGERY. The hemorrhage, which was great, was suppressed by two or three ligatures and the cautery, and the subsequent symptoms 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 disease. 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 1828, the disease also returned, but the patient did not die until two years after the operation.* Remarks.—Although the character of these fungous tumors of the dura mater has long been well known, having been thoroughly described by Louis,f Abernethy, and others, all of whom enter- tained the opinion that they originated from the dura mater, or in the bones of the cranium, yet few surgeons have deemed it advisable to recommend an operation for their relief. Velpeau, however, in an able article upon the complaint,! states that in his opinion "extirpa- tion is indicated in these cases of fungous tumors of the head as well as in those situated elsewhere, but that they, like other forms of can- cer, also present contra-indications." From reviewing the opinion expressed by him, in the article referred to, it may, I think, be said that, if an operation can be thoroughly performed without excessive loss of blood, the chances of the return of the disease and the ulti- mate cure of the patient may be placed on a par with the operations for cancerous developments in other portions of the body. In four cases which it has fallen to my lot to witness, the post-mortem examination of two not operated on satisfied me that the disease had progressed from the outer lamina of the dura mater towards the scalp. In the other two cases, though the tumors were moderately developed, no operation was deemed advisable, and the subsequent result is unknown; but when last seen, one was rapidly progressing to ulceration. It may therefore be doubted, whether the chances of death from the operation would be greater than those from the natural progress of the disease. * Warren on Tumors, p. 510. f Memoires de FAcad. de Chirurgie, tome vi. p. 361, edit. Fossone, 1837. X Dictionnaire de Medecine, tome 10eme, p. 532, Paris, 1835. ANATOMY OF THE FACE. 87 CHAPTER III. OPERATIONS UPON THE FACE. The Face being composed of various parts, the operations required for their relief, when diseased, will be treated of under their special heads after a brief anatomical description of the portion concerned. SECTION I. 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 superior maxillary, inferior maxillary, malar, nasal, palate, and ethmoid bones, together with the vomer, and inferior turbinat- ed. Its external portions are formed by the skin, muscles, vessels, and nerves. The skin of the face presents nothing of special 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 tumors upon the face are so situated as to leave a wound in a very movable portion of the in- teguments, the use of a stitch or two of the interrupted suture will, as a general rule, be found to answer better as a means of uniting its edges than the employment of adhesive plaster. In all operations upon the integuments of the face, the attention of the surgeon should be especially given to the line of the incision in order that he may bring the cicatrix 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 and of the buccinator should be especially recollected in the operations for hare-lip, their con- traction being the main cause of the difficulty experienced in uniting the edges of the wound after the operation. 88 OPERATIVE SURGERY. The vessels of the face are principally branches of the facial ar- teries and veins, hemorrhage from which may be easily checked by the ligature or by compression at the point where the artery passes over the jaw. The nerves are branches of the second branch of the fifth pair coming out at the infra-orbitar foramen, or branches of the seventh pair, or portio dura, which, emerging at the stylo- mastoid foramen, are distributed to most of the muscles. The divi- sion of the main trunks of either of these nerves, in removing tumors or other operations upon the face, is apt to cause distor- tion of the features or loss of sensibility. But, in nearly every instance, as any deep incision must necessarily 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 excising their trunks if they should be divided, as union may possibly restore their function. The Face is subdivided into the regions of the eyes, nose, and mouth, the anatomical details of which may be briefly referred to before mentioning the operations practiced upon them. § 2.—ANATOMY OF THE APPENDAGES OF THE EYE. The appendages of the eye consist of the lids and the lachrymal apparatus. The lids are composed of a thin delicate skin, in which are nu- merous horizontal folds; of a loose and very movable cellular tissue, which latter is often the seat of encysted tumors; of a layer of cir- cular muscular fibres, the orbicularis palpebrarum, and on the upper lid of a vertical muscle, the levator palpebrse, which together create the folds of the skin just referred to; and of two tarsal cartilages, which are thick upon the margin of the lids, thinner at the distance of a few lines, intermediate to the muscle and the conjunctiva, and bevelled on their margin so as to secure a gutter for the tears. The cartilages tend to prevent the puckering of the lids, which would otherwise ensue upon the contractions of the orbicularis muscles. The levator muscle is situated in the upper lid between the orbicu- laris and the cartilage; arising near the optic foramen, it is attached to the edge of the cartilage near its middle. The conjunctiva or mucous coat of the eyeball is the last layer of the lids. It is re- flected from the ball over the posterior face of the lids as far as ANATOMY OF THE LACHRYMAL APPARATUS. 89 the edge of the cartilages, and by its character as a mucous mem- brane favors the motion of the lid upon the eyeball. Between this membrane and the cartilages lie the Meibomian glands, or tortuous canals, which open upon the edge of the cartilage, and lubricate its surface, thus preventing the escape of tears over the lids to the face, and facilitating their passage along the grooved 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 palpebrarum muscle. Rendering this ligament tense by extending the lids towards the external canthus, furnishes a guide for the point of incision in puncturing the lachrymal sac if the swelling is not too great. § 3.—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 XII, Fig. 1) is placed immediately below and within the external angular process of the frontal bone. Its secretion is emptied upon the ball by six or seven ducts which lie between the conjunctiva 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, &c, accidentally introduced between the lid and the ball, or upon the ball. The course of the tears to- wards 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 punctum looks down- wards, and the lower points upwards, and each in the ordinary condi- tion 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 behind 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 90 OPERATIVE SURGERY. of the lid for about two lines, after which they converge and enter the lachrymal sac behind the internal palpebral ligament. Stretch- ing or elongating the lids outwardly towards the temple will generally remove the angular commencement of the canals, and favor the pas- sage of a fine probe into the saccus lachrymalis. The lachrymal sac (Plate XII, Fig. 1) is an oblong cylindrical cavity, or enlargement of the ductus ad nasum, situated in the de- pression of the os.unguis and of the upper part of the same depres- sion 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 forwards and from above downwards, but from the level of the orbit it passes obliquely backwards 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 designated simply as the nasal duct. It is composed of two layers, an external fibrous one, continuous with the perios- teum, and an internal mucous membrane which is continued from the puncta or even the conjunctiva, into the Schneiderian mem- brane. On a line with the floor of the orbit there is a doubling 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 intro- duction of sounds, from the nostril, into the ductus ad nasum, as re- commended 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 beneath the inferior turbinated bone about five lines from its anterior extremity (Plate XVIII, Fig. 1), about seven lines from the bony orifice of the anterior nares, and about eight lines from the posterior inferior corner* of the orifice of the nostril in the recent subject. * Special Anat. and Histology, by Wm. E. Horner, M. D., vol. ii. p. 400, et eeguitur. TUMORS OF THE EYELIDS. 91 CHAPTER IV. OPERATIONS ON THE APPENDAGES OF THE EYE. The disorders of these parts requiring operations may be divided into such as involve the eyelids, and such as affect the lachrymal apparatus. SECTION I. OPERATIONS PRACTICED ON THE EYELIDS. § 1.—TUMORS OF THE EYELIDS. Several of the tumors seen in other portions of the body are sometimes found developed in the eyelids. Most frequently they are varieties of the encysted tumor; seated in the cellular tissue, and readily removed either by incision of the cyst and the intro- duction of a sharp-pointed pencil of nitrate of silver, so as to create a slough of the sac; or by incising the integuments and sac, and drawing the latter out with fine forceps; or by dissecting them out, if care is taken to avoid cutting an opening entirely through the lids, as this is apt to prove difficult to heal, from the con- stant escape of tears through the wound. An important rule in removing these tumors is to make the incision parallel to the course of the fibres of the orbicularis muscle, either through the skin from without inwards, or from the inside 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 produce a scar. Desmarres, of Paris, employs a pair of forceps with broad ends, with a fenestra in one of the blades (Plate IX, Fig. 2), well cal- culated to support the lid, and, at the same time, circumscribe the tumor. Most frequently, however, this operation is too simple to require more than closing of the lid, if the external incision is prac- 92 OPERATIVE surgery. PLATE X. OPERATIONS FOR THE RELIEF OF AFFECTIONS OF THE EYELIDS. Fig. 1. Extirpation of an encysted Tumor from the upper eyelid, by an incision on its external surface. 1. The tumor as exposed by the incision. 2. Desmarres' ring forceps, as applied to the lid. After Bernard and Huette. Fig. 2. Extirpation of a Tumor from the lower lid, by an incision through its mucous membrane. 1. Desmarres' double pronged forceps holding the lower lid everted over. 2. The handle of a cataract needle. 3. Fine forceps raising the tumor from the lid. 4. Its dissection with a straight bistoury. After Bernard and Huette. Fig. 3. Operation of Von Ammon for Symblepharon. The portion of the lid which adheres to the eyeball has been included in two incisions, 1, 2, and 3,2, which, starting from the tarsus cartilage, extend downwards through the lid. After Bernard and Huette. Fig. 4. The same operation when completed; the edges of the incision through the skin and muscle of the lid have been united by three sutures, so as to leave a triangular fold of the mucous membrane attached on the edge of the tarsus cartilage, but otherwise free from the lid, so as to facilitate the motions of the ball. After Bernard and Huette. Fig. 5. A view of the ordinary operation for Ptosis. 1. A pair of forceps raising a horizontal fold of 2. The skin of the lid. 3. The scissors ex- cising the raised portion close to the grasp of the forceps. After Bernard and Huette. Fig. 6. The shape of the wound 1, 2, 3, left by the removal of the flap in Hunt's operation for Ptosis. " " Fig. 7. The wound united by fine figure of eight sutures, and its effects in exposing the eyeball. " " Fig. 8. Operation of Von Ammon for the relief of Epicanthus. 1, 2, 3, 4. The elliptical wound resulting from the removal of a fold of the skin at the root of the nose, the cicatrization of which will uncover the inner canthus of the eye. After Bernard and Huette. Fig. 9. Jones' operation for Blepharoplasty, or the formation of new lower lid, by sliding a flap up from the cheek. The drawing represents the opera- tion as finished. 1, 2, 3. A triangular flap which has been raised and fitted into the deficiency, where it is held by numerous points of the interrupted suture, the threads being all introduced before being tied, so as to favor ac- curacy of adjustment in the flap. 3, 4. Closure of the wound left by the elevation of the flap from the cheek. After Bernard and Huette. Fig. 10. Dieffenbach's operation for the relief of a triangular wound result- ing from the removal of a Tumor. 2, 3, 4, 5. The triangular flap which is to be inclined inwards to the wound at 1, 2, ?>. After Bernard and Huette. Plate 10 •>::f%mmwfffl^ 0$++*% H ANKYLOBLEPHARON. 93 ticed, or its ev.ersion if the tumor is incised through the conjunc- tiva, and the seizure of the tumor with fine and small forceps, or a tenaculum, which will be quite sufficient for its removal. The ope- ration of Desmarres, as well as that by eversion of the lid and incision of the conjunctiva, is shown (Plate X, Figs. 1, 2). Nsevi Materni, or 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 nsevi, or those of such size as to promise free hemorrhage, the production of inflammation in the tumor by the introduction of a seton through it, as practiced by Mr. Lawrence, will generally answer a better purpose.* § 2.—ENCANTHUS. This complaint, named from its position (sv in, *£ -. * V . f. J • OPERATIONS ON THE LACHRYMAL APPARATUS. 103 cut through by the side of the tarsus, and disengaged at each extre- mity.* Sutures subsequently united the remainder of the tarsus to the upper edge of the wound, and also left but little deformity. Remarks on 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 decision of their value to the judgment of the moment. In deformities resulting in Ectropium and consequent on burns or ulcers, the tendency to contraction is so great, that,'in operating, 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 adhe- sions 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 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 intention. Six months subsequently, the cicatrization of the wound from which the flap was taken, and the contraction of the latter, had elevated the lid nearly to the edge of the orbit. In Entropium, the operation of Dr. Dorsey is preferable to that of Mr. Saunders, from its simplicity, as it only requires that a tenaculum should be passed through the edge of the eyelid, in order to gain ft secure hold; and then, seizing the lid in a pair of forceps, that a sufficient portion should be removed by two or three clips of the scissors. SECTION II. OPERATIONS ON THE LACHRYMAL APPARATUS. The principal disorders to which the lachrymal apparatus is exposed are scirrhus, and such other degeneration of the lachrymal gland as may necessitate its removal; or obstruction of the puncta lachrymalia, thickening and stricture of the ductus ad nasum, or suppuration and ulceration of the sac itself. At present, this ac- count may be limited to such operations as are required by disorders of the tear passages; the removal of the lachrymal gland being * Dorsey's Elements of Surgery, vol. i. p. 334. 104 OPERATIVE SURGERY. usually accomplished by such means as are employed for the extir- pation of other tumors, that is, by an incision through the lids, and the dissection of the gland from the surrounding parts. When the gland is removed, the loss of its secretion will be in a measure sup- plied by the increased action of the conjunctiva as a mucous mem- brane, the mucus of this being generally sufficient to favor the action of the lid over the ball. In contraction of the puncta lach- rymalia, or of the canalicula lachrymalia, it occasionally becomes necessary, after employing antiphlogistic measures, and mild colly- ria, to dilate them by a probe, or to wash out the sac and ductus ad nasum. Dilatation of the Puncta.—To one familiar with the anatomical relations of the parts, catheterism of these ducts is a simple affair, and may be accomplished by introducing Anel's probe, or the blunted point of a fine cambric needle, into the punctum, and repeating the operation, from time to time, as it may be required. To dilate the Canals and Ductus ad Nasum.—Draw the eye- lid towards the temple in order to straighten the canalicula, and introduce a fine probe or needle, fastened into a light handle to facilitate its manipulation (Plate IX, Fig. 7), into either punctum by passing it perpendicularly into the orifice; then, carrying the handle towards the temple or nearly parallel with the lids, move it gently towards the inner canthus of the eye. On reaching the sac, elevate the instrument from the horizontal nearly to a perpendicular direction, and on carrying the handle obliquely forwards, the point will pass readily into the nose (Plate XII, 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 downwards. The in- troduction of a probe from the nostril into the duct, as suggested by Laforest, is also shown in the drawing, but the operation has little to recommend it, being opposed to the anatomical relations of the parts, and the same end being also better accomplished by operating from above. To wash out the Canals and Sac.—Introduce one of the fine points of Anel's syringe into the lower punctum, holding the instru- ment with the forefinger upon the piston, as shown in Plate XII, Fig. 3.. Then straightening the lid, throw in the fluid by the mo- tion of the forefinger, taking care not to press the point of the syringe into the membrane lining the canals, nor to push a fold of it in advance of the instrument. If the liquid does not pass out operations on the lachrymal apparatus. 105 of the syringe as freely as the orifice should permit, withdraw the point a little, and again passing it forwards it will be easy to avoid any duplicature of the membrane. Whilst 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 appa- rent by its escape either from the nose or throat of the patient, according as the head is held forwards or backwards. The liquid injected may consist either of simple water or of mild or 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. Fistula Lachrymalis.—When inflammation of the lachrymal sac results in suppuration, or when an abscess of this structure ulcerates, and opens upon the integuments, there is usually such a constriction of the ductus ad nasum as requires the introduction of a foreign body to dilate it and restore the patulous condition of its channel. Introduction of a Bougie or Style, or Canula.—The introduc- tion of any of these instruments requires the formation of an opening through the integuments into the sac, unless the discharge from the abscess has created an orifice by ulceration. The ordinary operation is performed as follows: Endeavor to render the ligamentum palpe- bral prominent by drawing the lids outwards, as it is the great point of reference, the sac lying somewhat in front and below it. Sometimes, on account of the swelling and inflammatory thickening of the integuments, the operator cannot feel this ligament, and must therefore be guided in his puncture by the distended sac, or by his knowledge of its proper position, and especially its relation to the edge of the orbit. Having decided on this, let him take 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 pressing the point of the instrument with its back to the nose obliquely downwards and backwards. On entering the sac, bring the handle to a nearly upright position, and carry it forwards, slightly towards the nose, and downwards, so as to make the point pass backwards and obliquely outwards and downwards (Plate XII, Fig. 4). Retaining the bistoury in the duct, pass a probe along the knife as a director until it reaches the nostril, and, withdrawing the bistoury, pass the 106 operative surgery. style or bougie, or canula, along the course of the probe, and with- drawing 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 the 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 almost universally re- sorted to. 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 resort to 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 serviceable; and I have more than once seen surgeons entirely baffled in the introduction 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 punc- ture, 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 obliteration of the cavity as well as to disease in the bone. Whenever, there- fore, 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 recommended by Dr. Robert W. Haxhall, of Richmond,* will be found serviceable. The plan proposed by Dr. 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 Dr. Nath. Smith, of Dartmouth College, in 1817, though he employed caustic potash instead of the lunar caustic. His mode of using it is as follows: Render the tendon of the orbicularis (lig. palpebrale) conspicuous, cut into the sac, introduce a probe, and find the obstruc- tion. Then substitute a bougie armed with a morsel of caustic pot- ash, press the alkali upon the opposing membrane, and the obstruc- tion will soon be overcome or the passage dilated.f When the duct is so perfectly obliterated that its patulous character cannot be * Boston Med. Magazine, p. 147,1832. t Ibid., p. 403,1833. operations on the lachrymal apparatus. 107 restored, then it may be necessary to make a perforation into the nostril by means of a punch (Plate XIV, Fig. 2), or a fine trocar, or the bone may be punctured and the fragments carefully 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. After Treatment.—After the introduction of the style or bougie, they may be fastened in their position by a morsel of adhesive plas- ter, 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 movement 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 nostril 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, the antiphlogistic treatment, and the dilatation of the passage by Anel's probe passed through the punctum into the nose, will often suffice for the cure; but when the disease is more advanced, punc- ture of the sac and the subsequent introduction of a bougie or style in the manner just detailed will be requisite. Puncturing the os unguis is very seldom required when the surgeon is familiar with the relative changes of position necessary for the introduction of an in- strument into the nose, and it should only therefore be attempted as a last resort. 108 OPERATIVE surgery. CHAPTER V. OPERATIONS UPON THE EYEBALL. As the anatomical details of the eyeball are comparatively limited in their relations to operative surgery, they can readily be referred to in connection with the operations practiced upon them. The operations practiced on the eyeball consist in those required by diseases of its tunics, muscles, and humors. SECTION I. OPERATIONS ON THE COATS, OR EXTERNAL PORTIONS OF THE EYEBALL. The conjunctiva covering the eyeball being a reflection of that covering the lid, is liable, like it, to such a degree of inflammation, as may result in thickening, granulation, ulceration, or the develop- ment of accidental growths. When from violent or repeated attacks of ophthalmia, the con- junctiva is left in an hypertrophied or simply cedematous and thick- ened condition (Chemosis), it is desired to excise one or two of the largest vessels, or a small fold of the conjunctiva, it is only neces- sary to raise the latter in a pair of fine forceps, and cut it off with scissors, according to the long diameter of the ball. Granulations, even when exuberant, generally yield to the action of the lunar caustic, or to the sulphate of copper, applied either in solution or in mass. The fungous growths occasionally seen after the operation of strabismus, may also usually be treated in this manner, and if a warty growth be found upon the adnata, as re- ported by Dr. Physick,* the caustic will readily remove it. Pterygium.—Pterygium (rttspov, a wing), or a vascular thicken- ing of a portion of the conjunctiva, on either side of the cornea, may be removed simply by seizing the growth with a pair of fine forceps, and excising it with the curved scissors usually known as * Philadelphia Medical Journal, vol. v. 1827. ANATOMY OF THE MUSCLES CONCERNED IN SQUINTING. pterygium scissors, or by dividing the vessels composing it trans- versely, and then cauterizing the wound with the nitrate of silver, so as to prevent reunion of the divided vessels. SECTION II. OPERATIONS ON THE MUSCLES OF THE EYEBALL. Strabismus, or squinting (a*paj3i?«s, I squint), is a variation of the eye from the centre of the orbit, in consequence of which the paral- lelism of the optic axes is destroyed. This affection may result from various causes, but only becomes a fit subject for an operation when positively dependent on spasmodic contraction of the muscles which move the ball. If the eye turns in, the squint is said to be con- vergent; but if the cornea is turned outwards, it constitutes a divergent squint. In addition to the deformity, this complaint also impairs vision, and it is in the latter case that surgical interference is especially demanded. If judgment is exercised in the investiga- tion of the cause, and it is found that on closing the sound eye the patient with a convergent squint can turn the other eye towards the temple, then the operation may be attempted with confident expecta- tions of success; but if, when the sound eye is closed, that which squints cannot be turned in the opposite direction to the squint, an operation will prove of little benefit to the patient. § 1.—ANATOMY OF THE MUSCLES CONCERNED IN SQUINTING. The eyeball is moved by six muscles, two of which are oblique and four are straight, the internal straight one being mainly con- cerned in the production of the convergent or most common form of strabismus. The straight muscles all arise from around the optic foramen, and are inserted by broad and thin tendons into the scle- rotic coat of the eye about three or four lines from the cornea. The superior oblique muscle also arises from near the optic fora- men, but the inferior oblique takes its origin from the nasal process of the superior maxilla at the side of the os unguis. Both are in- serted into the sclerotica, about half way between the cornea and the optic nerve. Between all the muscles and the conjunctiva is found 110 OPERATIVE SURGERY. PLATE XIII. OPERATIONS FOR STRABISMUS OR SQUINTING. Fig. 1. A vertical section through the external face of the right Orbit, showing the position of the muscles of the right Eye. 1. The eyeball. 2. The levator palpebrae superioris muscle. 8. The rectus superior muscle. 4. The rectus externus muscle. 5. The rectus inferior. 6. The inferior oblique muscle near its insertion. 7. The point of origin of the recti muscles near the optic foramen. The cavity of the antrum has been exposed on this side, but a considerable portion of the eyelids remain uninjured. After Bernard and Huette. Fig. 2. A side view of the sheaths of the muscles of the right eye, and their expansion upon the ball so as to form the Sub-conjunctival Fascia, as described by Malgaigne. 1. The eyeball. 2. Sheath of the levator palpe- brae. 3. Sheath of rectus superior. 4. Sheath of rectus externus. 5. Sheath of rectus inferior. 6. Sheath of inferior oblique. After Bernard and Huette. Fig. 3. The general arrangement of the Ocular Muscles at their insertion into the Sclerotica, as shown in a front view of the Eyeball when the muscles are stretched from behind forwards. The tendinous expansion upon the ball is well displayed. 1. Superior rectus. 2. Rectus externus. 3. Rectus in- ferior. 4. Rectus internus. 5. Superior oblique muscle, in its trochlea. After Bernard and Huette. Fig. 4. A front view of the first steps in the operation of Strabismus, as practiced by Dr. I. Hays, of Philadelphia, and about to be performed on the left Eye. The sound eye being covered by a handkerchief, the eye to be operated on becomes straight and tolerably steady. The eyelids are then separated by the spring speculum, placed on the outside of the tarsus. The operator, holding the forceps in his right hand, seizes and raises a fold of the conjunctiva near the internal canthus, and divides it vertically by scissors held in the left hand. If not ambidexter, the surgeon may reverse the posi- tion of the hands by standing behind the patient; but that shown is the most convenient to many. The muscle is subsequently seized and divided as in Fig. 7. Drawn from nature. Fig. 5. The operation of Sedillot, of Paris, for Strabismus. 1. The specu- lum applied inside the lids. 2. A double hook held by an assistant, so as to evert and steady the ball. 3. Forceps raising a fold of the conjunctiva. 4. Scissors in the act of cutting the fold so as to expose the muscle. After Bernard and Huette. Fig. 6. 1. A blunt hook passed under the muscle. 2. The muscle as raised on the hook. After Bernard and Huette. Fig. 7. 2. The hook raising the muscle. 2. Curved scissors in the act of dividing it. After Bernard and Huette. Hate i3 OPERATION FOR STRABISMUS. Ill a white fibrous membrane which lines the ocular conjunctiva through- out. This membrane extends from the palpebral ligament in front as far as the cornea, and then turning backwards 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 sclerotica it is very movable, and a layer of sero-cellular substance is interposed between them. At the points of insertion of the tendons it is folded around them so as to form a fibrous sheath (Plate XIII, Fig. 2), which degenerates into cellular tissue on the muscle.* This mem- brane is designated by Malgaigne as the Sub-conjunctival Fascia, and, in most cases of squint, requires to be divided. In the operation for strabismus, it is, therefore, necessary to incise the conjunctiva and fascia, expose the muscle or its tendon, and di- vide it entirely, but without removing any portion, lest its subse- quent power be entirely destroyed. § 2.—OPERATION FOR STRABISMUS. The credit of suggesting this operation is generally assigned by European writers to Stromeyer, but in the United States it is well known that it was practiced in four cases, with partial success, by Dr. Wm. E. Gibson,f of Baltimore, in 1818, who laid it aside from the recommendation of Dr. Physick, the latter gentleman fearing that the result might be injurious to vision. To Stromeyer, how- ever, is certainly due the credit of having brought the operation into general notice in 1838, and to Dieffenbach belongs the honor of having established its success beyond a doubt. It was subsequently performed in New York by Dr. Willard Parker in 1840, and by Drs. A. C. Post, Gross, Detmold, and Dixon, shortly afterwards, who in several papers called attention to its utility. J Various modes of operating have been employed by different sur- geons, but all have the same object, and only differ in the means employed. Stromeyer controlled the movements of the ball by a fine hook inserted into the conjunctiva, elevated a fold of the same membrane * Malgaigne, Operative Surgery, Phila. edit., p. 288. t Now Prof, of Surgery in the University of Pennsylvania. See Principles and Practice of Surgery, vol. ii. p. 375, Philad. 1841. X Cooper's Surg. Diet.; Appendix by Reese; article Strabismus. 112 OPERATIVE SURGERY. in 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, de- pressed the lower lid by the finger of an assistant, drew the eyeball outwards by a fine hook in the conjunctiva, elevated a fold by an- other 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 con- junctiva with forceps, and divided it with curved scissors (Plate XIII, Figs. 5, 6, 7), pursuing in the remainder of his operation the course just detailed. Dr. Joseph Pancoast, of Philadelphia, operates very much in the same manner.* 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 pro- cess long pursued at the Wills' Hospital, for the eye, in this city, is much more simple. To Dr. I. Hays, senior surgeon of the hospital, and editor of the American Journal of the Medical Sciences, is due its introduction into that institution, where it is now generally resorted to. Operation of Dr. Hays.—Dr. Hays closes 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 separated the lids by a specu- lum, he seizes a fold of the conjunctiva over the muscle, with a pair of good forceps, elevates it, incises it with a snip of the curved scissors, divides the fascia, if necessary, in the same way, passes a large curved hook (Plate IX, Fig. 23) having a convexity at least equal to that of the ball, beneath the muscle from below upwards, and divides 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. This eye should then * Operative Surgery—Strabismus. EXTIRPATION OF THE EYEBALL. 113 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 re- sults from the incision, and may require excision or to be removed by caustic, though it is not common except where the conjunctiva has been very freely divided. Guerin has proposed a sub-conjunctival division of the muscle, but this is necessarily uncertain, and, as the ordinary operation causes little inconvenience, the plan has nothing specially to recom- mend it. § 3.—EXTIRPATION OF THE EYEBALL. When from malignant disease or other causes, it becomes neces- sary 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 artificial 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. This will give the assistant the control of the tumor. The surgeon should then incise the lids at the external commissure, carrying the incision at least as far as the outer edge of the orbit; rapidly dissect the lids from the ball by cutting through the reflexions of the conjunctiva, and, passing the scalpel or straight bistoury along the os planum (internal canthus), carry it around the orbit so as to divide the attachments of the two oblique muscles, and on cutting towards 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 the attachments of the ball and remove it, arresting the hemorrhage by stuffing the orbit with lint. The advantage of the ligature over forceps or a tenacu- lum, 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. 8 114 OPERATIVE SURGERY. § 4.—TUMORS IN THE ORBIT. When tumors in the orbit are of such a size as will prevent their extirpation through the lids, it may become necessary to divide the external canthus, and then to 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 espe- cially those which resemble scirrhus, are found upon the tarsal car- tilages, their removal may be accomplished by a V incision, or in a manner similar to that spoken of under the operation for Ectropion. CHAPTER VI. OPERATIONS PRACTICED ON THE HUMORS OF THE EYE. An account of the anatomical relations of the component parts of the eyeball may either be limited to a brief enumeration of the general characters of each portion, or extended into a minute de- scription 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 detailed account of them. SECTION 1. ANATOMY OF THE EYEBALL. The eyeball is composed of six coats and three humors. These coats are the conjunctiva, sclerotica, and cornea, which may be described as external; and the choroid, iris, and retina, which are within the former. The humors are the aqueous, crys- talline, and vitreous. The Conjunctiva, or mucous coat, after lining the lids, is reflected ANATOMY OF THE EYEBALL. 115 upon the ball, and covers both the sclerotica and cornea. To the sclerotica it is loosely attached by cellular 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 occasionally 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. As connected with the operations per- formed upon the eyeball, it may be described as extending from the optic nerve as far forwards as the circumference of the cornea, the two being closely adapted to each other by a bevelled surface. The resisting character of the sclerotica 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 cellular 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 laminae, separated from each other by a thin pellucid fluid in the healthy condition, but liable to become opaque from inflammation. The section of the cornea, owing to its density, and the arrangement of its layer, requires that the instru- ments employed should be of the best quality, and also that some caution be exercised by the operator, lest he 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 condition, though in inflammation its capillaries will admit it. In health, it possesses little sensibility; but, in disease, it is occasionally exceedingly sensitive, its incision having caused faint- ing, as occurred in the practice of Dr. Physick. Dr. Horner also reports 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 choroid coat.* The arteries * Horner's Anatomy, vol. ii. p. 414. 116 OPERATIVE SURGERY. PLATE XIV. EYE INSTRUMENTS. Fig. 1. A side view of a narrow, straight, sharp-pointed Bistoury for punc- turing the Sac in Fistula Lachrymalis. Drawn from the Instrument. Fig. 2. Laugier's Trocar for perforating the Os Unguis, or the bony Ductus ad Nasum, when the ordinary communication with the nose cannot be ren- dered pervious. After Bernard and Huette. Fig. 3. Benjamin Bell's Speculum. " " Fig. 4. Self-acting Speculum of Drs. Goddard and Ruschenberger. The lower bar moves upon the shaft, and is capable of resisting the contraction of the eyelids to any extent, in consequence of the friction at the shaft; with this instrument no assistant is necessary. Drawn from the. Instrument. Fig. 5. Physick's Forceps for Artificial Pupil; one end is made like a sad- dler's punch, and the other, which is flat and solid, supports the iris. Drawn from the Instrument. Fig. 6. A modification of Wardrop's Forceps for stretching the free edge of the eyelids in excising the tarsus cartilages. After Bernard and Huette. Fig. 7. A front view of Dupuytren's Cataract-Needle. " " Fig. 8. A side " " " " » " Fig. 9. A side " Scarpa's " " " " Fig. 10. A side " Walther's " " » « Fig. 11. Beer's Knife for enlarging the incision in the cornea in extracting Cataract. " " Fig. 12. A front view of Scarpa's Needle. " " Figs. 13, 14. Side and front views of Adams's Needle. " " Fig. 15. Beer's triangular Cataract Knife. " " , Fig. 16. Richter's Knife, slightly differing in the width of the blade from that of Beer. " « Fig. 17. Wenzel's Cataract-Knife. " " Fig. 18. Beer's Lancet-shaped Knife. " " Fig. 19. Curved Knife of Cheselden, for incising the capsule, or enlarging the incision in the cornea, in the operation of extraction. Daviel's scoop or spoon is attached at the other end of the handle. " " Fig. 20. Beer's Hook for extracting the Capsule. " " Fig. 21. Bellocque's Canula for tamponing the nostrils, as shown with the spring expanded. " " Fig. 22. The same, as introduced into the nostril with the spring closed. " " 'late 14 H >■ H* Kr» I'lO.l I rigifi l-ig. OPERATIONS FOR CATARACT. 117 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 diameter. 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, but this power may be best referred to under the ope- rations for cataract. The Retina has so little connection, 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 Crystaline humor is a double convex lens, of which the pos- terior convexity 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 prevent the depression of cataract, unless its cells are previously lacerated with the needle. SECTION II. OPERATIONS FOR CATARACT. In the healthy condition of the humors and of the transparent cornea, the rays of light are so transmitted as to make the proper impression upon the retina. Any change in the transparency of the media through which these rays pass necessarily impairs vision, and when the change results in opacity and is seated in any por- tion of the lens, it takes the name of Cataract. Various minute 118 OPERATIVE SURGERY. divisions of cataract have been made by ophthalmic surgeons, such as true and false, or black, white and green, to which it is unnecessary here to refer; the three grand divisions of the disease, according to the structure involved, into capsular, lenticular, and capsulo-lenticu- lar, comprising all that it is necessary to mention in connection with operative surgery. In membranous cataract, the opacity is supposed to be limited to the capsule; in lenticular, it is either in the proper structure of the lens, or in it and the liquor Morgagni, the latter being very rare; whilst the term capsulo-lenticular cataract designates both varieties, and is the most common, the affection of the capsule alone seldom existing, except in a limited degree, without the early de- velopment of a similar complaint in the lens. Cataract has also been divided, according to its density, into hard, soft, milky, and cheesy, all of which may usually be recognized by the color. Hard cataracts are generally of a brownish or amber color, are generally confined to adults, and are the kind especially adapted to the operation of extraction, although depression may relieve them. Capsular cataracts are usually soft, of a brighter and lighter color than the preceding, and often met with in children. Milky or cheesy lenticular cataract is usually of a bluish or yel- lowish gray, or white color, mottled, and with streaks in various directions through the structure. Soft cataracts bulge forward, as a general rule, and, consequently, are apparently more superficial than the hard class; hard cataracts, on the contrary, are deeper seated and further from the pupil. All varieties commence with very much the same symptoms, such as dimness of vision, and an inability to see anything distinctly directly in the axis of the eye, the opacity most frequently commencing in the centre of the pupil. Diagnosis.—The distinction of the various kinds of cataract, or an accurate diagnosis, is of much importance, not only in order to decide on the propriety of an operation, but also to assist the sur- geon in the selection of the kind of operation to be performed. No means, within my knowledge, will prove more conducive to this object than the application of the catoptric test of Sanson. To accomplish this, dilate the pupil freely by means of belladonna, placing the patient in a dark room on a low seat, and passing a lighted candle transversely and vertically across the axis of vision. If the cornea, capsule, and lens are clear, three reflections of the flame will be seen, one large, upright, and superficial, formed by the front of the PRELIMINARY TREATMENT. 119 cornea; one deep, pale, small, and inverted image, formed by the posterior segment of the lens; and one deeper and upright figure, formed by the anterior portion of the lens and its capsule, a little brighter than the inverted image, but not so bright as the first. The absence of either of these images, or their absence at any point, will indicate the character of the disease and the portion affected.* § 1. PRELIMINARY TREATMENT. As the result of the operations for cataract depend, in a great measure, on the absence of inflammatory action, attention to the adjuvants of the operation is essential to its favorable termina- tion. In every instance, strict attention should 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 practiced. 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, a strict antiphlogistic 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 circumstances. 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 employment of such collyria as will reduce the vascularity of the various coats of the eye and diminish the risks of their inflammation. Another important step in the preliminary local treatment of cataract is the production of such a dilatation of the pupil as will * See Lawrence on the Eye, by Hays, Phila. edit., 1847, p. 90, also Smith's Minor Surgery, for fuller details of the catoptric test. 120 OPERATIVE SURGERY. 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. § 2.—DILATATION OF THE PUPIL. Dilatation of the pupil may be 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: or their active principles (daturia or atropia) may be dissolved in water in the proportion of one grain to the fluidrachm of water, and a few drops be inserted about ten minutes before operating. The latter mode is the quickest and cleanest, but not quite so certain in all patients as the extracts. I have occasionally employed the following formula, and found it very prompt, and not so irritating as the extract:— R.—Atropise gr. iss; Acid, nitric, gtt. ss; Aquae ^ij. Of this, a few drops may be introduced between the lids, and then a rag wet with the solution applied externally. The dilatation, in two instances, was prompt, and in one continued for three days after the operation, 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 to Himley, of Gottingen, who recommended the use of the extract of belladonna in 1801 ;* but, four years prior to this period, a similar suggestion had been made, and published in Philadelphia, by Dr. Samuel Cooper, a gra- duate of the University of Pennsylvania, who, in an inaugural essay, published in 1797, f reported numerous experiments on the effects of the datura stramonium on the system generally, as well as on the pupil of the eye.J I have also been informed by Dr. Benjamin H. * Lawrence on the Eye, by Hays, p. 360. f Littell on the Eye, p. 202. X 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. DILATATION OF THE PUPIL. 121 Coates, of Philadelphia, that Drs. Rush and Physick both taught this in their lectures, and that the latter always resorted to the formula of Dr. Cooper for its preparation.* Another step in the treatment of cataract, previous to operating, consists in the application of a bandage on the opposite eye to that which is to be operated upon, as advised by Celsus, as it tends very materially to steady the eye, 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 adds to his safety, by diminish- ing the tendency in the humors of the eye to escape through the opening in the cornea; but, in the operations of depression or ab- sorption, 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 without arms, so as to be at perfect liberty in his movements. Some ope- rators prefer following the advice of Scarpa, and employ a stool on which they place the foot, of the same side as the operating hand, resting the elbow on the knee thus raised. Such a position is, how- ever, purely a matter of convenience, 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. The position of the assistant should be behind the patient, with one hand placed under the chin so as to steady the patient's head against his own breast; whilst 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 towards the superciliary ridge, where it should be retained until the surgeon directs its release. If the eyelid is moist and difficult to hold the assistant should dry it thoroughly, or touch the points of his fingers m a little flour or other dry powder, previous to seizing the lid. A speculum, or the elevator of Pellier, may be resorted to * Several copies of the Dissertation may be found in the Library of the Pennsylvania Hospital, Philadelphia. 122 OPERATIVE SURGERY. 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, whilst the best period, in reference to the maturation of the cataract, is that when its presence in both eyes is well ascertained. The existence of opacity being once well settled, every week is liable to increase the density and toughness of the diseased structure, and, conse- quently, add to the difficulty and risks of the operation. Three kinds of operations are performed for the removal of cata- ract, to wit, extraction, absorption, and depression, the selection of either being 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; but they are only well adapted to soft cataracts, or to those in which the anterior chamber of the eye and the eye itself are small. Depression of a hard cataract is also liable to produce amaurosis by paralyzing the retina; and not unfrequently the lens, when depressed, will rise again into the axis of vision. 2d. Extraction is especially 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. Of the two operations, extrac- tion is the more prompt and brilliant; absorption, depression, or re- clination the safer. Drs. Physick and McClellan in Philadelphia, and Roux in Paris, favored extraction, but the majority of surgeons, except in cases of hard cataract, prefer the other operations. In order to operate upon both eyes, it becomes necessary for the surgeon to change his position unless he is ambidexter, as he must operate upon the left eye with his right hand, whilst in front of the patient, and on the right eye with his left hand, if in front, on account of the prominence of the nose. If he wishes to employ the right hand in both eyes, he will be compelled to place himself behind the patient. Having considerable facility in using the left hand, a change of position has never been necessary in my case, and as this facility can be readily acquired by daily exercise, 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 to retain OPERATION OF ABSORPTION. 123 his position in front of the patient, as this offers many facilities in manipulating as well as in sight. § 3.—OPERATIONS. The operations for cataract are, as 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 be- low the axis of vision, and lies buried in the vitreous humor; and extraction, in which it is promptly removed from the eye. Reclina- tion 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 ope- rator should be to lacerate it and its capsule, and throw them for- wards into the anterior chamber of the eye. The preliminary steps in all the operations are very much the same; it being, however, of more consequence in absorption 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 (Plate XIV, Figs. 7, 9, 12), and seem to have been selected very much at the fancy of each operator, that of Saunders or of Scarpa being most frequently resorted to. All that is really essential is that they should have a sharp double edge. 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, the surgeon should depress the lower lid with the index and second finger of the hand corre- sponding 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 dexterous, he may sustain both lids himself. Then, seizing the handle of the needle between the thumb, fore, 124 operative surgery. and second finger of the hand opposite to that of the eye to be ope- rated 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 upwards and its edges transverse, one or two lines behind the circumference 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 whilst the patient is looking towards his nose, puncture the sclerotica, and, rotating the handle of the instrument between the fingers, turn the concavity of its point, if Scarpa's, or the breadth of the blade, if that of Saunders, backwards, passing it towards the centre of the eye, and depressing the handle towards the temple. When the point, dexterously managed, has reached the centre of the pupil, turn the cutting edge of the needle to the cataract, and cut the capsule and lens into several fragments, throwing them forwards into the anterior chamber, where they will subsequently disappear by dissolution. 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 pur- sued as is directed in extraction. The pupil should, however, be kept dilated for several days after the operation, and it is not requisite to enjoin such absolute rest as is then directed. 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 intro- duced through the cornea, was suggested by Conradi, but introduced into practice to a considerable extent by Mr. 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. OPERATION by depression. 125 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 and of the surgeon being that of 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 XV, Fig. 2). Then depressing the handle, cause the point of the instrument to apply itself on the top of the lens, and depress it backwards and downwards, by elevating the handle and carrying it slightly forwards (Plate XV, Figs. 3, 4). 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 sclerotica, with its convexity forwards. The different positions of the needle during the operation are shown in Plate XV, Fig. 5. 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 horizontally instead of being depressed perpendicularly (Plate XV Fig. 6). ' Operation of Malgaigne.—M. 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 pos- terior and inferior part of the lens; the capsule divided, and then the needle being passed above the lens with its concavity looking down- wards, 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 M. Malgaigne prefers, espe- cially when the lens is hard.* Bretonneau and Velpeau lacerate algaigne's Operative Surgery, Phila. edit. p. 301. 126 OPERATIVE SURGERY. PLATE XV. 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 hu- mor. 9. The optic nerve. After Bernard and Huette. Fig. 2. 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 secoud 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. 3. The same operation after the needle has entered the posterior chamber. 1. The relative position 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, pre- vious to couching it. After Bernard and Huette. Fig. 4. The same operation, as the lens leaves the axis of the pupil: the handle of the instrument being moved alternately from 1 to 2, and the re- verse, the point of the needle will carry the lens downwards and backwards, until imbedded in the vitreous humor. After Bernard and Huette. Fig. 5. 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 about two lines behind the cornea, but below the transverse diameter of the eyeball. 2. The second position of the needle in the operation, or the same as that shown in Fig. 3. 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. 6. Reclination of the Lens, as shown by a vertical section of the eye. 1. The natural position of the lens. 2. Its reclination in the vitreous humor. riate 15 r'10. 2 nc. fi EXTRACTION. 127 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 found it often successful. III. EXTRACTION. The operation of Extraction is especially 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 Pellier's speculum be- neath the lid, drawing it directly upwards, 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, in 1839, I saw an assistant of Velpeau's eva- cuate the entire contents 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, whilst depressing the lower lid; but it can rarely become necessary 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 recommended for this operation, and are known as those of Beer, Wenzel, Richter, and Ware,* but most surgeons resort to the trian- gular knife of Beer in preference to the others, except under pecu- liar circumstances. The other instrument consists in Daviel's scoop and Cheselden's knife, together with small scissors and forceps (Plate XIV, Figs. 11, 15, 16, 17, 18, 19). The operation consists in three parts, incision of the cornea, laceration of the capsule and extraction of the lens, although occasionally the first two are per- formed at the same time. The incision of the cornea may be performed either at the superior, exterior, or inferior portion of its circumference (Plate XVI, Figs. 1, 5, 6). Mr. Lawrence deems the superior section the best, the exterior next, and 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 * See Plate XIV. 128 OPERATIVE SURGERY. 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.* Ordinary Operation.—The pupil being fully dilated, and the preliminary measures completed, the operation may be performed as follows, varying the line of the incision according as it is the wish of the operator to perform the superior, exterior, or inferior section. The latter, being the simplest, may be taken as the type. The surgeon, either sitting or standing, according to the position of the patient, should depress the lower 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 a pen, and resting 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 instrument penetrates the entire thickness of the cor- nea, and enters the anterior chamber of the eye, and that it has not passed between its lamina, pass it parallel and in front of the iris, in the line of the transverse diameter of the eye, over to the inter- nal side of the cornea at a point corresponding with that at which it entered (Plate XVI, Figs. 1, 2). 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, whilst depressing the lower lid, should press very gently against the ball, so as to render the lens prominent, and, introducing the back of the little knife attached to Daviel's curette beneath the edge of the corneal flap, press its point against the capsule of the lens and lacerate it (Plate XVI, Fig. 3). Frequently the lens will instantly escape 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 XVI, Fig. 4), or seizing the lens with the forceps, or with the curette, will facilitate it; but in all these movements great caution must be exercised lest * Lawrence, by Hays, Phila. edit. 1847, p. 640. ANATOMICAL RELATIONS OF THE IRIS. 129 the vitreous humor also protrude. The operator should then see that the iris has not prolapsed or been caught between 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. After Treatment.—The after treatment must be regulated by circumstances, 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. Should mucus collect between the lids, it may be gently wiped away with a soft linen rag, or with a camel's hair pencil. On the third or fifth day, if the lids are not red or swollen, and if the patient is free from fever and pain, the eye may be gradually opened, and the condition of the parts inspected. 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 superior and exterior sections of the cor- nea are so similar to that just detailed as not to require a special description. SECTION III. ANATOMICAL RELATIONS OF THE IRIS. ^ The Iris, by filling up the circular space left at the anterior por- tion of the choroid coat, constitutes a diaphragm or curtain, with an opening near its centre capable of transmitting or excluding, accord- ing to its size, the rays of light which pass through the cornea to the retina. Being a circular septum, the iris is attached only by its external circumference, adhering to the ciliary ligament, but yet in such a manner that it can be separated from it by gentle traction without injury either to itself or the ciliary body. y 130 OPERATIVE SURGERY. PLATE XVI. OPERATIONS FOR EXTRACTING CATARACT AND THE FORMATION OF ' ARTIFICIAL PUPILS. Fig. 1. Extraction of the Cataract from the left eye, by the inferior sec- tion. 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. Incision of the Capsule of the Lens, in the same operation by the knife of Cheselden, as modified by Boyer. 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. 4. Expulsion of the Lens. 1. The forefinger of the operator steady- ing 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. 5. Extraction by the oblique section of the Cornea. Fig. 6. Extraction by the superior section of the Cornea. " " 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. " " Fig. 9. 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. Fig. 10. Mulder's operation for Artificial Pupil. An opening in the cor- nea admits scissors, by which the four angles resulting from the crucial incision made in the iris are excised. After Bernard and Huette. Fig. 11. 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. 12. 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. Plate ii: ]}!,. 2. ftp u fiu. a FORMATION OF AN ARTIFICIAL PUPIL. 131 The Tupil, or opening in the centre of the iris, is capable of dilatation or contraction in certain conditions of the eye, in conse- quence of a peculiar power possessed by the iris, but whether this power is due to the action of muscular fibres, or the result of vas- cular or nervous action, is a point on which anatomists are not agreed. Dr. Physick taught that the contraction and dilatation of the pupil were due to the existence of two sets of muscular fibres, a series of those arranged circularly causing its contraction, and a radiated or longitudinal set producing its dilatation; but, as this fact has been denied by Arnold and others, it is sufficient for all practical purposes to know that the iris possesses this power under the stimulus of oertain causes, without attempting to explain how it is produced. The action of narcotic agents in producing dilatation of the pupil, together with the experiments of Dr. Samuel Cooper, of Philadel- phia, in 1797, on the effects of Stramonium, have been already alluded to under the article on Cataract. When, from a partial opacity of the cornea, or from contraction and closure of the pupil, vision is impaired, and light cannot be freely transmitted to the retina, the operation of forming a new pupil may be resorted to. § 1.—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 " Philosophical Transactions" for that year, and also in the appendix to the fourth edition of his " Anatomy," as well as in Ledran's " Surgery." Mr. Cheselden furnished, however, so brief a description of his plan as to create doubts in the minds of his cotem- poraries as to the various steps of the operation, though it was well understood that his object was the formation of an opening 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 * See Observations, &c, Cheselden's Anatomy, 13th edit. Lond. 1722. 132 OPERATIVE SURGERY. 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 (xopq the pupil, and to^ a section). 2d. Excision of the iris, Corectomia (xopy the pupil, and cxtofttj excision). 3d. Separation or tearing of the iris from its ciliary attachments called Coredialysis (xopr; the pupil, and Siaxixjts dissolution or loosening). 4th. Separation and excision combined, or a modification of the corectomia of Wenzel. 5th. Distortion of the natural pupil. (Hays.) I. CORETOMIA. Operation of Mr. Cheselden, of England. — With a very narrow and pointed knife or needle, cutting on but one edge, Mr. Cheselden punctured the sclerotica about two lines from the cornea, as in the operation of couching. Passing 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 forwards, by a sawing motion, and withdrew the instrument as it entered. n. 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 extraction, Wenzel carried its point through the iris, and made a slit in it of sufficient length to permit free vision, 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 forwards, and this being increased by gentle pressure with the finger on the ball, a portion of the iris was then cut off with fine scissors. COREDIALYSIS, OR LACERATION OF THE IRIS. 133 Operation of Dr. Physick.—Dr. Physick made a section of the cornea and iris by a cataract-knife, in a manner similar to that per- formed by AVenzel, and, introducing through the opening a pair of forceps (Plate XIV, Fig. 5), 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 projecting 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 back- wards, penetrated the posterior chamber, and, passing a line or two across it, brought the knife out again into the anterior chamber, by cutting through the iris from behind forwards. Passing the point again through the cornea, he cut a flap both in the iris and cornea at the same moment (Plate XVI, Fig. 9), the flap in the iris retract- ing upon itself, and leaving a triangular artificial pupil.f This operation is also but a modification of that of Wenzel. Mulder, after incising the cornea, introduced fine scissors, and cut out the four angles of an opening made through the iris (Plate XVI, Fig. 10). III. COREDIALYSIS, OR LACERATION OF THE IRIS. This operation, as suggested by Scarpa, was performed by him, in 1801, as follows :— Operation of Scarpa.—" The patient being seated and held as in the operation 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 * Dorsey's Surgery, p. 347, Philadelphia, 1823. f Bernard and Huette, p. 153. 134 OPERATIVE SURGERY. 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 anterior chamber, it should be pressed upon the iris from above downwards, and from the internal towards the external angle, as if with the view of carrying the instrument in a line pa- rallel to the anterior face of the iris, in order that 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 towards the temple, and carrying the instrument from before backwards, in a line parallel to the anterior surface of the iris, and the greater axis of the eye."* (Plate XVI, Fig. 12.) 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 upwards, 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 XVI, Fig. 11). It is essential to the success of this operation that the opening in the cornea should not be larger than is requisite for the introduction of the hook, other- wise it will be difficult to retain the prolapsed portion of the iris in the wound. IV. DISTORTION OF THE NATURAL PUPIL. Dr. Isaac 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 * Observations on the Principal Diseases of the Eyes, by Antonio Scarpa. Translated from the Italian, by James Briggs, Surgeon, Lond. 1806, p. 412. distortion of the natural pupil. 135 third finger. Then a section of the cornea, commencing near its junction with the sclerotica, a little below its middle, and extending so as to divide one-fourth of the circumference, was made by a cata- ract-knife being carried steadily and quickly forwards so as to pre- vent the escape of the aqueous humor, and prevent prolapse 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 ex- cellent vision.* After 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 va- , riety of circumstances 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 create a pupil near the cir- cumference 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. Mr. Gibson, of England, with others of extensive experience, object to this, and deem the opening on the temporal side preferable to any other, as permitting a wider field of vision ;f but here, as in the other ques- tions 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 superior is objectionable from being more covered by the eyelids. As illustrative 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, * Lawrence on the Eye, edited by Hays, Philadelphia, p. 456; also, Am. Journ. Med. Sciences (see Bibliography). t Littell on the Eye, p. 267. 136 OPERATIVE SURGERY. 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 anteriorly or posteriorly, the other operations mentioned may be re- sorted to. The extent and importance of the subject will, however, forbid any special recommendation of any operation; and in this, as in- deed in most of the affections of the eye, the reader will find it advantageous to consult the works of those who have devoted them- selves especially to ophthalmic surgery. CHAPTER VII. PLASTIC OPERATIONS ON THE FACE. The production of deformities, in consequence of the loss of in- tegument 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 was generally obtained either by drawing upon the sur- rounding 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 production of such an amount of inflammation as should result simply in adhesion, whilst, at the same time, sufficient vitality was preserved in the new portion to ensure the preservation of its structure. On recalling the position 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 Mr. John Hunter, we cannot but regard their operations as indicating a high degree of skill, as well as illustrative of their close observation of the efforts of nature in healing wounds; and notwithstanding the restoration of the integuments on the forehead. 137 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 account of the different kinds of operations may be best given in connection with the section devoted to disorders 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 sug- gested and performed by Dr. John Watson of New York, and is, it is believed, the first operation of the kind ever practiced. The following account is condensed from a paper by Dr. Watson,* who has also very politely afforded me an opportunity of having the figures illustrating the case copied from a drawing in his portfolio. Anaplastic Operation for a Hole in the Forehead.—A car- penter, eet. 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, contracted some twenty years previous, and of which he believed himself cured; the disease on the forehead, ac- cording to his own account, having resulted from an injury. At his admission, a large ulcer existed on the forehead, exposing a consider- able 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 opening existed at the upper border of each orbit, and another was on the left temple, through which pus escaped. The upper eyelids were somewhat * Am. Journ. Med. Sciences, vol. viii. p. 537, 1844. 138 OPERATIVE surgery. PLATE XVII. METOPLASTY AND RHINOPLASTY, OR PLASTIC OPERATIONS ON THE FOREHEAD 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 beiug operated on by Dr. John Watson, of the New York City Hospital. The ulcer is represented with thickened and in- verted edges, and as retainrlfe 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 Dr. 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 Dr. Watson. Fig. 3. Represents the line of incision, together with the sutures and lines of union in the wound immediately after the operation. After Dr. Watson. Fig. 4. Rhinoplasty, as practiced according to the Indian method, by Del- pech. A triangular, or somewhat V-shaped flap, 1, 2, 3, has been cut upon the forehead, 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 incision 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 alae, and to preserve the orifices of the nostril, are also represented. 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. Plate 17 RESTORATION OF THE INTEGUMENTS ON THE FOREHEAD. 139 elevated and deformed by adventitious adhesions around these fis- tulse. The exfoliated portion of bone was removed by Dr. J. K. Rodgers, who was obliged to enlarge the opening by a short inci- sion in the scalp at the upper and left angle of the ulcer; the un- dermined integuments, rolled in upon themselves from want of sup- port, turning a portion of the hairy scalp inwards upon the face of the sore, and adhering in a fold along the left border of the ulcer. (Plate XVII, Fig. 1.) Operation of Dr. Watson.—After shaving the scalp, and remov- ing the cuticle from the centre of the ulcer, by washing it with con- centrated aqua ammonise, 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 circumference 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 backwards, and nearly parallel with each other, two on each side, one from each upper, the other from each lower angle of the opening, 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 towards the crown of the head; the flap thus made being dissected up and rotated so as to bring its lower and right angle downwards on the centre of the forehead, thus supplying effectually the deformity; the edges being then accurately adjusted 140 OPERATIVE surgery. by numerous points of sutures (Plate XVII, 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 cicatrized, with the exception of a pupillary opening communicating with a small point of carious bone that had been overlooked in the operation, and had not then exfoliated. Plate XVII, Fig. 2, represents the patient as cured. CHAPTER VIII. OF THE EXTERNAL NOSE. SECTION I. ANATOMY OF THE EXTERNAL NOSE. The general relations of the nose to 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 composed of the skin, cartilages, bones, and mucous membrane. The skin on the upper portion, or base of the nose, is similar to that on the forehead, is loosely attached to the subjacent parts by a free cellular 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 follicles, and is attached to the cartilages by short fibrous filaments which render it very immovable and dif- ficult to dissect from the subjacent parts, without injuring them. These follicles are generally the seat of the lipomatous tumors found in this reo-ion. 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 OPERATIONS UPON THE EXTERNAL NOSE. 141 upwards and backwards from the cartilaginous septum. The contact of the oval cartilages with each other forms the columna nasi. The alse nasi, or convexities on the sides of the nostril, 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 II. OPERATIONS UPON THE EXTERNAL NOSE. The operations upon this part 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 ex- tremity of the nose. These tumors have been very indefinitely de- scribed by European writers, and the soundest view of their pathology will, it is thought, be found in a paper on Polypi and other Tumors of the Nose, by Dr. John Watson, of New York.* Dr. Watson regards these external tumors "as neither carcinoma- tous nor lipomatous, but as dependent on hypertrophy of the integu- ments and cellular tissue, and attended with serous and fibrinous infiltration and excessive development of the sebaceous cryptae pro- per to the integuments. These tumors are analogous to the poly- pous growths, are slowly developed, unattended with pain, and occur either singly or in groups; are 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." Their development is often a strictly local complaint, being limited to the skin; does not involve the nasal cartilages; and though vascular, and disposed to bleed freely, they may be removed by shaving or dissecting them off from the cartilages, care being taken previously to introduce a finger into the nostril so as to pre- vent the injury of the alge by the incisions, the ulcer being allowed to heal by the second intention. * Amer. Journ. of Med. Sciences, April 1842, p. 345. 142 OPERATIVE SURGERY. The relief of the contraction of the nostrils resulting from lupus, scrofulous 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 alse, is often very difficult, cicatrization and subsequent contraction often closing it as soon as the tubes or tentes are removed. In a young lady, in whom both nostrils were completely closed, as the result of scrofulous ulceration, the mucous membrane was per- fectly sound, and its secretion free enough to escape by the posterior nares ; yet, notwithstanding free excision, the use of sponge tentes, caustic, &c, I failed to effect a restoration of the passage. SECTION III. RHINOPLASTY. The restoration of the whole or of part of the nose constitutes a variety of the class of plastic operations designated as Rhinoplasty. These operations are among the most tedious and painful in surgery, and before undertaking them the surgeon will find it advantageous to resort to the following preliminary measures: 1st, make the patient fully aware of what it is necessary 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 organ; 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, let the surgeon next 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-thirds of the portion at first taken; and, cutting pieces of thick, or moderately stiff paper or kid, fit them to the part, or mould a wax nose upon the deficient portion, and by flattening it endeavor to obtain an accurate pattern of the shape of the integuments that will be required, marking it upon the skin by means of lunar caustic. In addition to this, let him also prepare his patient most carefully by an appropriate general treat- ment, and select such a period and locality as will be most likely to RHINOPLASTY OPERATIONS. 143 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 de- stroyed, 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 rhinoplasty, like the other plastic operations, have been arranged under three classes: 1st, the Indian method, or original plan of the Brahmins, 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 fore- arm, with some modifications, as practiced by Graefe and others among the Germans; and 4th, the French plan, in which a piece taken from the neighboring 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, and attached to the deficient part. The plastic operations practiced on the Face date from a very early period, having been long resorted to in India in order to remedy the losses occasioned by the punishment of criminals. In 1597, Taliacotius, of Venice, published a volume on the subject, in which he detailed his methods of operating; and the term Taliaco- tian has since been often employed to designate all plastic opera- tions, 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; whilst 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 Taliacotian operation had nearly fallen into oblivion, when it was successfully revived, in 1837, by Dr. J. Mason Warren, of Boston, who modified the operation of Grsefe by taking the flap directly from the forearm instead of the arm. Since then, rhinoplasty in different forms has been frequently resorted to with varying success, by Drs. Joseph Pancoast and Thomas D. Mutter, of Philadelphia; and, very recently,* the original Taliacotian operation for restora- tion of the end of the nose has been performed by Dr. Horner, of * May, 1851. 144 OPERATIVE SURGERY. the same city, but without success, owing to the sloughing of the edges of the flap. § 1.—INDIAN OR BRAHMIN METHOD OF RHINOPLASTY. Operation of Dr. J. Mason Warren, of Boston.—" The pa- tient, a young man, aged 28 years, had lost, from ulceration, the whole nose, cartilages, septum, 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 cir- cumstances 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 delicacy 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, corresponding 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 necessary to remove the integuments for planting the new skin taken from the forehead. This1 was done the night previous to the operation. The clothing being arranged, the patient was laid on a table with his face towards the window and the operator behind him, so as to have the full com- mand 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 commenced between the eyebrows and the flap of skin dissected up so as to isolate it entirely from the skin of the forehead except INDIAN OR BRAHMIN METHOD OF RHINOPLASTY. 145 where, for the purpose 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 incision included the skin, subcutaneous cellular tissue, and a portion of the occipito-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 diminish- ing the large wound made in the scalp (forehead); 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 approxi- mated 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 adhesive plaster; and a little scraped lint filled up the remainder of the wound. 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 open- ing in the nasal fossa, the traces of which, as stated, had been pre- viously made with the nitrate of silver. For this purpose, a short, narrow knife, somewhat similar to a cataract-knife, was used (re- sembling 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 between the lip and upper jaw, in which existed, as before stated, an opening large enough to pass a probe, and the adhesions between the two for 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 be- tween 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 inter- rupted suture." In a subsequent operation, the interrupted suture was used, and is generally preferable. 10 146 OPERATIVE SURGERY. " From that portion of the skin which was to form the columna, the epidermic side was pared a little, so that it might form an adhe- sion, not only underneath to the jaw, but on its sides to the quad- rangular 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 ad- hesion ; another strip was placed upon the nose to preserve its tem- perature, and the dressings were confined by a band of adhesive plaster fixed to the forehead above and partially divided in the mid- dle, 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 § 2.—TALIACOTIAN OPERATION. 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 skin of the arm. In the operation on the nose, Taliacotius made two parallel in- cisions 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 corre- sponded with the vertical portions of the letter H. Or the skin was elevated by broad forceps, and then transfixed, 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, Taliacotius intro- duced a piece of linen spread with cerate in order to prevent adhe- sions between the flap and the subjacent parts, and allowed the wound to suppurate for ten or fifteen days, in consequence of which a con- traction of the width of the flap was effected, whilst it was also thickened and rendered more organizable. A bandage, consisting * Boston Med. and Surg. Journ., vol. xvi. p. 69,1837. f See Smith's Minor Surgery. taliacotian operation. 147 of a jacket, with a hood for the head, and a sleeve to contain and support the arm, with bands to hold it fast to the head, so that the flap could be steadily kept attached to the nose, was next prepared. The edges of the surface to be restored being then freshened by paring off the cicatrix, by means of a thin and broad-bladed knife, the flap was 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 (Plate XVII, Fig. 5). After fifteen or more days, when union had taken place, the at- tachment of the flap to the arm was divided and trimmed so as to fill up the remainder 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, according to the part operated on.* Remarks.—This operation, though applied to all parts of the face, is especially adapted to the restoration of the tip of the nose, the loss of portions 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, it has been successfully performed by Dr. J. 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, Dr. J. Pancoast has succeeded in restoring the middle of the nose, together with the • ala of the left side. In his case, a great portion of the hard palate, the sockets of the upper incisor teeth, the cartilaginous septum, superior lateral cartilages, inferior turbinated bones, together with a considerable portion of the inferior oval cartilages, and the in- teguments of the nose, had been destroyed by scrofulous ulceration, the tip and margin being drawn upwards and also depressed inwards by the cicatrization. Operation.—The patient being laid on a table with his head sup- ported by pillows, the integuments of the depressed cicatrix, just * Gasparis Taliacotii Borroniensis. De Curtorum Chirurgise per insitionem, additi cutis traducis, instrumentorum omnium atque deligationum iconibus et laterilis. Venetiis, 1597. This book, together with many other rare and an- cient medical works, may be found in the Loganian portion of the Philadelphia Library. f Boston Med. and Surg. Journ., vol. xxii. p. 261. 148 operative surgery. below the ossa nasi, were dissected off so as to obtain a bevelled raw surface, to receive the margins of the flaps. The end of the nose was then separated from the ossa nasi by pushing a sharp-pointed, straight bistoury, with the back to the cheeks, across the cicatrix, and cutting outwards. It was also found necessary to divide some adventitious adhesions within the nostril, and to extend the incision of the cheek outwards and downwards through the root of the oval cartilages, before the tendency to retraction of the tip could be overcome. A triangular flap of integuments was 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 being 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 bevelled inwards towards their centre, so as to furnish an oblique surface, by which they might rest in the raw edges of the nose. Being dis- sected up with as much subcutaneous cellular substance as could be taken without involving muscular fibres, the hemorrhage was arrested by torsion, and the flaps twisted upon the pedicle, from below up- wards, so as to make the lower margin of the flap on the cheek be- come the upper on the nose. The flaps were then united by their bases upon the dorsum of the nose, and by their sides to the adjoining parts, 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, applied so that the stress should be towards 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 dressing. At the first change of dressing, com- plete 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 ulcer- ation and contraction, the nose, ten months after the operation, looked quite natural. In his subsequent operations, Dr. Pancoast employed the interrupted suture as preferable to the twisted.* Restoration of the Al^: 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 * Pancoast's Operative Surgery, Philad. 1844, p. 350, and Amer. Journ. Med. Sciences, vol. iv. p. 337, N. Series, 1842. RESTORATION of the columna nasi. 149 immediately attached in the opening, an operation which has fully succeeded in the hands of Dr. J. Mason Warren, of Boston.* § 3.—restoration of the columna nasi. Liston's Operation.—In deficiency of the columna nasi, the late Mr. Liston took the flap from the upper lip, 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 upper lip, a flap was cut of the entire thickness of the part, wide enough to allow of shrinking, and the fraenum being freely dissected off, the flap was everted upwards, so that the mucous membrane presented outwardly. Removing the membrane from the top of the flap, it 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. Ex- posure 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 experi- ence, the reader may advantageously consult the papers of Drs. Warren, Pancoast, and Mutter, as quoted in the Bibliography, all of which contain drawings explanatory of the various steps in the operations. Value of these Operations.—In estimating the value of these Rhinoplastic operations, and especially of that 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 is very great, and under such circumstances even an imperfect-look- ing nose will be deemed, by most patients, better than none. But, when it is remembered that the integuments of the new organ will retain most of the ordinary appearances of skin, whilst 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 cicatrix 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 * Boston Med. and Surg. Journ., vol. xxii. p. 268, 1840. f Liston's and Mutter's Surgery, p. 168, Philad. 1846. 150 OPERATIVE SURGERY. to import from Paris, or elsewhere, an artificial nose, the manufac- ture of which has now attained considerable perfection, and then, if on its reception the patient's vanity is not gratified, the operation may be undertaken with less chance of censure, should the result not entirely correspond with his or her anticipations. In the successful cases, which are those mainly reported, there is certainly great cause for satisfaction, but, as the operation 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 comparative oblivion ? Plastic operations for the restoration of small deficiencies have been positive triumphs of science ; but that for the restoration of an entire nose is by no means so well established, not- withstanding the Sclat attached to the successful cases. Those which have been seen by the author have certainly not presented capti- vating specimens of this organ. CHAPTER IX. OF THE INTERNAL NOSE, OR THE NASAL CAVES. SECTION I. ANATOMY. The internal nose consists of two large fossae in the middle of the superior maxillary bones, which present a very irregular surface. These fossae, or cavities, are separated by the vertical septum, which, in the natural condition of the part, is a plane surface, and corre- sponds 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 turbinated 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 con- vexities or prominences (Plate XVIII, Fig. 1), which are intended OPERATION ON THE NASAL CAVITIES. 151 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 apparent, and tends much to dimi- nish the breadth of the nostril throughout its whole depth. The middle meatus of the nose, or the space between the middle and inferior turbinated bones contains the orifice of the antrum High- morianum. This orifice is usually situated about the middle of the bone, but its precise situation and direction are so uncertain that it is stated, by an accurate anatomist,* to be found with some diffi- culty 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 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 di- vided, like the anterior, by a vertical septum (vomer). Its perpen- dicular diameter is about an inch, but its transverse diameter is only six lines (Velpeau), points which should be remembered in the intro- duction of the tampon for the arrest of epistaxis. SECTION II. OPERATION ON THE NASAL CAVITIES. Removal of Foreign Bodies.—The introduction of beans, beads, grains of coffee, cherry stones, ribbon, &c, into the nostrils of chil- dren, sometimes gives rise to considerable trouble in their extraction especially when the article is one capable of swelling from heat and moisture. In every instance, however, it is desirable to attempt it at as early a period as possible, in order to avoid the turgescence and serous infiltration of the lining membrane of the nose. Unless of considerable size, these bodies are seldom arrested upon * Special Anat. and Histology, by Wm. E. Horner, M.D., vol. ii. Phila. 1851. 152 OPERATIVE SURGERY. the floor of the nostril: more frequently they will be found be- tween the inferior or middle turbinated bones and the septum; and, in attempting their removal from this position, the delicacy of these bones should be borne in mind. A piece of annealed wire, covered with thread, such as is used by the milliners in the manufacture of ladies' bonnets, and formed into a loop, will often prove a simple and efficient instrument for the removal of the substance, when there is but a small space at its side through which to pass an instrument. Foreign bodies may be extracted either from the front of the nostril or pushed back into the throat, according to their proximity to one or other of these orifices. As they seldom fill up the entire front of the nose, a curette or curved probe, or Leroy's instrument for re- moving fragments of calculi from the urethra, may generally be passed on one side of the article, so as to enable the operator to draw it forward. If jammed between the inferior turbinated bone and the septum, gentle pressure from above downwards, by placing it upon the floor of the nostril, will facilitate its subsequent removal either by the instruments before named, or by polypus or common dressing forceps. If, however, the foreign substance should be a piece of ribbon, or something similar, which has been stuffed high up in the cavity, washing out the nostril by a stream of water from a syringe, will often dislodge one end and enable the operator to seize and draw it out with his forceps. § 1.—ARREST OF HEMORRHAGE FROM THE NOSTRIL. Bleeding from the nostril, when excessive, and when the use of powdered galls or tannic acid, or matico, or gum Arabic, or alum have failed, may usually be arrested by plugging up both the ante- rior 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 Instrument.—This instrument (see Plate XIV, Figs. 21, 22) 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 button, with an eye capable of readily receiving a ligature; to the other is screwed a probe, which is in- tended to push out the spring. polypi in the nostrils. 153 Operation.—After preparing a little pellet of charpie, of a size corresponding 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, the surgeon should pass the tube along the floor of the nostril, 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, or its passage in front of the uvula may be 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 a pellet of charpie attached to it by tying the ligature round its middle. (Plate XVIII, Fig. 1.) Then, on withdrawing the spring into the canula, and removing it from the nose, the pellet may 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 towards 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 for- ceps, 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 simply by employing the end of the ligature left in the mouth. § 2.—polypi in the nostrils. Pathology.—In order to appreciate the value of the different modes of treatment which have been proposed for the relief of po- lypi, it is necessary that reference should be briefly made to their structure and general position. 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 Dr. John 154 OPERATIVE surgery. PLATE XVIII. ANATOMY OF THE INTERNAL NOSE TOGETHER 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. Ante- rior 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. Section of the uvula. 11. Bellocque's canula passed along the floor of the nostril and soft palate, behind the uvula into the pharynx. The spring has been protruded, 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 nostril. 12. The epiglottis cartilage. 13. Section of the oesophagus. 14. Genio- hyoglossus muscle. 15. Origin of genio-glossus muscle. 16. Section of 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 vertical section of the Nose, showing the application of a liga- ture around a guttural polypus by means of the "porte" 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 detached from the ligature without difficulty. The forefinger of the surgeon will often do quite as well. After Bernard and Huette. Fig. 3. 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 Physick. After Sir Charles Bell. Fig. 4. A side view of Dr. Mott's operation for the removal of a large nasal polypus, which filled the entire nostril. The integuments have been incised and dissected back, whilst the dotted lines show the course of the saw through the bones. After Dr. Mott. Plate lfi ) POLYPI IN THE NOSTRILS. 155 Watson, of New York,* much has been added to our knowledge of the origin and structure of these tumors, and I cannot present the reader with any details more valuable than those furnished by his article. From this, the following account is, therefore, condensed. Kinds of Polypi.—Six kinds of polypi may be noticed in con- nection 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 consistence of the mucus itself, or from obliteration and obstruction of the ducts, resembling, in this respect, the seba- ceous 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 mucous and submucous tissues of the nostril, and similar to the tumors frequently seen near the lower part of the rectum. These tumors are, in fact, a prolapse of the thickened and infil- trated Schneiderian membrane, and attended with an effusion of fluid into the subjacent cellular tissue, as the result of inflammation. 3d. Fleshy polypi or caruncular excrescences, of a florid red color, and though not painful except when irritated, possessed of a certain degree of sensibility. These are less disposed to assume a pedun- culated 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 forwards or backwards. These tumors are, as stated by Dr. Watson, invariably attached by a firrn and fibrous pedicle. 5th. Gelatinous polypi, which are of rare occurrence, Dr. Wat- son having seen but one. In this case, the disease appeared to have originated in the antrum between the mucous membrane and the bone, and then to have encroached on the surrounding parts. It was surrounded by a sort of imperfect capsule, with subdivisions of * Amer. Med. Journ., vol. iii. p. 325, New Series, 1842. 156 OPERATIVE SURGERY. cellular 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 calf's-foot jelly, without any visible envelop, but here and there the tumor contained opaque, grumous, 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 deranging surrounding tissues. Seat of Polypi.—This is to be ascertained mainly by dilating 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 them forward. Most frequently polypi arise from the membrane spread over the turbinated bones, or near the orifice of the maxillary sinus, being seldom found on 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 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 in consultation with my friend, Dr. J. M. Wallace, 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. Operations.—The mucous polypi may frequently be cured by the plan proposed by Dr. Watson, of puncturing them and evacuating their contents, after which the sac wastes away. The extraction of other polypi may be attempted either by the polypus forceps, by the * Watson, loc. citat. polypi in the nostrils. 157 wire ligature and double canula of Levret (Physick and Randolph), (Plate II, Figs. 11,12), or by the knife, caustics, sternutatories, &c. being comparatively limited in their application, or resorted to either as palliative means, or as adjuvants to the 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, the surgeon should introduce 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 his hand so as to twist the tumor, pull it away with a jerk as soon as it is felt to yield to the torsion movement. Strangulation and Extraction by the Wire Ligature and Double Canula.—This plan, which is most frequently resorted to, and which is the least liable to injure the bony structure, is practiced as follows: Pass a piece of well annealed iron wire through the bar- rels of the canula, and fasten one end firmly around one wing of the instrument. Then, seizing 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 pediculated portion; 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 pos- sible. If the polypus is not too dense in its structure, this will con- strict 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 especially on the side affected, when the surgeon, again forming a loop, fishes about in the nostril for another tumor, which is extracted as before (Plate XVIII, Fig. 3). In large polypi, and especially where they protrude by the poste- rior 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 perfect strangulation accomplished by it should cause the surgeon to give it the preference. But its large size will occasionally preclude the use of it in this manner. 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, Dr. Physick, after vainly attempting to extract it 158 operative surgery. 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 Dr. Wm. 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. In a large fibrous polypus which filled the nostril, Dr. Valentine 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 turbi- nated bone.* (Plate XVIII, Fig. 4.) Excision.—Except in the very rare cases of exceedingly firm polypi, or those near the nasal orifice, this operation is seldom prac- ticed. When resorted to at the anterior orifice, the tumor should be hooked forwards, 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, tamponing the nostril may be required. Value of these Operations.—In most cases, the wire ligature and double canula will prove most serviceable, next the forceps, and lastly excision, simple polypi requiring only to be punctured, or their coats to be ruptured by sternutatories, in order to evacuate their contents. CHAPTER X. SECTION I. ANATOMY OF THE EXTERNAL PORTION OF THE MOUTH. In studying the parietes of the mouth, two parts are to be sepa- rately noticed: first, its orifice as formed by the lips, and its sides as * Amer. Journ. Med. Sciences, vol. v. p. 87, 1842. ANATOMY OF THE EXTERNAL PORTION OF THE MOUTH. 159 constituted by the cheeks. The tissues composing both these por- tions are the skin, cellular substance, fat, blood-vessels, muscles, and nerves, together with the mucous membrane. The skin and cellular substance present nothing requiring a spe- cial description. 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; and the masseter, which assists in closing the jaws, being in- serted into the lower jaw in advance of its angle. The depressors 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 ante- rior edge of the masseter muscle; being at this point quite super- ficial, 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 distri- buted over the face after it emerges from the parotid gland (Plate XXIII, Fig. 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 sensation to the branches of the fifth pair. The salivary glands (Plate XXIII, 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 operations 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 ante- rior edge of the gland a few lines below the zygoma, traverses the outer face of the masseter, 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 XVIII, Fig. 1). Its position may be accurately marked by drawing a line from the tip of the nose to the lobe of the ear (Physick). The duct of the submaxillary gland may be found opening by a small projecting orifice on the anterior margin of the fraenum linguae. The ducts of 160 OPERATIVE SURGERY. 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 refer- ence to the explanations of the .figures (Plate XVIII, Fig. 1, and Plate XXIII, Figs. 1, 2). SECTION II. OPERATIONS ON THE LIPS. The operations upon the lips are chiefly those required for the cure of hare-lip, of cancer, of contraction 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 sur- geons, but 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 generally found successful. Operation.—The child, being either firmly held 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. The surgeon, then seizing the left half of the lip with/his left forefinger and thumb, should dissect it freely from its attachment to the gum, and seizing the right half in the same manner, dissect it also freely from the gum, this free dissection of the lip from its attachments being essential to success, by diminishing the subsequent strain on the line of union. After freeing the lip very fully at this point, let him next introduce a spatula of soft wood beneath the lip, and have its free extremity held by an assistant. Then seizing the left * Horner's Anatomy. SIMPLE HARE-LIP. 161 half at its free angle, with a tenaculum or forceps, let him 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 outwards at the cross-piece, the joint or angle being near but not quite in the centre, as proposed by Dr. J. Rhea Barton, and also by'Guerin* (Plate XIX, Fig. 1). This edge of the lip being then seized by the assistant, the coronary artery may be compressed between his 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 towards the median line of the fissure. The surgeon, then passing a ligature through the lower edge of each flap, and drawing upon it, should accurately adjust 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 to right, taking care not to carry it through the mucous membrane. After surround- ing this pin with a twisted suture, let him 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 XIX, Fig. 2), when the ligature first introduced at the lower edge of the lip, and which should have been held by the assistant during this time, may be withdrawn. The sutures should then be supported by strips of adhesive plaster, slit so as to allow the ends of the pins to pass through them, and extended from the front of one cheek across the lip to the other cheek, in order to take the traction off from the pins. Four days subsequently, the latter must be withdrawn by a rotatory movement, without, if possible, disturbing the ligatures or plaster, and this 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 supported by an assistant, these strips may be re- moved, and new ones applied every three days during the first week or two, until the union is accomplished. Throughout, or at least until the sixth day, the child, if unweaned, must 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 * Gazette Medicale, June 1844. 11 162 OPERATIVE SURGERY. PLATE XIX. 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 Dr. Rhea Barton. 1, 1. The semi-ellip- tical incisions. Modified from Bernard and Huette. Fig. 2. Arrangement of the Sutures at the close of the operation. After Bernard and Huette. Fig. 3. Operation of Mirault, of Angers, for single Hare-lip. 1. The flap cut from One side. After Bernard and Huette. Fig. 4. The same operation, showing the line of union and position of the principal pin. After Bernard and Huette. Fig. 5. Front view of a double Hare-lip, showing the septum or anterior edge of the inter-maxillary bone, containing the two central incisor teeth. 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 central part from excessive inflammation or want of vitality, is an ob- jection to this mode of operating. After Bernard and Huette. Fig. 7. A contracted Mouth consequent on ulceration, showing Dieffen- bach'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, towards 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 Nature. Fig. 9. The appearance of Fig. 8 after the integuments have been re- moved. 1. The mucous membrane untouched. This is to be divided in the me- dian line of the mouth, and reflected so as to form a rounded edge to the new hPS- After Bernard and Huette- Plate ig '-%~- fig. ri£ !> I~ - SIMPLE HARE-LIP. 163 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 arte- ries, the compression 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 XIX, Fig. 3). 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, pre- vents the formation of any notch or depression (Plate XIX, Fig. 4). Malgaigne, in order to avoid the notch on the free surface of the lip, makes a curved incision from above downwards, so as to pare off the mucous covering of the fissure, but without cutting it free from the inferior angle or that continuous with the margin of the lip. Leaving the portion pared off adherent, and depending by this pedi- cle, he unites the wound by pins and the twisted suture. Then, trimming and shortening the pediculated 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.* Remarks.—Judging from personal observation, Hare-lip is a very common complaint in this locality, it having occasionally happened to me to have three patients under treatment at one time, and in one winter at the Clinic of the University of Pennsylvania, ten were treated in the course of six months. Out of the large number that have been seen (I should think some fifty), but two failures have occurred, after pursuing the plan above stated, and in one of these (double) the result was undoubtedly due to an attack of cholera infantum, of which the child died. After operations by the scissors * Operative Surgery, by Brittain, p. 334, Phila. edition, 1G4 operative surgery. and the ordinary straight incision, I have seen several (five?) failures. As respects the period for the operation, the earliest possible time, after the tissues seemed to be firm, has always been selected, usually soon after the third month of infancy, and it has always been deemed necessary to continue the adhesive strips a week after the removal of the pins. Dr. J. Mason Warren, of Boston, as well as several other sur- geons, also prefer an early period for their operations, but resort to the interrupted suture in place of employing the hare-lip pins. § 2.—DOUBLE HARE-LIP. In the variety of the disease known as Double Hare-lip, there is usually 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 XIX, Fig. 5). The projecting extremity 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 judg- ment, 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 detailed; 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 cir- cumstances induce the surgeon to think differently, both sides may be united at the same time by transfixing them with the pins, as represented in Plate XIX, Fig. 6. Remarks.—Some surgeons recommend, 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; and 2d, from the inflammation or compression of the middle flap by the ligatures being more apt to induce sloughing. cancer of the lip. 165 To operate first on one side and then repeat it, 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 intermaxillary bone before proceeding to the incision in the lips. But in children, unless the portion of the alveolar processes to be removed is limited, the germs of the permanent incisors will be entirely destroyed. When the projection 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 downwards, behind the alveolar processes, and then to bend or force back the projecting portion, any attempt to push back this end of the bone by bandages alone being very apt to induce such inflammation 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 opera- tion ; though it will often be much diminished or cured, simply by the contraction and constriction 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 mentioned. The treatment of the fissure in the soft palate will be referred to under the head of Sta- phyloraphy. § 3.—cancer of the lip. This affection may be seen either in the form of a small shot- like tumor, of a larger induration, or as an ulcer. 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 tissue, 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 ope- rating, he may proceed as follows :— Ordinary Operation.—Make either with the scissors or scalpel a V incision 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 1G6 OPERATIVE surgery. 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 recently seen two patients, in each of whom I removed a piece over one inch in width at the base of the V, near three }Teavs since, 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 formation of a new lip, or to the operation of Cheilo- plasty, 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 con- traction or closure from the cicatrices resulting from ulceration or from burns. Among the best plans of operating in these cases is the very ingenious one of the late Professor Dieffenbach, of Berlin. Dieffenbach's Operation.—Wishing to preserve enough of the mucous membrane to cover the edge of the incisions required in en- larging the mouth, Dieffenbach introduced into the patient's mouth the forefinger of one hand, and sticking 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 membrane (Plate XIX, Fig. 7). On pushing the point forwards to the contracted orifice, he was enabled to incise all this texture in the line (3, 4) of the free edge of the lower of the new lips; then, re-introducing 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, 5) cor- responding with the free edge of the upper lip. The triangular piece (1, 2, 3, 4, 5) being then carefully dissected off from the lining membrane of the mouth, 1, 2, the latter was left uninjured (Plate XIX, Fig. 9). On dividing this membrane in the middle, to within two lines of the angle of the first incisions, it only remains to attach it neatly by sutures to the bleeding surface in order to complete the mouth. After union has taken place, the resemblance of the new mouth to a normal one is often excellent. cheiloplasty. 167 On two occasions, I repeated this operation (Plate XIX, Fig. 8) with entire satisfaction; and many other surgeons, especially Dr. Mutter, have reported similar instances of success.* § 5.—cheiloplasty. Plastic operations for the restoration of the lip may be required in diseases of either of them, though it is most frequently demanded in that of the lower lip. In either case, the operation is termed Chei- loplasty. 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 hare-lip operation, ren- ders 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, and the loss of substance from cancerous degeneration or ulceration, when so extensive as to require any plastic operation, may be more readily supplied by either of the following methods: — Operation of Dr. J. Pancoast, of Philadelphia.—In a case of cancer of the lower lip, Dr. Pancoast excised the diseased margin of the lip by an incision which entirely circumscribed it. A vertical incision was then 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, were 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 XX, Fig. 1). The margins of the upper flaps were then 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.J—Chopart, in a case of cancer of the lower lip, included all the diseased structure between two paral- lel vertical incisions, which, commencing at the margin of the lip, extended down to near the os hyoides. These incisions formed a square flap which was dissected off from the chin from above down- * Amer. Journ. Med. Sciences, vol. xx. p. 342. t Pancoast's Operative Surgery, p. 356, Philad. 1844. X Bernard and Huette, p. 179. 168 OPERATIVE surgery. PLATE XX. THE OPERATIONS OF CHEILOPLASTY" AND GENIOPLASTY. Fig. 1. A front view of the operation of Dr. Pancoast for the removal of an extensive Cancer and the formation of a new Lower Lip. The cancer is shown as circumscribed by a curvilinear cut. A vertical incision in the me- dian line of the chin, extended from the curvilinear cut nearly to the os hyoides, and another 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, when the lower flaps, 3, 4, were also united on the median line so as to cover the front of the chin. After Pancoast. Fig. 2. A front view of Chopart's operation for the same object. 1, 5, 3, 6. The vertical incisions. 2, 4. The horizontal cut circumscribing the disease. 2, 4, is to be raised to the level of 1, 3. After Bernard and Huette. Fig. 3. 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. Fig. 4. A three-quarter view of Dr. Mott's operation for the relief of An- chylosis of the Jaw dependent on Cicatrization of the Mouth, with the restora- tion 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. 5. A side view of Dr. Mutter's operation for the Formation of a New Cheek. The edges of the ulcer which resulted from extreme salivation were first freshened, 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_ Plate 20 t\g.2 J ^ ,.-4.f X— :?..&■- lv- Fig 5 CHEILOPLASTY. 169 wards. The diseased portion 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 seve- ral stitches placed in the line of the vertical incisions (Plate XX, Fig. 2). When the preservation of a portion of the mucous membrane can be accomplished, it will add much to the natural appearance of the new lip. Operation of Malgaigne.—This accomplished surgeon removes all the diseased structure 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 horizontal cut, as in the upper inci- sion 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 trans- verse 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.* Dr. Pancoast, in a case of extensive loss of substance from the explosion of gunpowder, also made a new lip by the following process:— Operation.—After removing the rounded edges of the cicatrix in a V-shaped piece, he carried two curved incisions from a point four lines above the apex of the V (which was on a level with the lower surface of the inferior maxilla) in the direction of the extremities of the os hyoides. Then, freely separating the integuments from the bone and rotating the flaps a little upwards, he drew them inwards, and united them to each other on the middle line by two twisted * Malgaigne, Op. Surg. p. 340, Phila. edit. 170 operative surgery. sutures, closing the incision below the chin with adhesive strips.* Other instructive cases are reported in the same paper, which is amply illustrated by woodcuts. § 6.—genioplasty. The application of the principles of plastic surgery to the restora- tion of deficiencies in the cheeks must, like the operations already spoken of, depend upon the peculiarities of the case. The two in- stances hereafter stated may, therefore, suffice as illustrations of this class of operations. In a patient of Dr. Mott's, of New York (see Plate XX, Fig. 4), 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 fol- lows, April 8th, 1831 :— 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 over- coming 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 and neck (Plate XX, Fig. 4). 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 ad- jacent parts, and sufficient for all the purposes of circulation. The edges were 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, when 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.f Dieffenbach, in cases where the sides of the ulcer could be at all approximated by drawing upon the substance of the cheek, freshened the edges of the opening and united them by sutures; then, in order * Amer. Journ. Med. Sciences, vol. v., New Series, p. 106.- f Ibid., vol. ix. p. 47, 1831. SALIVARY FISTULA. 171 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 granulation. Operation of Dr. Mutter, of Philadelphia.—In order to re- lieve a shocking deformity of the face, resulting from the sloughing consequent on profuse salivation, Dr. 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, he detached the integuments from the side of the jaw, so as to permit some approximation of the wound. Two incisions above and below the ulcer were then made so as to form four flaps (Plate XX, Fig. 5), and these were united to each other in the line of the teeth, as far forwards as the angle of the mouth. The edges of the remaining ulcer, being partly approximated by the hare-lip suture, were subse- quently eaused to cicatrize under the use of the nitrate of silver. The result was entirely satisfactory.* § 7.—REMOVAL OF TUMORS FROM THE CHEEKS. From disease of the buccal glands and other causes, it sometimes becomes necessary to remove tumors from the substance of the cheeks. No other rules need here be given, in reference to elliptical or such other 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 conceal the cicatrix by bringing it into the direction of the natural folds of the cheek; and 2d, if the tumor is far back, or towards the angle of the jaw, to guard against injury of the duct of Steno. § 8.—SALIVARY FISTULA. As the position and general anatomy of this portion of the face have been already given (page 159), it is only necessary at present to mention the operations resorted to in cases where from a wound * Lecture on the Operations in Surgery, by Robert Liston, with numerous additions, by Thomas D. Mutter, M. D. Philad. edit., p. 244. 172 OPERATIVE SURGERY. or ulceration the duct of Steno has been opened and the saliva flows out upon the cheek. 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 simple incised wound, the greater will be the chance of its closure; and the following operation, as proposed by Dr. Horner, by reducing the parts to this condition, has, both in his hands and my own, been followed by perfect success. In a patient on whom I recently operated,* the cure was accom- plished in a few days, the external parts healing by the first intention. Operation of Dr. Horner, of Philadelphia.—The patient being seated with the head well supported by an assistant, the ope- rator introduces a strong broad wooden spatula within the cheek of the affected side, where it should be firmly held by an assistant, who also supports the patient's head. The wound being then slightly elongated by incising its sides in the line of the zygomatics major muscle, a round punch, like that of the saddlers, should be placed over the fistulous orifice, care being taken to avoid the anterior edge of the masseter. Then, on pressing the punch firmly against the spatula within the mouth, a piece of nearly the entire thickness of the cheek will be removed, and a fresh opening made directly into the mouth, when the external wound, being accurately closed by sutures and adhesive strips, will usually 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 supported inside, in order to obtain a clean cut (Plate XXIII, Fig. 3). SECTION III. DIVISION OF THE MASSETER MUSCLE FOR IMMOBILITY OF THE LOWER JAW (FALSE ANCHYLOSIS). This disease, which has been claimed as peculiarly an American one, was first treated of as a distinct affection by Dr. Mott, of New York.f 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 Dr. J. W. * June, 1851. f Mott's Velpeau's Operative Surgery, vol. iii. p. 1139. DIVISION OF THE MASSETER MUSCLE. 173 Schmidt, of New York, Oct. 1841.* Subsequently, Dr. J. Murray Carnochan, of the same city, published an account of a similar operation performed by him in 1840; but, as his publication was after that of Dr. Schmidt, the latter has generally received the credit of priority. In Dr. Schmidt's case, a young lady, in conse- quence of rigidity of one of the masseter muscles, caused by an extensively ulcerated throat 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, Dr. Schmidt operated as follows:— Operation of Dr. Schmidt.—A narrow bistoury being passed through the mucous membrane of the mouth immediately in front of the anterior 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, the bistoury passed over the masseter between it and the integuments, but without cutting through the latter, and the muscle completely divided to the bone, after which the mouth was immediately opened by a lever. Consider- able 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 subsequent contraction of the muscle as before, pieces of soft wood of a wedge-shape were kept in the mouth during the night, and occasionally during the day.f The danger likely to ensue from inattention to the anatomical relations of this region will be readily foreseen by every anatomist, and may be recognized by reference to Plate XXIII, Fig. 2, where the position of the vessels and of the salivary duct is shown after the removal of the parotid gland. Dr. Mott's Operation.—In seventeen cases of false anchylosis of the jaw, reported by Dr. Mott,J forcible dilation was practiced, after, or in some instances without, division of the contracted tis- sues. To overcome the contraction and expand the jaws, Dr. Mott employed only a screw and lever, similar to that of Heister, as de- picted in the " Armamentarium Chirurgicum" of Scultetus, and also in the "Surgery" of John Bell. The levers, being introduced be- tween the teeth, are to be gradually expanded by turning the screw. An instrument suggested, and frequently employed by Dr. J. * Published in the Amer. Journ. of Med. Sciences, p. 516, Oct. 1842. t Ibid., loc. cit. X Mott's Velpeau, loc. cit. 174 OPERATIVE SURGERY. Rhea Barton (Plate XXII, 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. CHAPTER XI. 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 anatomical relations of the parts within the mouth may at present be confined to such portions of the cavity as arc found within the line of the teeth, and require therefore but a brief de- scription. The Tongue, being composed in a great measure of the genio-hyo- glossus, hyoglossus, and lingualis muscles, which connect it both with the os hyoides and the lower jaw, is covered by a mucous mem- brane, the reflection of which to the floor of the mouth constitutes the Fraenum Linguae. The general arrangement of the fibres of the genio-hyoglossus, and their expansion from their origin into the bulk of the tongue, may be understood by referring to Plate XVIII, Figs. 1, 2. The Lingual artery is the main source of the blood supplied to the tongue. Coming from the external carotid, this artery pene- trates the hyoglossus muscle just above the os hyoides, and of course lies too deep for any operation upon this organ except its extirpa- tion (Plate XXI, Fig. 1). The sublingual 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-hyoglossus muscles, to supply the floor of the mouth and ANATOMY OF THE MOUTH. 175 its lining membrane. Except in an attempt to extirpate the sub- lingual 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 anas- tomosis of the vessels of each side. The ranine veins are especially superficial, and may be seen just beneath the mucous 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 hypoglossal nerve is shown in Plate XXI, Fig. 1, 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 sub- lingual, 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 XXIII, Fig. 1) terminates by a small projecting orifice on the anterior margin of the fraenum. The obstruction of this orifice gives rise to the disease 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 concretions which are usually situated in the duct itself. The Tonsil glands (Plate XXI, Fig. 5), 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, towards 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 remem- bered 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 Be'clard, in which the internal carotid was opened in an operation upon this region.t The Palate is composed of two portions—the hard or bony struc- ture, formed by the palate plates of the palate and superior maxillary * Homer's Anat., vol. i. p. 569. f Blandin, Anat. Topographique. 176 OPERATIVE SURGERY. bones, and the soft palate, which is composed of the mucous mem- branes and the muscles. The soft palate stretches across the back of the mouth from side to side, and obliquely downwards and back- wards 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 XXI, Fig. 5) 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 a half 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 inflammation often becomes (edematous, swollen, and elongated, so as occasionally 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 lining membrane, called the Half Arches, and designated as anterior and posterior. Within or beneath these folds lie the mus- cles of the part, some of which are important in connection with the operations on this region. The Constrictor Isthmii Faucium is within the anterior half arch, arises from the soft palate near the base of the uvula, and is in- serted into the side of the tongue near its root. It will close the opening between the mouth and pharynx. The Palato-Pharyngius 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 cartilage. It draws the soft palate downwards, or draws the pharynx upwards. The Tensor Palati arises from the spinous process of the sphenoid bone; passes downwards; 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 arises from the point of the petrous bone, and passes downwards to be inserted into the soft palate. It draws the soft palate upwards.* * Horner's Anat. vol. i. p. 490, eighth edition. CANCER OF THE TONGUE. 177 In the various operations for fissure of the palate, attention to the action of these muscles is essential to a successful result.* SECTION II. OPERATIONS UPON THE TONGUE AND THROAT. The operations practiced on these parts consist in such as are required for the relief of cancer, ranula, or hypertrophy in the tongue, together with those upon the uvula and tonsils. § 1.—CANCER OF THE TONGUE. When the development of cancer 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 before attempting any operation upon the tongue, the surgeon will find it necessary to obtain entire control of the mem- ber by inserting into its tip a tenaculum, a needle and ligature, or a pair of hooked forceps; but the former is preferable, both on ac- count 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 in- strument will then have this unruly member entirely in its power. Ligatures, either of silk or wire, may be resorted to for the re- moval 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. The Double Canula and Wire Ligature.—When the wire liga- 12 * See Staphyloraphy. 178 operative surgery. PLATE XXI. OPERATIONS PRACTICED ON THE TONGUE AND TONSILS. Fig. 1. A side view of a vertical section of the Mouth and Tongue, show- ing the anatomieal relations of the Vessels and Nerves of the Tongue. 1. The lingual artery. 2. Its sublingual branch. The veins accompany the arteries. 3. The hypoglossal nerve. 4. The ranine vessels as seen near the tip of the tongue. After Bernard and Huette. Fig. 2. A front view of the Removal of the end of the Tongue as prac- ticed either for Cancer or Hypertrophy. 1, 2, 3. The lines of the V-shaped incision. 4. A pair of tumor-shaped forceps (Plate I, Fig. 1), 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 hemor- rhage is checked and the flaps partially united. After Bernard and Huette. Fig. 3. The preceding operation as completed. " " Fig. 4. A three-quarter view of a Hypertrophied Tongue (Lingua Vitula), as it existed in Dr. Harris's patient prior to the operation. After Harris. Fig. 5. A front view of the anatomical relations of the parts about the Fauces, as shown with the Mouth widely opened. 1. The dorsum of the tongue as depressed within the teeth. 2, 3. The tonsils in sM. 4. The uvula. 5. The anterior half arch. 6. The posterior half arch with the tonsil between it and 5. 7. The soft palate. After Bernard and Huette. Fig. 6. A vertical section of the Mouth and Pharynx, to show the extir- pation of the Tonsil, by Physick's instrument. 1. The right tonsil, excised and about to be removed in the instrument. 2. The Tonsilitome of Phy- sick. Modified from Bernard and Huette. Fig. 7. A similar view of the parts in the Throat, showing the excision of the Tonsil by means of the probe-pointed curved bistoury and tumor-forceps. L The forceps holding the gland. 2. The bistoury in the act of excising it. Modified from Bernard and Huette. Plate 21 H Fi£ 4 Fio.5 f*~* HYPERTROPHY OF THE TONGUE. 179 ture is employed, the double canula of Levret (Plate II, Fig. 11) should be prepared as directed for polypus of the nose; the motion of the tongue be perfectly controlled by the means just 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 carried around the tumor in the incision first made. The wire should then be drawn as firmly as possible, fastened to the wing of the canula, and the latter left wrapped with linen or tin foil, protruding at the angle of the mouth nearest to it until sloughing occurs, when the instrument may be removed. Extirpation.—Excision of these tumors may be 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 XXI, Figs. 2, 3), as mentioned under Hypertrophy, may be required. § 2.—HYPERTROPHY OF THE TONGUE. Under the name of Lingua Vitula, authors have described an en- largement of the body of the tongue which sometimes has been so great as to require the excision of the enlarged portion in order to enable the patient to retract the tongue within the mouth. The fol- lowing operation, by Dr. Thomas Harris, of Philadelphia, in May, 1835, which was the first performed in the United States, sufficiently illustrates the ordinary proceeding in such cases. Amputation of the Tongue, by Dr. Harris.—The patient, aged 19, had the tongue enlarged at birth. A short time previous to the operation, it projected beyond the upper incisors three inches; its circumference was six inches, and its vertical thickness one inch and a half (Plate XXI, Fig. 4), and filled up the jaws so com- pletely that it was necessary 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 180 OPERATIVE surgery. 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, made to cut a flap, which terminated near the first bicus- pid tooth. The left ranine artery being then secured with a liga- ture, 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 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 ordi- nary length. A year subsequently the patient articulated distinctly, and was relieved of all deformity.* Having had the opportunity of witnessing this operation, I could not but notice the great advantage possessed by the operator from the use of the means employed 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 ad- justed by sutures without any difficulty. In a previous case, June 1829, the same surgeon applied a liga- ture to the enlarged portion, in order to cause it to slough off, but the irritation was so great that he was subsequently obliged to am- putate 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 vertical thickness one inch and three-fourths, f In a case, also congenital, operated on by Dr. H. S. Newman, of Pennsylvania, the enlargement Avas very great, the portion ampu- tated measuring in length 2| inches, circumference 7J inches, thick- ness If inches.| The operations for the relief of tongue-tie, and also that for ranula, will be found among those of minor surgery.§ * Amer. Journ. of Med. Sciences, vol. xx. p. 15. f Ibid., vol. vii. p. 17. X Med. Kecorder, vol. vii. p. 541. g See Smith's Minor Surgery. EXCISION OF THE UVULA. 181 § 3.—EXCISION OF THE UVULA. When, in consequence of chronic inflammation, the mucous mem- brane of the uvula becomes infiltrated, or when it and the muscle become relaxed, its end 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 for those of this complaint. The effect of this state of the parts, and the mode of relief were early suggested by the late Dr. 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 object; 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 joint of the instrument, or by a spoon in the hands of an assistant. Then, with a pair of scissors hooked at the end like Plate XXV, Fig. 1, or curved on the flat, and held in the right hand, cut entirely through the elongated part, removing the piece in the grasp of the forceps. If the mucous membrane is not cut 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. After Treatment.—Nothing more is requisite after this opera- tion 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 hemorrhage of consequence, touching the end of the stump with the nitrate of silver will generally ar- rest it. 182 OPERATIVE SURGERY. § 4.—EXCISION OF THE TONSILS. Chronic inflammation of the tonsils, or repeated attacks of quinsy, sometimes cause such effusions of lymph into the parenchymatous structure of these glands as results in induration and permanent en- largement, or in the condition sometimes, though improperly, desig- nated as scirrhus. The continuance of this enlargement being a constant source of irritation, such patients are liable to inflamma- tion of the throat on the slightest change of temperature. To relieve this sensibility, after the failure of other means an operation for their removal may become necessary. Operation of Dr. Physick.—In order to accomplish this object without any risk of hemorrhage, Dr. Physick proposed and prac- ticed, 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 consequence of the pain and inflammation which sometimes ensued, this application has justly been supplanted by the operation of excision. Various instruments have been recommended for this operation, and for a list of those suggested by surgeons in the United States, the reader is referred to the Bibliographical Index at the commencement of the volume. At present, one of two instruments is most frequently resorted to in this country, viz., that of Dr. Physick, slightly modified by Schively (Plate XXV, Fig. 3), and that of Dr. Fahnestock. The instrument of Dr. Physick consists of a ring, which sur- rounds the part to be excised, and of a triangular-shaped knife, which, sliding in the ring, guillotines the gland. Dr. Fahnestock's instrument was also formed of a ring, but his knife was of a similar shape, and excised the tonsil by drawing it towards the operator. This instrument has justly been objected to from the difficulty of giving a good edge to a circular blade, and also from its cutting by pulling upon the gland rather than dividing it like a knife. That of Dr. Physick, as modified by Schively, having none of these defects, and its cutting edge being of such a shape as enables the surgeon readily to preserve or renew it him- self, is preferred by many, and has much to recommend it. M. Velpeau prefers the instrument of Fahnestock, but has modified it to some extent; and I have lately seen a further modification by Charriere, in which the knife is only half a ring, and made to cut RESECTION OF THE BONES OF THE FACE. 183 like a curved bistoury. This is, however, nothing new, a similarly- shaped knife having been suggested and used by Drs. Rogers and Cox, of New York, nearly twenty years since.* 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 promi- nent 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 instru- ment, and pushing the knife backwards, 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 XXI, Fig. 6). Should this instrument not be at hand, a probe-pointed bistoury and dressing forceps may be made to answer by a skillful manipu- lator (Plate XXI, Fig. 7). After Treatment.—The only after treatment that is requisite is that referred to in excision of the uvula. The simplicity of the operation, as performed by the Tonsilitome, is such that it is difficult, at the present time, to realize the anxiety and discussions of the surgeons of the period when extirpation of the tonsil was first suggested. CHAPTER XII. resection of the bones of the face. The sawing or removal of a portion of any bone, having long been designated by surgeons as a Resection, and being also generally understood to mean the cutting or paring off of any part,f it does not seem necessary to change the word, as has lately been suggested under the erroneous idea that resection means the repetition of a section, to obviate which inaccuracy, the use of the term Exsection * See Bibliography. f Webster's Dictionary. 184 OPERATIVE SURGERY. PLATE XXII. A VIEW OF SOME OF THE INSTRUMENTS EMPLOYED IN ANCHYLOSIS AND RESECTION OF THE JAW BONES. Fig. 1. A three-quarter view of Dr. Rhea Barton's Dilator for expanding the Jaws in cases of False Anchylosis. The horse-shoe plates are to be placed upon the teeth as far within the mouth as possible and separated by turning the screw. This instrument will also be found highly useful in cases of mania where it is necessary to employ the stomach tube. Schively's pattern. From the Instrument. Fig. 2. 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. From the Instrument. Figs. 3, 4. Strong double-edged and curved Scalpels, for operating about the Bones of the Face. Rohrer's pattern. From the Instrument. Fig. 5. A triangular Knife, employed by Dr. Horner for the transverse division of the soft palate in Resection of the Upper Jaw. From the Instrument. Figs. 6, 7. Strong Knives, or Scrapers, for excising carious, or other dis- eased bones. Luer's pattern. From the Instrument. Fig. 8. A fine and flexible Saw, useful in incising various parts of the facial bones. From the Instrument. Fig. 9. Dr. Rhea Barton's metacarpal Saw, originally employed by him in resecting the femur for the relief of anchylosis of the Hip-joint. Schively's pattern. From the Instrument. ft Fio 1 Plato 2 2 I-V.5 Fig.., ANATOMY OF THE BONES OF THE FACE. 185 has been suggested.* As the old nomenclature is entirely correct, the introduction of a new term has nothing to recommend it, and in the subsequent remarks the word "resection" will be employed, as it has heretofore been almost universally used, to wit, to designate the section of any portion of a bone, whether performed for the first or on any subsequent occasion. SECTION I. ANATOMY. The Superior Maxillary bone articulates with the frontal, nasal, and unguiform bones; in front with the os frontis by its nasal process, by means of a firm regular suture; with the ethmoid in the orbit of the eye, and with the malar bone at its anterior external angle also 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 extend- ing entirely around it from ear to ear. It articulates with the tem- poral bone just in advance of the external meatus of the ear by means of its condyloid process. This process is a transverse cylin- drical ridge directed inwards and slightly backwards, and springs from the ramus of the jaw by a narrow neck. The coronoid pro- cess is in advance of this, and has the temporal muscle inserted into its point. 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 position in advance of the glottis. When these attachments are divided, the tongue will be drawn in upon the glottis, and may induce suffocation unless artificial means are employed to prevent 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 forwards and downwards, the artery will be * Mott's Velpeau, by Townsend. 186 OPERATIVE SURGERY. separated to some extent from the bone, in consequence of the posterior adhesions of the parotid. SECTION II. OPERATIONS UPON THE JAW BONES. § 1.—RESECTION OF THE UPPER JAW BONE. The growth of tumors, generally of a fungous or malignant charac- ter, and their encroachment on the surrounding bony structure of the mouth, has suggested the important operation of Resection or amputation of the Superior Maxilla, in order to remove the mass entire. The credit of originating this operation has been assigned to different modern surgeons, most of whom had, however, been an- ticipated by the surgeons of a previous period. The earliest reference to the removal of this bone which is known to have been recorded, is that of Acoluthus, a surgeon of Breslau, who is stated by Gensoul* to have removed a portion of the upper jaw for a tumor in 1693. Jourdain, in May, 1768, in consequence of the presence of a tumor, also removed a part of the antrum. In 1820, Dupuytren likewise amputated a considerable portion of the alveolar cavities of the bone. In the year 1824, Dr. David L. Rogers,f of New York, removed nearly the entire portion of both upper jaws, as far back as the posterior parts of the antrum.J Mr. Lizars, of England, and Gensoul, of France, operated about 1827. Drs. A. H. Stevens, of New York, in 1840, and Warren, of Boston, in 1842,§ with many others, subsequently accomplished the same thing. To Grensoul, of Lyons, however, is generally ascribed the credit of having first described a general and available method of extirpating the bone, in consequence of his having published a treatise on this subject, the operation of Dr. Rogers, of New York, not having removed the entire bone, on which the claim to priority seems to rest, although the latter showed most fully the practicability of the proceeding three years before Gensoul's operation. But, as the possi- bility of extirpating the upper jaw was first suggested by the success * Gensoul, sur les Maladies du Sinus Maxillaire, &c. Paris, 1833. t Cooper's Diet., Appendix, by D. Meredith Reese, M. D., N. Y. 1849. X Bibliography. \ Bost. Med. and Surg. Journ. RESECTION OF THE UPPER JAW BONE. 187 attendant on the removal of most of the lower one, and as this was performed in the United States by Dr. Deaderick, two years before the operation of Dupuytren, the priority of American surgeons might be readily sustained in any claim for originality were the operation in reality a new one. The most, however, that can be said in favor of its modern origin, and the claims of any surgeon to its suggestion since 1820, is that the operative proceeding took a definite form at that period, though it had been spoken of and per- formed in various degrees more than one hundred years previously. As characteristic of the ordinary operation as at present pursued, the following one, performed by Dr. Warren, may be first referred to. Operation of Dr. Warren.—The patient being seated with his head well supported, 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 was then quickly dissected forwards to the middle of the nose, cutting off the attach- ment of the cartilage of the left abe of the nose, and 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 now rapidly dissected from the os malse and supe- rior 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 ap- plied to the broadest part of the os malge directly opposite to the perforation, by which it was smoothly divided in a few seconds. The same instrument was next applied at the internal angle of the eye in an oblique direction from the lower edge of the orbit to the lower termination of the os nasi, and the bone divided without dif- ficulty. In the mean time, the blood flowed in torrents ; one large artery required immediate ligature; but the bleeding of the others was con- trolled by compression 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. 188 OPERATIVE SURGERY. PLATE XXIII. 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 integuments. 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 external 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 re- moval of the sublingual 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 longi- tudinal incision is made at the external fistulous orifice, and the hand of the surgeon 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 Resecting the Upper Jaw, as practiced by the incision of Dr. 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. Yelpeau's operation is nearly the same as that of Dr. 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. After Bernard and Huette. Plate 23 Fip. ■). hoi 4 RESECTION OF THE UPPER JAW BONE. 189 The most difficult part of the operation remained, that of dividing the sound from the diseased parts within the mouth, and separating the maxillary 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 for- wards to the front edge of the jaw, and then upwards 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 cutting 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 forefinger of the left hand was passed into the mouth to the last molar tooth, and its pulp turned forwards 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 sepa- rate them and also free the maxillary from the pterygoid process of the sphenoid, thus accomplishing the disunion of all the bones con- cerned. Finally, the knife was passed externally behind the upper maxil- lary bone into the space between this and the pterygoid process, and seizing the bone with the left hand by its orbitar and alveolar por- tions, it was, by a gradual movement, started from its situation (Plate XXIII, 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 afterwards, the patient went home, and three months from that time continued well.* Dr. Wm. E. Horner, in a case of scirrhus of the antrum, has succeeded in removing the whole of the upper jaw without any external incision, thus saving the patient the scar in the face. The removal of a considerable portion of the same bone was also success- fully performed by Dr. A. H. Stevens, of New York, in 1823, and published in the N. Y. Journ. of Med. and Surg, for 1849. The publication of the case having been delayed for several years, from * Boston Med. and Surg. Journ. vol. xxvi. p. 9, 1812. 190 OPERATIVE SURGERY. motives of delicacy to the patient, who was widely known, Dr. Ste- vens has not received that general credit to which his ingenuity entitled him. Dr. Horner was ignorant of it at the time of his operation. Removal of the superior maxillary bone without any ex- ternal incision in the cheek.—Dr. 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, whilst 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 were then drawn, and the corresponding alveoli cut through in the middle line by a narrow saw (Plate XXII, Fig. 8), which worked its way from the mouth into the left nostril; then a pair of strong hawk-bill scissors (Plate XXII, Fig. 2), 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 XXII, Fig. 3), 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 forwards and separate the maxillary bones from each other in the middle. The narrow saw was again used to cut through the root of the nasal process of the maxillary bone, and strong scissors, curved on the flat, cut through the orbitar plate at its margin, the incision being carried back to the pterygoid process of the sphenoid, around and below the malar bone. The base of the soft palate was then detached by a short triangu- lar knife (Plate XXII, Fig. 5), 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, but left. The tumor, in addi- tion to the bone, was also attached to the posterior part of the cheek, and to the external pterygoid muscle. The gouge and scis- sors, however, removed any part that could be detected. The bleeding was profuse, especially from what was believed to resection of the upper jaw bone. 191 be the posterior palatine artery; but the vessel was readily secured by means of a ligature and Physick's needle; and a few other liga- tures, with charpie, arrested the remainder of the hemorrhage. The drawing (Plate XXIY, 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 overlooked by the engraver. The additional time required for this mode of operating is pro- bably fifteen or twenty minutes; but it saves the patient a scar for life.* Seven months afterwards, the patient continued well; and his daguerreotype (Plate XXIY, Fig. 2) shows the small amount of de- formity. Dr. Stevens, of New York, in August, 1823, extirpated a fun- gus from the antrum maxillare, and removed a considerable portion of the bone also without any external incision. Operation of Dr. 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 now bored through by means of a trocar, which was carried backwards and downwards 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 downwards, 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.f * Med. Exam., No. 1, p. 16, 1850. f Yelpeau's Surgical Anatomy. Appendix, by John W. Sterling, M D Vol. ii., p. 518. N. Y.,1830. 192 OPERATIVE surgery. Dr. 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 integuments 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 dissecting back the two flaps thus made, he divided the necessary portion of the bone with a saw.* In certain tumors requiring the entire amputation of the jaw, this kind of incision will be found to expose the bone freely; and in the case of a very large tumor, where removal by the plan of Dr. Horner could not succeed, this incision would open the parts sufficiently, and create a scar that would be well placed for concealment. Remarks.—In this as in every other surgical operation, the cir- cumstances of the case exert so great an influence on the decision of any 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 Dr. Horner, for the removal of the bone without an external incision, is the best for the patient, as it 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 develop- ment of the disease requires a more free opening of the integuments, in order to afford space for acting in the various steps of the disar- ticulation, then the simple curved incision from the outside of the malar bone to the angle of the mouth, as practiced by Dr. Warren, and subsequently by Yelpeau, will probably answer better. 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 dissections as to leave it uninjured in the lower flap of the integuments. The severity of the operation of amputating this bone, together with the deformity which it was supposed would ensue on the re- moval of so considerable a portion of the face, at first created great distrust among surgeons as to its propriety. Subsequent experience having shown that these objections were without foundation, the cases in which it has been repeated have become more numerous, f and the result, as far as learned, has been satisfactory, the greatest evils having resulted rather from delaying the operation until the * Velpeau's Surgery, by Mott, p. 907. t See Bibliography—article on Upper Jaw. RESECTION OF THE INFERIOR MAXILLA. 193 disease had progressed too far into the surrounding structure than from its performance in those cases where the bone was removed whilst the complaint was limited to the antrum. Statistics of this Operation.—Resection of the entire bone has been performed by Dr. Jno. C. Warren twice; one patient was cured, the other died; and the same surgeon has also performed partial resection many times with perfect success.* After collecting all the cases reported by Drs. Rogers, Warren, Stevens, Mott, Eve, Horner, Gensoul, Lizars, and others, and analyzing them, the follow- ing result is shown:— Of seventeen cases reported, twelve were cured and five died, or about three-fourths were cured, that is, the patients were doing well at periods varying from six weeks to five years after the operation. But 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 this operation, it should therefore be remembered that, though its happy termination is more marked than that of other great operations (nearly three-fourths recovering), yet the tendency to ultimate death from the disease is but slightly diminished by removing it from the point in which it was first apparent. § 2.—RESECTION OF THE INFERIOR MAXILLA. This bone may be resected either partially or entire, the latter having been successfully performed by Walther of Bonn, by Grsefe of Berlin, and lately by Dr. Carnochan of New York, and the former accomplished so often as to render it difficult to register all the cases.| At one period, the amputation of even part of the lower jaw was regarded by surgeons as a most formidable operation, and its practi- cability doubted; and to the surgeons of the United States is cer- tainly due the credit of having shown its feasibility, the amputation of nearly one-half of the bone without ligating the carotid artery having been successfully performed by Dr. W. H. Deaderick of Rogersville, Tennessee, in Feb. 1810,! on a boy fourteen years of * Manuscript of Dr. Warren. f See Bibliography—article on the Lower Jaw. J BiblioTaphv. 194 OPERATIVE SURGERY. PLATE XXIV. RESECTION OF THE 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 incision in the cheek. The soft palate is shown as preserved, but the en- graving has reversed the side from which the bone was taken, making it appear as if performed on the right side. After Nature. Fig. 1, a. A side view of the portion of bone removed from the mouth. " " Fig. 2. A likeness of the patient seven months after the operation. " " Fig. 3. 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 integuments, as shown in the figure, brings the cicatrix under the chin, where it is hardly perceptible. After Nature. Fig. 4. An outline of a Skull, showing the relative size and position of the Tumor in Dr. Barton's patient. After Barton. Fig. 5. An Outline of an Inferior Maxilla, showing the line of incision in the Jaw. " " Fig. 6. A side view of Lisfranc's operation for Resection and Disarticula- tion of half of the Lower Jaw, at the moment of removal, the jaw being everted and drawn forwards and downwards in order to avoid any injury to the artery at this point. After Bernard and Huette. Fig. 7. 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 backwards, or by the chain saw passed around the bone and made to cut from behind forwards. The latter is preferable, in most instances. After Bernard and Huette. Plate 24 "£■■- Fiy 1 a, RESECTION OF ONE SIDE OF THE JAW. 195 age—a fact deserving of more notice, as claims to the credit of originating the operation have been advanced in Europe by the surgeons of both England and France. Whether the evils resulting from the loss of the entire maxilla should not forbid its repetition, is at present a question that experi- ence has not settled. It should therefore be deliberately considered by every surgeon before attempting it, the difficulties of the opera- tion not being so great as the evils likely to ensue to the patient on its completion. § 3.—RESECTION OF ONE SIDE OF THE JAW. Operation of Dr. Deaderick.—An incision was commenced under the zygomatic process, and continued over the tumor (which almost entirely enveloped 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 at 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 con- necting medium between the ends of the divided bone.* The de- scription of the tumor shows it to have been osteo-sarcoma. Remarks.—As the account of this operation was not published by Dr. Deaderick until nearly one year after Dr. Mott's operation, and the latter surgeon had performed his operation before he heard of that of Dr. Deaderick, the credit of priority has been strongly urged and by many accorded to the latter gentleman. But, as the case of Dr. Deaderick, though not published until 1823, contains the evidence of those who know it to have been performed in 1810 justice would seem to demand that Dr. Deaderick should obtain the renown which has been so frequently attached to those who only followed in his footsteps. The decision of this point seems, how- ever, to have been a difficult one even at an early period, a special committee of the New York Society having been unable to settle the questionf as to the priority of the claims of American or Euro- * Amer. Med. Recorder, vol. vi. p. 516. Phila., 1823. f Bibliography. 196 OPERATIVE SURGERY. pean surgeons, hesitating between those of Dr. Mott and Dupuy- tren, but being at that time ignorant of Dr. Deaderick's operation. European surgeons usually assign the credit of the first operation to Dupuytren in 1812; but there is, as just shown, every reason to believe that the operation of Dr. Deaderick anticipated that of Dupuytren two years, and the credit of having first performed it is therefore due to the surgeons of this country, and especially to those of the Western States. In the early operations performed by Dr. Mott, ligating the caro- tid artery a few days prior to removing the bone was deemed essen- tial to success; but many cases operated on by others, as well as that of Dr. Deaderick, have proved that this step is only a complication of the proceeding. Dr. Wm. Gibson, in a late operation before the medical class of the University of Pennsylvania (Jan. 1851), removed the entire half of the jaw, without tying any vessels of consequence; and if the bone is drawn well forwards previous to attempting its disar- ticulation, and the knife made to shave off the soft parts close to the angle and ascending ramus of the jaw, it will be found that there is really very little risk, as the artery, by remaining in situ, is removed several lines from the incisions required for the disarticulation of the bone. 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 back- wards, and having his head supported by an assistant, the surgeon should 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 downwards and backwards. 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 outwards and forwards, use it as a lever; and, whilst 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, depress the bone so as to dislocate the condyloid process, and, drawing it forcibly forwards so as to remove it from the artery, divide the capsular li^a- resection of one side of the jaw. 197 ment and the pterygoid muscles, which will generally free the jaw entirely (Plate XXIY, Fig. 6). The wound may then be closed with a few stitches, and with adhesive plaster. Removal of the Middle of the Bone.—The patient being ar- ranged as before, the surgeon seizes one angle of the mouth with his left hand, while an assistant does the same with the other, and, drawing the lip tense, divides it immediately in its middle by a single vertical incision. The two flaps, being then shaved off from the bone to the desired extent, are to be held by the aids; and the teeth at the points of division being extracted, the bone may be cut through either by Hey's or the chain saw, the latter cutting from behind forwards, after being passed around the jaw by means of a needle. If it is desirable to divide the bone from before backwards, one similar to that of Hey (Plate XXIY, Fig. 7) must be employed. The point of the tongue being now held, either by a ligature intro- duced through it, or by means of a tenaculum, so as to prevent its being drawn into the pharynx, the surgeon should 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 perhaps be necessary to attach the tongue to the side of the cheek for a few days by means of a suture, in order to prevent its retraction upon the glottis, as this may induce suffocation. Barton's Operation for removal of half the Jaw, by a longi- tudinal 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 possession 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 XXIY, Fig. 4), protruding the lips, cheek, and neck on the left side. Operation.—An incision, being commenced over the left angle of the lower jaw, was carried on a line with the under edge of the base around to 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 towards the left com- missure of the mouth was then cut through vertically, so as to meet the first incision at a right angle. The tumor, being thus exposed, was found to be adherent to the anterior and posterior surfaces of the bone. These adhesions were detached from the anterior face 198 operative surgery. of the bone as high up as it was sound. With a small narrow saw (Plate XXII, Fig. 9), the bone was cut through longitudinally from without inwards, in a line parallel to the base of the jaw, and just below the maxillary canal. This section 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 was then made through the alveoli between these teeth, so as to meet at a right angle the hori- zontal division of the bone (Plate XXIY, Fig. 5). The portion thus insulated contained the diseased mass, and, after separating the attachments of the soft parts, enabled the operator to take it away entire (Plate XXIY, Fig. 3), leaving the base of the bone in a healthy state, except at one point on the surface, which was readily taken off with the nippers. 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 rest 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.* Remarks.—Although so important a portion of the general out- line of the face is necessarily removed in these operations, the de- formity which results from the operation is by no means such as might be anticipated. In the case of a gentleman formerly an In- terne of Lisfranc's at the hospital of La Pitie', and whom I saw in Paris in 1839, the deficiency was admirably concealed by his whis- kers ; and in the modification proposed by Dr. Barton, of Philadel- phia, 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, Dr. Barton's method of operating will be found to be the most advan- tageous ; 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 should be preserved in order to obviate the risks of necrosis from the want of circulation. 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 credit- able to the surgery of the nineteenth century. * Amer. Journ. of Med. Sciences, vol. vii. p. 331, 1831. STAPHYLORAPHY. 199 Out of about one hundred and sixty cases collected from various sources by Yelpeau, there have only been forty deaths, or one- fourth of the whole number operated on, a success which is very great when compared with the serious character of the operation.* SECTION III. 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 co-existent 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 consequence 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 re- quired 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 subsequent operation; but if both hare-lip and fissure of the palate are present in an adult, the ope- ration 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 with that resorted to for the relief of hare-lip. § 1. STAPHYLORAPHY. This operation, which was suggested by a French dentist, Le Monier, in 1764, and termed Staphyloraphy (ita^v%tj, the palate; and pafr;, suture), 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 performed by Dr. John C. Warren, of Boston, he being at the * Yelpeau—Med. Operatoire, vol. ii. p. 620. 200 OPERATIVE SURGERY. PLATE XXV. A VIEW OF THE INSTRUMENTS EMPLOYED IN OPERATIONS UPON THE THROAT AND ESPECIALLY IN STAPHYLORAPHY. Fig. 1. Scissors for Excising the Uvula. Schively's pattern. Drawn from the Instrument. Fig. 2. Gibson's Glosso-catochus, or Spatula, to depress the Tongue. Schively's pattern. Drawn from the Instrument. Fig. 3. Schively's modification of Physick's Tonsilitome for excising the Tonsil Gland. The ring surrounds the ton- sil; the needle transfixes it, and the angular knife shaves it off. " " Fig. 4. Along-handled double-edged Scalpel, for freshen- ing the edges of the fissure in the operation of Staphyloraphy. " " Fig. 5. Curved Scissors, with long handles for the same purpose. " " 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 may be 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. Schively's pattern. Fig. 7. Gibson's Forceps for inserting the ligatures in Staphyloraphy, at the moment when the needle is passed through the palate. " " Fig. 8. The same instrument drawing the ligature into its position. " " 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. Schively's pattern. l'late 2 b STAPHYLORAPHY. 201 time ignorant of the views or operations of the other surgeons. In many respects, the steps proposed by Drs. Warren and Roux cor- respond, though the means suggested by Dr. Warren are the simplest. The operation of the latter 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 M. Roux, of Paris.—Four different objects, which are to be attained in four different stages of the operation, have been laid down by M. Roux as likely to facilitate the surgeon's ma- nipulation, 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 margins. 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 Mr. 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 dress- ing forceps; and of a probe-pointed bistoury, and curved scissors. Operation.—The patient being seated before a strong light, with the head thrown back and supported against the chest of an assist- ant, 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 (Plate XXYI, Fig. 1); and, with his right hand armed with the needle-holder, introduces the point of the needle from before backwards behind the uvula, in order to traverse the flap from behind forwards at three or four lines from the free edge of the fissure. The needle, being thrust in as far as its head, is then freed from the needle-holder, and seized at its point by forceps, which draw it and the ligature through into the mouth. After rest- ing 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 202 OPERATIVE surgery. fissure. Plate XXVI, 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 to- wards the pharynx, the surgeon proceeds to Freshen the Edges of the Fissure.—To accomplish this (Plate XXVI, 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 be- hind forwards with the probe-pointed bistoury, 2, or curved scissors, (Plate XXV, Fig. 5,) held in the right hand, cutting from below upwards, 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, M. Roux commences by knotting the middle ligature (Plate XXVI, Fig. 5) with the fingers, and, after making a simple knot, confides it to an assistant, who holds with a serre-nceud (knot-tier), whilst 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 are then cut close to the knots, and the patient kept from eating, drinking, or speaking 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 ligatures, 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 XXVI, Fig. 5), and allowed these wounds to heal by granulations. Operation of Dr. Jno. C. Warren.—In the case of a young girl, aged seventeen 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 Dr. Jno. C. Warren, of Boston, as follows:— * Bernard and Huette, p. 207. Paris, 1850. STAPHYLORAPHY. 203 " 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; and the same was done on the opposite side, so as to cut out a piece in the form of a 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 doubled 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 in 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 stitcbes were removed, and she left the hospital a day or two after. Two years subsequently she swallowed perfectly and spoke well."* In 1826, a similar operation was successfully performed on a boy aet. eleven. The cure was perfect.f Remarks on the American Operations.—The first of these operations is stated by Dr. Warren to have been original with him- self, as he was not at that time acquainted with the operations per- formed in Europe. From the simplicity of the instruments em- ployed, and the freshening of the edges from above downwards, his method has advantages over that of M. Roux, from the fact that * Amer. Journ. of Med. Sciences, vol. iii. p. 1, 1821; and MS. Records of Mass. Hospital. t Amer. Journ. of Med. Sciences, vol. iii. p. 1, 1828. 204 OPERATIVE SURGERY. PLATE XXVI. A FRONT VIEW OF THE OPERATION OF STAPHVLORAPHY. 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 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. For- ceps holding the free end of the palate. 2. The bistoury paring off a strip. Fig. 3. Operation of Warren. 1. The knife freshening the edge of the fissure from above downwards. 2. The forceps steadying the margin so as to favor its regular incision. Modified from Pancoast. Fig. 4. The introduction of the Sutures by means of Physick's Forceps and a curved needle. 1. Physick's forceps introducing the needle. 2. Dress- ing forceps 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 longi- tudinal incisions made on each side of the soft palate, so as to remove the strain from the line of union. After Bernard and Huette. Plate 26 ^ STAPHYLORAPHY. 205 the incision of the soft tissues is facilitated by the traction, whilst the flap, being left adherent above until the completion of the oppo- site 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 first operation of Dr. Warren, Dr. A. H. Stevens, of New York, Sept. 1826,* operated successfully by first inserting the ligatures, and then paring the edges, f Dr. Mettauer, of Virginia, in 1827, operated for staphyloraphy, and in 1837 published an excellent essay,! from which the reader may gain much that is of practical value.- Dr. M. employed the leaden ligatures recommended by Dieffenbach. Dr. Wells, of Columbia, South Carolina (1832), in a case of recent wound, was enabled to apply the sutures by heating a common (sur- geon's) needle in a lamp, bending it to a proper curve, and passing it through the fissure by the aid of Physick's needle.§ This simple contrivance seems to have answered perfectly, and is certainly capable of supplanting all the more complicated instruments, and has been successfully used by Drs. Mutter and Pancoast, of Phila- delphia, || in staphyloraphy. Dr. Gibson,T[ of Philadelphia, operated with instruments of a useful kind, some of which have been transferred to these pages. Dr. Alexander Hosack, of New York, also published, in 1833, a memoir upon this subject, with illustrations of his own instruments; and Dr. N. R. Smith, of Baltimore, employs a peculiar hook or needle for the suture. 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 introduc- tion of the needles, thus showing that placing the ligatures is the most difficult step in the operation. The simplicity and efficiency of Dr. Physick's forceps, as employed by Dr. Wells, of South * North American Medical Journal, vol. iii. p. 233. f North American Medical and Surgical Journal, vol. iii. p. 233, 1827. X Amer. Journ. of Med. Sciences, vol. xxi. p. 309, 1837. § Ibid., vol. x. p. 32, 1832. || See Bibliography. f Instit. and Pract. of Surg., vol. ii. p. 40. 206 OPERATIVE SURGERY. Carolina, and subsequently by Drs. Mutter and Pancoast,* removes, however, this great obstacle 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 re- cently been more systematically presented and specially urged on account of their anatomical relations, by Mr. Ferguson, of London, in the Transactions of the Royal Medical and Surgical Society for 1845.f By many, the views of Mr. Ferguson are regarded as ori- ginal ; but the following facts show that he had been anticipated. In connection with the history of an operation for fissure of the palate, Dr. J. Mason Warren published, in the New England Quarterly Journal of Medicine and Surgery, No. IV, p. 544, April, 1843, an account of the division of both the pillars of the palate, and of its happy influence upon the union of the freshened edges of the fissure. Mr. Ferguson's paper did not appear until December 21, 1844, when, in the Medical Times, he published an account of the dissection, from which he was led to suggest the special division of the levator palati and palato-pharyngeus muscles. As Mr. F. entered minutely into the anatomy of the structure concerned, and also demonstrated the importance 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 previously by Dr. Warren. Froriep also appears to have been fully aware of the value of this muscular division, having described and figured the part in his "Nottizen" early in 1823.\ Dr. Mettauer, of Virginia, in 1837, also recommended the section of the muscles 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, &c, as suggested by Velpeau in staphylo- plasty.! To Mr. Ferguson, however, is certainly due the credit of demon- strating in a scientific manner the special effects upon the fissure of each of the muscles, which had been previously divided without reference to the anatomical details of the region. * See Operative Surgery, by Jos. Pancoast, M. D., Philada., and the papers referred to in the Bibliography. f Ferguson, Practical Surgery, p. 506, Philadelphia edition, 1848. X Chirurgische Kupfertafeln. Weimar, 1823. § Amer. Journ. Med. Sciences, vol. xxii. p. 309, 1838. STAPHYLOPLASTY. 207 § 2. STAPHYLOPLASTY. In the operation of staphyloraphy, as just detailed, the attempts of surgeons 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 Dr. J. Mason Warren, of Boston, presents a means of remedying the opening in the bones, as well as that in the soft tissues, by means of a portion of the neighboring structure. As the opening is thus closed by a flap taken from the adjoining soft parts, being made to slide over the fissure, as in plastic operations elsewhere, the operation has been termed Palatoplasty, Staphylo- plasty, 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 Dr. J. M. Warren.—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 cir- cumstances 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 operator and restrain all efforts at coughing, in all which he should be encouraged by the surgeon. The use of a speculum is deemed by Dr. Warren alto- gether 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 difficulty of making any sawing motion with the knife in this confined position, 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 dis- section is terminated, it will generally be found that, by seizing the soft palate with the forceps, it can be brought 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 208 operative surgery. 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 introduced at the upper edge of the fissure, and carried from before backwards on the left side, and from behind forwards on the right, or vice versd. 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, beginning at the upper and proceeding gradually downwards, wait- ing 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. Dr. Warren has always arrested the hemorrhage consequent on the incisions by iced water and the finger, and does not wait before introducing the ligatures. The ligatures also were generally re- moved in forty-eight hours, or on the third day; drinks were em- ployed 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 palate, in consequence of its firmness and slight vascularity, was very apt to mortify and slough, either in whole or part, the opera- tion 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 towards each other. Then, 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 * Operations for Fissures of the Soft and Hard Palate (Palatoplasty), by J. Mason Warren, M. D. New England Quarterly Journal of Medicine and Sur- gery, No. IV. p. 358. Boston, 1843. ANATOMY OF THE EAR. 209 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.* Dr. Pancoast, of Philadelphia, has repeated this operation, with some modifications, and obtained partial success, f Statistics.—The results of this operation are shown by the fol- lowing cases: Of twenty-four cases operated on by Dr. Warren,J it appears that he has succeeded 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. CHAPTER XIII. OPERATIONS PRACTICED UPON THE EAR. The operations resorted to for the relief of disorders of the Ear consist in those required for the external, and those demanded by the internal portions of this organ. As the details of this department of surgery are sufficiently extended to have engaged the entire attention of a special class of those who have desired fully to treat its various complaints, the present account must be limited merely to the general anatomical and operative details. SECTION I. ANATOMY OF THE EAR. Of the two portions of the ear, one is external, being the ear of common language, whilst the other is designated as the internal ear, being the structure mainly concerned in the sense of hearing. The External Ear consists of a fibro-cartilaginous and fleshy sub- * Velpeau, Med. Operat., tome i, p. 681. f Operative Surgery, p. 357. X See Bibliography, on Staphyloraphy. \ Gazette M6dicale. 14 210 operative surgery. PLATE XXVII. instruments and operations upon the ear. Fig. 1. Dupuytren's Forceps for the removal of Polypi. Fig. 2. Fabrizj's Forceps for the removal of foreign bodies. Fig. 3. A Curette for the same purpose. i Fig. 4. Itard's Ear Speculum. Fig. 5. Bonafond's Ear Speculum. Fig. 6. Caoutchouc Bottle, fitted with a pipe and cock, for injecting Air or Ether into the Eustachian Tube. Fig. 7. Itard's Catheter for the Eustachian Tube. Fig. 9. Blanchet's Catheter for the Eustachian Tube. Figs. 10, 11. Deleau's Instrument for Perforating the Tympanum. In one the perforator is concealed; in the other it is protruded from its sheath. Fig. 12. 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 pharyn- geal 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 tymrjani. 6. The external auditory canal; its direction com- pletes the arch formed by the Eustachian tube. 7. The carotid artery. Fig. 13. Removal of a Polypus, by the Forceps, from the External Audi- tory Canal. Fig. 14. 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. at.- 27 ho. 1 ] Fie, 12 \ N&9- i. K&-3 ANATOMY of the ear. 211 stance, which is covered by the skin and attached to the side of the head by ligaments and muscles, and of a cartilaginous tube which leads from the external meatus to the internal ear. The Lobus, or soft and fleshy portion of the ear, is at the inferior extremity of the organ. When lost, it may be, in a measure, replaced by a plastic operation (technically known as otoplasty), in which a flap is taken from the adjacent integuments and attached to the cartilaginous portion, as will be detailed hereafter. The Meatus Auditorius Externus, or orifice of the cartilaginous tube, is at the bottom of the concha or fossa, found in the external ear. Its orifice is about three lines in diameter. The canal itself in the adult is an inch long from its orifice to the membrana tym- pani, or septum which closes it inwardly, and it is narrower in the middle than at either of its extremities. This tube is also more expanded downwards than it is transversely; consequently, foreign bodies lodged in it may be most readily seized by forceps passed beneath and above the object. The speculum should also be opened in the vertical line instead of transversely. As the cartilaginous tube runs inwards with a slight inclination forwards, and with a convexity upwards in its curvature, it is requi- site to pull the external ear upwards and backwards when it is wished to look to the bottom of the canal. The Membrana Tympani is a complete membranous septum inter- posed between the meatus externus and the tympanum at the bottom of the canal just spoken of. It is placed very obliquely across the meatus, so that its upper edge inclines outwards, and its lower edge inwards, the latter forming a very acute entering angle with the floor of the meatus or the cartilaginous canal (Plate XXVII, Fig. 12), which gives it an additional length, and renders it difficult to see to its bottom. An examination of the part, therefore, requires a strong light. The membrane of the tympanum is slightly tense, and has its mid- dle drawn inwards in consequence of its being attached to the handle of the malleus. In the Internal Ear, the tympanum is the portion which is interposed between the meatus auditorius and the labyrinth. At the fore part of the tympanum is the Eustachian tube, which runs for six or eight lines in the petrous portion of the temporal bone and terminates in a cartilaginous and membranous portion, 212 OPERATIVE surgery. which communicates with the pharynx at the posterior nares (Plate XXVII, Fig. 12). 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 turbinated bone. It is rounded, oval, or trumpet-shaped, and large enough to admit the tip of the little finger (Plate XXVII, Fig. 12). The canal in its whole length measures nearly two inches, and its course is nearly horizontal, backwards and outwards towards 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 membrane, which is continuous with that in the throat.* In catarrhal affections, its mucous secretions sometimes fill the whole cavity of the tympanum; and it is also liable to ad- hesion of its side as well as to stricture. SECTION II. OPERATIONS ON THE EAR. § 1.—OTOPLASTY. The formation of a new lobe for the ear is a plastic operation, invented by the late M. Dieffenbach, of Berlin, 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 Rhinoplasty. Another mode of operating will be found in the following method of Dr. Pancoast, of Philadelphia.f Operation.—A piece of integument rather larger than the natu- ral size of the lobe was marked out by an incision in front of the ear, and a semicircular portion of larger size, but narrowed where it touched the cicatrix, 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 * Horner's Special Anatomy, vol. ii., Philadelphia, 1851. + Amer. Journ. of Med. Sciences, vol. v. New Series, p. 100, 1843. EXTRACTION OF FOREIGN BODIES. 213 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, the poste- rior 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 downwards by the cicatrix, retracted when loosened during the operation to nearly the natural length, and the success was perfect. Remarks.—The operation of Dr. Pancoast is a slight modifica- tion of that of Dieffenbach, and was performed to relieve the cica- trix 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 resemble the lobe, whilst the removal of the flap produces cicatrices upon the neck, which are apt to cause a greater deformity than that arising from the original defect. The removal of tumors from the lobe requires the same steps as those demanded by tumors elsewhere. § 2.—FOREIGN BODIES IN THE MEATUS AUDITORIUS EXTERNUS. These may consist of insects, beads, coffee grains, and similar articles, accidentally 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. I. 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, which may be retained in the ear a few minutes, simply by keeping the head in an inclined posi- tion. The oil thus occupying the tube closes the respiratory pores 14* 214 operative surgery. of the creature, and soon either kills it or causes it to seek the surface to obtain air or to escape, when it may be seized, or subse- quently washed out with a syringe and tepid water, especially if inflammation exists, as this increases the sensibility of the part. If the foreign body should be a hard substance, and one not capa- ble of absorbing water, then the best plan of removing it will be to wash it away by the force of a stream of water thrown in on one side of it, and made to fly outwards from the resistance created to its entrance by the surface of the membrane of the tympanum. II. TO WASH OUT FOREIGN BODIES. Operation of Dr. Marion Sims, of Alabama.*—Introduce the point of a long, but 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 passage of a stream of water on one side. Then drive in a full stream with all the force of 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. Remarks.—In introducing an instrument into the ear of an adult, the peculiarity of the structure should be recollected, and the ope- rator should, therefore, pass it either from above or below, as the vertical diameter of the meatus is greatest in this direction; but in a child it must be directed either in the front or back of the meatus, the transverse measurement being here the greatest. Hardened wax may be softened by warm oil or water, and then either picked out with the scoop or washed out, .the ear being drawn upwards, out- wards, and backwards, in order to facilitate its escape, by straight- ening the cartilaginous tube. Should every other means fail, the surgeon may resort to the plan of Paulus iEgineta, and, perforating the meatus below, intro- duce a probe behind the foreign body, and thus push it outwards. * See Bibliography—Article, Ear. PERFORATION OF THE MEMBRANE OF THE TYMPANUM. 215 § 3.—POLYPI IN THE MEATUS EXTERNUS. 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 tympanum, or its membrane, and distending the meatus, sometimes project externally (Plate XXVII, Fig. 13). If of the soft kind, they may be removed by seizing them with forceps, and rotating the latter until the polypus is twisted, when simple traction will suffice; or, if it is possible to pass a loop around it, the strangulation may be effected by a wire or silk ligature in a small double canula like that of Levret, as I have done in two cases suc- cessfully. If more firm, the polypus may require excision in pieces, the hemorrhage being readily arrested by compression in the meatus. In all cases, however, it is usually desirable to apply the nitrate of silver to the base of the tumor after its removal; to keep the meatus clean, by repeated syringing, and to introduce, occasionally, astring- ent washes. Where the polypus is very large, and fills up the meatus externus entirely, the repeated applications of the wire ligature will enable the surgeon to remove it entirely. Operation of Fabrizj, of Modena.* The patient being so seated as to throw the light into the meatus, the surgeon passes 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 towards the base of the tumor. 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. Then, constrict- ing the tumor by this, remove the first ligature and canula, and if the second does not cause the tumor to come away, carry a silk or buckskin ligature in a flexible canula below it, and twist the ligature until the tumor is cut off. (Plate XXVIII, Figs. 9, 10.) § 4.—PERFORATION OF THE MEMBRANE OF THE TYMPANUM. This operation, which was suggested by Sir A. Cooper in 1800, in order to permit the entrance of air into the middle ear when the * Bourgery, Med. Operat. tome 7me, p. 33. 216 OPERATIVE SURGERY. PLATE XXVIII. INSTRUMENTS AND OPERATIONS UPON THE EAR. Fig. 1. A Brass Air-Syringe, employed by Horner for filling Fig. 2. Drawn from the Instrument. Fig. 2. A Tin Drum or Air-Chamber, employed by Horner. 1. A cock to regulate the exit of the air. When charged, and the syringe removed, the opening of the tube is to be applied to a catheter previously passed into the Eustachian tube, and the force of the current regulated by turning the cock at 1. Drawn from the Instrument. Fig. 3. Horner's Knife for Perforating the Tympanum. Fig. 4. A Syringe, employed by Horner for forcing ether, air, or water through the Eustachian tube, from the external meatus into the throat, after perforating the membrane of the tympanum; being the most certain mode of testing the permeability of the tube. Drawn from the Instrument. Fig. 5. The Nozzle of Fig. 4 passed through a cork so as to enable it to plug up accurately the external meatus in injecting the ear through the per- foration in the tympanum. Drawn from the Instrument. Fig. 6. A Coil of Silver Wire, forming a Spring for the retention of a Catheter passed through the Nostril into the Eustachian Tube. After Bourgery and Jacobson. Fig. 7. A Frontlet employed by Itard for the same purpose. After Itard. Fig. 8. A view of the Frontlet as applied on the patient. " Fig. 9. Fabrizj's Mode of Strangulating Aural Polypi by the repeated ap- plication of the ligature with its canula. 1. The hand of an assistant holding the canula as applied with the first ligature. 2. The second canula and ligature about to be applied below the first. The operator is seen passing its loop over the first canula and ligature and around the tumor; whilst with a probe he endeavors to press the ligature deep towards the membrane of the tympanum. After Bourgery and Jacobson. Fig. 10. A Vertical Section of the Ear, showing the subsequent construc- tion of the base of the tumor. After Bourgery and Jacobson. WASHING OUT EUSTACHIAN TUBE. 217 Eustachian tube was permanently closed, or when the membrana tympani was too much thickened and changed to vibrate, is a simple operation, though it has not been much practiced, owing, apparently, to a want of confidence in its utility, or of 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 in the meatus, introduce a small trocar, or the instrument of Deleau (Plate XXVII, Figs. 10, 11), or the knife of Horner (Plate XXVIII, Fig. 3), at the anterior inferior side of the membrane, and transfix it so as to avoid the han- dle of the malleus. In cases where the Eustachian tube is closed by mucus, and the surgeon finds it difficult to clear or dilate it by catheterism through the nostril, or when he wishes to assure himself positively that this tube is patulous, 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 certainty 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 wound in the membrane will heal readily, the patient runs no risk of injury if the Eustachian tube prove to be totally imper- vious, whilst, if choked, it can be thoroughly cleansed by driving the mucus into the throat in the natural course of the tube. By thus demonstrating the pervious condition of the tube, the diagnosis of the character of the deafness will be much simplified. Operation of Dr. William E. Horner, of Philadelphia.—A method, which Dr. Horner has practiced on many occasions, ena- bles him to pass a stream of water from the meatus externus into 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 XXVIII, Fig. 3), by first plunging the cutting edge upwards, and then re- volving it on its axis, so that the incision may be angular, or the shape of a /N, which will leave a flap easily moved. A small pipe, surrounded by a cork, should then be introduced tightly into the meatus externus, and a small syringe, holding an ounce and a half, adapted to the pipe, in order to force the water through the hole pierced into the membrana tympani, as just directed. The stream 218 OPERATIVE SURGERY. being thrown in, as thus directed, will then be found to wash out the tympanum and the Eustachian tube, with great facility, as may be readily ascertained by seeing the water escape from the nose. The air douche may also be most perfectly accomplished in the same man- ner ; 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 vial, 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 Eusta- chian tube from the nostril, as usually practiced. Dr. Horner has yet done no harm by this operation, but has, on the contrary, done some good. The principal idea of the profession, now existing in regard to the cause of deafness, and evolved by the assertions of leading aurists, is the fact of there being an obstruc- tion of the Eustachian tube, but this Dr. Horner believes to be a mistake, the obstruction of this tube being, in his experience, very unusual as a simple form of disease, though very large claims are made upon public credulity by operators who boldly assert its exist- ence.* In the air douche, by the Eustachian tube, as usually advised, the introduction of the air may be regulated by a column of water act- ing on a large reservoir of air, or by means of the cock in the canister (Plate XXVIII, Fig. 2), or by simply resorting to the caoutchouc bottle (Plate XXVII, Fig. 6). § 5.—CATHETERISM OF THE EUSTACHIAN TUBE. When the position of the orifice of the tube in the pharynx is recollected (Plate XXVII, Fig. 12), it will be seen that this 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 XXVII, Figs. 7, 9. Ordinary Operation.—The patient being seated with the head slightly thrown backwards and firmly supported, the surgeon takes the catheter in his right hand, and, after oiling it, introduces it into * Dr. Horner in MS. CATHETERISM OF THE EUSTACHIAN TUBE. 219 the nostril on the side to be sounded. Then, keeping its point upon the floor of the nostril, and its convexity upwards and inclined against the septum narium, slides it backwards until it reaches the soft palate, as may be readily told by the sense of touch trans- mitted along the instrument, or by the patient making a slight gulp or effort to swallow. At this moment, the surgeon should turn the point of the catheter upwards and outwards by rotating it a quarter of a circle, and then, by a slight movement forwards and backwards, he may slip it into the tube with as much, if not more ease than a catheter can be made to enter the bladder, when the proper position of the instrument will be at once known by its steadiness, and also by the sensation of the patient. Then, in order to inject air or liquids, it is only necessary to com- press the nostrils and catheter in the fingers of one hand, and em- ploy the syringe or gum elastic bottle with the other, or to resort to a little wire spring (Pla'te XXVIII, Fig. 6), or to a frontlet, (Plate XXVIII, Fig. 8). The frontlet, forceps, air-drum, &c, will all be found essential to the operations of those who may wish to devote themselves especially to aural surgery; but, for the general operator, the instruments, figured in Plates XXVII and XXVIII, will prove sufficient. Remarks.—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 ordinary courses of education of our medical schools, has, for many years, induced the majority of the profession to shun the treatment of aural complaints, and forced patients into the hands of empirics. All the operations upon the ear are, however, so easily practiced, and the character of the com- plaints requiring them so very limited, that this condition of things may be remedied by any surgeon. In order to prove this, an effort has now been made to describe as fully as is necessary all the ordinary operations required for the relief of deafness, and if the reader will follow the description, in connection with the plates, he will, it is hoped, find them quite full enough. Pages have been written on most of these operations, but with the tendency to confuse and embarrass rather than encou- rage the reader. Washing out the external and internal auditory tubes, with perforation of the membrana tympani, or perhaps the mastoid cells, really constitutes the entire portion of aural operative 220 OPERATIVE SURGERY. surgery, and are certainly easily executed. 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 surgeon may effect much good by assuring the patient of the impossibility of his being relieved, and every operator should, therefore, gain such an amount of practical skill as will enable him to give an opinion. By washing out the meatus externus, and examining the condition of the membrane of the tym- panum ; by catheterizing the Eustachian tube, or by perforating the membranum tympani, and testing the permeability of the passage to the throat, as above described, much advantage will often be gained by the patient, whilst many persons will be saved from the hands of unprincipled men, who in the majority of cases only do them harm. OPERATIVE SURGERY. PART III. OPERATIONS PRACTICED ON THE NECK AND TRUNK. PART III. OPERATIONS PRACTICED ON THE NECK AND TRUNK. CHAPTER I. SURGICAL ANATOMY OF THE NECK. The Neck is usually described by anatomists as that region of the body which is situated between the head and the trunk, being bound- ed 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 scapulae. In its general outline, this region is cylin- drical or cylindroid, with the base upon the shoulders. On the front and sides it is decidedly convex, presenting certain well-marked pro- minences, which, by establishing fixed points of reference, are highly useful to the surgeon. On its posterior face it is flat and regular, presenting nothing deserving of especial 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 median 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 median line, is the prominence caused by the larynx and trachea, and a little out- wardly 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 position of the vessel, its pulsations may be readily felt. At the base of the neck, near the clavicles and exterior to the ster- no-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 224 OPERATIVE SURGERY. space adjoining the angle of the jaw, are several important parts which will be referred to more in detail hereafter. 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 generally be found necessary either to make all such pieces of dressing quite narrow, or to gire 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 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 sec- tions demands special attention, the advantages of such a subdi- vision being found in the facility as well as accuracy with which the position of their 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 M. Blan- din, in his Anatomic Topographique, and the following descrip- tions will, therefore, be based mainly on the accounts furnished by him. In mapping out the regions of the neck, M. 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 the Supra-Hyoid or Hyoglossal 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- Tracheal and the Supra-Sternal regions, whilst those on the sides are designated as the Sterno-Mastoid, Ca- rotid, and Supra-Clavicular regions. The mapping out of any por- tion of the body being, however, entirely optional, some difference will be found in the descriptions of different writers. By some of the English anatomists* the disposition has been shown to apportion the neck into regions of a more mathematical * Surgical Anatomy, by Joseph Maclise, Philada. edit. 1851. SUPRA-HYOID OR GLOSSO-HYOID REGION OF THE NECK. 225 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 importance. 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 experience 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 SUPRA-HYOID OR GLOSSO-HYOID REGION OF THE NECK. The glosso-hyoid portion of the neck is bounded above by the in- ferior part of the tongue or base of the lower jaw; below, by the os hyoides, and laterally by an imaginary 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 platysma-myoides; of the anterior belly of the digastric, of the mylo-hyoid, genio-hyoglossus, hyoglossus, 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 perfect septum from the anterior and inferior por- PLATE XXIX. THE SURGICAL ANATOMY OF THE NECK. Fig. 1. A view of the arrangement of the Fascia of the Neck. 1. Paro- tid gland. 2. Masseter muscle. 3. Submaxillary gland. 4. Os hyoides. 5. A portion 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 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 max- illary bone. 2. Lingual artery. 3. Os hyoides. 4. Superior thyroid ar- tery. 5. Descending branch. 6. Position of carotid artery. 7. Sternal origin of sterno-cleido-mastoid. 8. Clavicle. 9. External jugular vein. 10. Its anterior branch. 11. Parotid gland and veins near 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. Hypoglossal nerve. 8. Facial artery. 9. Facial vein. 10. Occipital and internal maxillary veins. 11. External carotid artery seen after removal of parotid gland. 12. Masseter muscle. 13. Pectoral muscle and clavicle. 14. Hook holding aside exter- nal jugular vein. After Bernard and Huette. Fig. 4. A front view of the Veins of the Neck. 1, 1. Base of lower jaw. 2. Os hyoides. 3, 3. Internal jugular. 4. Omo-hyoid muscle. 5. Larynx. 6. Sterno-hyoid and thyroid muscles. 7, 8. Superficial veins. 9. External jugular. 10. Sterno-cleido muscle. After Bernard and Huette. Fig. 5. A side view of the (Esophagus 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 thy- roid artery. 8. Sterno-cleido-mastoid, cut across. 9. Primitive carotid. 10. Internal jugular. 11. Upper portion sterno-cleido-mastoid muscle. After Bernard and Huette. ■■'Vr«e}%3 THE PAROTID REGION. 227 tion of the parotid. (Plate XXIX. Fig. 1.) This reflection of the fascia superficialis and its attachment to the stylo-maxillary liga- ment 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 neighbor- hood of the parotid or submaxillary glands from communicating or traveling either forward or backward; it has also considerable influ- ence on the development of tumors and their subsequent shape and condition. The principal Arteries found in this region are the facial, lingual, and sublingual. 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 hyoglossus muscle. The Nerves are the hypo-glossal, lingual, glossopharyngeal, and their branches. (Plate XXIX. Fig. 3.) SECTION II. THE PAROTID REGION. The parotid region of the neck comprises its superior and late- ral portions, and, though limited in extent, is of the highest im- portance to the surgeon. Bounded in front by the ramus of the inferior maxillary bone; behind, by the mastoid process of the tem- poral as well as by the meatus externus of the ear; above, by the zygomatic arch ; below, by a horizontal line drawn a little below 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 circum- scribed 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, and the styloid muscles within. The parotid gland -in its normal condition, being seated between the angle of the jaw and the mastoid process of the temporal bone, is limited to these points; but, when diseased, it will be found to encroach considerably upon surrounding parts. Owing, however, 228 OPERATIVE SURGERY. to the expansion of the superficial fascia, and its attachment to the angle of the jaw, as before stated, the parotid is separated from the submaxillary gland, and cannot therefore extend itself to any great degree forwards. The styloid process and ligaments limiting its deeper progress, and the sterno-mastoid muscle resisting its poste- rior development, nothing is, therefore, left it but to enlarge out- wardly or towards 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 have also an important influence upon the blood-vessels con- nected with it. In two cases which occurred under my observation, it led to the entire obliteration 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 the parotid tumors is always at first more or less flattened from this expansion of the fascia over the surface of the gland, though ultimately they may attain considerable size and a globular form. Having no pro- per capsule, the parotid gland owes its shape, and the continuity of its structure, to cellular substance; the induration of which, as well as the expansion of the fascia just alluded to, renders the ex- tirpation of the gland much more easy when diseased than it is in the normal condition. The Arteries of the parotid region are numerous and among the most important 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 sur- face, and extends between the ramus of the jaw and the ear to near the level of the neck of the jaw, when it gives off the internal max- illary and the temporal arteries. The internal maxillary, winding around the neck of the bone between the pterygoid muscles, is hence difficult to ligate, and sometimes gives rise to considerable recurrent 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 follow 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 intro- duced into the latter vessel, whence it may readily pass to the heart and cause death. LARYNGO-TRACHEAL AND SUPRA-STERNAL REGIONS. 229 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 downwards and forwards. Lymphatic glands are also found in considerable numbers around as well as beneath the structure of the parotid, and the disease of these glands occa- sionally renders the diagnosis of tumors in the parotid region diffi- cult, and leads to mistakes in respect to the structure involved in the complaint. SECTION III. THE LARYNGO-TRACHEAL AND SUPRA-STERNAL 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 immediately below it constitutes the laryngotracheal, 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 deve- lopment of the thyroid gland; then the rounded surface of the trachea, and lastly the supra-sternal fossa or depression, the depth of which is generally increased when the patient expands the chest, as in taking a full inspiration. On the external or lateral portions of the region, near the anterior edge of the sterno-mastoid muscles, may be felt the pulsations of the primitive 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 230 OPERATIVE SURGERY. that is important from the same tissue elsewhere. Beneath it is seen the common fascia superficialis, and beneath this, but separated by sparse cellular substance, is the fascia known as the Cervical Fascia of Allan Burns,* or the fascia profunda, a laminated ex- pansion 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 inferior margin of the gland, descends to the sternum in two lamina, so as to form a perfect sheath for the sterno-hyoid and thyroid muscles. At its inferior extremity it is firmly attached to the sternum, sternal ends of the clavicles, and cartilages of the ad- joining ribs, for about one inch below the upper edge of the breast bone, thus forming an elastic and resisting membrane from the top of the sternum to the larynx. Directly above the sternum it sur- rounds the arteria innominata and brachio-cephalic vein; and beneath it are the trachea, roots of the large arteries of the head and upper extremities, and the trunks of their veins, as well as important nerves, f Between these organs and the fascia there is much loose cellular substance filled with lymphatic glands, the former being liable to serous infiltration, and to extensive 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, whilst 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. Count- ing from the sternum upwards, we find the innominata passing obliquely from left to right and from below upwards. 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 reach- ing this level, they give origin to the two superior thyroid arteries. These, in connection with the two inferior arteries of the same name * Burns on the Anatomy of the Head and Neck. t Special Anatomy and Histology, by Wm. E. Horner, vol. i. p. 378, eighth edition. LARYNGO-TRACHEAL AND SUPRA-STERNAL REGIONS. 231 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 surrounding organs into the jugular vein. The deep-seated veins have three principal directions: the superior follow the course of the superior 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 towards the left subclavian vein, crossing the inferior portion of the trachea in an opposite course from that taken by the arteria innominata, and being also more su- perficial than this vessel. (Plate XXIX. Fig. 4.) The superficial veins are more variable, and anastomose in various ways with the deep veins.* The variable size and direction of these veins renders a minute and accurate 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, there- fore, be upon his guard, in all incisions 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 cellular 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 cellular 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 * Blandin, Anat. Topographique, p. 191. f Porter, Surg. Anat. of Larynx and Trachea. 15 232 OPERATIVE SURGERY. PLATE XXX. INSTRUMENTS EMPLOYED UPON THE CESOPHAGUS AND TRACHEA. Fig. 1. Stomach-pump of Dr. Goddard. Schiveley's pattern. Fig. 2. Physick's oesophageal catheter for the evacuation of the contents of the stomach. Fig. 3. Ordinary oesophageal probang. Fig. 4. (Esophageal hook and probang of Dupuytren. Charriere's pattern. Fig. 4'. (Esophageal hook of Dr. Nathan Smith After Smith. 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, employed by Dr. Horner. After Horner. Figs. 7, 8. Bond's oesophageal forceps. After Bond. Fig. 9. Sponge for cauterizing the larynx, as advised by Trousseau. Charriere's pattern. Fig. 10. Instrument employed by Dr. Green for the same purpose. Schiveley's pattern. Fig. 11. Tongue depressor; by which a patient can depress his own tongue without incommoding the operator. Rohrer's pattern. Fig. 12. Ring made of watch spring, so as to be readily adapted to any neck, and intended to hold open the sides of the trachea after the operation of tracheotomy. Schively's pattern. Fig. 13. Ordinary tracheal tube or canula, intended to be placed in the trachea immediately after the operation of tracheotomy. Charriere's pattern. The objections to the employment of this tube have been stated in the text. THE SUPRA-CLAVICULAR REGION. 233 neck, as their relations, variable disposition and arrangement, can be better understood in connection with the special operations prac- ticed 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 mus- cle, and externally by the anterior borders of the trapezius and sple- nius muscles, is the region designated as the supra-clavicular. Being triangular in its outline, with the base below, the clavicle, trapezius, splenius, and sterno-mastoid muscles form its three sides. The skin and fascia covering this region, with a small portion of the platysma- myodes muscle, require little notice, as they present nothing of im- portance, 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, 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 contemplated. The Arteries usually found in the supra-clavicular region are such as supply 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 con- cavity of which surrounds the cul-de-sac made by the expansion of the pleura above the first rib.* The branches given off by the sub- clavian 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 scapu- lar, which runs close along the posterior margin of the bone, and is often in the way of the operator in attempting to ligate the sub- * Blandin, Anat. Topographique, p. 206. 234 OPERATIVE SURGERY. clavian, and transversalis colli, all of which run towards the back of the neck and top of the shoulder, while the vertebral, infe- rior thyroid and others, coming off within the scaleni muscles, run more or less perpendicularly. The perpendicular arteries, con- stituting the thyroid axis, arise at the inferior internal angle of this region, or at the space which exists between the sternal and clavi- cular 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 towards 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. Sometimes, instead of one trunk, there are two or three which unite at variable distances above the clavicle. The Nerves of this region belong chieflyto the brachial plexus; the four lower cervical and the first dorsal forming a plexus, which is more or less closely connected with the subclavian and the com- mencement of the axillary arteries. (Plate XXXIII. Fig. 1.) The other details of these parts will be given in connection with the operations practiced on the artery. In dissecting upon this region, the layers are usually presented as follows: First, the skin, then the superficial layer of the fascia, as well as the platysma-myodes muscle. Next, loose cellular 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 expansion 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 elevation or depression of the shoulder, by moving the inferior boundary of this region, will increase or diminish the apparent depth of the ves- sels, as well as relax or stretch the various layers which cover them. DISEASES OF THE PAROTID GLAND. 235 CHAPTER II. OPERATIONS PRACTICED ON THE PORTION OF THE NECK WHICH IS 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 advisable 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 downwards, according to the natural arrangement of the tis- sues. The surgical affections of the skin and fascia in this section of the neck, presenting nothing requiring special operative inter- ference, the disorders connected with the salivary glands become the first subject to which attention should now be directed. SECTION I. OF THE DISEASES OF THE PAROTID GLAND. The diseases of this gland, independently of the affections of its duct, of which mention has been already made in connection with the operations practiced on the face, consist either in such simple departures from a healthy state as yield readily to medical treat- ment, or in such degeneration of the cellular tissue and proper struc- ture of the gland as may necessitate its removal. The position of several of the superficial lymphatic glands of the neck, and the enlargement consequent on their diseased con- dition, sometimes create such a tumor in the parotid region, that any one who is not careful in forming a diagnosis, or who does not accurately examine the anatomical relations of the surrounding struc- tures may readily be led to suppose the enlargement to be due to an affection of the parotid itself. 236 OPERATIVE SURGERY. 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. Vel- peau* 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 incorporated with them, or by a change in the parenchyma of the glands themselves, rather than by a de- generation 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 pa- renchyma 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 natu- ral relations of the part, and marked departures from the normal condition may, therefore, be looked for when the removal of the dis- eased mass is attempted. Particles of a gland, which in the original state were separate and distinct, or very loosely attached, will often, when diseased, be found to be blended in one common mass; and por- tions 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 found that a diseased parotid is often surrounded with a dense capsule, formed chiefly at the expense of the surrounding cellular tissue and fascia, whilst its conglomerate parts are so fused into one conglobate mass, that the deepest portion of the gland had been pried out from the styloid process in consequence of 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 this gland, from comparing the operation with that attempted in a state of health, is certain, and daily experience is now leading many to place confidence in the views of those surgeons of the eighteenth century who advocated the operation. When, therefore, circumstances induce the belief that the re- * Med. OpSratoire, tome 3me, p. 644. EXTIRPATION OF THE PAROTID. 237 moval of the diseased structure can add to the patient's days, the operation should be performed, the entire gland having been extir- pated beyond all doubt, though 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. § 1.—EXTIRPATION OF THE PAROTID. For many years the removal of this gland entire was a vexed question, the possibility of accomplishing it being denied by high authority, among whom were Boyer, Richerand, and others; and some of the surgeons of the present day yet speak of the matter in terms of doubt, notwithstanding the most positive proofs of its feasi- bility and execution. To the late Dr. George McClellan, of Phila- delphia, is due, I think, the credit of having done more than any sur- geon in the United States to demonstrate the reasonable character of this operation; whilst by recalling public attention to the means of treatment which had been warmly advocated by Heister, Von Swie- ten, Garanget, and others who had preceded him, both in Europe and this country; he secured for the operation a certain degree of con- fidence which has since led to its more frequent performance. This operation had, however, been previously performed in the United States, being first done as early as 1798, when Dr. J. War- ren, of Boston, removed the entire gland;* in 1805, Dr. McClellan,f of Franklin County, Pennsylvania, did the same thing; and, in 1808, the operation was successfully performed by Dr. S. White, of Hud- son, New York.J But until the time of Dr. McClellan these operations were over- looked, though several authors had shown that the operation was not only feasible, but that the difficulties of its performance, and the entire removal of the gland in a diseased state, were much less than those experienced in accomplishing the same end, when it was in a healthy condition. Since his first operation, the removal of the entire gland has been successfully accomplished in numerous instances. Operation of Dr. George McClellan, 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 * Dr. John C. Warren, in MS. f See Bibliography. X Reese, Cooper's Diet., edit. 1849, p. 259. Article on Parotid. 238 operative surgery. 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. Dr. McClellan, thinking otherwise, proceeded to the operation, Feb. 27, 1826, as follows:— 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 be- tween 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 farther in these directions, progress was made beneath the tumor by burrowing under its lower edge. The posterior belly of the digas- tric 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 consequence 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 cellular substance, and some of the fibres of the styloid muscles which adhered to the tumor, the mass was elevated above the ramus of the jaw and the mastoid pro- cess. 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 scalpel, as the layers of fascia were too strong to be lacerated. * In this step, the main trunk of the temporal artery was necessa- rily cut, and a profuse hemorrhage coming from the recurrent circu- lation, 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 rupturedin the act of wrench- ing 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 EXTIRPATION OF THE PAROTID. 239 of the interrupted suture, in order to prevent their being reflected inwards; adhesive strips, a compress and head bandage, completing the dressing. The patient recovered with less deformity than ex- isted before the operation.* The gentleman is believed to be yet alive and residing in the city of New York.f Operation of Dr. Valentine Mott, of New York.—Determin- ing to ligate the external carotid artery before attempting the dis- section the operation of Dr. Mott was commenced by an incision about three inches long, which was carried from the posterior angle of the lower jaw downwards and inwards, 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 digas- tric muscle, or a little above the upper border of the thyroid carti- lage. An incision was next commenced above the jugum temporale, and carried downward in a semicircular direction, until it terminated upon the os occipitis, when the incision on the neck was extended upwards 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 and cellular tissue along the inner edge of the tumor was divided until the masseter was exposed. The finger being then in- troduced into the mouth and cut upon, in order to avoid the division of the buccal membrane, the tumor was separated 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 upwards, the dissection was continued from above down- wards, 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 * New York Med. and Phys. Journ., vol. v. p. 650. f See also Principles and Practice of Surgery, by the late Geo. McClel- lan, edited by J. H. B. McClellan, p. 335, note. 240 OPERATIVE surgery. 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 separat- ing 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 Dr. J. Randolph, of Philadelphia.—The dis- ease being seated in the left parotid, the head was inclined to the right side, and an incision made from the zygoma down to the edge of the sterno-cleido-mastoid muscle; 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 downwards. 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 secured 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; and Drs. Rhea Barton, William E. Horner, Norris, Coates, and others who wit- nessed the operation, all coincided in the opinion that the entire gland was extirpated.f The wound healed readily and the patient left the hospital well, but about ten months subsequently I heard of his death from a re- turn of the disease. The tumor is now in the Wistar Museum. J Operation of Dr. William E. Horner, of Philadelphia.— A crucial incision over the centre of the tumor being freely conti- nued along the base of the jaw, so as to include some enlarged lym- phatic 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 be- hind, 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 at- * Am. Journ. Med. Sciences, vol. x. p. 17. f Ibid., vol. xxiii. p. 517. X University of Pennsylvania, Philadelphia. EXTIRPATION OF THE PAROTID. 241 tachments. The primitive carotid artery 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 thick- ening 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 adhesions. 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 deep- est points. The division of the internal maxillary giving rise to considerable hemorrhage, the internal and external carotids were also 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 ex- posed; 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, 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 disease was returning. Statistics.—Of eleven cases in which the parotid gland was ex- tirpated by Dr. George McClellan, one died on the fourth day, from hemorrhage, and one died three years subsequent to the operation."}" Three cases have been operated on successfully by Dr. John C. War- ren, of Boston;J one by Dr. John H. B. McClellan, of Philadelphia, successfully; and one each by Drs. Mott, Horner, and Randolph. From an examination of the account furnished by Velpeau§ it ap- pears that there are over thirty-five cases of this operation in which there is good reason to believe the entire gland was extirpated; making, in all, fifty-three cases of removal. As regards the possibility of accomplishing the extirpation of the entire parotid gland, there can, therefore, be no doubt; though it is also equally certain that the ultimate.result to the patient will * Medical Examiner, vol. vii., N. S., p. 30, 1851. f Principles and Practice of Surgery, p. 332. X Dr. Warren in MS. I Velpeau, Op. Surg., by Mott and Townsend, vol. iii. p. 413. 242 OPERATIVE SURGERY. be found to correspond with the operations performed for the re- moval of malignant growths in other portions of the body. Remarks on the Operation.—In the descriptions of the opera- tive proceedings of the distinguished surgeons just deferred 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 ena- ble 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. 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 prevents hemorrhage. 4th. The edge of the scalpel should be directed towards 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 primitive 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, whilst the internal remains 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 princi- ples. In three instances, it has fallen to my lot to attend to the hemorrhage during the 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 Dr. Horner, and in that of Dr. John H. B. McClellan,* the internal jugular vein was entirely ob- literated; and in the others that have fallen under my observation, the artery has either been much thickened in its coats, or diminished in its calibre, the most troublesome hemorrhage having been that * Principles and Practice of Surgery, p. 336. EXTIRPATION OF THE PAROTID. 243 which arose from the recurrent circulation. The paralysis arising from division of the portio dura, in one case, was 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 Dr. Warren, it had nearly disappeared a few months after the operation.* That the division of this nerve was the cause of the intense suffering, described by some of the earlier operators, 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. Upon the whole, there is reason to think that, though this opera- tion is one which involves a high responsibility, it is yet one which every good anatomist may readily succeed in performing. But whe- ther, 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 patient of the distressing neuralgic pains and oesophageal difficulties under which he formerly labored; and, as an euthanasial measure, or one capable of prolonging life for even a limited period, its propriety should, therefore, be calmly considered in every case where its performance may be demanded. § 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 in cases of scirrhus, long-continued compression of the gland, or ligature of the carotid artery, have been occasionally prac- ticed. After ligating the primitive carotid artery, Dr. Alexander E. Hosack, of New York, succeeded in causing the entire absorp- tion of this gland in two cases; and, in a third, absorption had visibly commenced.f In estimating the value of this operation, one difficulty certainly exists, and that is the utter impossibility of deciding whether the * Warren on Tumors, p. 290. t Cooper, Surgical Dictionary. Appendix, by D. Meredith Reese, M. D., Article, Tumors. 244 OPERATIVE SURGERY. tumor is formed by the parotid, or by the adjoining lymphatics. Under ordinary circumstances, any surgeon who could accomplish the ligature of the artery could also remove the tumor, render the removal of the disease certain, and, under the use of anaesthetics, cause his patient but little additional suffering. The selection of either of these operations must, therefore, depend chiefly upon the abilities of the operator. SECTION II. OPERATIONS PRACTICED ON THE SUB-MAXILLARY 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 considering the disorders of this body. Like the parotid, the sub-maxillary gland is rarely, or ever, the starting-point of ma- lignant disease, whilst the lymphatics in its neighborhood are often involved. But, should circumstances induce the surgeon to attempt its excision, he may accomplish it by the following plan:— Operation.—Direct the patient to shut his mouth and throw back his 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 integuments, and 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 downwards and backwards, whilst the dissection is prosecuted in front of the gland, or outwards and upwards when it is carried below and behind the gland, free the latter from its pouch, avoiding all in- jury to the surrounding parts, by directing the edge of the knife constantly towards 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 under diseases of the lymphatic glands of the neck, and the treat- ment of r.anula has been placed among the operations of minor sur- gery.* * See Smith's Minor Surgery, third edition, p. 373. surgical anatomy of the larynx and trachea. 245 CHAPTER III. OPERATION PERFORMED ON THE LARYNX AND TRACHEA. The operations practiced on this portion of the neck, are cauter- ization 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 cartilages. These cartilages, of which the thyroid, cricoid, and epiglottis (Plate XXXI. Fig. 2) are the most important to the sur- geon, as connected with the operations on this part, extend from im- mediately below the os hyoides and root of the tongue to the first ring of the trachea, being lined throughout by a mucous membrane, be- tween which and the cartilaginous structure is a sparse cellular tissue, liable in certain forms of disease to dropsical 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 com- pleted in this portion of the canal as well as united to each other by elastic ligamentous matter. The tissues covering the trachea are the skin, superficial fascia, sterno-hyoid and thyroid muscles, and deep cervical fascia, to- gether with the thymus gland, which latter, or rather its isth- mus, sometimes extends as low as the fifth ring. Beneath these parts is a cellular tissue immediately around the tube, which has been spoken of by Mr. 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 impor- tant of the surgical relations of this portion are the numerous blood- 216 OPERATIVE SURGERY. vessels, whose varying position renders them especially trouble- some to the surgeon. Between the isthmus of the thymus gland and the top of the sternum are usually found several veins. Of these the superficial veins are found in front of the sterno-hyoid muscles, and cause but little trouble in operating; 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 be found to be frequent 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 ope- rating on this part. Thus, the suporior thyroid artery occasion- ally sends a large branch to the crico-thyroid ligament and then turns down to supply the thyroid gland; sometimes the inferior thyroid arteries are given off by the primitive carotid on a level with the thyroid gland; or the left carotid may arise from the inno- minata 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 superficial at its upper portion, where the vertebrae are con- vex in front, but becomes deeper as it approaches the chest, so that near the sternum it is over an inch beneath the integu- ments, or even more in short fat necks; whilst the changes pro- duced by oedema, 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. OPERATIONS UPON THE LARYNX. The operations practiced on the upper portion of the trachea, consist in such as are required for the relief of inflammation of the part, and those demanded by the presence of foreign bodies. § 1.—CAUTERIZATION OF THE LARYNX. The introduction of lunar caustic into the larynx is an operation * Anat. Topograph., p. 196. CAUTERIZATION OF THE LARYNX. 247 which may be demanded in the treatment of various forms of inflam- mation, and especially in membranous croup. The credit of suggesting and applying this remedy is due to M. Trousseau, of Paris,* who first introduced a strong solution freely into the canal, both by means of a sponge as well as by a syringe; whilst in the United States, particular attention has been called to the advantages of its employment by Dr. Horace Green, of New York.f The operation is simple, and may be readily performed 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 the operator finds 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 in- convenience will be caused to the patient than might have been anti- cipated. 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 which is not very marked. Remarks.—Cauterization of the larynx is an operation of so simple a character, that reference to it in these pages might seem unneces- sary were it not that it is an important preliminary step in the treat- ment of croup, and one that should always be employed before tra- cheotomy 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 practitioners who deny the possibility of introducing a sponge into the glottis. To Dr. Green of New York is, therefore, due the credit of having done more than any other in the United States towards establishing pro- fessional confidence in an operation, which has since proved to be both easy and useful in many instances. The tendency to quack- ery, (so often observed in the treatment of affections of the wind- pipe, dependent on chronic inflammation), has, however, shown itself in this as in other rational plans of treatment; and a measure which is capable of doing much good, when judiciously directed, * Traite de la Phthisie Laryngee et des Maladies de la Voix. Paris, 1836. Mem. de l'Acad., &c. f Diseases of the Air-passages. New York, 1846. 16 248 OPERATIVE SURGERY. 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. Thyroid gland and veins in front of crico-thyroid ligament. 6. Rings of the trachea. 7. Common carotid artery. 8. Superior thyroid arte- ries. 9. Inferior thyroid artery. 10. Carotid artery, as divided. 11. Out- line 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 Bloodvessels. 1. Os hyoides. 2. Thyro-hyoid ligament. 3. Thyroid cartilages. 4. Crico- thyroid ligament. 5. Cricoid cartilage. 6. Trachea. 7. Internal jugular vein. 8. Transverse 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. External 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 incising the rings. 3. Line and termination of the external in- cision. 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 upwards from the bronchia. After Bourgery and Jacobson. 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 oedema of the Glottis. 1. The epiglottis cartilage much swollen by serous infiltration of its submu- cous cellular tissue. After Gurdon Buck, Jr. Fig. 8. The operation of scarifying the Glottis for the relief of oedema. 1. The forefinger in its position as a director. 2. The knife in the act of scarifying the part. After Gurdon Buck, Jr. Fitf 1 ffiDEMA OF THE GLOTTIS. 249 seems now likely to be cast aside by many, on account of its lia- bility to be misemployed. That this application has been resorted to in cases which did not require it, is doubtless true, but time will soon settle the positive and correct indications which should direct its use, and remedy the evils which always ensue upon the first employment of & fashionable remedy. § 2.—GEDEMA OF THE GLOTTIS. Pathology.—In the rare form of disease of the upper ex- tremity of the larynx, which has been designated as oedema of the glottis, there is commonly found an infiltration of the sub- mucous cellular tissue of the part, in consequence of the develop- ment of such a degree of inflammation, as results either in an effu- sion 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 of the larynx becomes distended and formed into folds, or doublings, which rising upwards, and also extending downwards as far as the vocal cords (Plate XXXI. Fig. 7), render the epiglottis 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, oedema 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, rather an cedematous inflammation of the larynx itself, consequent on, or accompanied by, a similar condition of the surrounding parts. In many instances, this infiltration is the result of an inflammatory affection of the ton- sils, uvula, or soft palate, which are then seen increased in color, and accompanied by all the symptoms consequent on tonsilitis, though at other times they are unnaturally pale and swollen. 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 oedema of the glottis was not thoroughly understood at the period of his death, the explanation 250 OPERATIVE SURGERY. thus advanced is due to the observation of more modern patholo- gists, as may be seen by referring to the views of various writers on this subject.* Sometimes oedema of the glottis, instead of being an acute com- plaint, 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 con- fided in, as it alone will often enable the surgeon to recognize the condition of the top of the larynx, and enable him correctly to appre- ciate the diminished state of its orifice, the latter having been some- times so completely closed, as scarcely to permit the passage of light into the trachea when removed from the body. Without referring 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 Dr. Gurdon Buck, Jr., of New York. Operation of Dr. Buck.—The patient being seated on a chair, with the head thrown back, and supported by an assistant, should first be 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 intro- duced 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 epiglottis, 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 epiglottis for- wards towards 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 downwards 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 instrument 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 withdrawing it from the larynx. After repeating this two or three times, on either side, * See Cyclopaedia Pract. Med., vol. iii., art. Laryngitis; Diet, de Science MSdicale, tome 17; Pract. of Med., by George B. Wood, M. D., vol. i. p. 743. (EDEMA OF THE GLOTTIS. 251 without removing the finger, the margin of the epiglottis, and the swelling between it and the base of the tongue, as well as the mar- gins of the larynx, will be freely scarified ; or scissors curved flat- wise (Plate XXXY. 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 Dr. 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.* 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 oedematous swelling, pass the bistoury flatwise on the fingers down to the part, and when it has reached the larynx, turn its edge upwards and forwards, 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, f Statistics.—Of six cases reported by Lisfranc, five were cured. Of eight reported by Dr. Buck all terminated favorably, though in one, tracheotomy was also resorted toj and in six additional cases reported lately§ as occurring in the hands of Dr. Buck, or in that of other surgeons in New York, all were likewise cured, making nienteen cures out of twenty cases. Remarks.—Previous to the year 1821 there seems to have been no operation practiced for the relief of this complaint excepting tra- cheotomy, though Dr. Marshall Hall had suggested the idea of scari- fication at that time. This suggestion was, however, generally dis- countenanced till Lisfranc, in 1823, resorted to punctures and pres- sure. His idea seems also to have been forgotten, or at least not generally resorted to, being viewed as a " fantastic operation," until Dr. Buck called the attention of the surgeons of the United States to the result of his operations. When we recollect the serious nature * Transact. Amer. Med. Association, vol. i. p. 137. t Malgaigne, Operat. Surg., Philad. edit., p. 369. X Op. cit, p. 145. § Transact. Amer. Med. Association, vol. iv. p. 277: 1852. 252 operative surgery. 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 Dr. 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 Dr. 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 Dr. Buck has collected, the oedema 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 cedema 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 ex- plained 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 rational means of affording relief from a dis- tressing and dangerous complaint, the operation of scarifying the glottis and epiglottis may be regarded as one of the mgst useful of those suggested by the surgeons of the nineteenth century. § 3.—tracheotomy. The perforation of any portion of the trachea by means of a cut- ting instrument, 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 opening is limited to those portions of the trachea which are above the sternum, the term Tracheotomy is now more generally employed. Either may, however, be used to designate the operations practiced on the larynx or trachea proper, the opening of the larynx being, however, 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 opera- tion may be best described separately. I. tracheotomy for croup. The operation of tracheotomy dates back to a very early period, * Diet, des Science M6d., tome xvii. tracheotomy for croup. 253 Antyllus, A. D. 340,* having recommended and performed it in se- veral 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. This plan having been first brought to my notice in a paper by Dr. Joseph Pancoast, of Philadelphia, f and since then frequently repeated by him, as well as tested by myself, has been selected as presenting a methodical course of proceeding, as well as one which opens the trachea perfectly without unnecessarily exposing the patient to risk from hemorrhage, or to the subsequent inconvenience caused by the use of the canula. Preliminary Measures.—When the operation has been decided on, the surgeon should prepare a sharp scalpel; two curved spatulse or blunt hooks; a director; straight, sharp, and probe-pointed bis- touries ; dissecting forceps, and dressing forceps if it is intended to remove a foreign body; a tenaculum or a pair of torsion forceps; threaded needles; ligatures, and several small pieces of sponge at- tached to sticks or quills as handles, as well as one or two pieces of sponge, cold water, and towels, together with such other articles as may be demanded in the dressing. Operation of Dr. Pancoast.—Place the patient upon his back, with the head thrown sufficiently backwards over a pillow, yet not so as to stretch it too much, or compress the trachea by contract- ing the muscles in front of it. Then, whilst the surgeon stands on the right side of the patient, let one assistant steady the head, another confine the arms and steady the shoulders, a third attend to the lower limbs, and a fourth hand sponges, &c, as needed, after which the operator may place the fingers of his 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, and raising the fascia puncture it, and divide it upon a direc- tor. After finding the line of junction of the sterno-thyroid muscles, let him next separate them with the handle or back of the knife, by * See History of Surgery, Part I., p. xviii. of this volume. t Amer. Journ. of Med. Sciences, vol. xvii. N. S. p. 307. 254 operative surgery. tearing the cellular tissue between them, and have them held back by curved spatulae so as to expose the parts beneath. The isthmus of the thyroid gland, if found to come so low down as to be in the way of the incision, should now be tied by means of two % liga- tures passed beneath it by needles, after which it may be di- vided between them. At 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, push- ing aside the two inferior thyroid veins, or ligating any anasto- mosing branches, or the middle thyroid artery if it exists, the sur- geon should next divide freely the condensed cellular tissue which has been called by Mr. Porter* the tracheal fascia, and dissect a small portion of it from around the contemplated opening of the tra- chea, in order to prevent the parts from subsequently becoming em- physematous and closing the orifice. The trachea being now freely exposed, and the bleeding checked, a tenaculum may be inserted in the »median line of the rings, and the part thus raised excised by sharp-pointed scissors; or a bistoury may be at once passed in and the trachea slit open from below upwards, to the extent of three or four rings, counting from 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, as suggested by Dr. Pancoast, of Philadelphia, or by resorting 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 suf- fice 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 Messrs. Lawrence and Porter, of England, or simply incised, the use of the blunt hooks, or the watch-spring, will always prove service- able by keeping the soft parts from contracting and closing the ori- fice in the trachea, and this is especially the case when the rino-s are merely divided without excising any portion of them; but as * Surg. Anat. of Larynx and Trachea. tracheotomy for the removal of a foreign body. 255 soon as the parts are sufficiently retracted, which is sometimes the case in thirty-six hours, the hooks or spring should be removed. II. tracheotomy for the removal of a foreign BODY. The performance of tracheotomy, for the removal of a foreign body, differs in no way from the operation usually resorted to in croup; but the following plan being presented in connection with a case of this kind, and showing the results of a prompt incision into the trachea, has been related in order to enable an operator to make a selection. The chief difference between this and the preceding ope- ration will be found in the fact, that Mr. Liston does not advise de- laying the opening into the trachea until the hemorrhage is arrested, as is done in the method of Dr. Pancoast and others. Operation of Liston.—In a patient, five years old, who had swallowed a small glass seal, the operation of tracheotomy was per- formed by Mr. 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 horizontally with his face upwards, 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 seconds 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 movements of respiration, was seized by means of a small hook, and drawn forwards towards 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 upwards and its back towards the verte- bral column, with the handle kept low, and with a light hold of the in- strument so as to avoid injuring the oesophagus by any sudden move- ment of the patient, two or three of the rings were divided, and the assistant immediately directed to turn the child over with his face downwards. For an instant, the little patient seemed on the point of suffocation, 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 position, the blood trickled on the floor, a deeper inspiration was taken, the foreign body was expelled with 256 operative surgery. force, and, as if by magic, the breathing became quiet and the venous hemorrhage ceased spontaneously.* 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 article 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), and sometimes it has remained 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 justify the operation. Caution in diagnosis and prognosis is, therefore, a matter of much importance with patients who are thus situated. III. LARYNGOTOMY. Operation of Desault.—After dividing the skin and fascia su- perficialis by an incision which extended from the projecting angle of the thyroid cartilage to a little below the cricoid, but not near so long as that required in tracheotomy, this surgeon separated the thyroid muscles, placed his forefinger on the crico-thyroid ligament, and feeling for the artery of the same name, endeavored to depress or raise it out of the line of the incision, and then plunging the scalpel into the ligament, cut it either upwards or downwards, according 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. * Lectures by R. Liston, with additions by T. D. Mutter, p. 326. TRACHEOTOMY. 257 § 4.—ESTIMATE OF THESE DIFFERENT OPERATIONS. Tracheotomy presents so few dangers that are not equalled 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 employed by Dr. Pancoast and others, and described at the commencement of this section. The advantages which I think it possesses are, first, less risk of hemorrhage in conse- quence of lacerating the parts about the median line of the muscles, instead of dissecting them, as well as from ligating the isthmus of the thyroid gland previous to incising it; second, the preservation of the opening in the trachea without irritating its lining membrane, or resorting to an instrument that exposes the patient to the risk of suffocation by its escape from the wound, or by its 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, Dr. Pancoast, and others, seem to have been due to their judicious after- treatment; a few drops of a solution of the nitrate of silver, ten or twenty grains to the ounce of water, being dropped in or applied upon a little probang, or the trachea itself swabbed out by a similar instrument whenever the clicking sound of the respiration led to the belief that false membrane or mucus was collecting at this point. 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 likely to cause a subsequent contraction of the canal when the wound cicatrises. But in the cases which have r eco vered, both in the hands of Dr. Pancoast and in those reported by others, this has not been the case. 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 ligature before opening the canal; 3d, to clear away the cellular substance (tracheal fascia), around the proposed opening; and, lastly, either to excise a portion of the rings, or keep the slit distended by a spring or by blunt hooks. To those not familiar with the details of the operation, it may also 258 OPERATIVE SURGERY. be useful to state, that the puncture of the trachea will generally bring on a most violent 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 consequent on the puncture being sometimes so marked as to alarm thejby-standers for the life of the child. Remarks.—It is doubtless apparent, from reading the above estimate of tracheotomy, that I regard it as an operation re- quiring some skill and preparation on the part of the surgeon, and that it should not be attempted by any practitioner, 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 de- pressed 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 lead them to anticipate difficulties if they are induced to operate, and in all cases special precautions should be taken in regard to hemorrhage. In some instances, the flow of blood has been of the most alarming and intractable kind. Dessault,* whose skill no one can doubt, was, it is said, compelled to give up an ope- ration, 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 patients 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. When, therefore, tracheotomy is spoken of " as an operation not much more difficult than venesection," such cases should be remembered. Supposing, however, that the operator is aware of these dangers, * Diet, de Med. tome vi. p. 58. TRACHEOTOMY. 259 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 who are liable to die asphyxiated? That such a recommendation should not be universally admitted requires no argument, and the proposition may therefore be more definitely settled, by showing in what cases the performance of the operation may be advisable. That an opening may be made into a healthy trachea for the re- moval of a foreign body, or in order to overcome a spasm of the glottis caused by inhaling a noxious vapor, or in cases of oedema of the glottis, is a point which I cannot but regard as settled by sta- tistics. From an examination of the various papers referred to in the Bibliographical Index,* as well as from a review of many of the works upon Surgery, from a very early period, I am induced to think that tracheotomy, in such cases, is not only a justifiable operation, but also one which furnishes the patient with a ready means of escape from the dangers likely to ensue. And although instances are recorded where even nails and coins have remained in the windpipe for years without destroying life, there are others, well authenticated, where the presence of a small bean, or of a grain of coffee or of corn, have induced laryngeal phthisis, ulcera- tion, and death. In oedema of the glottis, though the operation may be required, I would not resort to it until scarification of the parts had been fairly tried; but this being done, I should antici- pate from tracheotomy prompt and permanent relief. In hydropho- bia, I should be disposed to try it rather than see the patient die without it. As to the propriety of advising tracheotomy in cases of membran- ous croup, there is apparently so much of the result that might be charged to the peculiarity of the mode of operating heretofore em- ployed, and to the delay that has generally preceded its perform- ance, 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 performed, may be rea- dily obtained, and it is one which has gone far towards diminish- ing 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 it at the last * See Tracheotomy. 260 OPERATIVE SURGERY. moment. In the United States, the experience of Dr. Physick was adverse to it; and statistics show that the prognosis of the opera- tion, as heretofore performed, should be very guarded. But, in most of the cases thus reported, tracheotomy was defer- red until the complaint had existed some time, and progressed 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, as well as an unhealthy condition of the lining membrane of the trachea at the point operated on. Until then we can acquire such statistics as will show that 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 not liable to clog with mucus, as well as free from the continued irritation that has been caused by the presence of a tube, correspond with the mor- tality under the former mode of operating, the question must be regarded as unsettled. Cauterization of the pharynx and trachea through the mouth, together with early depletion, calomel and eme- tics, have saved many cases of true membranous croup, and will, consequently, be a strong argument against the performance of an early operation. But when croup occurs in those who are heredita- rily predisposed 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 tube which was to be opened, and the wound in the trachea was kept open, either by the hooks introduced upon its sides, or if that was not sufficient by their being placed upon the edges of the rings themselves. But I would not advise tracheotomy in any case, where the operation had been delayed until asphyxia was threatening, and the blood had ceased to be well aerated. Like the operation for strangulated hernia, tracheotomy, to be successful, should be done before the changes in the part are likely to render it useless. § 5.—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 results of the operation, as performed for the relief of croup, as well as for other purposes, and present them in tabular form. STATISTICS OF TRACHEOTOMY. 261 I. TRACHEOTOMY FOR CROUP. The following table shows the success obtained from the operation of Tracheotomy, as usually performed for the relief of membranous croup, the wound being chiefly kept open by means of a canula in the windpipe. 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* Maslieurat, 2 1 1* Petit, . )6 3 3* Roux, 4 0 4* Velpeau, 6 0 6* Trousseau, 153 41 112f Pancoast, 7 3 n Page, 1 0 Smith, . 1 0 Thompson, 1 0 E. Atlee, 1 0 Townsend, 1 0 Van Buren, 1 0 Buck, Jr., 1 1 0 Johnson, 1 0 1 245 57 188 From this it is seen that of 245 cases of tracheotomy performed for the relief of croup, but in which the operation was not resorted to until nearly every other means had been tried, only 57 were cured, whilst 188 died, that is, in more than three-fourths of the cases operated on the patients died. The next table shows a very different result, the same operation being performed at a period when the trachea was not diseased. * Condie on Children, edit. 1844, p. 310. f Lond. Med. Examiner, Aug. 1851, p. 131, from Gazette des HSpitaux. X J. Pancoast, in MS. Jan. 29, 1852. 262 OPERATIVE SURGERY. II. TRACHEOTOMY FOR THE REMOVAL OF FOREIGN BODIES. CURED. DIED. SUBSTANCE. John Newman, N. C. . . .1 Bullet. Amassa Trowbridge, N. Y. .1 Bean. H. G. Jameson, Md. ... 1 Watermelon seed. " " " ... 1 Pebble. Samuel Cartwright, Miss. . 1 Watermelon seed. H. T. Waterhouse, N. Y. . .1 Watermelon seed. Joseph Palmer.....1 Bean. Richard Burgess.......1 Peter P. Woodbury, N. H. .1 Bean. Calvin Jewett, Yt.....1 Bean. « " " .... 1 Iron nail near two inches long. Enos Barnes, N. Y. ... 1 Abner Hopton, N. C. . . .1 Grain of corn. Zadok Howe, Mass. ... 1 Bean. J. F. Hardy, N. C. . . . .1 Watermelon seed. Charles Hall, Vt.....1 Pipe stem. J. Mason Warren, Mass, . . 1 Bean. Twitchell, N. H......2 Beans. William Davidson, Ind. . . 1 Grain of corn. W. H. Van Buren, N. Y. . . L Plum stem and watermelon seed J. H. Kearney Rodgers, N. Y. 1 Cherry stone. Evans, Ky.......1 Vapor of hot water. N. R. Smith, Md.....1 (Laryngotomy.) Cockle bur. Liston........1 Glass seal. Pancoast, Phila.....3 Result not stated. Cured 28 Died 1 From this it appears that, in twenty-nine cases of tracheotomy performed for the removal of foreign substances from the trachea, twenty-eight were cured, and only one died—the trachea being allowed to close and heal as soon as possible after the operation. From a comparison of the results of these two tables, it is very evident that the dangers which ensue upon incising a healthy tra- chea 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 opera- tion, is a point which can only be settled by each operator hereafter specifying the peculiarities of his cases. SURGICAL ANATOMY OF THE PHARYNX AND ESOPHAGUS. 263 CHAPTER IY. OPERATIONS UPON THE PHARYNX AND OESOPHAGUS. The (Esophagus, or musculo-membranous canal, which extends from the mouth to the stomach, 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 sub- stances, of a hard and irritating nature, which being inadvertently introduced into the mouth, are thence carried down the oesophagus towards 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 difficulties of reaching it from the outside of the neck, its relations to surrounding parts should be thoroughly studied by the surgeon before attempting any of the cutting operations some- times required for its relief. SECTION I. SURGICAL ANATOMY OF THE PHARYNX AND ESOPHAGUS. Although, to an ordinary observer, the (Esophagus is one continu- ous 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, between the cervical vertebrae and the posterior part of the nose and mouth, and into the oesophagus pro- per, or tube, which extends from this cartilage, or the lower part of the fifth cervical vertebra, to the cardiac orifice of the stomach. 17 264 OPERATIVE 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 convey the food from the pharynx 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 cellular tissue, in which are found the bloodvessels and nerves of the part, the arteries being branches from the carotid; the veins emptying directly into the internal jugular, and the nerves being branches of the glossopharyngeal, pneumogastric, and fifth pair. The muscles of the pharynx mainly arise from the surrounding bony prominences on each side, and, being joined to their fellows, are enabled to diminish the transverse diameter of the opening, and force the bolus of food or other substance downwards, till it reaches the oesophagus. § 2.—OF THE C3S0PHAGUS. The (Esophagus extends from the pharynx to the stomach, is from ten to twelve lines in diameter, about ten inches in length, and, when quiescent, flattened from before backwards. 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 towards 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 muscular, cellular, and mucous. The muscular coat has its fibres arranged circularly, internally; and longitudinally, externally. The cellular coat is well developed, adhering more closely to the mucous membrane than to the muscular fibres, presents a filamentous character, and contains numerous lym- phatic glands. The mucous coat, in the undistended condition, presents itself HYPERTROPHY OF THE FOLLICLES OF THE PHARYNX. 265 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 con- nection with the nose, inflammation of the upper portion resulting in stoppage of the Eustachian tubes, as mentioned in the diseases of the ear, and the formation of abscesses, the treatment of which can- not properly be included in an account of operations, except by saying that their evacuation, when required, is to be accomplished by a simple puncture of the swelling at its most prominent point. The other disorders, demanding surgical interference, are the hy- pertrophied condition of the muciparous follicles, and the removal of foreign bodies arrested by its walls. § 1.—HYPERTROPHY OF THE FOLLICLES OF THE PHARYNX. The hypertrophy, or enlarged condition of the follicles of the mucous membrane 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 inexpe- rienced 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 enlarged follicles have existed a long time without attention being directly called to them, until they have been knowingly spied out as the seat of symptoms with which they are by no means certainly connected. But when, after a skillful investigation of the case, the surgeon be- lieves that they really cause the patient any inconvenience, he may do much towards 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's-hair pencil, sponge, or swab. 266 OPERATIVE SURGERY. § 2.—FOREIGN BODIES IN THE PHARYNX. From the efforts made in swallowing, it occasionally happens that foreign substances of various kinds, but especially those which are sharp and fine, are arrested in the pharynx, and retained there in such a manner as enables them to be reached with the finger or forceps. Generally, the most serious part of their removal is found in the difficulty of recognizing their position. When the foreign body is small and sharp-pointed, like a pin, needle, or fish-bone, it may be looked for about the posterior half arches, or near the ton- sils ; as these articles, from their small size and pointed character, are more apt to lodge in the line of the superior constrictor muscle than those which are larger, and which, being more readily seized by the muscles, are carried further into the oesophagus. Thus, in eat- ing fish, the softer portion of the bolus may pass, but the constric- tion of the mass forcing the point of a bone into the upper part of the pharynx, it will nearly always be seen presenting itself trans- versely to the pharynx, or be found about the points just designated. The same is true of pins or needles, of which one escaping from the mouth, suddenly induces an effort to swallow, in which effort the pharynx, being contracted laterally, the point pricks the walls of one side, induces further spasmodic effort, and, at last, is found to have been buried by its point in the mucous coat, or, perhaps, a little deeper. When foreign substances penetrate deeply through the pharynx, there is, in addition to the inconvenience caused by their position, also some risk of their inducing such inflammation of the tissues as may result in an abscess, or they may cut their way into the larynx, or injure the arteries of the neck;* for these reasons, they should be promptly removed, if possible. Operation.—Place the patient in a strong light, depress the tongue with the forefinger of the left hand, and look for the foreign body, or, if it cannot be seen, pass the same forefinger into the throat, and feel for it. Then, using the finger as a guide, pass a pair of suitable forceps along it, and endeavor to seize the substance so as to extract it lengthwise and not transversely, lest its escape be * See Bibliography, article OSsophagus, from a paper by PaulF. Eve, M. D., Georgia. REMOVAL OF SUBSTANCES FROM THE CESOPHAGUS. 267 resisted by the contraction of the half arches consequent on the gagging which the presence of the instrument will induce. SECTION III. OPERATIONS UPON THE C3S0PHAGUS. 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 masti- cated, or foreign bodies intended to be held temporarily in the mouth, but which are suddenly swallowed, or a diminution of the caliber 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 con- nection with other parts of the neck; to wit, the removal of foreign substances from it, or from the stomach, and the restoration of its natural caliber, in cases of stricture. § 1.—REMOVAL OF FOREIGN SUBSTANCES FROM THE OESOPHAGUS AND STOMACH. In order to estimate correctly the principles especially applicable to the removal of foreign substances from the oesophagus, some at- tention should be given to the anatomical relations of this part, as well as to its functions. In a well-written paper upon this subject, by Dr. Henry Bond, of Philadelphia,* may be found some sound views of the physio- logical action of the part, as well as of the means required for the extraction of foreign bodies from the canal; and from this paper many of the following facts have been extracted. * North Amer. Med. and Surg. Journ., vol. vi. p. 278. 268 OPERATIVE SURGERY. I. EFFECTS OF THE INTRODUCTION OF A FOREIGN BODY INTO THE OESOPHAGUS. The general anatomical relations of this canal having been already stated, it is sufficient, at present, to mention that the posterior surface of the trachea and larynx, as far as they are in connection with the oesophagus, present to it a yielding ligamentous structure capable of being impinged upon by any substance which may be arrested in the latter. As the anterior wall of the oesophagus is that which is chiefly expanded in the effort of swallowing, the foreign article is generally brought more immediately in contact with the back of the larynx and trachea, at those points where there is merely a ligamentous struc- ture, where, by exciting the muscles of the glottis, it causes irritation and efforts to cough, which occasionally become spasmodic. If, then, an article should remain in the oesophagus, at a point sufficiently high to enable it to impinge upon this portion of the trachea, coughing or threatening of suffocation must ensue. Cause it to pass either above or below the larynx and trachea, and the most annoying symptoms will disappear. Two plans of treatment in these cases have, there- fore, been resorted to, the selection of either being guided by the judgment of the surgeon at the moment, to wit, either to carry or force the substance into the stomach, which answers very well when the article is an innocuous one, or to remove it by some suitable means, such as the efforts of the patient when excited by vomiting or by manual interference on the part of the surgeon. For the accomplishment of the latter, various means have been suggested, as forceps, hooks, and sponges. But, without entering into the de- tails of these inventions, it may be sufficient merely to direct atten- tion to such as will be found in Plate XXX., among which can be seen the admirably adapted forceps of Dr. Bond, and a hook, brought to the notice of the profession in the United States, by the late Dr. Nathan Smith, of New Haven.* An instrument, very simi- lar 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 Dr. Smith, or * New York Med. and Phys. Journ., vol. iv. p. 576. 1825. FOREIGN BODY IN THE OESOPHAGUS. 269 preceded him, the latter states explicitly that " his hook is unlike anything which he has known to be employed for a similar purpose;" and he, therefore, furnishes a drawing of it in the paper referred to,* 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, are thought to be inferior to the instrument of Dr. Bond. The latter is capable of taking hold firmly, and extracting safely any foreign sub- stance, no matter how fine or small, which is within the length 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, whilst the hooks are only adapted to larger ob- jects. Operation with the Forceps of Dr. Bond.—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 compress- ing the trachea against the bodies of the vertebrae, the foreign article be caused to impinge on the larynx, and such a spell of coughing in- duced as will materially interfere with the operation. Then, placing a plug between the molar teeth, depress the tongue with the fore- finger of the left hand, 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 de- pressed by an assistant by means of the instrument (Plate XXX. Fig. 11), when the surgeon opening and shutting the blades of the forceps, should carry the handles from left to right, or the re- verse, so as to sweep the oesophagus with the points of the instru- ment. 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 operator need not fear an injury to the walls of the canal, as the instrument is so constructed as to render such an event almost im- possible. Dr. Constantine Weever, of Michigan, has also publishedf the description of a pair of forceps, consisting of a two-bladed whale- bone stylet, which being inserted in a flexible catheter, is passed * See Plate XXX. Fig. 4/ f Am. Journ. Med. Sciences, vol. xiv. p. 111. 1834. 270 operative surgery. PLATE XXXII. OPERATIONS PRACTICED ON THE OZSOPHAGUS AND LARYNX. Fig. 1. A front view of the application of the (Esophageal Hook of Dupuy- tren, as represented upon the subject, by a section of the mouth. 1. A lon- gitudinal 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 extremity with the basket attached to it. 6, 6. Dotted lines showing the course of the (Esophagus. After Bourgery and Jacobson. Fig. 2. A front view of a section of the Mouth and Throat, showing the application 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 car- tilage. 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 Jacobson. 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 Dr. 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 Dr. Goddard. After Nature. NOXIOUS SUBSTANCES EXTRACTED FROM STOMACH. 271 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 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 useful 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 pro- bang. If the article to be removed is barbed and sharp-pointed, like a fish-hook and line, no expedient will probably answer better than that suggested, under similar circumstances, by Dr. 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. When the dangers that may result from the perforation of the aorta or trachea, f as the result of the continued presence of irritat- ing articles in the oesophagus is recollected, it may be well for the surgeon to be as unceasing as is prudent in his efforts to carry the article either upwards or downwards. Where the foreign body is so placed in the oesophagus that its position can be distinguished by the touch externally, the propriety of performing cesophagotomy is a question worthy of consideration. Many substances of a durable nature have, however, been known to remain for years in the oesophagus without creating intolerable in- convenience, one of which is reported by the late Dr. Dorsey, of Philadelphia, J and the possibility of such a condition should always, therefore, be recollected. In this case, a copper coin remained thirteen years in this tube without destroying life. 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 occasionally created abscesses, and thus been discharged exter- nally. § 2.—EXTRACTION OF NOXIOUS SUBSTANCES 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 sim- ple an operation as to require but a few words. * See Bibliography, article Oesophagus. f See Ibid., by Paul F. Eve, M. D. X Bibliographical Index. 272 OPERATIVE SURGERY. Operation.—After placing a plug between the back teeth, so as to protect the fingers or the tube from being bitten by the patient, pass the forefinger of the left hand to the root of the tongue, and gently depress this organ. Then pass the catheter rapidly back- wards till it reaches the back of the pharynx, when, if the resist- ance that it meets with is not sufficient to depress its point, it may be readily turned down by the forefinger previously introduced. By carrying the point of the catheter towards either half arch, there will be little risk of introducing it 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 sto- mach-pump, (Plate XXX. Fig. 1),* or by a large 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 this operation 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. To Dr. Physick, of Philadelphia, is due the merit of first employing the now well-known stomach-tube, or oesophageal catheter, the benefits 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,^ Dr. Caleb B. Matthews published a paper, in which he showed very satisfactorily the origin of this instrument, Dr. Philip Syng Phy- sick, in 1800, having recommended it in his annual lectures in the University of Pennsylvania. Dr. Dorsey, who was in Paris in 1803, also states that he had a gum-elastic tube, or catheter, made to Dr. 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. In 1809 this instrument was employed by Dr. Dorsey,| and, by * See Bibliography. Paper by P. B. Goddard, M. D. f Am. Med. Record, vol. x. p. 322. Philad. 1826. X Eclect. Repertory, October, 1812. STRICTURE OF THE C3S0PHAGUS. 273 others subsequently, an indefinite number of times. From a claim afterwards made for the priority of this invention by Dr. 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 into practice. Dr. Physick, though admitting at a later period the coincidence of this suggestion, always stated his ignorance of the thesis in which it was published; and being the first person who had one constructed and employed, 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 Dr. Physick, will also be found a reference to the apparatus of Dr. Ewell, of Washington, as proposed in 1808, and of Mr. Jukes, of London, who contrived simi- lar means in 1822, as well as the testimonials 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 Dr. Physick, he having, in the paper referred to, also furnished drawings of the stomach-pump, to which it was adapted. § 3.—STRICTURE OF THE G3SOPHAGUS. Pathology.—The analogy existing between strictures of this canal, and that 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 proposed for its relief. In an able article, written by Velpeau,* will be found much valu- able information, and to it I am mainly indebted for the following details:— The condition of the oesophagus, under the various causes producing stricture, is very varied; but, however excited, the con- striction 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 * Dictionnaire des Sciences Medicale, tome 21me, p. 397. Paris, 1840. 274 OPERATIVE SURGERY. 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 cellular coat of the oesophagus, the induration of the part is so marked as to present a mass closely analogous to scirrhus, whilst 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 commenced. The extent of a stricture in the oesophagus is very variable, usu- ally 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 contraction, or bandlike thickening, above and below which the indurated part is less constricted, whilst the portion of the canal immediately around the seat of the stricture, has been known to be dilated into a pouch capable of holding 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 stric- tured 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 formed between the posterior face of the trachea and the front of the oesophagus, 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 surgeon must see the dangers attending any attempt to over- come old strictures of the oesophagus; and he should, therefore, be especially cautious, not only in his prognosis, but also in the em- ployment of the various means that have been suggested for the relief of the complaint. The operations that have been recommended for the cure of oeso- phageal contraction consist in dilatation of the stricture, in the ab- DILATATION OF THE STRICTURE. 275 sorption or destruction of the diseased substance, or in a direct in- cision through the constricted portion, so as to restore the permea- bility of the canal. I. DILATATION OF THE STRICTURE. Instruments.—Without entering upon an account of the various instruments that have been suggested for the purpose of dilatating the stricture, this account will be limited to the operation as accom- plished by means of bougies. As originally suggested by Sir Ever- ard Home, these bougies were made of waxed linen in the manner that will be referred to under the head of operations 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 stricture, so as to dilate the canal as they advanced. The ordinary condition of these bougies, when made entirely of linen, does not, however, afford sufficient firmness to prevent the pres- sure 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 instru- ment which I have found to answer better, is one employed by Dr. Wm. E. 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 obstruction 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 continued pressure answers 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 this complaint in the oesophagus. But as before mentioned, the canal about the seat of stricture is liable to dilatation, and to softening or ulceration, and if the bougie should be made to bear too forcibly on such a point, perforation of the canal must ensue, and the patient be exposed to all the risks of suffocation or 276 OPERATIVE surgery. 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 va- riety, dilatation presents many chances of success; but, like stric- tures in the urethra, dilatation of those in the oesophagus will prove but a temporary means of relief if the surrounding parts are much indurated. 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 de- cidedly preferable. It maybe employed in the following 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 another bougie, by scooping a little hole in the end of the waxed linen, and fitting in this a small piece of the nitrate of silver: be careful to fasten it accurately in its place, so that it may project a little beyond the level of the point of the instrument. Mark 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 neu- tralize it and prevent its continued action. Remarks.—The application of the nitrate of silver in this disease is beneficial in two ways. 1st, by repeatedly creating a superficial eschar on the surface of the stricture, it gradually destroys it; and 2d, by stimulating the absorbents, and modifying the action of the mucous membrane, it does much towards the radical cure of the complaint. After a few applications of it, the simple bougie will often be found to pass readily, whilst the relief will be more per- manent than that which ensues upon the simple dilatation of the part, CESOPHAGOTOMY. 277 except in the spasmodic form of the complaint. 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 position in the bougie as will prevent its action elsewhere. III. C3S0PHAG0T0MY. Under peculiar circumstances, as when it is necessary to remove a foreign body from the canal, or when, in cases of impervious stric- ture, there is a necessity for the introduction of food in order to sus- tain life, it has been advised to incise the oesophagus from the out- side 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 example of which has been reported by Taranget,* where the patient was thus nour- ished sixteen months. Nearly equal success has, however, been obtained by a direct opening into the intestines or stomach, while the injection of nutri- tive substances into the rectum presents a very good substitute for such a hazardous means of treatment.f In a paper by Dr. John Watson, of New York, may be found the history of a case in which the patient's life was considerably pro- longed by this operation, though he ultimately died from the exten- sion of the disease to the bronchia. (Esophagotomy is, however, very rarely resorted to, having only been performed five times, two of which were reported more than a century since. Three modes of operating have been suggested, to wit, that of Guattani, who incised the left side of the neck, and dissected to the oesophagus, between the trachea and the sterno-hyoid and thyroid muscles (Plate XXXYI. Fig. 6); that of Eikholdt, who made his incision between the two origins of the sterno-cleido-mastoid mus- cle ; and that of Boyer, who cut between the sterno-hyoid and sterno- mastoid muscles. Boyer only opened the oesophagus for the extrac- tion of foreign bodies, and was, therefore, guided by the projection of the substance. Giraud and Yacca Bellingheri first introduced a silver sound, so as to render the oesophagus prominent; and Begin trusted entirely to the anatomical relations of the part.J * Diet, des Science Med., tome xxi. p. 412. f Bibliography, art. (Esophagus, paper by Dr. D. J. Cain, of Charleston. X Malgaigne, Philadelphia edit., p. 376. 278 operative surgery. 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 Dr. Watson, in February 1814. Operation of Dr. Watson, of New York.—The patient being placed on a cot near a window, with his back well supported by pil- lows, and his head thrown gently backwards, the incision was com- menced on 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, nearly 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 hazlenut, was exposed and re- moved from among the layers of the deep fascia. It proved to be very hard, and contained a yellowish concrete pus in the centre. The dissection being then continued through the deep fascia, the omo- hyoid muscle was exposed and divided; the superior thyroid artery brought into view, secured by two ligatures, and divided between them and the loose cellular tissue between the carotid and the tra- chea, 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 spatulse, an attempt was made to seize and puncture the wall of the pharynx, but owing to the difficulty of accomplishing it without en- dangering 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 transversely, and the upper border of the thy- roid gland turned down. The recurrent nerve being now brought into view, one of the CESOPHAGOTOMY. 279 branches of the superior thyroid artery was divided as it entered the gland, giving rise to the only hemorrhage during the opera- tion that required attention, and this being arrested, the division of the stricture was effected by an incision through it of at least an inch and a half in length, the obstruction depending appa- rently on a simple induration and contraction of the part not over five or six lines wide. A stomach-tube being now intro- duced through the wound, wine and arrow-root were administered. This tube was then secured to the side of the head by its free extremity, the transverse portion of the wound closed by a single suture, and the remainder allowed to remain open. At the end of six days, the tube being removed, a second one was introduced through the nostril, down through the stricture, and worn twenty- five days, the wound being closed by adhesive plaster. Several changes in the catheters being made from time to time, the patient continued wearing them for nearly seven weeks, the wound hav- ing healed around it. At the end of this period, the tube was withdrawn on account of the irritation in the throat, the obstruc- tion in the oesophagus re-appeared, so as to require the re-opening of the wound in the neck, and the patient died about three months subsequently. Remarks.—That (Esophagotomy is an operation requiring much deliberation 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 Dr. Watson. The question, there- fore, naturally presents itself whether, in order to prolong life, it may be right to advise a patient to submit to it. Deeming the relief afforded by it dearly purchased at the risks of the ope- ration, except in very skilful hands, I cannot but think that the dangers of making an opening directly into the stomach, as subse- quently referred to by Dr. Watson, in the paper before quoted, is certainly not greater than that incurred in oesophagotomy. The number of instances in which wounds and openings into this organ have not proved fatal will, on examination, be found to be much larger than might at first sight appear probable.* The well-known case of St. Martin, and the case reported by Etnmller, where a fis- tula in the stomach remained open ten years, together with nume- * See Bibliography, art. Abdomen. 18 280 OPERATIVE SURGERY. rous other facts collected by Dr. Watson's extended research, will at least warrant the assertion that an opening into the stomach is an operation as justifiable in urgent cases of stricture of the oeso- phagus, and probably quite as favorable to the recovery of the patient, as that of oesophagotomy. But no surgeon, it is presumed, would attempt either operation, unless especially urged thereto by the peculiar circumstances of his patient. In the event of the distribution of property, or to accomplish some great moral good, or in order to fulfil 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 impera- tive on a surgeon to resort to such means as will enable him to ob- tain the desired time. CHAPTER Y. OPERATIONS DEMANDED FOR THE RELIEF OF DEFORMITIES IN THE NECK. The affections of the neck which lead to such deformities as de- mand direct surgical interference in the way of an operation, being due usually to contractions 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 re-appearance of the deformity after the operation. In most instances, therefore, the assistance to be derived from proper dressings and mechanical con- trivances should be remembered, and proper preparations made, be- fore any incision is commenced. The deformities of this region may be subdivided into those affect- ing 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. DEFORMITIES FROM BURNS. 281 SECTION I. DEFORMITIES FROM BURNS. The destruction of the skin and cellular 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 pro- per 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 inability to elevate the head, or such a contraction of the in- teguments 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 different 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, as wrell as to the almost unvarying tendency of the struc- ture involved, to reproduce similar contractile tissues, unless the diseased portion is removed, and the space filled in by healthy struc- ture, 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.* In an excellent paper upon Cicatrices and Cicatrization, by S. Laugier, in the Dictionnaire de Medecine, ou Repertoire des Sci- ences Medicales, vol. vii., is an extended reference to the pathologi- cal changes produced by destruction of the skin, as the result of wounds and similar injuries; and from this and other sources, the following account has been condensed. Pathology of the Cicatrices from Burns.—Delpech having shown that, in all wounds which suppurated freely, or did not unite by the first intention, the granulations resulted in the formation of * See Part II. p. 136. 282 operative surgery. a fibrous tissue unlike the ordinary structure of the part, and which structure he named the "Inodular," all cicatrices, and especially those resulting from burns, are often spoken of simply as the "Ino- dular Tissue." This tissue is always the result of suppurative inflammation; is manifestly fibrous in its character; of a dull white color; without the shining appearance of fascia, or the satin-like character of the surface of a tendon. In consistence and hardness it has been com- pared to the strongest ligaments of the joints; but its fibres, unlike these ligaments, run in all directions.* The contraction of this structure, although, at first, highly useful in closing any wound, may, by its continuance, create such traction upon surrounding parts as will result in the evils just referred to in connection with burns; and, as it continues to contract for various periods after its formation, Dupuytren established three rules of practical value in the selection of such cases as could be relieved by a surgical operation. 1st. He advises the surgeon not to attempt to correct the deform- ity resulting from these cicatrices, until many months, or even years, have elapsed after their production. 2d. Never to operate unless certain of obtaining a larger cica- trix than that which it is wished to correct. 3d. To be certain that the operation can restore the parts to their shape; consequently, in cases of anchylosis of a joint, the opera- tion would be improper. In relation to the different modes of operating, he also gives di- rections of much value. 1st. In a long narrow cicatrix, he recommends the operator to make several incisions so as to divide the cicatrix transversely through its entire thickness, without ever removing any part of it, in order to facilitate its stretching. 2d. To stretch the parts, and bring them into a direction differ- ent from that which the complaint had caused, in order to obtain a cicatrix by the production of new skin. This extension must, how- ever, be practiced with judgment, lest violent pain, inflammation, and gangrene result, as in a case reported by Delpech. In salient cicatrices, unaccompanied with retraction, he advises :— 1st. To remove the prominence by a subcutaneous section, the * Diet, de M6d., tome 7,ne, p. 579, et infra. deformities from burns. , 283 knife being introduced flatwise, and made to shave the skin from the cicatrix as far as its extremities, in order to loosen the latter. 2d. To keep the edges of the wound open. 3d. Frequently to cauterize the surface, so as to keep it a little below the level of the integuments. Delpech, on the contrary, advocates the removal, as far as possi- ble, of the entire cicatrix, and says that, when this is done, there will generally be found sufficient skin to draw upon, in a direction opposite to that which caused the deformity, thus enabling the operator to obtain immediate reunion. When it is possible to gain sufficient skin to permit this imme- diate reunion of parts, the method of Delpech will be found pre- ferable; but, in other cases, a large gaping wound would be formed, which would create even greater trouble than the original complaint. The decision of either operation will, therefore, necessarily de- pend chiefly upon the peculiarities of the case presented to each operator at the moment. In extensive cicatrices about the neck, where it is of great conse- quence to obtain free motion, without being liable to a modified re- production of the difficulty from the newly-made cicatrices, some of the various autoplastic operations will prove especially serviceable.* In these operations, the ordinary principles of plastic surgery must be followed out, and the flap, which should if possible be taken from a part of the skin where it is healthy, made of such a size as may be demanded to fill up the wound left by dissecting out the cicatrix, or by destroying its adhesions. This flap should be closely attached to the edges of the wound by numerous points of the interrupted suture, and then the sore left by the removal of the flap, either united, or allowed to heal by granulations. In a paper by Dr. Thomas D. Mutter, upon the relief of deformi- ties from Burns, f these principles have been well illustrated, and, from among several of the cases there reported, the following has been selected as applicable to the more severe injuries of this cha- racter. Operation of Dr. Mutter for the relief of Cicatrices from Burns on the Neck.—The patient, a young woman, aged twenty- eight years, had been burnt twenty-three years previously upon the face, throat, and upper part of the thorax, from her dress taking * See Plastic Operations on Face, Part II., page 136. f See Bibliography. Deformities of the Neck. 284 OPERATIVE SURGERY. PLATE XXXIII. OPERATIONS PRACTICED ON THE NECK. Fig. 1. A view of the Lymphatics, together with the Bloodvessels and Nerves found on the side of the Neck. 1. Carotid artery. 2. Par va- gum nerve. 3. Internal jugular vein. 4. Subclavian artery. 5. Subcla- vian vein. 6. Brachial plexus of nerves. 7. Lymphatic vessels and glands. 8. Phrenic nerve. 9, 9. Sterno-hyoid and sterno-thyroid muscles. 10. Thyroid gland. 11. Superior thyroid artery. 12. Lymphatic gland, situ- ated on temporal vein. 13. Lymphatic, at angle of jaw, imbedded in parotid gland, and liable, when diseased, to be mistaken for enlarged parotid. 14. Three superficial lymphatic glands on course of sterno-cleido-mastoid muscle. 15. Deep-seated lymphatic at lower part of jaw. 16. Facial artery and vein. 17. Lymphatic gland in advance of submaxillary. 18. Submaxillary gland. 19. Three superficial lymphatics behind sterno-mastoid muscle. 20. A large lymphatic gland situated outside, but adjacent to sheath of bloodvessels. 21. A chain of lymphatic glands which extend from side of neck to beneath the clavicle between the trapezius and sterno-mastoid mus- cles. 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 surgeon in the act of inserting the tenotome beneath the skin. 2. His left hand raising the muscle. After Bourgery and Jacobson. Fig. 4. A view of the position and development of a Carotid Aneurism. 1. Common carotid artery. 2. Aneurismal sac. 3. Par vagum nerve dis- placed by the tumor. 4. Hypo-glossal nerve forced downwards and forwards 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 Arteries about the Neck. L- Ligature of the lingual artery. 1, 1. Ligature passed beneath the artery. 2. Stylo-hyoid muscle. 3. Hypoglossal nerve. 4. Digastric muscle. 5. Incision through skin and fascia. 6. Platysma-myoides muscle. After Bourgery and Jacobson. C. Relative position of the parts concerned in Ligature of the Primitive Carotid. 1. Upper end of incision. 2. Skin and fascia. 3. Abnormal arterial branch from arch of aorta to pharynx, running parallel to carotid artery. 4. Common carotid. 5. Descendens noni nerve. 6. Par vagum. 7. Internal jugular vein drawn aside. 8. Sterno-cleido-mastoid muscle held back. 9. Blunt hook. After Auvert. A- Ligature of Axillary Artery. 1, 1. Line and extent of incision. 2. Pectoralis major as divided. 3. Axillary artery. 4. Ligature placed be- neath it. 5. Axillary vein. 6. Brachial plexus. 7. Pectoralis minor i After Bourgery and Jacobson. DEFORMITY FROM BURNS. 285 fire. She had been unable to throw her head to the left side, or backwards, or to close her mouth for more than a few seconds dur- ing the whole time. The right eye was also drawn down some dis- tance 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 cica- trix in the sound skin, and carried across the throat into the sound skin on the opposite side. This incision penetrated through the in- teguments as near the centre of the cicatrix as possible, and was about three-fourths of an inch above the top of the sternum, the ob- ject being to get at the origin of the sterno-cleido-mastoid muscles, which, in consequence of the long-continued flexion of the head, were 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 ele- vation 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 downwards and outwards 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 backwards, 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. * Am. Journ. Med. Sciences, vol. iv., N. S., p. 69 ; also Op. Surg., by J. Pan- coast, M. D., p. 359. 286 operative surgery. SECTION II. torticollis, or wry neck. By the term torticollis, or wry neck, is usually designated such dis- tortion of the head, from muscular contraction, as brings the back part of it forwards, downwards, and sideways, so as sometimes to turn the chin upwards and over the opposite shoulder, the former being raised in proportion as the occipital bone is drawn down. Although disease of the vertebrae, injuries 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 conse- quence of the partial paralysis of that of the opposite side, the con- tracted muscle being generally felt like a tense prominent cord, or, if not distinct, readily made so by any effort to turn the head towards 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 application of a suitable apparatus for making moderate extension of the muscle, and preventing the future contraction of the new tis- sue 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 frictions, 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 towards a cure, the division of the muscle or its tendon will materially expedite the result. Operation.—Various modes of operating have been suggested by different surgeons, in order to accomplish the accurate yet safe divi- sion of a muscle, which is known to be so closely connected with important bloodvessels and nerves throughout most of its course, as the sterno-cleido-mastoideus. These suggestions differ, however, mainly in the shape of the knife or in the point at which the muscle may be most advantageously incised; but, as the subcutaneous divi- torticollis, or wry neck. 287 sion is preferable to the old plan of dissecting down to the muscle, the description of the operation will be limited to this mode of ope- rating. In the United States, the simplicity of the operation, or its fre- quent performance, has apparently prevented the publication, by Burgeons, of such details as would be most serviceable to an inex- perienced operator, and the two papers published by the gentlemen hereafter quoted will therefore be found to furnish the principal ex- position of the views of surgeons, in this country, of an operation, the utility of which has been doubted. Operation of Dr. J. Mason Warren, of Boston.—A boy, six- teen years of age, having fallen from a height when four years old, was shortly afterwards found to labor under Torticollis. At the time of the operation, the head was drawn to the left side, the ear usually resting on the left shoulder, though it could be slightly raised, the inclination to one side being accompanied by such a rotation of the head as caused the face to regard the right shoulder. There was also a lateral curvature of the spine, the left shoulder being the highest. The sterno-mastoid muscle of the left side, on being ex- amined, was found to be strongly retracted, whilst the deep-seated muscles of the neck, the scaleni, especially, could also be distinguished in an unnatural state of rigidity, the sterno-cleido-mastoid being, however, the chief obstacle to the proper position of the head. In addition to these changes, the whole of the left side of the face was atrophied, and each of its component parts much smaller than those of the opposite side. This alteration of the features has been at- tributed by M. GueVin to the distortion which the great vessels of the neck experience in consequence of the deformity, whilst the cur- vature of the spine is regarded as due to the inclination of the cer- vical vertebrae on the dorsal; of the dorsal on the lumbar, and the lumbar on the sacral, in order to obviate the displacement of the head and bring it within the axis of the body. In consequence of this condition of things, Dr. Warren deter- mined to divide the sterno-mastoid muscle at its sternal origin, the opinion being entertained, as suggested by Guenn, that the complaint was mainly due to the retraction of this portion of the muscle. Ac- cordingly, its division was accomplished as follows:— Operation.—The head being well supported and carried a little forward, so as to throw the muscle outward from the subjacent parts, a puncture was made with a lancet through the skin about six 288 OPERATIVE surgery. lines above the clavicle, between the sternal and clavicular origins of the muscle. A narrow blunt-pointed knife (Bouvier's) was then in- troduced with its flat side towards the muscle, carried behind the sternal origin, its edge turned towards the muscle, and the section completed by a slight sawing motion, the effects being indicated by a distinct cracking sound and by the partial restoration of the head to its natural position. The little wound in the skin being then closed by plaster, a cap was placed on the head, to the back of which, op- posite the right mastoid process, was attached a strap, which, being drawn tight, was secured over the breast of the same side. A stiff stock was also subsequently added to the dressing, and, in the course of a fortnight, a great change in the position of the head was per- ceptible, though it yet remained somewhat inclined to the left, the cla- vicular origin of the muscle having become more prominent since the division of its sternal attachment. To remedy this, it was, therefore, decided to divide the clavicular origin also, which was accomplished as follows: The head being well supported, and the muscle suffi- ciently relaxed by inclining it to this side, the body of the muscle, just below the union of its two origins, was readily seized between the thumb and fingers, and completely isolated from the subjacent parts. A sharp-pointed knife was then carried beneath the muscle, until it could be felt under the skin by the finger on the opposite side, when the patient being directed to contract the muscle its sec- tion was readily accomplished. In forty-eight hours the wound was healed, and, nine months after the operation, the patient's appear- ance was so much improved that his former friends could scarcely recognize him.* Operation of Dr. J. C. Warren, of Boston.—A little girl nine years of age, also much distorted, was operated on as follows:— The head being supported, and the muscles rendered tense, a nar- row sharp-pointed bistoury was passed flatwise between the skin and the sternal origin of the muscle from without inwards (Plate XXXIII. Fig- 3), and the edge of the knife being then directed upon the muscle, its division was accomplished. The knife being now with- drawn 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 in the preceding case, were then applied, and two months after the operation her head was so nearly straight as not to be perceptible to ordinary observers.f * Boston Med. and Surg. Journ., vol. xxv. p. 123. f Idem., p. 124. torticollis, or wry neck. 289 Dr. John W. Brown, of the Boston Orthopedic Infirmary,* after dividing the muscle, employed a simple yoke to which bands from a cap were attached, and has published in a paper on the subject an expressive drawing of the apparatus, of which my present limits forbid a description. In Plate XXXY. Fig. 14, may, however, be seen a contrivance, made by Rorer, of Philadelphia, which I have found to be well adapted to the object in view. Remarks.—Having formerly followed closely the practice of M. Gue'rin in Paris, and also noted the results of such patients as have been presented to me in the United States, I am induced to think that more or less benefit will be derived from the section of this muscle in most of the cases which are unaccompanied by deformities in the bones, whilst, in those solely dependent on a contracted condition of the muscle, a perfect cure may be anticipated. Of the various modi- fications, suggested in the performance of the operation, there are none of great consequence; though the section of the muscle from before backwards, as practiced by Dr. John C. Warren and others, 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 inflammation 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 night-cap 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. * Idem., vol. xxvi. p. 58. 290 operative surgery. CHAPTER VI. TUMORS OF THE NECK. The word Tumor (tumeo, I swell) has been employed by Boyer to designate " any preternatural eminence developed in any part of the body;" by Hunter as expressive of " a circumscribed substance produced by disease, and different in its nature and consistence from the surrounding parts;" whilst by Professor Miller, of Edinburgh, it is applied " to any morbid growth or new structure which is the re- sult of perverted nutrition in a part, independent of the inflamma- tory process otherwise than as an exciting cause ; and possessed of a power of formation and increase distinct from those of the original tissues." These definitions, though not universally applicable, are, however, sufficiently correct to present any one with a good idea of the most general characters of this class of disorders, and in that of Mr. Miller may also be found a brief account of their physiology. As the changes of structure which result in tumors may happen in all parts of the body, and as the account of the pathology of the various kinds has been found sufficient to occupy entire volumes, no attempt can possibly be made in the present limits to investigate the subject in all its details. In the excellent volume by Dr. John C. Warren, of Boston,* may be found the results of many years of study, combined with the experience furnished by a long life of ob- servation, and to this work, as well as to the article on Tumors, to be found in Miller's Principles of Surgery, the reader is referred for such an account of the general pathology of these formations as would extend these pages beyond their proper bounds. Without, therefore, doing more than mention some of the different species of tumors found in the neck as well as elsewhere, I shall at present confine myself to a few general remarks on such of the varieties found in the neck as require operative interference, and to a brief allusion to the means of diagnosis applicable to most of them. * Surgical Observations on Tumors, with Cases and Operations. Boston, 1839. general pathology of tumors of the neck. 291 SECTION I. general pathology of tumors of the neck. No matter what may be the peculiar characteristics of the tumors found in this region of the body, no one can for a moment regard their growth, without being curious to know in what way they have originated, and what tissue has been made the nidus for their deve- lopment. The causes of tumors of the neck may, like those seen elsewhere, be very varied, thus a blow, strain, cut, burn, or chronic inflamma- tion, may all, under proper conditions of the system, result in the development of a tumor. In most instances, it may justly be pre- sumed that these causes only produce a modification of healthy inflammatory action, and that the abnormal growth originates, there- fore, like the healthy tissues, in the deposit of a blastema, which, instead of being reparative in its character, or proceeding to the production of a healthy structure, results in the formation of one whose character is dependent on various circumstances. Thus, a very slight modification of the primitive cell may result in the production of what has been justly designated as an Analogous tumor or a growth bearing considerable resemblance to the ordinary textures, whilst the influence of constitutional causes may lead to the formation of a Heterologous growth, or one which differs widely in its appearance, general arrangement, and subsequent pro- gress from that which usually results from healthy or eu-plastic lymph. In the neck, as in other portions of the body, the changes in the nutritive action of a part may result in simple induration, hyper- trophy, or increased formation of normal textures, or in the deposit of caco-plastic lymph and morbific matter in the lymphatic glands, or in the reticulated structure which is so freely developed through- out this region. Whether the new growth be Benignant or Malig- nant, it generally produces some change in the surrounding parts; thus, in most tumors, the surrounding cellular tissue becomes in- durated, lamellated, or cystiform, so as to surround them with a perfect sac; the muscular structure atrophied or hypertrophied, the first being the more common; the fascia either increased or 292 OPERATIVE SURGERY. diminished in density; the larger vessels thickened or contracted; the capillaries engorged and augmented in size, whilst the whole arrangement of parts will be more or less displaced in proportion to the tension of tissue created by the growth of the tumor. So va- ried, however, are the positions, structure, character, and modifying influences seen in different cases of tumors, that it is impossible to lay down concisely anything like a general law of progress. Usually, the surgeon will not widely err in prognosticating the changes that he will meet with in removing tumors of the neck, if he bears in mind the facts that, with the exception of the dermoid class, all tumors of this region are covered by a fibrinous expansion which limits their external development and causes pressure on adjacent parts; and that the progress of the inflammation excited around the mass will necessarily produce all the changes likely to result from this process elsewhere, such as serous or fibrinous effusions, adhesions, increased or diminished vascularity, and a general matting together of parts usually distinct. In the various attempts that have been made to group the differ- ent kinds of tumors, writers have always found it difficult so to arrange them that the classification would be accurate; the varied de- grees of departure from healthy structure exhibited by different cases preventing anything more than an approximation to their character. Among the older writers, the terms fleshy, fatty, pulpy, honey-like, or encephaloid, designated their appreciation of the sensible charac- ters of each class; whilst Abernethy and Laennec described them as pancreatic, mammary, medullary, tuberculated, melanotic, and car- cinomatous sarcoma. Miiller has more recently divided them ac- cording to their chemical nature, microscopic character, and mode of development, into fatty, jelly-like and albuminous tumors, such substances being a principal characteristic in all of these growths, though the proportions in each may be very varied. " The chemical constitution of tumors shows that the principles chiefly found in them are fat, gelatine, and albumen, and according as any of these predominate the nature of the tumor is found to vary. Those which consist chiefly or wholly of fat contained in a cellular parenchyma, are analogous, simple, and non-malignant. Those which, by long boiling, are reduced almost entirely to gela- tine are also non-malignant, and those which consist mainly of albu- men include both analogous and heterologous formations; some being CHARACTER AND POSITION OF TUMORS OF THE NECK. 293 malignant and others benignant, the carcinomatous being almost entirely composed of albumen.* All tumors of the soft tissues are either solid, or contain solid and liquid matter, more or less combined and variously arranged, con- sisting either of a more or less compact fleshy growth, whose enve- loping cyst is entirely a secondary formation,! being formed chiefly at the expense of the surrounding cellular tissue, or of a cyst, which is the original structure, and maintains the bulk and increase of the tumor by its secretory power.J The solid tumors embrace those known as sarcomatous, adipose, fibrous, cartilaginous, osseous, and cysto-sarcomatous, all of which are benignant; the tubercular or scrofulous, which is specific in its nature; and the carcinomatous, melanotic, medullary, and fun- goid, which are malignant. In studying merely the surgical treatment of tumors, many may be disposed to say that the peculiarities of each of these classes are a matter of little importance, provided the tumor is causing such a train of symptoms as renders it essential to the patient's safety or comfort that it should be removed. Though unwilling to admit the truth of such an assertion, the character of the present volume renders it inexpedient to spend more time on matters which are truly within the province of the principles of surgery. Atten- tion will, therefore, now be directed to the means of diagnosticating the probable constituents of the tumor as well as its relations to surrounding parts. § 1.—DIAGNOSIS OF THE CHARACTER AND POSITION OF TUMORS OF THE NECK. In diagnosticating these growths, the senses of sight and touch are those mainly required to arrive at a correct conclusion, though that of hearing may occasionally be called into play, in order to detect vascular disorders or connections. * Miller's Principles of Surgery, p. 388. Philad., 1845. t Miller, p. 392. + Loc. cit 294 OPERATIVE SURGERY. I. THE CHARACTER OF TUMORS. On looking at a tumor in the neck, the general shape and posi- tion of it should first be noticed. Tumors involving the glandular structures, and especially those of the lymphatic glands, will gene- rally be seen to be nodulated or irregular, provided effusions into surrounding parts have not created such changes in the integuments as would equalize their surface. Those which are encysted or fatty are, on the contrary, more smooth on the surface and globular. Pulsation, change in the color of the skin, as blueness or redness, together with a turgescence of the superficial veins, are also points that should attract the eye in this primary investigation. On feeling the tumor, a judgment should be formed of its solid or fluid character, of its hardness or softness, of its attachments to sur- rounding tissues, of its pulsations and of its sensibility. Hardness will generally characterize albuminous deposits, the majority of which are malignant; elasticity, amounting almost to a sense of fluctuation, characterizes the fatty class, whilst, unless the sac is very full, or the contents decidedly jelly-like, fluctuation and the presence of liquid may be readily told. Occasionally, the position of a tumor, and its confinement by the fascia, give to it a sense of pulsation that might lead to the supposition of its being a vascular enlarge- ment. Under these circumstances, an effort should be made to elevate it from the subjacent artery; or the circulation be stopped in the latter by pressure and the change in the size of the tumor noted; or the ear may be applied and the peculiar aneurismal whir listened to. Some surgeons, in addition to these means, aid their diagnosis by introducing a grooved or cataract needle into the tumor, and noticing the character of what escapes, or the sensa- tion of solidity given by the passage of the needle. When other means have failed, and a consultation are in doubt, or when the operator is prepared to remove the tumor at an early period, it may be useful to resort to this instrument; but personal expe- rience has induced the opinion that, as a general thing, this aid to diagnosis is liable to abuse and to the production of injury. If the tumor prove to be malignant, its development will frequently be rapidly accelerated by such an application. To assist such as are not familiar with the general aspect of different tumors, and thus diminish the necessity for the use of the lately fashionable POSITION OF TUMORS. 295 grooved needle, the following brief account of their external charac- ters is presented as collected from various sources, but especially from Miller's Principles.* The simple Sarcomatous Tumor has a smooth surface, a tolera- bly firm doughy feel; does not fluctuate or give any sensation ap- proaching fluctuation; is not painful even when freely handled; is loosely attached, and does not implicate adjacent parts; increases slowly and without pain; possesses no more vascularity than a similar bulk would naturally have, and varies from the smallest to the largest size, weighing often many pounds. An example of this kind of tumor may be seen in Plate XXXIV. Fig. 1. The Adipose Tumor, often designated as the Lipomatous tumor, may be either lobulated or non-tabulated, flat, globular, oval, or cylindrical, and either smooth or studded on the surface with small nodules. When touched, it is occasionally so elastic as to give a sensa- tion closely resembling fluctuation, and requiring considerable skill to avoid an error in this respect. When handled, it is free from pain ; the skin is pale, loose, and movable at first; but it and the tumor may become adherent by time and increased development of the com- plaint. The growth is slow and steady, and if the tumor is pedun- culated, the skin will be stretched and elongated, so as to resemble the neck of a sac. (Plate XXXIV. Fig. 3.) The Fibrous Tumor is the most dense and firm of the benignant class, being composed chiefly of dense fibrous matter. Its shape is generally globular, the surface often nodulated, and the investing cyst thick, strong, and slightly adherent to the tumor. It is generally perfectly circumscribed, movable, independent of adjoining tissues, painless, and slow of growth; but it often causes trouble by degene- rating into the malignant structures, or by compressing adjacent vessels and nerves. Examples of the lymphatic and encysted tumors may be seen well delineated in Plate XXXIV. Figs. 2 and 4. n. the position of tumors. The large number of lymphatic glands found in the neck, and the knowledge of their ordinary position, render a diagnosis of many * Principles of Surgery, by James Miller, F. R. S. E., p. 393, et suprd.— Phila. edition. 19 296 OPERATIVE SURGERY. PLATE XXXIV. APPEARANCE AND POSITION OF SOME OF THE TUMORS SEEN ABOUT THE NECK. Fig. 1. Large Steatomatous Tumor of the right parotid region, caused by the devolopment of a sebaceous follicle in consequence of a blow upon the part. Commencing as a lump the size of a nut, this tumor gradually in- creased 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 be- came 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 Tumor of the Neck dependent on degeneration of the lymph- atic 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 oppo- site side. Its appearance 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 Dr. Mott. After Mo,t' Fig. 3. Appearance of an immense Lipomatous Tumor of the Neck. This tumor was not painful; had no pulsation; was formed of numerous laro-e 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 tumour was found to be covered by a strong capsule formed of the surround- in"' cellular tissue, and to have originated in a hypertrophy of the surround- ing adipose tissue. After Auvert. Fig. 4. A large Encysted Tumor of the left Parotid and Submaxillary Re- gions, which was to the touch semi-elastic, unequally lobulated, and due to a chronic irritation of one of the sebaceous follicles, the duct of which had become closed, and thus caused a retention and degeneration of its secretion. After Auvert. THE POSITION OF TUMORS. 297 of the tumors of this part more easy than might at first sight be supposed. According to the views of Allan Burns, nearly all the glandular tumors of the neck may be referred to two classes, those which are without and those which are beneath 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 super- ficial glands there are, between the skin and the insertion of the sterno- mastoid muscle, from four to six; in the interstice between the cla- vicular 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 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 movable character will, however, prevent such an error in connection with the parotid. Around the submaxillary gland, especially at its anterior and posterior extremi- ties, 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 beyond the sterno-cleido-mas- toid muscle at its posterior edge, and in the removal of some of them a section of the muscle may be required. Between the infe- rior 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 bloodvessels towards the heart* (Plate XXXIII. Fig. The tumors, formed at the expense of the deep lymphatics, are exceedingly liable to contract adhesions, especially to the sheath of * U. S. Dissector. 298 OPERATIVE SURGERY. the vessels, so that their extirpation will involve these parts so di- rectly as to lead to danger unless caution is exercised. A3 a 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 con- sistence, is seated nearly on a line with the upper portion of the larynx or towards 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 extend and elongate the skin, so as to become pendulous, its at- tachments 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 apparently upon the edge of the sterno-mastoid muscle, and whose removal seemed to be a very simple affair, was undertaken by a fellow practitioner. Having noticed the liability to error of diagnosis in such cases, I was prepared for hemorrhage, and, in a very few minutes, was com- pelled 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 majority of the cases that may be met with. Surgical writers have, therefore, generally been satisfied with furnishing directions in regard to the form of the external OPERATIONS FOR REMOVAL OF TUMORS OF THE NECK. 299 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, whilst, at the same time, the deep-seated attachments of the structure to be removed are freely exposed. In the neck the latter recommendation is especially serviceable, as too much stress may be laid on the deformity likely to arise from the cicatrix. When compared with the increased difficulty 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, whilst 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 import- ance of the parts connected with tumors in the neck, the first ob- ject 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 dissec- tion 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 reference 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 elliptical incision exposes a part more freely, and is chiefly resorted to when it is desired to remove an excess of integu- ment, as in the case of large or pendulous tumors. The v incision is more free and adapted to tumors of moderate size, so situated as to render it necessary to insure the safety of particular parts; whilst 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 dissection. 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 useful to those who have yet to gain their experience. Thus 300 OPERATIVE SURGERY. Dr. Alex. H. Stevens, of Xew York, in an able lecture on the removal of tumors, 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. Malgaigne also advises that the dissection should be made by ex- tensive cuts (by which I understand 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 important organs, whether nerves, vessels, or muscles, he also directs that they should be drawn or put to one side by means of blunt hooks, 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 himself that no particle is left behind, lest it serve to reproduce the disease ; and 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, and in this case I must dissent even from such good authority as Mr. Malgaigne is generally admitted to be. 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 indi- vidual observation has rather led me to the observance of the prac- tice of the late Dr. 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 important 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, Langenbeckf pro- ceeds as follows. He first makes a free division of the integuments, dissects the muscles from over the tumor, but avoids cutting through * Malgaigne, Op. Surg., Philad. edit., p. 104. f Cooper's Surg. Diet., by Dr. D. M. Reese, N. Y., p. 377. EXTIRPATION OF TUMOR OF THE NECK. 301 or injuring them if possible, thus making the tumor sufficiently movable, whilst by preserving the muscles he is enabled to know accurately the place of the chief bloodvessels. Then, when the sur- face 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 considerable vessels are, and the dissection carried from thence towards the more hazardous portions. This distinguished surgeon has also recommended that the knife should not be introduced deeply where there are any large bloodvessels, but that the tumor should be strongly pulled outwards, so as to separate it from the vessels, and put the cellular substance around them on the stretch. The latter recommendation will be found especially serviceable, and the opera- tor 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 M. Langenbeck, though of a general kind, should be firmly impressed on the mind of every surgeon, when ope- rating on tumors of this portion of the body, or indeed elsewhere. But though sufficiently useful, as far as they go, they do not furnish such an accurate account of the best mode of overcoming the diffi- culties 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, there- fore, made a selection of a few difficult cases, with a view of furnish- ing the best possible substitute for the individual observation of any young operator, viz.: the experience of those whose skill and lifelong practice have enabled them to contend with difficulties in every shape. As these cases contain important practical precepts, they are fur- nished in full, in order that nothing of the details of the extirpation of tumors in this region may be overlooked. § 1.—EXTIRPATION OF A LARGE MALIGNANT TUMOR OF THE LYMPHATIC GLANDS OF THE NECK. Operation of Dr. 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 muscle and all the arteries, veins, and * Warren on Tumors, p. 175. 302 OPERATIVE SURGERY. nerves of the neck being presumed to be included in its substance, whilst a process extended under the jaw into the pharynx, and filled the left half of this cavity with a red tumor which greatly im- peded deglutition, the whole structure being very hard, knotted, uncolored, and insensible. Operation.—In commencing the operation, an incision was made from behind the ear to the anterior third of the clavicle; the sur- face 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 mus- cles, an attempt was made to get under the tumor just above the cla- vicle, and then the difficulties of the operation appeared, the carotid artery, internal 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 distinguish them. This being at last accom- plished by breaking down the lower part of the tumor, the vein was found to be obliterated and the artery diminished in size, but per- vious. 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 next attempted and success- fully accomplished, with the exception of the sub-lingual 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 hemorrhage, a fact stated by Dr. Warren as common in large and hard tumors. The patient, at first, did well after the operation, but died about a year subsequently of an ulceration of the throat, which created a diffi- culty in swallowing. A yet more complicated and severe operation was performed in another case by Dr. Warren.* " In this patient the tumor extended from the spinous processes of the cervical vertebrae to the lower jaw, pharynx, oesophagus, and larynx, running upwards behind the ear and downwards 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 * Warren on Tumors, p. 177. extirpation of tumor of the NECK. 303 dyspnoea. After examining and considering the case, Dr. 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 backwards under the trapezius to the spine, and forwards under the mastoid muscle to the pharynx; that it adhered to the splenius, complexus, and trachelo-maistoideus muscles, and also in- volved 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 glossopharyngeal, laryngeal, and great sympathetic, were also connected with it. After a full consultation and statement to the patient of the dan- gers of the operation, and the impracticability of disengaging the whole tumor, the propriety of submitting to it was left to the pa- tient's decision, and the latter deciding to do so, the operation was performed at Lincoln, near Boston. Operation of Dr. J. C. Warren.—" The patient being seated in a chair with his head supported, an incision was made from the spine to the angle of the jaw, to meet another incision which was carried from this point downwards to near the clavicle in the direc- tion of the anterior edge of the sterno-cleido-mastoid muscle. This flap of integuments being turned down after a laborious dissection, in consequence of its close adhesion to the tumor, the posterior half of the latter was exposed from the spine to near the trachea, show- ing 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 pos- terior half dissected out, and the anterior then disengaged by great care from the posterior face of the sterno-mastoid and digastric muscles as well as from the nerves, bones, parotid and sub-max- illary glands; but some portions remained adherent to the fore part of the bodies of the vertebrae and to their transverse processes, and could not be wholly dissected without exhausting the patient's 304 operative surgery. strength. The actual cautery was, therefore, applied to them with- out 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 jugu- lar 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 and divided, and others in the substance of the tumor were also divided, as indicated by the patient's sensations, although they were not seen. " The integuments being then laid down on the face of the wound, and moderately secured so as to protect it without too much confin- ing the parts destroyed by the cautery,"* the operation was com- pleted, and the patient is believed to have recovered. The details and symptoms after the operation, as well as the sub- sequent treatment, may be found in the valuable volume from which so much has now been quoted, that my limits prevent their being further referred to. Removal of large Lymphatic Glandular Tumors, by Dr. Valentine Mott, of New YoRK.f—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 be- hind 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 towards the opposite side. In appearance, the tumor was irregular and lobulated, whilst to the touch it was firm and without fluctuation at any point. (Plate XXXIV. Fig. 2.) The patient being placed completely under the influence of chlo- roform, the operation was then commenced. Operation of Dr. Mott.—In order to command the whole tumor, a crucial incision was made in the integuments, the first cut extend- * Warren on Tumors, p. 182. t Transact. New York Acad, of Med., vol. i., part i., p. 90. New York, 1851. extirpation of tumor of the neck. 305 ing 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 my- oides 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 dissect- ing 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 impracti- cable 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, whilst the dissection was continued. The tumor being 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 tra- pezius 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 structure was seen to pass beneath the mus- cle, 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 then separated from the side of the pharynx and larynx, it was found, after dissecting the tumor from the common 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 di- vided below it, leaving several inches of the vein in the tumor, after which the whole mass readily came away. More than twenty liga- tures being applied to different arteries and veins, and the effects of the chloroform being allowed to pass off, the wound was closed by 306 operative surgery. 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 reco- vered without inconvenience, notwithstanding the loss of the middle third of the mastoid muscle. 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 execution. In fact, no surgical operations require a nicer discrimination of structure than those arising from 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 accurately 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 fore- thought are ready to contend with it, the presence of skillful as- sistants, together with all the adjuvants likely to prove serviceable, being naturally prepared by the operator. 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 foolhardy, or those in whom boldness takes the place of discretion. The younger surgeon can- not, therefore, be too much upon his guard when consulted in refer- ence 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 pros- pect before him, his operations will not only be well performed, but acquire a simplicity of character that will be mainly due to his tho- rough preparation for all the contingencies that may arise, in conse- quence of the difficulty of settling a question that can only be de- cided by his operation, to wit, the attachments of a tumor in the neck. BRONCHOCELE, or goitre. 307 SECTION III. BRONCHOCELE OR GOITRE. In the preceding section, the account of the operative proceedings requisite for extirpating tumors of the neck has been limited to such as are sanctioned by the highest authorities, and therefore pre- sumed to be fit cases for such operations. There remain, however, a class yet to be described, the propriety of removing which is ex- tremely 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 (ppoi^os, trachea; and x^, 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 cel- lular structure and lymphatic glands. According to Dr. John C. 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, beginning at some one point, is apt to extend until, as in a case related by Alibert, it reached to the thighs of the patient. The changes within a goitre vary with its development; presenting some- times a soft gelatinous matter, or a more hardened structure inter- spersed with cysts containing a serous, glairy, or melicerous substance, and occasionally pus, fibrin, calcareous concretion, or pure blood.f Vascular derangement being here very evident, the thyroid arteries are commonly found to be much enlarged. In some cases, the swell- ing seems to consist almost entirely of a congeries of varicose veins, and, under these circumstances, there may be considerable san- guineous effusions, the blood being poured into the enlarged vesicles, * Warren on Tumors, p. 302. | Pathological Anatomy, by Samuel D. Gross, p. 407. 308 OPERATIVE SURGERY. or into the connecting cellular substance of the gland.* Besides the hypertrophy of the parts consequent on chronic inflammation of this gland, the thyroid body is also sometimes the subject of scrofulous, lymphatic, or scirrhous degeneration. In the Scrofulous Goitre, the cellular tissue enveloping the gland and prolonged throughout its structure is thick, compact, and re- sisting, so that each portion is transformed, as it were, into a cyst which is filled with a matter of varied color and consistence, though all the elements of the gland may yet 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 consisting of a spongy structure analogous to that of the placenta.f The Scirrhous Goitre presents a tumor covered by a firm fibrous capsule, and consist of a spongy texture, in which appears a consi- derable number of cells, some of which are of large size, and con- tain a bloody fluid. Its consistence is often firm, but not scirrhous, except at the upper part, which sometimes has the texture, consist- ence, and white color of true scirrhus.| Diagnosis.—The Goitrous tumor has a smooth surface, a some- what 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 mul- tilocular, give the sensation of fluctuation. Tumors similar to these have been described by Maunoir as "Hydrocele of the Neck." Scrofulous enlargement about the thyroid gland tends to suppura- tion, and the patient shows the marks of a scrofulous diathesis. In Scirrhus, the tumor grows very slowly, is small, and its surface is hard, lobulated, or tuberculated; it is accompanied by pain, and is liable to ulceration. In Fungoid degeneration, there is the ordi- nary constitutional disturbance of the complaint, as seen elsewhere. Owing to the position of the thyroid gland, it has occasionally hap- pened 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 Dr. Samuel Griffiths, of Philadelphia. § In this case, dissection * Opus citat t Diet, de M6d., tome xiv. p. 172. X Warren on Tumors, p. 307. I Eclectic Repertory, vol. ix. p. 120. BRONCHOCELE, OR GOITRE. 309 alone revealed the disease. As a general rule, however, the pulsa- tions 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 very general 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 months, before entertain- ing for a moment such an idea. To those who desire more de- tailed information of the pathology of this disease than is to be found in most of the general works which treat of this tumor, I would recommend the articles in the volumes above quoted; an ex- tended article by Dr. William Gibson, of Philadelphia, f reference to which has been accidentally omitted in the Bibliographical Index; and the memoir of Dr. Benjamin Smith Barton, of Philadelphia, pub- lished in 1800. Although the extirpation of a goitre cannot be regarded as a jus- tifiable 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 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 been described with the accuracy that micrht 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 ligature of the whole-tumor, or of a ligature upon the thyroid arteries, compression, and 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 * Diet, de M6d., tome xiv. p. 177. f Philadelphia Journ. Med. and Phys. Sciences, vol. i. p. 44, 1820. 310 OPERATIVE SURGERY. different views in relation to the condition of the diseased part held by those who have suggested them. Any operation upon a true goitre being usually regarded as inadmissible, except as a dernier 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. § 2.—TREATMENT OF GOITRE BY COMPRESSION. Operation of Dr. Wm. C. Dwight, of New York.*—After preparing " three straps 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 bloodvessels 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, accord- ing 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 * Transact. Am. Med. Association, vol. iv. p. 248, 1851, from Buffalo Med. Journ., Jan. 1851. SUBCUTANEOUS LIGATURE OF GOITRE. 311 the integuments assume their natural appearance, when the applica- tion may be renewed. " The first application of these strips has, in one case, been suf- ficient to effect the cure, but the average repetition of them has been as high as four times in each case. When the bronchocele be- comes diminished to half its size at the time of the first applica- tion, the tumor will continue to disappear without further care, Dr. Dwight in twenty cases having had no failure from this mode of treatment. The iodine had not succeeded with him in several in- stances. In two patients, the disease returned at the end of two years, but disappeared on a new application of the strips."* § 3.—LIGATURE OF ONE OF THE THYROID ARTERIES. Operation of Dr. Horatio G. 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-mas- toid muscle, and having reached the thyroid artery by a very cau- tious 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 subse- quently, the tumor by actual measurement 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 con- cerned. Four cases of cure from the use of the ligature have been recorded by European surgeons. § 4.—subcutaneous ligature of goitre. Operation of Ballard and Rigal de Gaillac.J—" 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 * Opus citat. f See Bibliography. X Malgaigne, Philad. edit., p. 378. 20 312 operative surgery. 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 describe 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, whilst the other thread, or that passed across and beneath the upper third, was destined for its middle portion. The second and third ligatures being then passed in like manner, it was only requisite to form round the middle third a complete and subcutaneous loop, which was effected by using the remaining curved needle, when all were tightened by a serre-nceud." A reference to the diagram accompanying the account will render this operation easy of comprehension. 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. i. dissection of the skin and ligature 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 the late Mr. Liston, of London, and is represented in Plate XXXVII. Fig. 1. Extirpation of a Scirrhous Thyroid Gland, by Dr. J. C. Warren, of Boston.*—The patient being in the upright position, * Warren on Tumors, p. 305. extirpation of goitre. 313 an incision nearly four inches long was carried along the anterior edge of the sterno-mastoid muscle, so as to expose the platysma- myoides, which was incised so as to present the edge of the sterno- mastoid. On turning this aside, the sterno-hyoid and thyroid mus- cles were perceived to cover the tumor in such a way that it was necessary to separate them and dissect between them. The sur- face of the tumor, being then brought into view, was fully exposed by dissection and separated from the sheath of the carotid artery by the handle of the knife. This apparently loosened its at- tachments, 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 upwards and backwards, in order to extract the superior corner of the gland. The superior thyroid artery being divided in so deep a position as to prevent its ligation between the muscles, the common carotid was therefore tied. The inferior thyroid did not bleed, or was sup- posed not to exist, and the patient, after serious symptoms, recovered in about one month. Remarks.—Of the different operations just detailed, compression is certainly the safest, and judging from the account furnished by Dr. Dwight, the most successful. Ligature 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 addi- tion 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 compression by the fingers of assistants, during eight consecutive days, having rescued the patient. Although I have placed among the preceding operations an account of the extirpation of the thyroid body as performed by Dr. Warren, it has been done rather to complete the record than from a wish to lead any one to its repetition, even when sanctioned by such excellent authority. Though occasionally performed, an attempt to extirpate a goitrous tumor is so liable to cause immediate death from hemor- rhage, that few, as before stated, deem the operation justifiable, more than one patient having died on the table. The ligature, both by the subcutaneous method, and also after the exposure of 314 operative surgery. the tumor has succeeded, yet the obstruction of the circulation through the part by this method has also been followed by alarm- ing symptoms of suffocation and congestion of the brain. Every surgeon, therefore, should avoid operating on any case of true goitre, unless fully prepared to encounter great difficulties, 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 («$«£, water; and zy*y, tumor), though generally limited to collections of fluid within the tunica vaginalis testis, has also been applied by Mr. Maunoir, of Geneva, to encysted tumors of any portion of the neck which are filled with liquid contents. " These tumors are met with at various periods of life and in both sexes; their progress is slow, and they arise with- out any appreciable cause, being occasionally congenital. Though seldom larger than a walnut, they may acquire the size of an orange, and impede respiration and deglutition. The contents of the tumor 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 apparent. The tumor is free from pain or tenderness on pressure, fluctuates slightly, 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.f * Liston's Surgery, by S. D. Grose, M. D., Louisville, p. 386. f See Bibliography. aneurisms in general. 815 Remarks.—From the similarity of these tumors with those seen in other regions, they are generally regarded as belonging merely to the encysted class; and the application to them of the term Hy- drocele 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." I 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 evi- dent, puncture and the introduction of a seton effected the cure. CHAPTER VII. ANEURISMS IN GENERAL. The term Aneurism (avsvpwsiv, to dilate) has been long employed to designate such tumors as were caused by dilatation, or rupture of the coats of an artery, in consequence of which the patient is sooner or later liable to sudden death from hemorrhage, by the giving way of the sac, or diseased portion of the vessel. In addition to certain constitutional means which, by diminishing the force of the circulation, prevent too great distension of the sac, these tumors have been cured by mechanically obstructing the cir- culation of the blood through the diseased portion of the vessel, thus compelling it to pass by collateral branches until it could again enter the main trunk beyond the seat of the disorder, or by retarding it until the more fibrinous portion was deposited in and about the sac on the weakened side, so as to enable these parts to sustain the force of the current passing through the main channel of the artery. Without, however, entering into the details of the various kinds of aneurism, as well as the modifications of treatment suggested and practiced at different periods, it must suffice at present merely to show the diagnostic signs of the tumor, and the different operations applicable to its treatment, many entire papers having been occu- pied in demonstrating the pathology of the complaint. 316 OPERATIVE SURGERY. SECTION I. DIAGNOSIS OF ANEURISM IN GENERAL. When an aneurism has occurred in an artery, which is so situated as to permit the use of the sense of sight, and has not attained any very great size, there may often be noticed, when pressed upon near the usual course of the vessel, a round or ovoid tumor. This tumor gives the sensation of elasticity to the fingers, disappears more or less under the pressure, reappears when the force is removed, softens and diminishes when the main trunk is compressed between the tumor and the heart, and may be felt pulsating with each contrac- tion of the ventricles. The skin at first preserves its natural ap- pearance, but in the progress of the disease furnishes signs of venous congestion, then of inflammation, and lastly, of ulceration or spha- celus. Most frequently the swelling increases slowly and without much pain, though sometimes the latter is very acute, especially if a sentient nerve is put upon the stretch, or compressed by the develop- ment of the tumor. When the complaint has existed some time, the swelling becomes more firm from the fibrinous deposits going on in its interior, or from the formation of clots, and, in consequence of these changes, the pulsations, which were before felt in it, now become less distinct, so that in some cases it may be necessary to resort to the aid furnished by auscultation, either by applying the ear directly to the tumor, or where it is wished to circumscribe the part that is to be examined, by employing the stethoscope. By ausculting the tumor, in either of these methods, the surgeon will hear either a sawing or bellows' sound, or the peculiar noise which has been designated as "whirring." Apparent pulsation in the part is, however, liable to lead to grave errors. If, as has been before stated, a solid or firm tumor should be seated over the course of an artery and bound down to it by fibrinous or muscular expansions, pulsation may apparently be perceived in the tumor, and yet be caused solely by the proximity of the vessels; but if such a tumor be drawn to one side, or the muscles be relaxed by change of position, then the pulsation will cease, which is not the case in aneurisms. The diagnosis in these cases is, how- ever, often one of great difficulty, and many instances have been recorded where the most experienced surgeons have been mistaken. DIAGNOSIS OF ANEURISM IN GENERAL. 317 Several years since, I saw, in the Blockley Hospital, a large abscess in the iliac region pulsate so as to simulate an aneurism, and the difficulty of diagnosticating it was so great that an eminent surgeon spoke of it as a decided example of vascular enlargement. In all cases of doubt, palliative measures alone should be resorted to until the character of the complaint can be more positively esta- blished. But if delay does not elucidate the case, and the pain and other urgent symptoms require a prompt decision, the practice of Guattani may be repeated, and an exploratory puncture made, the hemorrhage, if it be an aneurism, being arrested by pressure. The opening of the aneurismal sac, under these circumstances, has not, however, been attended by the serious results that might at first be anticipated. Several instances of its having been done, without causing serious difficulty, have been mentioned by surgical writers, among which is one by Dr. John Rhea Barton, of Philadelphia,* where an empiric plunged a lancet into the tumor under the suppo- sition that the disease was an abscess. Fainting arresting the hemorrhage at the time, the patient lived six weeks, and afterwards died of mortification of the limb; when, on a post-mortem exami- nation, the inguinal tumor and femoral artery were found in such a condition that Dr. Barton expressed the opinion " that, if the pa- tient (aged seventy years) had had a little more vigor of constitution, the opening of the aneurismal tumor would have cured the com- plaint." Lest, however, such fortunate results should not always ensue, it will be safer for the surgeon, when compelled thus to test the character of the tumor, to be prepared to ligate the main trunk of the artery immediately. SECTION II. GENERAL PRINCIPLES TO BE OBSERVED IN THE LIGATURE OF ARTERIES. The accumulated experience of the profession in the application of the ligature to an artery has established certain general rules, which are mostly regarded as essential to the proper performance of the operation, although some few surgeons have modified them, * Philad. Journ. Med. and Phys. Sciences, vol. i., N. S., p. 127. 1825. 318 OPERATIVE SURGERY. or substituted others, either to meet particular difficulties, or because they were more in accordance with their individual experience. As the object to be attained in every ligature of a vessel is a direct change in the course of the natural circulation, all rules in reference to this subject may be condensed into two, and on these two all surgeons it is believed agree, to wit: 1st, to expose the vessel with- out opening it; and 2d, to ligate'it with as little disturbance as possible of surrounding parts. These two general principles may be carried out in various ways; but I shall adopt the views of Lis- franc in relation to the details, not only as being the soundest, but also because personal experience has enabled me to test their value to a considerable extent upon the subject as well as upon the patient. In ligating any artery, Lisfranc advises the surgeon— 1st. To make sure of the position of the vessel. Special anatomy, as usually taught, presents every medical man with accurate infor- mation in regard to the ordinary position of the arteries; but, as these vessels are liable to various anomalies, 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. To do this, notice should be first taken of the position of such muscles as usually indicate the course of the artery, or of those which have been termed "muscles of reference." By causing these muscles to contract and become prominent, the surgeon may readily recognize any deviation of the artery from its natural relations with these parts; or he may feel for the pulsation of the artery; or, if 4 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. After recognizing the position of the vessel, its exposure becomes the next point for consideration ; and, in order to prevent any varia- tion from the proper line of incision, as well as to fix the skin, Lis- franc 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, whilst he incises the integuments by drawing the scalpel close along the edges of the nails. Malgaigne, however, objects to this direction as being likely to displace the integuments over the vessel, though my own expe- rience is favorable to it. LIGATURE OF ARTERIES. 319 2d. When the artery is superficial, the incision through the inte- guments 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. When the aponeurosis of the part is directly in contact with the sheath of the vessels, it is generally safer to open it 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 flattened and col- lapsed when the circulation is interrupted between it and the heart. 3d. In order to isolate the artery with as little disturbance as possible of surrounding parts, the relative position of the ad- jacent veins and nerves should be recollected, and the adhesions of the sheath and other tissues only loosened sufficiently to per- mit the passage of the ligature. To do this, it is important that a good 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 in order to facilitate its per- foration by the instrument. Another rule, which is an excellent one, and which Malgaigne* has designated as "the rule of the guiding points," is the following: " The surgeon should not at the commencement of his operation occupy himself with looking for the artery, but should seek the first marked point of reference, then the second, then the third, if there be one, and so on to the vessel." Dr. Mott, of New York, whose experience in ligating arteries has probably been greater than that of any other surgeon in the United States, advisesf that in every operation upon a large artery, after the edge of the muscle of reference is laid bare, but little use should be made of the scalpel; the fingers, director, or handle of the knife being capable of separating the 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. * Operat. Surg., Philad. edit., p. 140. t Mott's Velpeau, vol. i. p. 301. 320 OPERATIVE SURGERY. PLATE XXXV. INSTRUMENTS EMPLOYED IN THE LIGATURE OF ARTERIES; WRY" NECK; OEDEMA 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, as employed by Drs. Parrish, Hewson, and Hartshorne. Fig. 3. Another form of this needle. Each needle has two * eyes, and the ligature is passed through the one nearest the handle. . " " Fig. 4. Another needle, very much curved. m . " • " Fig. 5. Blunt points, adapted to a common shaft, and intended to be detached in order to pass the ligature around the artery. " Fig. 6. Sharp point, intended jto be similarly attached and detached. " " Figs. 7, 8. Needles of other curves and lengths, adapted to deep arteries in confined points. " " 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. " " Fig. 10. Knot-tiers, to tighten deep-seated ligatures. " " Note.—The above set comprise the instruments included in the operating case of the late Dr. Jos. Parrish, for the use of which I am indebted to the politeness of Dr. Isaac Parrish. The full account of the investigations of Drs. Parrish, Hewson, and Hartshorne may be seen in the Eclectic Reper- tory, vol. iii. p. 229, 1813. Fig. 11. Horner's aneurism needle. Schively'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. " " Fig. 13. Tenotome or knife adapted to the section of the sterno-cleido-mastoid muscle. " " Fig. 14. Apparatus to bring the head into position in cases of wry neck, especially after the division of the muscle. Rorer'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. Schively's pattern. Fig. 20. Small, blunt-pointed Hernia bistoury. " " Fig. 21. Straight-pointed Hernia bistoury. " " ANATOMY OF THE BLOOD-VESSELS OF THE NECK. 321 The late Dr. Joseph Parrish, of Philadelphia, in connection with Drs. Jpseph Hartshorne and Thomas 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.* In order to hold the parts asunder, Dr. Mott employs curved spatulae (Plate II. Fig. 10), and divides the sheath of the vessels perpendicularly, and only upon the front of the artery, never dis- secting 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 permit the aneu- rismal needle to pass. He has generally employed the Philadelphia 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 last rule is equally applicable to the introduc- tion of any instrument which is intended to pass a ligature around an artery. CHAPTER VIII. ANEURISM OF THE CAROTID ARTERIES. SECTION I. ANATOMY OF THE BLOOD-VESSELS OF THE NECK. The great points of reference in ligating the arteries of any por- tion of the body are, as has been stated, 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 part. 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 for the general rules of operating upon these vessels. The Common Carotid Artery arising from the innominata on the * Eclectic Repertory, vol. iii. p. 229, 1813. 322 OPERATIVE SURGERY. 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 female. In the lower part of the neck, the right artery inclines more outwardly 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 enclosed in a firm sheath, which is connected with the fascia of the neck, the vein being on the external side of the artery, and swelling in front and above it, whilst the nerve is situated between the two vessels or a little be- hind them. Directly above the sternum and clavicle, the vessels and nerve, ar- ranged 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. Along-side of the larynx, the carotid artery is very superficial, being covered only by the skin, superficial fascia, and platysma-myoides, 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 vertebrae of the neck, in front of the internal jugular vein, and having 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 afterwards concealed by the ramus of the jaw\* Horner's Anatomy. LIGATURE OF THE CAROTID ARTERIES. 323 " The External Carotid extends from the termination of the pri- mitive 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-myoides, 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 tonsil gland. About its middle, it is crossed internally by the stylo-glossus and stylo-pharyngeus muscles, 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."* 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 from the mastoid pro- cess to the inner edge of the clavicle, or by the course of the sterno- mastoid muscle, when it can be recognized. SECTION II. LIGATURE 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 carotid 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 in- terference was demanded. The object of all the applications of a ligature to the carotid being the same, to wit, to cut off the circulation through the artery, * Opus citat., vol. ii. p. 207. 324 OPERATIVE SURGERY. it is unnecessary 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 greatest 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 elsewhere; but to a dexterous operator, the selection of an aneurismal needle will prove a matter of but little moment in this artery, and any of them may therefore be taken, the choice being guided mainly by individual predilection. § 1.—LIGATURE OF THE PRIMITIVE CAROTID. 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 in- clined 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-mastoid 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, commencing 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 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-myoides and superficial fascia, and lay bare the fibres of the sterno-mastoid muscle, when an assist- ant may draw the inner edge of the wound towards the trachea, and the operator push its external edge outwards 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 fibro-cellular layer which extends from the sterno-hyoid and thyroid muscles to the posterior surface of the * Med. OpSratoire, tome i. p. 240. ligature of the primitive carotid. 325 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 divided upon the director, if it should be in the way of the ope- rator, though generally it may be avoided by being drawn to one side. Above and below the line of the muscle will now be seen the yellow- looking sheath of the vessels, on the anterior surface of which is the descendens noni nerve. The sheath being then picked up in the forceps over the artery, and 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 expiration, so as to embarrass the operator, it should be compressed, as advised by Mr. 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, and being, by a slight rocking motion, made to pass round the vessel, its point should be made to perforate any cellular tissue that opposes its exit by the pressure of the fingers 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. To avoid error in the first incisions, it has been advised to cut directly upon the belly of the sterno-mastoid, and then draw the wound towards 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. Mr. Chassaignac* has advised the surgeon, in case of difficulty, to feel for the tubercle or projection made by the ante- rior branch of the transverse process of the sixth cervical vertebra, * Malgaigne, p. 155. 326 OPERATIVE SURGERY. which is in front and a little inside the artery, if, in operating for the inferior third of the vessel, he finds the parts so infiltrated as to prevent their being recognized. I have tried this rule repeatedly upon the subject, and seldom failed to find the artery simply by the touch. § 2.—EFFECTS RESULTING FROM LIGATURE OF THE CAROTID. When the circulation is cut off from one side of the head by the application 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 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 enlarge- ment would be the chief means employed by nature to compen- sate for the temporary loss occasioned by the operation, and such has been accurately found to be the result. From a dissection made by Dr. Mott,* of New York, of a subject whose arteries were in- jected after a death consequent on a pulmonary affection, three months and nineteen days subsequent to the operation, it appeared that the carotid, which had been tied (right side), had been entirely oblite- rated from the innominata to the angle of the jaw, leaving a firm ligamentous cord divided into two parts 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; the left carotid enlarged to twice its natural size, and its branches increased in the same ratio. The branches arising from the right subclavian artery were also enlarged. The inferior thyroid was enlarged in the ramus thyroidea and the thyroidea ascendens to twice their natural size, but the transversalis cervicis and transver- sals humeri, though arising from the same trunk, retained their natural dimensions. The thyroidea ascendens was found mounting up the neck in a zigzag direction, forming many communications with the vertebral artery, and with the mastoid branch of the occi- pital. The left carotid artery was also equal in size to the inno- minata and furnished the greatest part of the blood to the right side, the superior thyroid, lingual, pharyngeal, and internal maxil- * Amer. Journ. Med. Sciences, vol. viii. p. 45, 1831. EFFECTS RESULTING FROM LIGATURE OF THE CAROTID. 327 lary, inosculating with those of the opposite side, so as to have the appearance of continuous trunks. The mental, inferior labial, coro- nary, 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 sub- clavian, 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 in- stances, no serious disturbance of the function of the brain ensues upon ligature of the carotid,* yet the reverse has been noted, the failures having been ascribed to some disorder or anomalous arrangement of the arteries chiefly concerned in equalizing the circulation after the operation. In a patient operated on by Mr. 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 hearing of the side operated on. A patient of Magendie, one of Ba- roven, 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, f It is better, therefore, in all cases to watch the effect upon the patient after tying the first knot before forming the second, so that, if requisite, the ligature may be removed from the vessel. The application of a ligature to both carotids, at intervals, varying from two to six weeks, has, however, been successfully ac- complished by Drs. McGill, Mussey, Mason Warren, Ellis, and Blackman 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 Dr. Mott for extensive disease of the parotid gland, the patient died in twenty-four hours.§ Death also ensued upon a ligature of the primitive carotid by * Chelius, by South and Norris, vol. ii. p. 507. f Diet, de MSdecine, tome vi., article Carotides. X See Bibliography. § Am. Journ. Med. Sciences, vol. xiv. p. 530. 1834. 21 328 OPERATIVE SURGERY. PLATE XXXVI. OPERATIONS UPON THE NECK. Fig. 1. Ligature of the Carotid, Lingual, and Facial Arteries. C- Liga- ture of primitive carotid. 1. Lowest point of incision. 2. Fascia profunda. 3. Internal jugular vein. 4. Carotid artery raised on the aneurismal needle. 5. Par vagum nerve. L- Ligature of Lingual Artery. 1. External inci- sion. 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 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 Carotid and Subclavian Arteries and Branches of the Subclavian. 1, 1. Aorta. 2. Innominata. 3. Primitive carotids. 4. Right subclavian. 5. Left subclavian. 6. Scalenus anticus muscle. 7, 7. Vertebral arteries. 8, 8. Thyroid axis. 9, 9. Posterior scapular arteries. 10, 10. Internal mammary. After Bernard and Huette. Fig. 4. Ligature of the Subclavian and Axillary Arteries. A- Ligature of subclavian. 1. Incision in skin. 2. Deep fascia. 3. Omo-hyoid muscle. 4. Brachial plexus. 5. Subclavian artery raised on the needle. 6. Scalenus anticus muscle. 7. Subclavian vein. B- Ligature of axillary below the Clavicle. 1. Incision in skin. 2. Deep fascia. 3. Fibres of pectoralis ma- jor 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 (Esophagotomy. 1, 1. Incision in skin. 2. Deep fascia. 3. Blunt hook drawing trachea inwards. 4. The oesophagus. 5. Fingers of the surgeon drawing the bloodvessels outwards, 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. Primitive carotid artery. After Bernard and Huette. Fig. 2 ^Jft A .;/••. \A vi ^P ■ 370 OPERATIVE SURGERY. extirpate degenerations 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 described 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. / /' i / 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 dia- meter by seven and a-quarter in the transverse. Its circumference at the base was thirteen inches, and 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 lobu- lated, of a bluish color, and traversed by large veins, the skin being sound, and the part free from pain. Operation of Dr. Gross, of Kentucky.*—After ascertaining, by an exploratory puncture with a cataract needle, that the con- tents of the tumor were liquid, a small trocar was introduced, and seven ounces of serum, colored like Madeira wine, were drawn off, leaving about one-third of the contents in the tumor. The punc- ture was then closed by adhesive plaster. Three days subsequently, six ounces of liquid were evacuated in the same manner, emptying the sac entirely; after which the collapsed walls were approximated by a compress and bandage. Four days subsequently there was a partial re-accumulation which was drawn off, and a few silk threads introduced to act as a seton, as in the treatment of hydrocele. At * Am. Journ. Med. Sciences, vol. xvii., N. S., p. 22. 1846. SURGICAL ANATOMY OF THE THORAX. 371 the end of forty-eight hours, sufficient inflammatory action being excited, the seton was withdrawn, and the patient, after a convul- sion and serious constitutional disturbance, recovered. (See note.)* CHAPTER XII. OPERATIONS PRACTICED ON THE WALLS OF THE THORAX. Owing to the existence of caries, necrosis, spina ventosa, 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 neces- sary to resort to such operative measures as will facilitate the re- moval 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 ante- rior, posterior, and lateral portions, to the latter of which the sur- geon 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; whilst 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 exterior to them, and are mainly concerned either in respiration, or in the motion of the body. * By an error in the Bibliographical Index, the paper by Dr. Foltz is quoted as vol. xii. instead of vol. xi. of the Journal. The tumor also was on the side of the pelvis, and not, as there stated, on the chest. 372 OPERATIVE SURGERY. Of these muscles the intercostal fill up each intercostal space, and present their fibres in different directions, those of the outside pass- ing from above downwards and from behind forwards, 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 in- terlocked 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 forwards, 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 membrane 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 distant from the ribs, in con- sequence of the formation of exterior abscesses depressing 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. § 1.—RESECTION OF THE RIBS. Resection of the ribs has been demanded in cases of serious dis- eases of these bones. RESECTION OF THE RIBS. 373 In a patient of Dr. George McClellan,* a spina ventosa was de- veloped upon the sixth and seventh ribs of the right side, which extended from their cartilages nearly to the dorsal vertebrae, 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 de- stroy the function of the lung. Operation of Dr. G. McClellan, of Philadelphia.—By two elliptical incisions, which included a portion of the skin, the integu- ments over the tumor were removed from over 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 detached 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 creasote. The cavity left by the disease was now seen to be quite large, being capable, without exaggeration, of admitting with ease a child's head of the ordinary 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 operation. A remarkable case of resection of the fifth and sixth ribs, per- formed by Dr. Antony, of Georgia, may also be found by reference to the Bibliographical Index, but my present limits forbid its inser- tion. 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 * McClellan's Princ. and Pract. of Surg., note by Dr. J. H. B. McClellan. f Malgaigne, Philad. edit., p. 207. 374 OPERATIVE SURGERY. by a straight-curved or crucial incision. (Plate XXXVIII. Fig. 5.) Divide the intercostal muscles above and below the rib, either from without inwards, 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 the surgeon to think of the resec- tion of the ribs, as well as the risk of injuring the pleura, has ren- dered this operation not only uncommon, 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 as that reported by Dr. Antony, unique, 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, f there may be found a reference to numerous instances in which this operation has been performed, the periods varying from the time of Galen up to the present day. Velpeau mentions a case reported 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 removed to the ex- tent 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. Ac- cording to Velpeau, Severin, J. L. Petit, Duverney, David, Lapey- ronie, 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. Dr. Warren, of Boston, has successfully excised the seventh, and in another case the sixth and seventh ribs successfully for caries, and Drs. McDowell of Virginia, Mott of New York, and McClellan, in three other instances, have also performed this operation with vary- ing success. As an operation, its execution is said to be compara- * Diet, de M6decine, tome 9me, p. 147. f Operat. Surg., by Mott, vol. ii. p. 738. PARACENTESIS THORACIS. 375 tively 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 respi- ration, should be most urgent. Indeed in this, as in many other cases, surgical skill and judgment are often best shown when the surgeon can cure the complaint without resorting to the knife. Caries or necrosis of the sternum may usually be relieved when an operation 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. The evacuation of liquid from the cavity of the chest is among the most ancient of surgical operations, being referred to by Hip- pocrates, B. C. 460, as well as by many others at different periods subsequently. Pathology of liquid effusions into the Chest.—The word empyema (*v in, *«<» pus) though originally employed to desig- nate a collection of pus in any cavity, and especially in the chest, is now often 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 especially for the relief of collections of pus within the pleural cavity, or for the re- moval of the fluid of hydrothorax, a brief reference to the patholo- gical 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 result 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 bursting 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 necrosis of the adjoin- ing ribs, the tumor which indicates the collection being made by pus 376 OPERATIVE SURGERY. which comes from within the pleural cavity. In most instances, however, whether of external or internal empyema, the pleura ex- hibits the ordinary 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 honey- comb-like arrangement, or a genuine fibrous, cartilaginous, 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 paracentesis. 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 skilfully employed in every instance, before the surgeon attempts the operation. The operation of paracentesis thoracis has been variously per- formed, but the object of all the plans is to evacuate the liquid con- tents 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 PARACENTESIS THORACIS. 377 little difficulty will be found in tracing them from below upwards; but in those who are fat, or in those who have the side oedematous and swollen, it may be impossible 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 inferior angle of the scapula.* Ordinary Operations of Paracentesis Thoracis.—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, the skin is to be divided to the extent of one and a half inches in a direction parallel with the superior edge of the lowest rib on the in- tercostal space, that is selected for the puncture. After dividing the superficial fascia, and any portion of a muscle of the chest that may intervene, as well as the external and internal intercos- tal muscles, the pleura will be found generally to bulge into the wound. After being distinctly felt by the forefinger, so as to esta- blish the fact that only a fluid is behind it, the puncture should be made with the point of a bistoury, and the opening gradually enlarged as the liquid escapesf (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. A similar case may be found in the Bibliographical Index. Velpeau entertains the opinion that in cases which require the operation, the effused liquid, or even an abscess, will remove the lung from the point of puncture. 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 bis- toury in the same manner as an ordinary abscess. After-Treatment.—If circumstances render it desirable to keep the wound open, a tent may be introduced, and removed from day to day; but if the whole of the liquid be evacuated, the opening may be at once closed with adhesive strips, a compress, and band- age. If the subsequent 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, being subsequently employed. ' In order to evacuate the liquid, and yet prevent the entrance of air, various contrivances have been employed. Pelletan employed a syringe for this purpose, and Reybard placed a piece of gold-beaters' * Malgaigne. f Velpeau, Op. Surg., by Mott, p. 515, vol. iii. 378 OPERATIVE SURGERY. 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. Dr. 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, which he thinks is preferable to the ordinary mode of incising the soft parts. " Remarks.—The value of the operation of paracentesis thoracis has been differently estimated at various periods, most of the sur- geons, up to the time of the discovery of Laennec, having regarded it as a doubtful or dangerous operation, especially from the diffi- culties attendant on the diagnosis. Since the more general resort to auscultation, many of these difficulties have been removed. Dis- eases of the lungs are now no longer confounded with those of the pleura, and a skilful auscultator can in most instances render the knowledge of the presence of a liquid in the chest absolutely cer- tain. But, though the cases can now be better selected than they were formerly, a successful result is not always obtained. The true re- sult of the operation may, it is thought, be correctly stated thus: Paracentesis always affords temporary relief, and about one-half of the cases recover; but whether these patients would have died with- out it, it is difficult to tell. The idea is certainly erroneous that paracentesis thoracis is an eminently easy and successful operation, and though its results have been such as to justify its performance, the prognosis should be guarded. In the statistics which I have collected from various sources, it will be seen that the mortality is considerable, and the objections that have been 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 permeable, the evacuation of the liquid without the entrance of air into the pulmonary cavity may distend it so rapidly as to excite violent inflammation. If, on the contrary, the lung has shrunk so * Transact. Am. Med. Assoc, vol. iv. p. 245. PARACENTESIS THORACIS. 379 much as to yield but slowly to the entrance of air, the void which is immediately left about the parts is very liable to derange the respiration and pectoral circulation. The introduction 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. 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 presence 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 dissection of layers would be preferable. Where, however, the diagnosis is positive, and the chances of failure from the accident of pushing forward the thick- ened membrane, instead of perforating it, is guarded against, the in- strument of Dr. Wyman, of Massachusetts, may prove advantageous. In Boston, the experience of the profession is said to be favorable to it. Under all circumstances, the surgeon may anticipate an anxious and long-continued convalescence 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 instruments employed, as it is not so shaped as to obtain a keen edge, whilst the point of the canula, even when 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 ac- companied with thickening of the tunica vaginalis. When the sur- geon recals the constitutional effects liable to result from opening closed cavities, and especially those containing pus, and covered by a pyogenic membrane, he can readily foresee the consequences of opening the pleura in cases of empyema. The natural tendency of sucli collections is either to be absorbed or discharged by the efforts of nature. If discharged by nature, the inflammation of the sur- rounding parts, and the character of the opening made by ulcera- tion, 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 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 re- 380 OPERATIVE SURGERY. peated, 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 results obtained in the following instances show pretty correctly what may be anticipated from the operation, when resorted to after the diag- nosis has been made with the aid of auscultation :— STATISTICS OF THE OPERATION OF PARACENTESIS THORACIS. CURED. DIED. Of 11 cases treated in the United States,* there were, counting two reported as relieved, 9 2 Of 72 cases reported by Velpeau,f .... 41 31 Of 44 " " " Roe.J......32 12 Of 26 " " " Roe,? for hydrothorax, 17 9 Of 16 " " " T.Davis,||.....12 4 Total, 169 111 58 From this table it appears that nearly two-thirds of the cases ope- rated on have been cured. § 3.—EFFUSIONS IN 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, how- ever, this relief can only be temporary, and as the patient is exposed to considerable danger from various steps in the operation, surgeons have not been disposed to advocate it. In fact, the rare occurrence 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 opin- * Bibliographical Index. t Velpeau, M6d. Op6ratoire. X Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 38. Paper by "Wm. Pepper, M.D. I Ibid. || Ibid. OPERATIONS UPON THE ABDOMEN. 381 ion that doubt may be attached to all except the one performed by Dr. John C. Warren, of Boston; but this one has lately been re- ported to me* as successful, and is, it is thought, the only positively successful case on record. CHAPTER XIII. OPERATIONS UPON THE ABDOMEN. The parietes of the abdomen are liable, like similar tissues else- where, to the development of tumors of various kinds, the fatty, fibrous, and lipomatous being those most frequently met with. As the removal of these tumors is to be accomplished by pre- cisely the same means as those already designated in the account of the neck, this slight allusion to them may be sufficient to preserve the continuous arrangement of the subject adopted as the order of this volume. Within the walls of the abdomen there are, however, such a va- riety of organs that its contents require a more detailed consi- deration ; and whilst reserving the account of Hernia for another chapter, and the operations upon the genito-urinary organs through the abdominal parietes for Part IV., there remains to be described the surgical treatment adapted to the relief of certain 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 presented in an account of the special anatomy of the region, the operations for the relief of affections of the peritoneum may first claim attention; after which those demanded 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 generally recognized as justifiable ; extirpation of the spleen, or scirrhus of the pancreas, not being included in this class. * Dr. Warren in MS. 382 OPERATIVE SURGERY. SECTION I. PARACENTESIS ABDOMINIS. The accumulation of such an amount of serum within the peri- toneal cavity as seriously interferes with respiration has usually been deemed sufficient cause to justify its evacuation by an opera- tion, although little more than temporary relief can be anticipated. Ordinary Operation.—Having prepared a good flat trocar and canula, surround the patient's belly with a broad bandage, the ends of which should be cut into tails, crossed upon the back and drawn upon by assistants, in order to keep up a constant pressure upon the abdominal cavity as the liquid escapes; or the same may be effected merely by the pressure of their hands. 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, to allow the fluid to escape through the canula until he is satisfied that sufficient has been evacuated, when, removing the instrument, the wound may be closed by a piece of adhesive plaster, and dressed 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 evacua- tion of the fluid, whilst others direct the removal only a part of it; some have selected the trocar and canula, as mentioned in 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 pecu- liarities of the case. Dr. 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 operating. The use of the catheter has, however, been recently claimed for M. Fleming, of the Val de Grdce,f though it had, as is * Dorsey, Surgery, vol. ii. p. 365. f Malgaigne, Philad. edit., p. 387. HEPATIC ABSCESSES. 383 shown above, been employed many years before his suggestion was announced. Dr. Physick's Operation.—The patient being placed near the edge of the bed with a piece of oil-cloth under him, a lancet is to be inserted through the abdominal parietes in the line of thelinea alba, about two inches below the navel, and as soon as it is removed the fluid will escape through the puncture. After the liquid has par- tially escaped, and the stream begins to diminish, a female catheter may be introduced to favor its further evacuation. The subsequent dressing is the same as in the ordinary operation. Estimate.—The advantage of the operation recommended by Dr. Physick will be found in the slight pain caused by the puncture; in the greater tendency 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 evacua- tion 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 perito- neum by injecting iodine, or similar articles, will ever be generally adopted, is a matter of doubt. Velpeau has long been sanguine of success from this means; but his opinion is based mainly on theo- retical views, and no other surgeon, so far as I know, has attempted it, though several have favored a resort to his suggestion. SECTION II. HEPATIC ABSCESSES. The production of inflammatory action in the liver, as the result of disease, has not unfrequently resulted in the formation of pus, which, if allowed to accumulate, has a tendency to cause a dis- integration 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 into 384 OPERATIVE SURGERY. PLATE XXXIX. OPERATIONS PRACTICED ON THE ABDOMEN. Fig. 1. Evacuation of an hepatic abscess. An eschar has been formed near the abscess, in order to favor the adhesion of the adjacent serous sur- faces, 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 towards the finger nail, and, being introduced, enlarge the wound by slightly incising the abdominal parietes upwards. After Bourgery and Jacob. Fig. 3. A longitudinal wound of the intestines, closed by Pellier's suture. Whilst the left hand of the surgeon holds the two ends of the thread, the right hand is occupied in replacing the protruded bowel, com- mencing 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 Reybard. 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 external 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 towards the saphenous open- ing, whilst the fingers of the same and opposite hand press the viscera ver- tically upwards towards the femoral ring. After Bourgery and Jacob. \ HEPATIC ABSCESSES. 385 the cavity of the pleura, so as to constitute one source of empyema; or the abscess may open into the stomach, bowels, or cavity of the abdomen, or it may tend towards 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. Diagnosis.—When an abscess of the liver tends to point out- wardly, 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 travelled nearly as low as the spinous process of the ilium, though most frequently 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 Rumors of this region, from the swelling caused by a hepatic abscess, that Rdcamier 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 dis- countenanced. The best means of arriving at a correct conclusion will be found in studying the history of the case, and watching for the signs of fluctuation and inflammation about the part. When a diagnosis is firmly 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 adhesions have formed between the peritoneum, covering the liver and that lining the abdominal parietes. (Begin.) To the latter mode of operating I would 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 peritoneum lining the abdominal parietes is reached. Raise this carefully with the forceps and nick it, dividing it subsequently upon the director. If the intestine presents itself, it may be gently pushed to one side ; but when the patient is well etherized, there is but little tendency in the bowels to move towards 386 OPERATIVE SURGERY. the wound. 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. After three or 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 Dr. Savery, of New Hampshire.!—An intem- perate man, aged sixty, after laboring for some years under chronic hepatitis, presented a circumscribed swelling in the right hypo- chondrium, which became pointed and painful, and gave an obscure sense of fluctuation. An incision was therefore made into the ab- scess, and nearly a gallon of sero-purulent fluid discharged, the last portion evacuated having all the properties of bile. A broad band, having been carried around the body 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 ex- isted during the first week, and required the free use of wine and quinine, with other appropriate remedies. Remarks.—The opening of a hepatic abscess would be a very simple measure, were it not from the doubts that are often excited as to the actual existence of pus, and the difficulty of judging whe- ther 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 application of the bandage, as employed by Dr. 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. * Diet de MM., tome 13rae, p. 249. f See Bibliographical Index. Operat. on Abdomen. GASTROTOMY or enterotomy. 387 SECTION III. I. gastrotomy or enterotomy. Gastrotomy (yojr^p the belly, and tofirj 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 open- ing of the uterus in the Caesarian section, or the incision prac- ticed for the removal of ovarian tumors, though it should be limited to such operations as directly expose the stomach; enterotomy de- signating the similar operations practiced on the intestines, ovario- tomy the removal of ovarian tumors, and herniotomy that employed for the relief of constrictions 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, either in order to remove such foreign bodies as are not likely to pass through the alimentary canal, or to overcome the intestinal obstruction in cases of volvulus. Opening the stomach, or exposure of the intestinal canal cannot be an ope- ration of great difficulty to a person who is familiar with the gene- ral anatomical relations of the viscera. As a general rule, there- fore, it is only requisite to proceed in the manner just detailed for the treatment of hepatic abscess, that is, to cut through the abdo- minal parietes with caution, until the peritoneum is exposed; care- fully open it; hook or seize the front surface of the stomach, stitch it fast to the abdominal parietes, and then wait, if possible, for adhe- sion to occur, before puncturing it, lest its liquid contents escape into the peritoneal cavity. Should the patient be able to sustain the constitutional shock and disorder likely to ensue on such an operation, it may subsequently be necessary to treat the wound as any other fistula. In cases of volvulus, the difficulty of the diagnosis must render the resort to an abdominal incision a most hazardous and uncertain operation; yet such operations have been performed, and, when the patient is under the influence of an anaesthetic, might be again em- ployed with less risk and difficulty than has heretofore been the case. Although I doubt very much the propriety of such an operation, and 388 operative surgery. would urge the utmost caution in respect to diagnosis on the part of any surgeon who might be placed in such circumstances as appa- rently demanded it, yet it presents some chances of success, and perhaps quite as much as the operation of cesophagotomy; and as such a concatenation of circumstances may occur as will demand the consideration of this operation, there is good reason for exhibit- ing the few facts that have been presented in connection with the subject. By referring to the Bibliographical Index, several cases may be found in which the intestinal canal has been most rudely treated without causing death. But, though success has followed these cases, it is presumed that no judicious surgeon would take any of them as a precedent for an operation which is universally regarded as a forlorn hope, except under the most urgent circumstances, as where he is fully satisfied that the patient's chances of life are less without than they would be after the performance of the operation. Gastrotomy successfully performed by Dr. J. E. Manlove, of Tennessee.*—In July, 1844, Dr. Manlove was called to see a negro, aged seventeen years, who had had no evacuation of the bowels for twelve or fifteen days, and was laboring under fever, &c. After making every possible effort by constitutional means to re- lieve him, but without success, he 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 countenance anxious. A consultation decided that, although the operation of gastrotomy promised but little benefit, yet the certainty of death without it justified its performance. Operation.—An incision was, therefore, made in the median line of the abdomen, commencing about two inches below the umbilicus, and extending down towards the pubis four or five inches. The peri- toneum and bowels along the lower half of the incision being found adherent, an opening of about a fourth of an inch in length was made into the bowel, 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 previously. A further examination, showing that the intestines were united to the peritoneum by extensive ad- hesions at various points, within reach of the finger and probe, the wound was closed by sutures and adhesive strips, except at the in- testinal opening. The amendment in all the symptoms was prompt, * Boston Med. and Surg. Journ., vol. xxxii. p. 492. ENTEROTOMY. 389 the extremities becoming warm, and the pulse fuller and slower within an hour afterwards. On the next day the appetite was good, and the patient continued to improve, discharging the contents of the bowel through the artificial anus until the seventeenth day, when he had an evacuation per vias naturales, the opening having nearly closed. Nine months after this, he was presented to the Tennessee State Medical Society for inspection, being perfectly well. The ad- hesions were supposed to have been the result of a contusion of the abdomen, received six months previously. II. ENTEROTOMY. In the paper just quoted, Dr. Manlove also states an instance in which Dr. Wilson, of the same county, performed gastrotomy in a case of volvulus ; drew out the intestines until he reached the ob- struction, dissected the adhesions found at the invaginated portion, overcame the obstruction, replaced the bowels, and the patient rapidly recovered.* Successful Enterotomy, and Removal of a Silver Teaspoon, By Dr. Samuel White, of Hudson, New York.|—A man, aged twenty-six years, suffered in May, 1806, from rheumatism,'when, after a severe relapse, he became delirious and bent upon self- destruction. On the 7th of July, he procured a full-sized teaspoon with some fruit jelly, and forced the spoon down his throat in the absence of his nurse, and, by pressing his fingers against the han- dle, was enabled to swallow it. He was then greatly agitated, talked much, and declared that no attempt could save his life. On the 9th, a spasmodic affection of the stomach, alternating every fif- teen 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 suddenly 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 ilium near the line dividing the right iliac and hypogastric regions. It remained fixed in this * Boston Med. and Surg. Journ., vol. xxxii. p. 495. t New York Repository, vol. x. p. 367. 1807. 390 OPERATIVE SURGERY. position with increased heat and irritation in the adjacent parts till August 7th, when, fearing the consequences of further delay, it was decided to attempt its removal. Operation of Dr. White.—An incision three inches long being made through the abdominal parietes, and parallel with the epigas- tric artery, extending upwards to the level of the crest of the ileum, the peritoneum was opened with a lancet; the turn of the intes- tine, 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 IV. GASTRIC AND INTESTINAL FISTULA. From various causes, the creation of a fistula in the abdominal parietes, and a communication of it with the viscera of the part, may be produced. 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, whilst they also affect the nutrition of the patient, and expose him to a protrusion or even strangulation of the inner coat of the bowels, in a manner analogous 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, &c, by Dr. Cook.*—A widow lady, aet. thirty-nine years, had been attacked with constipation and violent pain at the pit of the stomach, which resisted every remedy until the nineteenth * Amer. Journ. Med. Sciences, vol. xiv. p. 271, quoted from Western Journ. Med. and Phys. Sciences, Jan. 1834. GASTRIC AND INTESTINAL FISTULA. 391 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's 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 corresponding 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 ex- ternal irritation soon healed; the bandage was gradually tightened and a cylindrical compress employed, under which treatment the fistula was completely healed in thirty days, and the patient subse- quently 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. As the experiments connected with digestion, per- formed by Dr. Beaumont upon St. Martin, who also labored under one of these fistula, have long been before the profession, it is only necessary to refer to his paper* for the evidence there presented of the powers of nature under such circumstances, as well as the means employed by Dr. Lovell, U. S. army, to obviate the incon- venience resulting from the creation of the opening. It is import- ant that the tendency of the mucous membrane to become everted and 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. * Med. Record., vols. viii. and ix. 1825. 25 392 OPERATIVE SURGERY. CHAPTER XIV. WOUNDS IN THE ABDOMEN. Incised wounds of this region, if limited to the abdominal parietes, demand only the ordinary treatment of wounds, to wit, the prompt and neat approximation of the edges, and their retention in apposi- tion until union occurs. To favor this the patient should be confined to bed, and the abdominal muscles relaxed by elevating the shoulders and flexing the thighs on the pelvis. The most important of these wounds are those complicated with a protrusion of some of the abdo- minal contents, as the latter, when once protruded, are 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. SECTION I. WOUNDS WHICH CAUSE PROTRUSION OR STRANGULATION OF THE INTESTINE OR OMENTUM. In treating these wounds it should be adopted as a universal rule of practice that, before resorting to any incision to facilitate the restoration of the protruded bowels, the surgeon should endeavor to replace them by manual means, aided by such a position of the pa- tient, use of anaesthetics and other constitutional measures, as will induce perfect relaxation of the tissues involved. Since the disco- very of ether, the replacing of intestines or omentum which have protruded through an abdominal wound, is much more easily accom- plished than was the case formerly. The following plan of treat- ment will, therefore, often succeed. Treatment.—Place the patient upon the 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 per- fect anaesthesia. As soon as this is accomplished, cleanse the parts WOUNDS OF THE INTESTINE. 393 by squeezing water upon them from a sponge, and gently seizing that portion which had last protruded between the thumb and fingers, compress it lightly so as to force back its contents, endeavoring to carry the bowel into the cavity of the abdomen by pressing upon it with the forefingers. The peristaltic action of the bowel being entirely arrested during anaesthesia, the muscles of the abdo- men perfectly relaxed, and the diaphragm partly quiescent, success will often crown the surgeon's efforts. When the protruded portion is returned, it only remains to unite the sides of the wound by a few points of the twisted suture, and sup- port them by adhesive strips and a bandage. But if it should be found impossible to accomplish the restoration in this manner, it may become necessary to introduce 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 done in a similar condition in hernia. SECTION II. WOUNDS OF THE INTESTINE. When an intestine is wounded in a 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 intestinal contents into the cavity of the abdomen. These means vary somewhat according to the extent of the wound, and its longitudinal or transverse 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 anaesthetic agents before commencing the operation. 394 OPERATIVE SURGERY. PLATE XL. SUTURES OF THE INTESTINES AND 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 ob- served 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 peritoneal coat of the intestine in contact with the abdominal parietes. 1. Abdominal 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 and knotted on the abdomen. Aftef 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. A{ier 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 and re-entrance, or the 2d 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. Sec- ond 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 be- tween 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 adjacent sides. 4. Lower orifice or point of artificial anus. After Bourgery and Jacob. Fig. 8. Artificial Anus, showing the funnel-shape of the cavity near the orifice. 1. Cavity of peritoneum. 2, 3. Ends of intestine. 4. Intervening mesentery. 5. The septum. 6. Funnel-shaped orifice formed around arti- ficial anus by the peritoneum. 7. Probe passed into orifice to show course of fecal contents. After Scarpa, from Bernard and Huette. Fig. 9. Another view of the same. 1, 2. Intestines. 3. Septum. 4. Course of contents of bowel. After Bernard and Huette. Fig. 10. The septum partially removed. 1, 2. Intestines. 3. Short sep- tum. 4. Mesentery. After Bernard and Huette. Fig. 11. A view of the Enterotome of Dupuytren as applied. 1. Abdo- minal parietes. 2. Instrument. After Bourgery and Jacob. Fig. 12. Enterotome of Liotard applied. 1. Septum. 2. Instrument. After Bourgery and Jacob. Ph. I. SUTURES IN WOUNDS OF INTESTINE. 395 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 treat- ment 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 ensues upon certain condi- tions of hernia, Sir Astley Cooper recommended that the sides of the opening should be gently gathered together, or pinched up, and then the adjacent portion constricted by tying a fine ligature around it, in the same manner that a divided artery is secured. But if the opening is more extensive, then resort must be had to some of the various sutures that have been recommended by sur- geons at different periods. Albucasis, A. D. 1100, Guy de Chau- liac, A. D. 1360, Le Dran, Ramdohr, Shipton, Travers, Thos. 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 foreign body (trachea of an animal) was in- troduced into the intestine, in order to support the sides of the wound; the looped suture of Palfyn; that of Le Dran; and the continued or interrupted suture, as recommended, with various modi- fications, by Reybard, Jobert, Bertrand, and 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 suture being made at one line from the upper angle of the wound, and 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 396 OPERATIVE SURGERY. assistant (Plate XXXIX. Fig. 3,) the surgeon should proceed to re- duce the intestine, and then drawing the ends of the thread towards the abdominal parietes, cause the outer coat of the intestine to ap- proximate the peritoneum lining the abdominal 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, whilst the edges of the wound are supported, the suture may be withdrawn without deranging the adhesions.* The Loop Suture of Ledran.—Having prepared as many ordi- nary sewing needles and threads as he wished to make stitches, the edges of the wound were approximated, and each needle passed trans- versely 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 Suture 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 ab- domen, after which the abdominal wound was closed, and the threads fastened upon the skin by adhesive strips. (Plate XL. Fig. 2.) Suture of REYBARD.f—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 the other, from the in- side outwards through the thickness of the intestine, and also of the abdominal parietes, the wooden plate was drawn upon so as to com- press the peritoneal coat of the intestine against the serous lining of the abdomen, thus closing the wound hermetically. When the adhesions thus excited seemed to be sufficiently strong, that is in about two or 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 * Malgaigne. f Mott's Velpeau, vol. iii. p. 623. SUTURE OF TRANSVERSE WOUNDS. 397 needle, and passed the threads transversely through them, at suffi- cient 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 approxi- mated, 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 farther 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 ab- domen, and three days subsequently cut off one end of the thread near the wound, and draw out the other, f (Plate XL. Fig. 1.) § 2.—SUTURE OF TRANSVERSE WOUNDS. Suture of Ramdohr.—Invagination of the two ends of the in- testine 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 in- terfered 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 inwards with one needle, he then passed both needles from within outwards through the lower end of the intestine, and after placing as many threads in this manner as were sufficient to unite the wound, invaginated 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 ab- domen. (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 inwards, and then repassed from within outwards, 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 inwards, at a similar distance from the opposite side of the wound, and brought * Malgaigne, p. 399, Phil. edit. f Ibid. 398 OPERATIVE SURGERY. 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 inwards, 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 described, 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, most of the details having been collected from various surgical works. The importance of the subject, and the numerous experiments that have been per- formed upon animals in order to test the result of similar injuries in man, might perhaps have authorized my adding much to the above account, but as this would have transcended my present limits, 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 Mr. Travers,f it appears that sutures of every description, when applied to an intestine and left unconfiried at the external wound, ulcerate through into the bowel and are discharged by stool, the opening made by their escape through the intestine 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 whilst the thread ulcerates into the bowel, the external coverings are replaced by new tissue. But if the liga- ture 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 observation of Dr. Smith of Philadelphia,! Gross of Louisville, Kentucky,§ as well as * Malgaigne, p. 404. f Inquiry into the Process of Nature in repairing Injuries of the Intestines, by Benjamin Travers. London, 1812. t 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 Philadel- phia Medical Society, 1805. Z An experimental and critical Inquiry into the Nature and Treatment of Wounds of the Intestines, by Samuel D. Gross, M. D. Louisville, 1843. SUTURE OF TRANSVERSE WOUNDS. 399 by many surgeons in Europe, no one can doubt the advantages of that mode of closing a wounded intestine which cuts off the ends of the thread and leaves the suture to be discharged 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; that the wound should be so accurately closed that fecal matter cannot escape; that two peritoneal sur- faces be brought in contact in order to promote adhesions; that the bowels be kept as still as possible, and that every means be em- ployed to keep down general peritoneal inflammation. Under pro- per 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.* Although such a case could not be taken as exemplifying the ordinary result, yet it may be mentioned as a fact justifying the surgeon in forming a prognosis of a more favora- ble kind than might be the case if he trusted solely to general ideas on the subject, and induce him to exert his skill towards 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 come next, according to the extent of the wound, and then the process of Jobert. In the union of trans- verse wounds, the interrupted suture is probably equal to any other. The plan of Ramdohr is generally deemed objectionable 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. * Bibliographical Index, p. lxii. 400 OPERATIVE SURGERY. CHAPTER XV. HERNIA IN GENERAL. The cases of hernia that may require a surgical operation, are those in which the contents of the tumor are strangulated at some one of the openings, usually designated as the inguinal, femoral, or umbilical rings. As the existence of hernial protrusions is very common, about one in every eight being believed to labor under them, and as the com- plaint 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 lau- dable desire to investigate the anatomical relations of a tumor which involves parts of such vital consequence, the examination of the structures connected with hernia has 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 descriptions, that has confused and puzzled the brains of many, who, under a less artificial account of the parts, would promptly have seized on all the facts possessing a practical value. The anxiety that has been shown to individualize tissues that in other parts of the body were scarcely noted, together with the habit of attaching to cellular tissue the inappropriate name of " fascia," has also tended not a little to add to the cloud which sur- rounds this subject as first presented to the mind of a young stu- dent ; 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 hernia, wears away. That the profession have materially benefited by the details furnished by the distinguished men whose names are identified with this subject, 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 can recall the earlier moments of professional experience. A very material defect in the usual account of hernia, as adapted GENERAL PATHOLOGY OF HERNIA. 401 to the wants of the surgeon, may also be seen in the tendency of surgical teachers to adopt the descriptions furnished by normal anatomy, instead of those presented in the pathological changes of the complaint; and, instead of describing the alterations of structure produced by disease, presenting a perfect and minute detail of the disposition of the parts as found upon subjects where no hernia has existed. In an account like the following, which is furnished for the prac- tical information of an inexperienced operator in the hour of need, it is thought to be inexpedient to dwell long upon the special ana- tomy of these parts. No one qualified for the study of operative surgery can be presumed to be ignorant of the principal facts in spe- cial anatomy; and in the effort which will now be made to present a concise account of the surgical or rather pathological anatomy of hernia, it will be assumed that the reader is familiar with the great points of reference as usually described by the anatomist. In this account there will first be presented those general facts which are applicable to the complaint wherever found; after which, such special descriptions will be given as may be demanded for the explanation of the peculiar condition of tissues found in the three most common varieties of the complaint, to wit, Inguinal, Femoral, and Umbilical Hernia. 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 pre- ternatural opening constitutes a hernia, though, in the majority of instances, the protruding part is composed of the intestines or omen- tum. These viscera being so situated within the cavity of the abdo- men as to have the great sac of the peritoneum in front and around them, it follows that their protrusion at any point will generally involve a prolapse also of this membrane, as well as of such other tissues as may be so situated as to be acted on by the mass. The envelops of every protrusion become, therefore, the first portion of structure to be examined. 402 OPERATIVE SURGERY. PLATE XLI. SURGICAL ANATOMY OF THE PARTS CONCERNED IN HERNIA. Fig. 1. A Sketch of the Exterior of the Abdomen, showing the general outline of the muscles, as well as the general points of reference required in operations 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 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 lineaalba. 2, 2. Rectus abdominis muscle, and linear transversa?. 3. External oblique. 4. Its ten- don, 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. Section of fascia trans- versalis 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 superficial veins. After Bernard and Huette. Fig. 4. Another view of the same as seen after a closer dissection, but especially in its relations to femoral hernia. 1. Fascia superficialis. 2. Per- forations in the superficial fascia of the thigh for the passage of the super- ficial vessels. 3, 3. Extension of the superficial fascia over the cord and testicles. 4, 4. Superficial arteries. After Bernard and Huette. rtg * H '■'■ ENVELOPS OF HERNIA. 403 § 1.—ENVELOPS OF HERNIA. The coverings of any hernia, which protrudes externally through the abdominal walls, must necessarily consist of a portion of every tissue which is to be found between the skin and the peritoneum, unless violence has destroyed the continuity of the layers, or na- ture left in them a deficiency or opening through which the tumor could escape; or unless the distension 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 a hernia, and tracing it from the abdomen outwards, we have first to notice the sac. The prolapsed portion of peritoneum, or the Sac, presents on its inside the smooth shining surface of a serous membrane, but when irritated displays the usual characteristics of the serous tissues, by giving rise to effusions of serum which often fill it, or to effusions of lymph which glue together its sides and its contents, or its density may be very much increased or diminished from that seen in the normal condition of parts. Outside of the peritoneum is generally found a cellular layer of greater or less density (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, whilst in front its adhesions are firmer and less easily overcome. In this extra-peritoneal cellular sub- stance, or outer layer of the sac, are found the more important of the bloodvessels directly connected with the operations of strangu- lated 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 cellular structure are varied. When pressure is made upon it, it becomes more developed, thick- ened, and laminated, acquiring a density and fibrous appearance which qualify it for the name of " fascia," which it has generally re- ceived. In the protrusions seen on the front of the abdomen, or in those found escaping at the groin, this layer constitutes 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 cellular tissue always more or less spread around them, or by the condensed eel- 404 OPERATIVE SURGERY. lular structure which fills up the spaces left around the vessels. Out- side of this again is found the fascia superficialis, or second grand tegumentary covering of the body, and outside of this is the skin. When, however, long-continued pressure or inflammatory action has existed for some time, these layers, which in the normal condition are easily distinguished, 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 laminse so increased, that nearly twice as many will be found over a hernia, as might be looked for as the natural envelops of the part. When muscular fibre forms one of the layers covering a hernia, there is less change observed in it than is the case with some of the other tissues. Its presence may, therefore, be generally told by its normal characteristics, and by these a distinction may readily be made of the different envelops of the tumor which otherwise it would be very difficult to recognize, the extra peritoneal and the subcutaneous fascia, or the cellular tis- sue 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 hernia will be again referred to in connection with the particular class to which it belongs. § 2.—SEAT OF HERNIA. The abdomen being a closed cavity, which is 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 occasionally been forced through it into the cavity of the chest.* Below, the abdominal contents are sus- tained by the bones of the pelvis and their attachments, the resisting nature of which is so marked, that hernia 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 opening for the thyroid artery; at the sacro-sciatic notch, where the gluteal artery passes out/and also alongside of the vagina of the female, or through a laceration of the perineum of the male. * See Bibliography, page lx. SEAT OF HERNIA. 405 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 hernia, 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 con- tents to press against the anterior parietes of the abdomen when the patient is in the erect position, and as many weak points exist in them for the transmission of the various organs of the male and female, this region is by far the most common seat of hernia in both sexes. In that part of the anterior parietes which is imme- diately at the line of the groin, there is also found openings for the escape of the femoral vessels, and at this point, anterior hernia are also frequently seen. Another class of anterior hernia which is usually designated as umbilical, presents a variety, which, though often supposed to be due to the passage of the viscera through the opening left by the umbi- lical vessels of the fetus, seldom or ever does so. This hernia, from having been rather loosely described, is liable to mislead such'as do not carefully attend to the normal relations of the part, the fact being that hernia seldom escapes by the umbilicus. In the foetus a perfect opening exists in this portion of the abdominal parietes, which is correctly designated as the^umbilicus, and through this the vessels- of the cord are transmitted; 'and whilst the latter exist, or shortly afterwards, a hernia may pass directly along the course of the vessels, but in the adult it is otherwise. At this age 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, and a hernia through the course of the umbi- lical vessels is, therefore, almost impossible. An examination of the linea alba shows, however, even in the normal condition, at many points, but especially in the neighborhood of the umbilicus a weak- ness of the structure around the course of the vessels, as well as a number of minute orifices in the tendinous parietes, which give exit to bloodvessels and nerves. When, therefore, one or more of these openings have yielded to the relaxation consequent on preg- nancies or such other causes as produce distension of the part the tumor may be designated as an umbilical hernia, because occurring m the neighborhood of the umbilicus, though, unless the aperture is 406 OPERATIVE SURGERY. found close to that through which the foetal vessels have passed, it would be more correct to designate it as a ventral hernia. § 3.—EFFECTS OF THE FORMATION OF HERNIA. 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 according to circumstances. Thus, if the protrusion has been gradual, there will generally be seen an elongation of all the tissues in front of it; whilst 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 hernia 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, and hence the protruding por- tion of the latter has been called the " sac." In order to distinguish points of the sac, it has been divided into different regions, so as to enable writers to define more accurately the part to which refer- ence is made, thus its mouth is the portion which is continuous with the abdomen ; the neck that which adjoins the opening in the abdominal parietes, through which it protrudes; whilst its body is the main cavity, and the fundus its inferior portion, or that which is most distant, from the abdomen. But, though these names gene- rally indicate the regions of the sac, and, therefore, to a certain ex- tent its outline, they are not universally applicable. Sometimes there are two distinct sacs, or the body of one sac is contracted in the mid- dle, so as to present a kind of hour-glass contraction, 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 seen immediately after its protru- sion, to replace both it and its contents in the abdominal cavity: a little later the contents may be returned; but the external surface of the sac, having contracted adhesions to the extra-peritoneal fascia (fascia propria), the sac remains (reducible hernia). Sometimes both the sac and its contents contract adhesions and are permanently fixed (irreducible hernia,) or the contents may be so constricted as to arrest the circulation, and lead to the development of a certain train of IRREDUCIBLE HERNIA. 407 symptoms designated as those of strangulated hernia. 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 demand- ed; but before proceeding to the details of this operation, the general symptoms of each kind of hernia may be advantageously described. § 1.—REDUCIBLE HERNIA. Symptoms.—All hernia, whether reducible, irreducible, or stran- gulated, give rise to tumors which vary in shape, size, and position. The constitutional disturbances caused by reducible hernia are such as may be chiefly referred to derangement of digestion, as con- stipation, belching, rumbling, dragging pains in the belly, and occa- sionally a disposition to nausea or vomiting, all of which are relieved when the contents of the tumor are replaced in their natural posi- tion, as sometimes happens when the patient lies down, or when pres- sure is properly made upon the protruded portion. The other symp- toms being often the result of the peculiar position of the hernia, will be detailed under their special heads. § 2.—IRREDUCIBLE HERNIA. Symptoms.—The tumor caused by this class of hernia is more or less permanent, varying in size and symptoms according to circum- stances ; thus constipation, flatulency, the erect posture, corpulency, or pregnancy, may increase it, by filling the cavity of the bowels, or by obstructing 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 hernia than it is in the reducible class, on 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 con- sequence of the fixed position of the omentum or intestine interfer- ing with the distension and upward movements of the stomach, espe-' cially after a full meal. Irreducible hernia 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 de- tailed as the result of strangulation. 26 408 OPERATIVE SURGERY PLATE XLII. A VIEW OF SOME OF THE PARTS CONCERNED IN INGUINAL AND FEMORAL HERNIA. Fig. 1. Surgical relations of the Bloodvessels in Inguinal and Femoral Hernia. 1. Skin, fascia, external oblique, internal oblique, and transver- salis muscles incised. 2. Fascia transversalis and peritoneum covering the intestines. 3. Position of internal inguinal ring. 4. Epigastric vessels. 5. Section of rectus abdominis. 6. 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. Cre- master and tunica vaginalis communis, or the fascia propria of the hernia. 4. Sac. 5. Omentum. 6. Intestine. After Bernard and Huette. Fig. 3. View of a direct inguinal or a ventro-inguinal 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 epigastric 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. Pe- ritoneal cavity. After Bernard and Huette. Fig. 5. Peculiar form of a sac, as occasionally seen. 1. Abdominal pa- rietes and ring. 2. Fundus of sac. 3. Body of the sac above an hour-glass contraction. 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 Huelte. Fig. 7. Next step of the formation, as seen in a recent hernia. 1. Ab- dominal 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. Ab- dominal parietes. 2, 2,2. Intestine. 3,3,3. Continuous line of peritoneum. After Bernard and Huette. ■;•;"'■:;■ ■■■■:.'■ n ^: \ % STRANGULATED HERNIA. 409 § 3.—STRANGULATED HERNIA. When either a reducible or irreducible hernia becomes constricted 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. These symptoms may arise either in consequence of a sudden protrusion of intestine through a small aperture; from the distension 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 bands at its mouth as the result of inflammation. Symptoms.—The symptoms of strangulated hernia 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 strangulation results simply from obstruction to the passage of matter through the protruded part, and when it is the result of inflammation. When the consequence of simple obstruction, the patient expe- riences a sense of uneasiness, fullness, or constriction, in the part or in the abdomen, as if a cord was drawn around the latter, accompanied with 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 con- tents of the stomach, then of mucus and bile, and subsequently by distressing retching, restlessness, moisture of the skin, irritation and excitement of the pulse, and the other usual symptoms of a bad at- tack of colic. If promptly relieved by a reduction of the tumor, these symptoms will all disappear, 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 ab- domen. 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 vio- lent symptoms may be the first indications given of the existence of constriction, 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 410 OPERATIVE SURGERY. greater tension and tenderness of the tumor, in increased tenderness and swelling of the abdomen, in increased vomiting, which often brings up stercoraceous matter, accompanied or followed by hic- cough, and in a change in the color of the tumor, which becomes dark red or livid, and gives a doughy or crackling 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. On examining the parts post mortem, there is no difficulty in recognizing the previous existence of such an acute inflammation as has resulted in a more or less advanced stage of mortification. Occasionally, however, patients rally even after mortification has been developed, the external coverings of the tumor ulcerate and open, the slough separates from the most diseased portion of the in- testine; but the adjacent parts being glued to the side of the seat of protrusion, by the lymph resulting from the inflammation, the peri- staltic action of the bowel forces its contents out at the opening thus made, and gives the patient the complaint designated as Artificial Anus. SECTION II. TREATMENT OF HERNIA. The symptoms above detailed having shown that the dangers of hernia, 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 may be resolved into either a prevention or removal of this constric- tion. 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, but bearing in mind, in all his 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. REDUCTION OF HERNIA. 411 § 1.—REDUCTION OF HERNIA. The manual treatment requisite for the reduction of hernia is de- signated by the term taxis (taau>, to arrange), signifying the replacing of the contents of the tumor in the abdominal cavity. To perform the taxis with success, it is desirable that the parts constricting the tumor, as well as the muscular system generally, should be placed in as perfect a condition of relaxation as possible, both by means of position and also by constitutional measures, and that the pressure of the fingers should be made in the axis of the tumor, unless its peculiar position requires some slight modification of the rule, as will be shown in connection with the special cases. At present, the general arrangements likely to facilitate the reduction of all hernia, where any difficulty is experienced, alone claim attention. The earliest causes of difficulty in the reduction of most hernia being found in the accumulation of matter within the protruded por- tion, the first point to be attended to is the emptying of the bowels below by enemata, and of the stomach by emetics, especially if a full meal has preceded the difficulty, and nature has not already accom- plished this object; whilst the bladder should be voided of its con- tents in order to give as much room as possible within the cavity of the abdomen. The next point of danger being the tendency of the constricted part to inflame, blood should be freely drawn, and will prove use- ful, not only by diminishing the general force of the circulation, but also by relaxing the system and promoting a freer circulation through the adjacent parts. 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 diminish the frequent action of the diaphragm and respiratory muscles. To accomplish this, nothing, in my expe- rience, is comparable to perfect etherization; as the patient, in this state, always lies perfectly quiescent, and has a respiratory movement of so slight a kind as, compared with the efforts which are usually made by them 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 reduc- tion without the abstraction of blood, the warm bath, or any of the other means usually employed; but the entire evacuation of the con- 412 OPERATIVE SURGERY. tents of the stomach should always precede the employment of the anaesthetic. Should circumstances prevent a resort to this powerful agent, then the practitioner must find some other means of inducing the same degree of muscular relaxation, such as the warm or hot bath, or the use of tobacco or tartar emetic. The employment of tobacco in the form of infusion in the proportion of a drachm to the pint of water, one-third or one-half of which is thrown into the rectum at a time, is a very powerful means of inducing this relaxation, but it is liable to the objection of exciting a longer and more tho- rough depression of the system than is desired, in consequence of the continued absorption of the infusion if the rectum does not expel it, as sometimes happens in consequence of the relaxation of its muscular coat, even though the sphincter ani offer no impediment to its escape. A much safer and more controllable method of ap- plying it will be found in the following 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 sup- pository, and when a sufficient constitutional effect is induced, draw the bag out by means of the string, which has been left pendulous at the anus. Various local means have 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 are mostly protruded through aponeurotic openings, little or no relaxation of the seat of the stricture can be anticipated, and the heat, by causing an afflux of blood to the part, must tend to increase the local congestion in the vessels of the tumor, especially if omentum constitutes a part of it. Cold, on the contrary, will diminish this congestion, excite con- traction or peristaltic action in the bowel, and thus favor the reduc- tion of the tumor, whilst 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. When a hernia has been reduced, a good truss should be well adjusted to the opening to prevent further protrusion. The other points connected with the treatment of reducible her- nia, will be detailed in connection with their special application to each of the three principal classes of this complaint. MEANS OF CURING REDUCIBLE HERNIA. 413 § 2. —MEANS OF RADICALLY CURING REDUCIBLE HERNIA. After the reduction of a hernia and the application of a truss, the patient is secure for the time from the dangers of strangulation, and though it has been asserted that radical cures have been effected by the constant use of the instrument inducing such adhesions and induration of tissue as plugged up the ring, my opportunities (and they have not been slight), have never enabled me to see one well- grown adult who had obtained this result from the use of an instru- ment. In children and young persons such a condition has been created as prevented the reproduction of the complaint for years; yet, even in these patients, the success has been far from constant. The most, therefore, that can be asserted of any truss is, that after its application, the patient is not liable to a descent of the hernia, provided it fits well, and is constantly worn. The manufacture and application of these instruments having, in many sections of the country, passed into the hands of ignorant men, professional evi- dence of the advantages resulting from the use of any particular kind of truss is rare. Some, I think, do more harm than good, and the surgeon should, therefore, make it his duty to examine the mode in which the truss is worn, as the instrument is often so badly adapted to the part as to increase the complaint. It being generally admitted that little or no reliance can be placed upon a truss for the accomplishment of the radical cure of hernia, several surgeons have endeavored to find some other means of effecting this important object. Most of these, though differing in the details, have had one grand object in view, and that is, the creation of such a condition of the parts as would effectually and permanently close the opening. One or two of these plans will now be briefly stated. Operation of Gerdy.*—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's-hair pencil, being prepared, the operation is thus perform- ed:— "Whilst the patient is lying down, the surgeon places his left forefinger under the anterior edge of the scrotum, pushes back the * Malgaigne. 414 operative surgery. skin from below upwards 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 portion 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, whilst 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 finger, 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's-hair pencil should be dipped in the ammonia, and the scrotal skin in the pouch cauterized sufficiently to destroy its epi- dermis. 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. Radical Cure of Hernia, by Dr. J. C. Nott, of Mobile.— A man, aged fifty, labored under enlargement of the testicle and scrotal hernia. After Dr. Hicklin, the attending surgeon, had re- moved the testicle, Dr. Nott proceeded to the cure of the hernia. Operation.—Extending the incision a little above the external ring, the latter was fully cleared of cellular 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 opposite 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 MEANS OF CURING REDUCIBLE HERNIA. 415 to.admit three fingers to pass into the abdomen, was only reduced •by' (he operationtb-^kfrut half its breadth. The integuments were tnow united by suture, &c. The wound suppurated very profusely, and was about six weeks in closing, owing to peculiar difficulties. Two months after the ope- • jp-tioira hard, insensible lump occupied the seat of the external ring, where the wire had* been placed, and four months subsequently the 'ialient, though engaged at hard labor, had had no return of his ^ernia. :■• i(RemarRS.—Attempts to oure hernia radically date back to a very early period' of the profession—Celsus, Aetius, Guy de Chauliac, and other surgeons, having advised various means of ac- complishing it. Few, however, seem to have presented unexcep- tionable facts, as ea'ch period seems to have been dissatisfied with the acts of its predecessors, and to have endeavored to remedy the operation, or suggest another. The application of a ligature around the sac was advised especially by Guy de Chauliac, A. D. 1360, ss}\o 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 Dr. Nott, present^ however, a modification which may prb've to have several advantages over the old-fashioned thread, and the strangulation of the neck of the sac. Of the operation of Mr. Gcrdy, I have only to say that my personal observation of some of husycases, several years since, did not induce any confidence in its ultimate success. A modification of the plastic operations was also tried many years ago by Dr. Jameson, of Baltimore, but though the patient was benefited, I am not aware of its having been repeated. ^ -Upon the whole^I incline to the opinion that the result of the operations for the radical cure of hernia will be doubtful in the majority of cases, though, as it has succeeded, at least for some few mpnths, other surgeons .may deem it proper to repeat the trial. If Galled on to seleciany one method of operating, I should prefer the .use of a leaden ligature around the ring and neck of the sac, in a manner somewhat similar to that reported by Dr. Nott. 416 OPERATIVE SURGERY. PLATE XLIII. SURGICAL RELATIONS OF THE PARTS CONCERNED IN HERNIA. Fig. 1. A view of the relation of the Internal Oblique and Transversalis Muscles to Inguinal Hernia, showing the mode of formation of the Cremas- ter Muscle. 1. 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. Common tendon of the last two muscles. 5. Cremaster muscle as seen upon the cord, but not extended upon the testicle, as is usually the case. After Bernard and Huette. Fig. 2. A view of the relations 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 external oblique everted. 2. Section of fascia transversalis. 3. Intestines seen through the peritoneum. 4. The cord. 5. Mouth of 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 external oblique, and 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 external oblique. 2. Same slit open. 3. Fibres of internal oblique and transversalis, or the cremaster muscle. 4. Tunica vaginalis communis. 5. Probe passed beneath vessels of 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 com- munis of the cord. After Bernard and Huette. Fig. 7- Mode in which a Hernial Sac is formed. 1, 1. Point of pro- trusion. 2, 2. Intestine about to escape. 3, 3. The peritoneum as pro- truded in front of the intestines. After Bernard and Huette. SURGICAL RELATIONS OF INGUINAL HERNIA. 417 CHAPTER XV. STRANGULATED INGUINAL HERNIA. Inguinal Hernia, in the male, consists 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. By briefly referring to the changes induced upon the parts by the descent of the testicle, the comprehension of the anatomical relations of such portions as are directly connected with the operation, will, it is thought, be aided. SECTION I. SURGICAL RELATIONS OF INGUINAL HERNIA. When the testicle of the foetus leaves the loins in its descent to the scrotum, 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 extra peritoneal fascia (fascia transver- salis) ; next a few fibres of the transversalis muscle ; then a few of the internal oblique muscle, the two together constituting the cremas- ter muscle. Passing then through a slit in the aponeurosis of the external oblique muscle of the abdomen (external abdominal ring), it extends a 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 superfi- cialis, cremaster muscle, condensed cellular tissue (tunica vaginalis communis), and by the peritoneum (tunica vaginalis testis), and the cord has the epigastric artery between the linea alba and the line of its descent (inguinal canal). Shortly after taking its position in the scrotum, the tube-like pro- cess of the peritoneum, which then extends from the scrotum to the 418 OPERATIVE SURGERY. abdomen, is obliterated, though sometimes it remains open (con- genital hernia, congenital hydrocele), or is only closed at points (encysted hydrocele, hydrocele of the cord). The process of fascia transversalis (extra peritoneal cellular tissue), which had been pro- truded 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 cord, whilst the remaining layers contract upon the cord and are dimin- ished in character and distinctness. A portion of intestine or omentum (hernia) pressing against the peritoneum at the same point of the abdominal parietes, does the same thing as the testicle did, that is, pushes a portion of the peri- toneum in advance of it, unless the sac formed by the descent of the testicle had 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, espe- cially in old hernia, and take on a defined shape (internal ring) whilst the centre is either absorbed or converted into a reticu- lated structure (fascia propria), and then the tumor passing on takes a position in front of the cord, but also a little towards the median line of the body. Being here beneath the fibres of the transversalis and internal oblique muscles (cremaster), it escapes through the opening in the tendon of the external oblique muscle (external ring), pushes before it the cellular tissue which usually fills up this ring (inter-columnar fascia), and pressing it against the superficial fascia, the two become blended in one, and there only remains the addi- tional covering of the skin. In operating upon an inguinal hernia there are, therefore, usually found the skin, superficial fascia, cre- master muscle, fascia propria and sac, all of which must be divided before the contents of the tumor can be made apparent. The only bloodvessels about this class of tumors, are a small artery and vein (arteria ad cutem abdominis), found directly beneath the su- perficial fascia, and the epigastric artery and vein, which is directlybe- neath the peritoneal fascia. The arteria ad cutem abdominis is there- fore between the fascia superficialis and the external oblique tendon, whilst the epigastric artery is between the fascia transversalis and the TAXIS. 419 peritoneum. In indirect inguinal hernia, the latter artery is towards the inner side of the contents of the tumor, that is, towards the linea alba, and runs parallel with the external edge of the rectus abdominis muscle, whilst in 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 peritoneum and fascia transversalis elongates the first, and causes a thickened margin to the second, this artery is removed a line or two from the edge 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 inter- nal 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, approximates these two rings, so that one is often very nearly in contact, and also behind the other, and the epigastric artery brought, therefore, more towards 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 side of the protrusion. SECTION II. OPERATIONS FOR THE RELIEF OF STRANGULATED INGUINAL HERNIA. The operations required for the relief of this kind of hernia con- sist in that performed for the restoration of reducible hernia, and that requiring the division of the parts by the knife for the relief of the strangulation. § 1.—TAXIS. Taxis, or the means resorted to for replacing a reducible hernia within the cavity of the abdomen, consists in manipulating the tumor so as to press the portion which was last protruded, first through the ring or opening at which it has passed, the remaining 420 OPERATIVE SURGERY. part usually following readily the course of the first, when a judi- cious continuance of the pressure is persevered in. In making the taxis in cases of inguinal hernia, it is essential to success that the parts concerned should be in a state of perfect re- laxation, and that the patient should offer no resistance 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 is, therefore, especially demanded in these cases, 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, he should, before being etherized, or when the latter agency ia 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 his right hand, and draw it gently downwards, 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 upwards and backwards the portion last protruded, 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 approx- imated to the summit, and the effort made with the fingers of the left hand near the ring to push into the abdomen some small portion of it, or this part may be slightly compressed by these fingers, whilst 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 upwards and backwards 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 towards the rincr, and then retaining it there a few seconds. (Plate XXXIX., Fig. 6.) If, after moderate manipulation in this manner, no dimi- nution 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 abdomen 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 TAXIS IN INGUINAL HERNIA. 421 replaced, the rest will usually follow; and when the protruding portion is intestine a distinct gurgling sound will be perceived as the last part returns to the belly, in consequence of the liquid or gas which had been confined in the constricted portion again passing into the main channel. If, after one or two trials of these means, no change is effected, then it may become a question whether it is better to resort to the knife, or to repeat the taxis. In small hernia, 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 inflammation in the part. When, therefore, in such cases, no progress is made, notwithstanding a judicious employ- ment of the adjuvants before alluded to, a repetition of the taxis can only tend to increase the patient's danger. But in large and old hernia, unaccompanied by much pain, or where the hernial con- tents have occasionally been down before, but reduced with some trouble, the repetition of the trial may succeed, especially if cold applications are continued to the tumor in the interval of the at- tempts. In recent and small hernia, 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 practiced, that is, in the line of the axis of the tumor, or upwards towards 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 orice happened that in these hernia, after everything has apparently been tried and a resort to the knife been decided on, a slight and appa- rently hopeless effort has suddenly caused the tumor to disappear. With young surgeons there is apt to be too much delay before re- sorting to the knife, and the force employed in the taxis is often too great. It should, therefore, be remembered that delicacy of manipulation will generally succeed better than force, and that the ultimate success of the operations for the relief of strangulation, has been most marked in those cases where it was not delayed until positive and high inflammatory action was established. Dessault assumed it as a maxim that "success might always be anticipated in a hernia which had not been touched before operating,* and was * ffiuvres Chirurgicales, as quoted by Parrish on Hernia. Philad., 1836. 422 OPERATIVE SURGERY. often successful where strangulation had existed five days, but almost constantly failed when strong efforts had been previously made in the taxis. The resort to cold combined with modcmtc pressure, and continued^for a half hour, has frequently succeeded even when judicious taxis had failed; and it may be readily accom- plished by the application of a flat-iron upon the swelling. But the dangers of delay should always be borne in mind, even when these means are employed, though they are less likely, to excite inflam- mation than the repeated pressure of the fingers in the taxis. Dr. Joseph Parrish, of Philadelphia, whose experience in hernia was quite large, coincided in the opinion of Mr. Hey, " that he had often had occasion to regret performing the operation too late, but never too early."* In making taxis for the relief of strangulated hernia, it is im- portant that the symptoms should disappear when the reduction is accomplished. Should they not do so, and yet'the restoration of; the parts within the abdomen be certain, it may be necessary to in- cise the canal and seek for the constricted tumor in the abdomen. The condition of the parts concerned in the reduction of hernia "en bloc" or "en masse," as the French describe* it, requires prom'p't.. relief. Want of space must, however, compel me to refer the reader to other sources for information on this important subject. In the work of Dr. Parrish, and in an article by Dr. Gre.o.. C. Blackman,t of New York, will be found many valuable details." § 2.—OPERATION IN STRANGULATED INGUINAL HERNIA. " v The operation of dividing the stricture in order to relieve the constriction of hernia, consists in dissecting the different coverings 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 subsequently unnecessarily exposed to a further, escape of the vis- . cera. • l '\'r'' 'A. Preliminary Measures.—Before commencing the operation, the surgeon should properly prepare such instruments as may be re- * Parrish on Hernia, p. 28. . f Am. Journ. Med. Sciences, vol. xii. N. S. p. 386, 1846. OPERATION IN STRANGULATED INGUINAL HERNIA. 423 quired, 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 tenaculum, 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 sub- sequent 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 supported on chairs, room being left for the operator to stand between the knees. Should the operation be demanded, as is often the case, after sunset, 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 to the wants of the patient. Ordinary Operation.—In commencing the operation, the selec- tion of a mode of incising the skin must depend upon the abilities of the operator. If the surgeon is dexterous, its division may be effected by holding the scalpel in the first position, or like a pen, 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 him to pick up a fold of it transversely to the axis of the tumor, between the thumb and fingers of his left hand, whilst 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 scalpel, incise it by cutting from within outwards, so as to expose the fascia superficialis to the full length of the proposed incision; or if the cut, as 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, according 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 * See Smith's Minor Surgery. 27 424 OPERATIVE SURGERY. PLATE XLIV. A VIEW OF THE OPERATIONS PERFORMED FOR INGUINAL HERNIA Fig. 1. The first step in G-erdy'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 the 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 in Inguinal Hernia. A fold of the skin having been raised transversely over the tumor is about to be divided by the scalpel from without inwards. After Bernard and Huette. Fig. 5. Mode of dividing the 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, towards the hand, 1, so as to give it a gentle rocking motion. After Bernard and Huette. Fig. 9. Mode of dividing the stricture upon a broad director, when the constriction is too tight to permit the passage of the finger bAeath it. 1. The director. 2. The bistoury. After Bernard and Huette. Fig. 8. Relations of 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. Kft- /. Fig. 4 Fig. 3. OPERATION IN STRANGULATED INGUINAL HERNIA. 425 the forceps, so as to form a little fold at the most prominent point of the tumor, and this being nicked by pressing the scalpel against it, whilst the surface of the blade lies flat upon the tumor, an opening may be made and a director passed into it so as to enable the operator safely to slit up the layer both above and below to the extent that may be desired. (Plate XLIV. Fig. 5.) Next, picking up another layer in the same manner, treat it likewise, and proceed to divide the laminae until the contents of the tumor can be distinctly felt, or per- haps indistinctly seen beneath the serous layer or sac, the latter being more or less thickened according to circumstances, although it never presents the shining appearance of peritoneum on its outside, owing to the changes produced by the complaint. 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 gene- rally 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 cellular tissue, or like the structure usually seen in front of the intestines when in situ, unless it has been very much engorged by the constriction. Having thus reached the contents of the tumor it only remains to divide the stricture, the position of which, though varying some- what, may generally 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 latter being, especially in old hernia, directly behind the external ring. Then, as it is 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 fore- finger as far up as possible, and endeavor to get the finger-nail be- tween the constriction and the bowel, depressing the latter by bear- ing on it with the back of the finger, whilst an assistant also keeps it as much as possible out of the way, or the director may be substi- 426 OPERATIVE SURGERY. tuted 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 fore- finger, or along the groove of the director, and carrying the point beneath the stricture, when, having accomplished this, it only re- mains to turn its edge directly upivards, 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 endeavor to dilate the stricture by means 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, as is sometimes the case, an instance of which is re- lated by Dr. 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 ligature, 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 lat- ter, they will be discharged per anum, and the opening that would otherwise have resulted, be filled with lymph, as the result of the inflammation thus excited. But if the sphacelus is more extended, 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 should escape into the cavity of the abdomen, and the separation of the slough give rise to peritonitis. If fastened in the wound, the sloughing of the bowel can only produce an artificial anus, the heal- OPERATION IN STRANGULATED INGUINAL HERNIA. 427 ing of which will often be accomplished by nature, or may be effected by some other means, as will be hereafter directed. Many expe- rienced surgeons have, however, regarded the use of this suture with distrust, Dessault and others having shown that the inflammation which preceded 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. Should the contents of the tumor be omentum instead of intes- tine, and the strangulated portion of this 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 open- ing, 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, and a morsel of lint being intro- duced into the lower angle of the wound to prevent the skin heal- ing, and also to preserve a vent for the subsequent suppuration, the adhesive strips, cerate, compress and spica bandage may be applied, and the patient 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 circum- stances, 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 castor oil, or rhubarb and magnesia, on the second day, the patient being compelled to keep in bed, and use a bed-pan or some other convenience, when it operates, and during the first week the diet should be 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 * Parrish on Hernia, p. 104. 428 OPERATIVE SURGERY. confined to the supine posture until the part has healed suffi- ciently to bear the pressure of a light truss over the compress and bandage. Remarks.—In the account just furnished of the operation re- quired for the relief of strangulated inguinal hernia, the effort has been made to limit the description to such details as are most fre- quently demanded. Several complications have, therefore, been in- tentionally omitted, lest reference to them should tend to embarrass the mind of the young surgeon, and render the operation unnecessa- rily difficult. It should, however, be remembered that all hernia 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 com- plaint, will soon enable any medical man who contemplates the pos- sibility of performing this operation, to obtain a knowledge of these peculiarities. Little has also been said of the appearances 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 contending with such difficulties, he should, if pos- sible, obtain the advantages of a consultation with some older practi- tioner. To be able to anticipate every peculiarity that may be met with in these cases, requires a combination of fortunate circum- stances that none but those who have been widely engaged in sur- gery, 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 hernia, if he opens the various layers cautiously, divides the stricture only so far as will relieve the ob- struction to the circulation of the part, and does not restore the contents of a hernia into 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 Mr. Key, and others, of high au- OPERATION FOR STRANGULATED INGUINAL HERNIA. 429 thority, but the propriety of it, as an operation adapted to the inex- perienced surgeon, is deemed by many others a matter of doubt. The greatest objection to it is the risk that is always run of reduc- ing 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 my opinion, a dangerous and uncertain operation. § 3.—Statistics. In order to present some idea of the usual results of this opera- tion, the following cases have been selected from various sources, and arranged so as to readily indicate the result. STATISTICS OF THE OPERATION FOR STRANGULATED INGUINAL HERNIA. South* reports......8 cases Astley Cooper! " ...... Geoghegang " . ..... Lawrence|| " ...... Brandfl " ...... Percival Pott** " ...... Scarpaff " ...... RichterJJ " ...... 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 have recovered. * Chelius, by South, vol. ii. p. 312. X Treatment and Anat. of Inguinal Hernia. \ Commentary on Treatment of Ruptures, by Ed. Geoghegan. || Treatise on Ruptures. \ Chirurgical Essays. ** Treatise on Ruptures. ft Treatise on Hernia; also Arnaud. XX See Scarpa. CURED. died; ARTIF ANUS. 8 cases. 6 2 11 " 8 2 1 3 " 2 1 9 " 5 4 2 " 1 1 1 " 1 0 7 " 6 1 1 " 1 0 430 OPERATIVE SURGERY. CHAPTER XVI. STRANGULATED FEMORAL HERNIA. Femoral or crural hernia is that form of rupture in which the protrusion 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 out upon the thigh. On reaching this point, a hernia will generally follow the course of the sheath of the femoral vessels and then pass out at the opening of a superficial vein (vena saphena), till, reaching the exterior surface of the aponeu- rotic 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, though, from the posi- tion of the ccecum, a portion of the large intestine has occasionally been found in the sac, instead of the smaller bowels, as is the case in inguinal hernia. SECTION I. ANATOMICAL RELATIONS OF FEMORAL HERNIA. The boundaries of the region concerned in femoral hernia, are formed posteriorly by the iliacus internus and psoas magnus muscles, covered by a condensed fascia, which, as it follows the course of the muscle, is hence called iliac fascia. Anteriorly, we find that por- tion of the tendon 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 the 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 ANATOMICAL RELATIONS OF FEMORAL HERNIA. 431 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 has been compared to that of a funnel, of which the abdomen forms the body and the course of the femoral vessels the spout, whilst the extension upon the vessels of the process of the iliac fascia behind, and the fascia transversalis in front, has given to the portions of these tissues which surround the vessels, the name of "infundibular fascia." It will, there- fore, 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 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 communication is established between the. thigh and the cavity of the abdomen. In health, the adhe- sions of the surrounding parts, together with cellular substance and lymphatic glands, close it entirely; but the action of any of the causes which would force the abdominal contents towards this point, may cause these adhesions to yield, and then the following results may be noted. The abdominal contents being behind'the peritoneal sac, must, in their course outwards, press before them first a portion of the peritoneum (hernial sac), then the cellular tissue of the opening, or the extra peritoneal cellular 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 432 OPERATIVE SURGERY. into the course and sheath of the femoral vessels, it has no other covering. As the psoas and iliacus muscles are on the outer side of the vessels as they pass beneath Poupart's ligament (crural arch), the tumor naturally tends towards 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 outside. (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 ves- sels and the superficial veins, this sheath is perforated at numerous points (cribriform fascia), through which the tumor, by gradual dis- tension, is enabled to escape. Here again the hernia would con- tinue 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 be- neath it and join the femoral vein, and at this point (saphenous open- ing), where this vein enters, the tumor escapes (Plate XLV. Fig. 3), and thus getting outside. The fascia lata lies directly beneath the fascia superficialis and 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 hernia, the peculiar arrangement by which the saphena vein gets through the fascia lata femoris has received considerable attention, and unfor- tunately 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 fas- cia, whilst that over the pectineus muscle is called the Pectineal fascia. The sartorius muscle being also above the level of the pec- tineus, the portion of the fascia lata covering it is compelled to double itself and take the form of a crescent, in order to expand upon the pectineus muscle, and this crescentic margin has, therefore, been named by Mr. Burns "the Falciform process" of the fascia lata, whilst the extreme point of the horn or crescent has received the appellation of " Hey's ligament.'' An ordinary observer will often fail to notice these points, but a close dissection, and removal of the loose cellular tissue, with some traction from the knife- handle, will make them and many other little details perfectly appa- rent to any one who will look for them. From the looseness of the cellular tissue between the fascia super- ficialis and the fascia lata femoris near the pubis, this hernia is most ANATOMICAL RELATIONS OF FEMORAL HERNIA. 433 apt to rise upwards towards the groin, instead of following the down- ward course of the saphena vein, and it therefore approaches the lower edge of Poupart's ligament. The relations of the different parts in this region are usually sim- ple. At the crural ring, counting from the outshie 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 becomes femoral, or directly beneath Poupart's ligament, we also usually find the epigastric artery, which consequently is at the outer margin of the hernial 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 pec- tineus and adductor muscles, may, therefore, be at the inner side of the tumor, whilst the internal circumflex, if it should arise from the epigastric, would be in front of it. Such an arrangement is, however, very rare, the usual relations of the vessels to the tumor being such as present the femoral vein outside, the epigastric artery also outside, but a little nearer to Poupart's ligament, and the obturator artery inside or near the-edge of Gimbernat's ligament. The division of any stricture at these parts should, therefore, be made very slightly but directly upwards, and at the middle of the ring, especially in males, because the position of the structures 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 the stricture upwards, and a very little inwards, 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 stricture, it is the 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. 434 OPERATIVE SURGERY. SECTION II. OPERATIONS FOR THE RELIEF OF STRANGULATED FEMORAL HERNIA. These operations, like those described for the relief of the other forms of hernia, consist in the Taxis, and in the division of the stricture. § 1.—TAXIS IN FEMORAL HERNIA. The general details of the performance of taxis having been al- ready given in connection with inguinal hernia, it is only necessary at present to refer to the peculiar direction in which these efforts should be made. The greatest diameter of the tumor in femoral hernia being transverse, in consequence of the development of the subcutaneous cellular tissue of the part, it is generally requisite to resort to a peculiar manipulation and position of the patient in order to favor this operation. Thus, on flexing the thigh on the pelvis, whilst 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 ; whilst the psoas and iliacus muscle will be less apt to compress it from be- hind. By carrying the limb of the affected side also a little to- wards that of the other side, and by turning the toes of the foot on the hernial side, very much inwards, 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 ether- ized, it only remains for the surgeon to press the tumor gently downwards and inwards, in the line of the saphena vein, in order to free the hernia from the projecting edge of the falciform process, and then, with the fingers of the other hand, to push it upwards in the line of the femoral canal. (Plate XXXIX. Fig. T.) The tight- ness of the parts through which femoral hernia passes, and the sharp edge of the constricting part, renders, 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. OPERATION FOR STRANGULATED FEMORAL HERNIA. 435 Less effort should, also, be made in the taxis of this hernia than in the preceding class, and when the tumor does not promptly yield to the judicious application of the means before mentioned, the operation of dividing the stricture should be promptly resorted to. § 2.—OPERATION FOR STRANGULATED FEMORAL HERNIA. As the tumor in femoral hernia is formed by the sac and its con- tents escaping at the saphenous opening, and then rising up towards 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 recommended, all based on the general direc- tion 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 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 tumor was so large as to render the skin tense and difficult to raise, by incising it with the scalpel as in an ordinary dissection. When the tumor is small, or not larger than an egg, 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 ±, 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 Mr. Lawrence one which, beginning an inch above the crural ring, ran obliquely downwards and outwards. After freeing the skin, the superficial fascia may be recognized by its containing several inguinal glands together with more or less fat; and from infil- tration, 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 struc- ture 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 436 OPERATIVE SURGERY. PLATE XLV. PARTS CONCERNED IN THE OPERATION OF FEMORAL HERNIA. Fig. 1. Position of Crural Ring and attachment of Poupart's Ligament. 1. Anterior superior spinous process. 2. Ilio-pectineal ridge. 3. Femoral ring. 4. Septum between femoral vessels and 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 Hernia. 1. External oblique muscle. 2. Its tendon cleared of the fascia. 3. Fascia lata femoris. 4, 4. Superficial femoral fascia everted. 5. Cribri- form 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. Exter- nal oblique. 2. Its tendon. 3. Fascia lata. 4. Its cribriform structure raised up. 5. Sheath of 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 abdomen. 2. Tendon of external oblique. 3. The muscle. 4. Spermatic cord. 5. Femoral artery. 6. Femoral vein. 7. Intestine protruding at 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. Ring. 2. Fundus of principal sac. 3,3. Cavity of peritoneum. 4. Fundus of 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 Hernia. 1. Tendon of external oblique. 2. Poupart's ligament. 3. Psoas and iliacus in course to their insertion. 4. Femoral artery. 5. Femoral vein. 6. Spermatic cord. After Bernard and Huette. Fig. 8. A posterior view of the reflections of the Peritoneum upon the abdominal parietes. 1. Bladder. 2. Reflection over round ligament of bladder. 3. Reflection over same on opposite side. 4. Reflection over urachus. 5. Position of indirect inguinal hernia. 6. Oblique inguinal. 7. Ventro-inguinal. 8. Femoral artery. 9. Femoral vein. After Bernard and Huette. m \ v ift., Pi v. 7 ;**Yj' .~j* • OPERATIONS FOR VESICO-VAGINAL FISTULA. 559 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 altogether, 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 consist entirely of liquid, mucilaginous food, until the ligatures separate; the bowels, which should be freely evacuated prior to the operation, be kept at rest for some days, and as little effort made by the patient to empty the bladder as is possible, till some weeks have elapsed. Remarks.—Out of nine of the cases operated on in this manner by Dr. Hayward, three succeeded perfectly; five were relieved, and the others not benefited; and I have also performed a similar ope- ration once with much relief to the patient. Operation of Dr. John P. Mettauer, of Virginia.*—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:— Operation.—After a preparatory constitutional treatment, the woman was placed .and confined as in the operation for lithotomy, the vagina dilated by two broad spatulae pressed against its opposite sides, and the edges of the fistula denuded by seizing them with delicate hooks, and trimming them with keen scissors, curved flat- wise. A straight needle, thirteen lines long, was armed with a silk ligature, doubled so as to form a noose at one of its free ends fully six inches long, upon which the bent extremity of a leaden wire, of small size, was fastened, and then by forceps and a porte needle the first leaden suture was applied and loosely twisted so as not to pucker the edges of the fistula. Eight distinct sutures, being then formed and loosely twisted, were progressively tightened until the opening was perfectly closed, when the ends of the wires were brought out at the vulva, the soft parts being protected by investing them with oiled silk, after which a catheter was fastened in the bladder. The wires were tightened on the third, and again on the seventh day; the bow- els were not moved until the eighth, and on the thirteenth day the sutures were removed, and "perfect union found to have 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 * Am. Journ. Med. Sciences, vol. xiv., N. S., p. 107. 560 OPERATIVE SURGERY. the patient subsequently had two children without a return of the accident. Operation of Dr. J. Marion Sims, of Ala.—Being dissatisfied with the success attending the repetition of the ordinary operations upon three cases in which he tried it, Dr. Sims, after devoting much time and study to perfecting instruments, and a mode of operating which could render this formerly intractable affection perfectly cura- ble, has, in a well-written paper,* described very minutely his views of the subject. To his more extended account, I must refer the reader who desires further details than is compatible with my pre- sent limits, confident that the perusal of the original article will fur- nish him with such information as will prove practically useful. Operation.—Having prepared the instruments figured in Plate LVIII., Figs. 1 to 10, and given every attention to the general con- dition of the patient, the operation should be conducted in the fol- lowing 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 whilst 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 abdo- men. 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 upwards and outwards open the os externum. The pelvic and abdo- minal viscera being thus made to gravitate towards the epigastrium, the presence of the atmosphere will suffice to distend the vagina to its utmost limits, thus freely exposing the os tincae and fistula. To facilitate the view of the operator, the assistant on the right side of the patient should also elevate the perineum and recto-va- ginal septum by means of the lever speculum (Plate LVIII. Fig. 1). A smaller speculum (Plate LVIII. Fig. 2) being used to press the urethra downwards against the symphysis pubis, when circum- stances demand it. In most cases, a good northern light a clear day will suffice for the display of the canal, but if more is requisite, a looking-glass should be so arranged as to throw the rays * Am. Journ. of Med. Sci., vol. xxiii. N. S. p. 59, 1852. operations for vesico-vaginal fistula. 561 of the sun upon the part. The orifice of the fistula being now dis- tinctly 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 fistulae, 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. 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 depending much upon the perfection of the freshened edges. During the scarification, there is always some hemorrhage, which may be readily removed by little probangs, 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 method of action, Dr. Sims designates 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 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 over- lap 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 until 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 re- moval of the clamps. Placing the Sutures and Closing the Fistula.—With a long needle (Plate LVIII. Fig. 4), armed with a 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 562 operative surgery. 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 ren- ders 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 where it will readily pass, when the small tenaculum (Plate LVIII. Fig. 6) should 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 operation 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 making small oblong openings in the soft bars of lead at distances corresponding with that between the points of the suture, fasten the distal ends of the wires to one bar, either by twisting it round it, or by passing it through a per- forated 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 above the fistula, or between its upper margin and the os tincae, using a fork (Plate LVIII. Fig. 8) broad enough to serve as a pulley for all the wires whilst being drawn into position. Now pass the proximal ends of the wires through another bar, push it into the vagina till it is placed in 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- OPERATIONS FOR VESICO-VAGINAL FISTULA. 563 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 usu- ally 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 anterior clamp from its bed by a blunt hook, when the posterior clamp may be hooked up with the wires attached, pushed backwards into the vagina, disengaged entirely, and then lifted out with for- ceps. The patient should then remain in bed, and use the catheter for several days to prevent any strain upon the new cicatrix. Remarks.—Although vesico-vaginal fistula cannot be regarded as a common 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 differ- ence 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 selec- tion of any one plan of treatment must, therefore, be left to in- dividual 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, cauterization closed the opening. In a larger orifice at the anterior end of the vesical triangle, the twisted suture and harelip 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 applied, afforded but partial relief. The recent ap- 564 operative surgery. pearance of the paper of Dr. Sims prevented the entire performance of his operation in the latter case, owing to the want of his instru- ments, though I was enabled to test the value of the position of the patient, as recommended by him, and the facility with which the fistula could be exposed. To his operation I should, therefore, at present, give the preference, and as complete sets of his instruments can now be readily obtained, I hope to hear of its successful repe- tition by others. By supporting the edges during the adhesive pro- cess, preventing traction in the transverse line of the vagina, and readily keeping the bladder empty, this operation seems to present every prospect of success, and in the hands of its inventor has af- forded relief to many sufferers. In the incurable cases, the vulva shield and bottle (Plate LVIII. Fig. 12) will be found to furnish much comfort, both mentally and physically. Plastic surgery has also been brought to bear upon the treatment, of this complaint in the hands of Jobert, of France, and of Pancoast in the United States. For a full account of the latter, the reader is referred to his work upon operative Surgery.* SECTION II. RECTO-VAGINAL FISTULA. Pathology.—In recto-vaginal fistulae, a communication is esta- blished between the rectum and vagina by an opening which is in the anterior wall of the rectum, and the posterior of the vagina. This 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 artificial anus open- ing into the vagina, is comparatively rare, though I have seen one within the last two years in the case of a child six months old, it being in this case complicated 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 cho- lera infantum preventing any attempt at relief, the child returned to its home in the country, and has not since been heard of. Recto- vaginal fistulae are mostly, however, the result of laceration or con- sequent on the improper use of instruments during delivery; they * Operative Surgery, by Joseph Pancoast, M. D., Philad. RECTO-VAGINAL FISTULA. 565 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 suf- ficient 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 also, the operative methods need not be so fully detailed as in the preceding class of fistula. Roux's operation for Entero-vaginal Fistula.*—" In a case where the ilium terminated in the vagina, Roux opened the abnor- mal parietes, separated 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 afterwards, the autopsy showed that, instead of invaginating the portion of the ilium in the inferior end of the large intestine, it had been inverted to its supe- rior end." Velpeau's operation by Anaplasty.—A lady, after undergoing an operation 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 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 ad- hered only on one of its sides, the fistula was diminished but one- third of its size. Velpeau, however, 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.f Operation of Dr. Jno. Rhea 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 caustics. 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 * Malgaigne, Phil, edit., p. 529. t Op. Surg., by Mott and Townsend, vol. i. p. 674. X Am. Journ. Med. Sciences, vol. i. N. S. p. 305, 1840. 566 operative surgery. 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 probe, thence passed through its whole extent, till it entered the rectum by its orifice to that cavity, 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 passed out of the vagina passed through the eye of a probe which was 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 then directed towards the perineum, 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 rec- tum, 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 only then 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 disease. CHAPTER VI. OPERATIONS PRACTICED ON THE DEEP-SEATED ORGANS OF THE FEMALE. The deep-seated genito-urinary organs of the female consist of the uterus, ovaries, and bladder, upon each of which operations are sometimes demanded, as will be hereafter shown. operations upon the uterus. 567 SECTION I. LITHOTOMY AND LITHOTRIPSY IN THE FEMALE. 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 female than in the male, though it is occa- sionally seen. Before the revival of lithotripsy, the treatment of such cases was usually accomplished by opening the neck of the bladder at various points, as in the operation of lithotomy in man. Such an operation was, however, often followed by incontinence of urine and by other evils, which did not ensue in the case of males, and as all calculi can now be readily removed by crushing, I do not regard the operation of lithotomy in the female as justifiable, and shall, therefore, omit all description of it. § 1.—LITHOTRIPSY IN THE FEMALE. Although a simple operation upon the male, the performance of lithotripsy in the female is even more readily accomplished, the ure- thra of the former being shorter and much more distensible, and the bladder so near to the vagina that the introduction of the forefinger into the latter will sometimes enable the operator to push the stone into the grasp of the instrument if he is otherwise unable to catch it. 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 risk of trouble in the after-treatment, owing to the facility with which large fragments are voided by the female urethra. It may be inci- dentally mentioned that the operation does not require exposure of the patient's person. SECTION II. OPERATIONS UPON THE UTERUS. The assistance rendered by the surgeon in the complaints of this organ may be made to include all the organic disorders to which it 568 OPERATIVE SURGERY. is subject, or limited to those in which he merely aids the accoucheur. The present account will, therefore, be confined to such operations as are surgical in their character, as those performed for the relief of obstructions of the os uteri, of polypus, prolapsus, excision of the neck, and extirpation of the entire womb. § 1.—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 mechanical causes, such a degree of inflammation has been excited as has led to the closure of the os uteri. Occasionally the obliteration of the mouth of the uterus is congenital, but, in some instances, it is simply closed by an adventitious membrane. The restoration of its patulous condition, or the formation 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; but, 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. § 2.—POLYPUS OF THE UTERUS. Polypi of the womb, like those found elsewhere, present us with a peculiar class of tumors, whose characteristics are mainly depend- ent on the mucous membrane to which they are attached, and the specific peculiarities of which have been already described.* When developed in the womb, polypi may be removed by very much the same means as were detailed as applicable to them when seated in the nostril, the chief difference being due to the structure of the part. The strangulation of polypi by the ligature being the most frequent mode of removing them from the womb will be taken as illus- trating the character of the operations demanded for their cure. * See Operations on the Nostril. OVARIOTOMY. 569 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 the back with the knees drawn up; introduce the speculum so as fully to dilate the vagina; and, re- cognizing 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, whilst 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. SECTION III. EXTIRPATION OF THE OVARY, OR OVARIOTOMY. When the ovary has been the seat of such changes as have in- duced a degeneration of structure, and especially of those resulting in the formation 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. Ovariotomy may be accomplished by an incision into the abdominal parietes, of sufficient extent to permit the escape of the mass. As the diagnosis is not easy, and the size of the tumor varies consider- ably under different circumstances, two operations have been de- scribed, 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 Mr. Wm. Hunter, the incision should be about two inches long, and the 570 OPERATIVE SURGERY. ovarium tapped, or the condition of the part, and especially the ex- tent 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 to make the cut from eighteen to twenty-four inches long. The minor operation is palliative, or intended to assist the diagnosis, whilst the major is for the removal of the mass. § 1.—THE MAJOR OPERATION. Operation of Dr. McDowell, of Kentucky.*—In December, 1809, a patient, with an enlarged ovarium, was operated on as fol- lows: Being placed on a table of the ordinary height, and all the dress removed that could impede the operation, an incision was made in the abdomen, parallel with the line of the rectus abdominis mus- cle, 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 travelled. 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 fim- briated extremity of the Fallopian 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 her left side so as to permit the blood to escape, after which the in- testines 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, * Eclect. Repert. and Analyt. Review, vol. vii. p. 242, 1817. t Ibid., vol. ix. p. 547. THE MAJOR OPERATION. 571 and in twenty-five days returned to her home, which was sixty miles off. Operation of Dr. Washington L. Atlee, of Philadelphia.* Preparatory Measures.—The diagnosis being carefully esta- blished, the bowels and bladder should be evacuated, the room warmed to the temperature of 80° Fahr., the finger-nails of the operator and his assistants trimmed close, and the following instruments placed upon a tray, to wit: two good and large scalpels for the abdominal incision; one probe-pointed bistoury ; one director; one tenaculum ; two dissecting-forceps; one pair of dressing-forceps; together with ligatures, sponges, towels, brandy, &c, 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 himself upon the patient's right side, and, commencing an incision immediately below the umbilicus, carry it boldly through the skin and subcutaneous tissues 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 by Dr. Atlee, to consist 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 vas- cular, one vein as large as a goosequill, extending along its at- tachments, and sending out ramifications which were much gorged with blood. This pedicle consisted of a double fold of peritoneum, Am. Journ. Med. Sciences, vol. viii. N. S. p. 51. 572 operative surgery. 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, whilst 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 hemor- rhage. 1, 1. Hands of the assistants. 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 procidentia 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 his thumbs and fingers 1, 1, in order to prevent their escape, whilst 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. Aner 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. 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. A»er Bourgery and Jacob. THE MAJOR OPERATION. 573 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, whilst the upper, which ran from the tumor to the uplifted sigmoid flexure, was one inch long. The Fal- lopian 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 saddlers' 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 soon as they were de- prived of their peritoneal coat, and gave rise to most of the hemor- rhage 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 carefully 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 harelip sutures and intervening adhesive strips, covered by patent lint and a soft com- press, and the whole secured by a broad towel, which extended from the thorax to the trochanters. The operation occupied about an hour; peritonitis supervened, 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 so well attended to, that the question of its success up to the present period, is readily settled. Through the industry of Dr. Washington L. Atlee, of Philadelphia, as well as of Dr. Tho- mas Safford Lee, who has pursued a similar course of inquiry in Great Britain, the profession have been for some time familiar with the result of most of the cases operated on, and an accurate idea may now be formed of the mortality which has ensued upon the operation. From the tables of Dr. Atlee,* it appears that— * A Table of all the Known Operations of Ovariotomy from 1701 to 1851, comprising 222 Cases, including their Synoptical History and Analysis, by Washington L. Atlee, M. D., Philadelphia, and published in the Transactions Am. Med. Association, vol. iv. p. 286, as well as in pamphlet form. 37 574 operative surgery. " Of the 222 cases thus collected, 52 were of the minor section, 153 of the major, and 17 unknown. " Of the 52 minor operations, 39 recovered and 13 died, or 1 in every 4, or 25 cases in 100. " Of the 153 major operations, 95 recovered and 58 died, or 1 in every 2§g, or 29.41 cases in 100. " Of the whole 222 cases, 146 recovered and 76 died, or 1 in every 2||, or 33.78 in 100. " Of 222 cases, the operation was not completed in 57, or 1 in every 3{f, and there was no tumor in 6." After carefully analyzing his cases, Dr. Atlee gives, as the mor- tality of the operation, " 1 in every 3§£, or 29.74 cases in 100." Remarks.—The operation of ovariotomy is one which, at the present time, has excited much discussion, and must yet be regarded as sub judice, the statistics not having as yet satisfied many in the profession of the propriety of its performance. The frequency with which the operation has lately been repeated, and the valuable tables above referred to, have, however, induced many to admit that, though great difficulties are to be anticipated in the diagnosis as well as in the after-treatment, sufficient success has been obtained to justify a calm consideration of the question. From the usual spirit of conservatism exhibited by the profession (a conservatism which is highly laudable as well as advantageous to the public inte- rest), much criticism has been exercised in relation to the accounts of the operations already furnished, and those who continue to operate, and to advocate the means of treatment, being in the posi- tion of those who propose and practice an innovation upon old-esta- blished rules, must anticipate opposition, strict investigation, and possibly unjust condemnation, as well as to be subject to such charges as are dictated by prejudice, and constantly renewed through envy. Such a result is no novelty, but has been seen heretofore in nume- rous instances, of which it may suffice to mention the cases of the discoverer of vaccination, of the attempt to introduce etherization, as well as other novel points of practice with which all are familiar. Instead, therefore, of anticipating any general approbation, the few surgeons who dare to advocate the propriety of this operation must be content to stand forward and bear the criticisms of its opponents, consoling themselves with the principle, that " the honest physician knows no other interest than the life and health of his patient."* * Hufeland. OVARIAN TUMORS. 575 The candid inquirer after truth may readily, it seems to me, obtain a clear view of this question, 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 investigating the merits of ovariotomy, this question stands prominently forward, and must mainly regulate an opinion of the value of the operation. To show the views of a few experienced surgeons, I cite the fol- lowing opinions:— Velpeau* says, "the diseases which require ovariotomy are, if left to the resources of nature, almost always fatal; but though incura- ble, 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 operation. Churchill! thinks "there are cases in which this operation would be justifiable on the grounds that the disease is incurable by medical means; that the patient will ultimately die from constitutional dis- turbance, after suffering more or less inconvenience, and that tapping in ovarian dropsy is attended with great danger." Colombat,! who seems to be least decided in his views, says, " without wishing to proscribe the operation, it ought not to be re- sorted to except as an extreme resource." Chelius§ 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 evacu- ated." Blundell|| says, " we may be justified in operating, provided it be the wish of the patient;" but he also^f says, "all the operations * Velpeau, Op. Surgery, by Mott and Townsend, vol. iii. pp. 538, 539. f Notes on Ovariotomy, quoted from Meigs's Colombat, p. 418. X Diseases of Females, Meigs's translation, p. 432. \ Chelius's Surgery, by South, vol. iii. p. 212. || Diseases of Women, p. 118, [quoted from Churchill, Philad. edit. p. 304.] \ Churchill, p. 305. 576 OPERATIVE SURGERY. upon the ovaries are worthy of consideration; for, if one can be made to cure an unhappy individual, who would otherwise fall a victim to disease, it will be an invaluable good to the fairest and least offend- ing 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 present space permit, we are, I think, justified in concluding that the majority of ovarian tumors cannot be controlled by medi- cine; 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 patient, and the latter is fully informed of the possibility of failure or the chance of death, such tumors are proper subjects for an operation. II. IS THE REMOVAL OF THE OVARIAN TUMOR ATTENDED BY ANY EXTRAORDINARY 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 an error of diagnosis, and yet, though many such instances are on record, they are few compared with the great number of cases in which the diagnosis was correct, and the operation successful. Thus, " out of 81 cases collected, by Mr. B. Phillips in 1844, in which ovariotomy 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 impossible to remove the tumor after the abdomen was opened, owing to the adhesions."* In the elaborate tables of Dr. Atlee,f it is also shown that there was no tumor present in 6 cases out of 222 operated on. In 83 cases, there were adhesions, but of these 49 recovered. In 57 cases, the operation was left unfinished ; in 27 of which other important diseases coexisted, 13 of which were diseases of the uterus, and in * Druitt's Op. Surgery, Philad. edit. p. 422, 1848. f Table of all the Known Operations of Ovariotomy from 1701 to 1851 Philadelphia, 1851. STATISTICS. 577 5 of the cases, complicated with other diseases, the operation was left unfinished. But, on the other hand, it appears that, out of 211 cases, 146 have been successfully operated on, a statement which strongly tells for the other side of the question, and positively establishes the fact that the difficulties that may be met with can in very many instances be overcome. The following table shows the American surgeons who have per- formed the operation, and the results in their hands. STATEMENT OF THE CASES OPERATED ON BY AMERICAN SURGEONS,* WITH THE RESULTS. SURGEON. CASES. CURES. DEATHS E. McDowell, Kentucky Nathan Smith, Yale College 7 3 5 3 3 0 Alban Gr. Smith, Kentucky . Jos. Gallup, Vermont . D. L. Rogers, New York 3 1 1 3 0 1 0 1 0 Jno. C. Warren, Boston 1 1 1 R. D. Mussey, Cincinnati 4 3 1 Jno. L. Atlee, Penna. . 2 1 1 W. L. Atlee, Phila. 16 10 61 Webster, Boston .... 8 1 0 Bellinger, Charleston . Bayless, Kentucky S. G. Parkman, Boston 2 1 1 2 1 0 0 0 1 H. Miller, Louisville 1 1 0 J. Deane, Mass..... 2 1 1 J. P. Buckner, Ohio . 4 3 1 D. Meeker, Indiana 1 0 1 Wm. H. Van Buren, N. York 1 1 0 J. H. Bigelow, Boston . Alden Marsh, Albany . . . . David Prince, St. Louis 1 1 1 , 1 1 1 0 0 0 A. H. Grimshaw, Delaware . 1 0 1 E. R. Peaslee, Maine . 1 1 0 57 40 17 In No. 17 of the British and Foreign Medico-Chirurgical Review, * These accounts have been condensed from the Bibliographical Index, p. lxxx., as collected by myself from various journals, as well as from the tables of Dr. Atlee, before referred to. f Reported to 1851. 578 OPERATIVE SURGERY. January, 1852, the question of the merits and demerits of ova- riotomy have been ably discussed. In this paper, the writer contends that it is necessary to correct the prevalent notion that a person may live for years with an ovarian tumor, as more than half the cases quoted by Mr. Safford Lee (63 out of 123) died in two years, and 90 out of 123 within four years. He, therefore, thinks it more correct to say that ovarian diseases, like other organic affections, tend to run their course in a space of three years; that these years are emphatically years requiring patience, resignation, and sweet temper to render them even tolerable to the sufferer.* Tapping, he contends, is also more fatal than is generally thought. That the dangers arising from the operation are great, will be admitted, and so they are in ligating the large arteries, and in many other operations; but that these dangers may be overcome, is evi- dent from the success which has attended its performance. Ac- cording to the tables of Dr. Atlee, the rate of mortality for the ope- ration is twenty-six and a half per cent., or a rate which places this operation on as good or even a better footing, than some of the other capital operations, and, in my opinion, justifies its repetition by a skillful surgeon in the case of a tumor of medium size, which is comparatively movable, uncomplicated with other disease, and in a patient whose sufferings render her anxious for the operation. Since the discovery of etherization, several objections to the operation have been removed; thus, it has ceased to be painful, the intestines remain quiescent, and do not protrude at the wound, whilst the latter can be accurately closed, and the risks of peritonitis thereby diminished. Experience has also reduced the accidents likely to arise during the operation in the after-treatment. The points most essential to success appear to be the extreme care exercised in the diagnosis, the selection of proper cases, the preservation of a high temperature in the chamber whilst the patient is uncovered, perfect quiescence through etherization, and a neat and close appli- cation of the dressing. Such adjuvants materially change the character of any operation, and when combined with a skillful after- treatment, must do much to diminish even the mortality which has hitherto followed ovariotomy. A few years must, however, enable any one to add materially to the statistics now collected, and will I think, place upon a firm basis the merits of an operation which I * Opus citat, p. 231. ON THE CESAREAN OPERATION. 579 admit is now viewed with distrust by many. But until this period arrives, it is to be hoped that prejudice will not be allowed to check the formation of a candid opinion of a means of treatment, which, if established beyond all cavil, is capable of adding materially to the comfort of a large and interesting class of the community. SECTION IV. ON THE C^SARIAN OPERATION. The term "Caesarian 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 mankind 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 a course 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 Mr. 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 an ordinary accouche- ment. 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 operated on by Dr. Wm. Gibson of Philadelphia,f and on whom it was performed twice, thus proving successful in two different pregnancies. * Op. Surg., loc. cit. f Am. Journ. Med. Sciences, vol. xvi. 1835, and vol. xxii. 1838. 580 OPERATIVE SURGERY. PLATE LXII. OPERATIONS UPON THE UTERUS THROUGH THE ABDOMEN. Fig. 1. Langenbeck's Operation for Extirpation of the Uterus. An in- cision having been made through the linea alba, the hands, 1,1, of two assist- ants elongate the angles of the wound, and retain the intestines in the abdomen whilst 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 hand. After Bourgery and Jacob. Fig. 2. A View of the Median Caesarian 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 whilst 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 de- liver the child. After Bourgery and Jacob. k. *'• M % 7 v» r ON THE CESAREAN OPERATION. 581 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, director, scissors, harelip pins, ligatures, a syringe, cathe- ter, brandy, ammonia, sponges, adhesive strips, spread cerate, com- presses, and bandages. The abdomen should also be entirely free from hair, and the rectum and bladder thoroughly evacuated also. The arrangement of the bed or table, as directed in lithotripsy, will usually be useful in this operation. 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 abdo- minal parietes. The surgeon then, with a large scalpel, should incise the integuments 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 upwards, 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 director, 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 cautiously incised, layer by layer, until the membranes around the foetus are exposed, 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 amnii 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 wound, and the surgeon then extracts the child according to its position (Plate LXII. Fig. 2). The mem- branes 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 abdo- minal wound, and the sides of the latter united by the harelip suture and strips, the uterine contractions diminishing and closing the opening in that organ. Spread cerate, a compress, and a body- 582 OPERATIVE SURGERY. bandage complete the dressing, when opiates may be administered, and an appropriate after-treatment directed, in order to combat peritoneal inflammation. SECTION V. EXCISION OF THE NECK OF THE WOMB. The existence of cancer, which was supposed to be limited to the neck of the uterus, has, within the last century, led some surgeons to excise or amputate the diseased portion, which may be accom- plished by the following operation :— Operation.—Place the patient upon her back, introduce a specu- lum, seize the neck of the womb with Museux's forceps, or other long tumor-forceps, or hooks, pull it down to the orifice of the va- gina, and cut it off by a circular sweep of a bistoury, or with the scissors, arresting the profuse hemorrhage which generally follows by the actual cautery or the tampon. Remarks.—Excision of the neck of the uterus is an operation which few experienced surgeons at the present day would willingly perform, whilst it is one to which I only refer in order to guard the inexperienced against it, by expressing the results of my personal observation as obtained during several months' close examination of the cases operated on by Lisfranc and others in Paris. So tho- roughly convinced am I of the impropriety of the operation that nothing could tempt me to perform it. As an operation, excision of the neck of the uterus is a trifling matter; but the risks of the patient may be found in the difficulty of establishing a positive diagnosis of cancer, in the impossibility of eradicating such a disease by an operation, and in the danger of the patient dying from hemorrhage within twenty-four hours, which I have seen in two instances in Paris, under the hands of Lisfranc. Appropriate constitutional treatment, with local medication, is also capable of retarding the disease, and in no instance has it led to so rapid a death as the operation. As performed by Lisfranc, in the cases that fell under my observation, amputation of the neck of the womb was not only useless torture, but in several instances evidently accelerated the death of the unhappy individuals who were submitted to it. EXTIRPATION of the womb. 583 SECTION VI. EXTIRPATION OF THE WOMB. Extirpation of the uterus is an operation that can only be thought of under extraordinary circumstances, and never attempted until all other means of relief have failed, and extirpation is deemed likely to offer a chance for life. As a remedy for cancer of the uterus, it offers certainly a better prospect of success than that presented by excision of the neck; but no judicious surgeon would advise either except as a dernier resort. In the United States, extirpation of the womb has been success- fully accomplished by Dr. Essellman, of Tennessee, and by Dr. Eve, of Georgia. Complete Extirpation of the Uterus by Ligature after Chronic Inversion of the Organ, by John M. Essellman, M. D., of Nashville.—A lady, thirty-two years of age, had labored under inversion of the uterus for several years, in consequence of the ma- nipulation of an old woman. Various symptoms inducing the belief in the existence of a polypus, a ligature of saddlers' 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 sink- ing 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 instead of a polypus.* The patient did not leave her bed for months after the operation, "but was finally restored to perfect health." Operation of Dr. Paul F. Eve, of Georgia.!—A negro wo- man, 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 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 chloro- form, the tumor drawn down to the os externum by forceps, and * Am. Journ. Med. Sciences, vol. vii. N. S. p. 254, 1844. f Ibid. vol. xx. N. S. p. 399, 1850. 584 operative surgery. then the mass carefully excised from above downwards, 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 sul- phate of zinc. There was no protrusion of the bowels, or any severe symptoms; a rigid diet and the horizontal position were main- tained 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 liga- ments, could be distinctly seen in the mass, and the preparation is now in the hands of Dr. Charles D. Meigs, Professor of Obstetrics in Jefferson College, Philadelphia. CHAPTER VII. OPERATIONS PRACTICED ON THE RECTUM. The operations performed on this portion of the body are such as are demanded for the relief of congenital defects, for the cure of a disordered condition of the rectal veins, and those owing to the de- velopment of abscesses in the neighborhood of the gutf. SECTION I. SURGICAL ANATOMY OF THE RECTUM. Arising at the inferior and left side of the fifth lumbar vertebra, the rectum descends obliquely downwards 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, vesiculse seminales, prostate gland, and membranous portion of the urethra to all of which it is very loosely attached by its anterior face; but SURGICAL ANATOMY OF THE RECTUM. 585 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 rec- tum in woman, but it is from two to three inches above the anus in man.f The muscular coat of the rectum, like that of the other intestines, is composed 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 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 longitudinal folds (columns), at the lower end of which are numerous small pouches of from two to four lines in depth, which point up- wards, and are occasionally the seat of a disease (encysted rectum) which is characterized by intense itching.J The arteries of the rectum are known as the hemorrhoidal, and are sufficiently large and numerous, about an inch and a half from the anus, to cause troublesome hemorrhage. When diseased, the hemor- rhage from them is also 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 hemor- rhoidal 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 ap- plied to the internal sphincter muscle, and branches of it pass through the muscle in so many directions, that its fibres are sometimes, and especially in bad cases of hemorrhoids, so intermixed with enlarged veins as to appear like an erectile tissue.§ The orifice of the rectum (anus) is closed by a sphincter muscle, which is under the control of the will; the contraction of which * Diet, de Med., tome 27me, p. 271. f Malgaigne. X Horner's Anat., vol. ii. p. 47, 9th edit., 1851. § Diet, de Med., tome 27me, p. 274. 586 OPERATIVE SURGERY. has an effect in producing the folds or wrinkles found in the skin about the anus, whilst its relaxation permits, in certain diseased conditions, the eversion of the mucous coat, together with the blood- vessels and nerves. Even in the ordinary evacuation 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 portion of the gut, and favors the escape of the fecal contents by forcing the matter to free itself from the surface of the bowel, whilst 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. OPERATIONS ON THE RECTUM. The affections of the rectum requiring operative treatment are so numerous, and its structure so important as to have engaged a large portion of the time of many surgeons, and were they at pre- sent to receive the detailed consideration that their frequency de- serves, would occupy the remainder of my space. A condensed description must, therefore, suffice. The aid of the surgeon may be required in this region for the re- moval of foreign bodies; for encysted rectum; fissure of the anus; imperforate anus; prolapsus ani; fistula in ano ; hemorrhoids; stric- ture of the rectum; and extirpation of the lower portion of the bowel for cancer. § 1.—REMOVAL OF FOREIGN BODIES. The removal of foreign substances from the bowels may be accom- plished by the finger, handle of a teaspoon, scoop, forceps, or other similar instrument, 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 specu- lum ani, so as to protect the mucous coat, unless the size of the object should forbid it. In a case reported by Dr. Ruschenberger, ENCYSTED RECTUM. 587 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 inch, was introduced into the rectum of a China- man, the whole was removed by Dr. Parker, of Canton, by crush- ing 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, Dr. 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 regarded as an imaginary complaint, and which had then been generally overlooked by surgical writers.f This condition is characterized by the following symptoms : " Some- times 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 pocket, which is so exquisitely sensitive to the point of the probe as to cause acute suffering." These pouches having since been minutely studied by Dr. Horner, of the University of Pennsylvania, and their anatomical relations strictly defined,^ are now usually regarded as a normal portion of the gut, which only demands interference when it becomes the sub- ject of diseased action. To relieve the symptoms above detailed, Dr. Physick proposed the excision of the pouch affected. Operation of Dr. Physick, of Philadelphia.—Bend the point of a probe backwards on itself for about half an inch, so as to form a hook, pass it into the anus, and by a movement backwards and * Am. Journ. of Med. Sci., vol. xvii. N. S. p. 410, 1849. f Am. Encyclop. of Med. and Surg., Article Anus, by Reynell Coates, M. D. % Special Anat. and Histol., vol. ii. p. 147, 9th ed. 588 OPERATIVE SURGERY. forwards, 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 these pouches are 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. § 3.—FISSURE OF THE ANUS. Fissure of the anus is the name applied 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 invariably attended by spasm of the sphincters, a characteristic sign which has been much insisted on since the time . of Boyer. This disease being usually well described in works on surgery, it is only necessary at present to designate the treatment. When something more than a palliative treatment by anodynes, and similar means of producing relaxation of the sphincters, is demanded, a cure may be accomplished by frequently cauterizing the surface, until the ulcer healed, or by paralyzing the external sphincter by a transverse division of its fibres. This may be accomplished either by dividing the muscle from the inside of the gut outwards, or by a subcutaneous incision, or by lacerating the ulcerated edges by dilat- ing the anus, either by introducing the fingers or tents, or an anal speculum. 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 direction of the fissure, cut through the mucous membrane, sphincters, cellular tissue, and integuments at a single cut.* In the subcutaneous incision, pass the point of a very narrow, sharp-pointed bistoury beneath the mucous coat near the fissure, and divide the fibres of the muscle by cutting outwards. Then turn the bistoury flatwise, and withdraw it at the point of entrance. * Am. Encyclop. of Med. and Surg., loc. citat. PROLAPSUS ani. 589 § 4.—IMPERFORATE anus. 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 con- traction' of the orifice supervene, as is frequently the case, make a crucial incision in the part, or dissect out a portion of the integu- ments. § 5.—PROLAPSUS ANI. By prolapsus ani is usually understood such an eversion of the rectum as is not replaced by the natural action of the levator mus- cle. Whether this eversion is limited to the mucous coat, or formed of the other portions of the bowel, it has been usual to designate the complaint under the same name, though the inversion of any other than the mucous coat should be regarded as an intussusception, and treated accordingly. Pathology.—In the natural condition of the bowel, the efforts at defecation create a disposition to partial eversion of the mucous coat in order to facilitate the escape of the fecal matter, as is daily seen in the defecation of the horse. In man, however, such a protrusion is rarely noticed, except when infiltration of the submucous cellular tissue, and a relaxed condition of the sphincter ani favors its pro- duction. But when once the mucous coat is fully everted, spasmodic contraction of the sphincter ani and the interruption of the circula- tion may so favor the congestion and infiltration of the part as to in- duce pain and the other symptoms of inflammation. For the relief of these evils, when simpler means have failed, various operations have been suggested, all having for their object either the diminu- tion of the protruded coat itself, of the folds of the skin about the anus, or of the sphincter ani muscle, these operations being always, however, preceded by an appropriate local and general treatment. One of the simplest and most effectual means of affording relief in prolapsus ani is the immediate restoration of the gut. I. TO RESTORE THE PROLAPSED PORTION. The restoration of a prolapse of the rectum may be accomplished as follows:— 38 590 OPERATIVE SURGERY. 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 ligature as applied by Dr. Physick. 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 asssistant, or by the surgeon. A short tenaculum transfixing the base of the pile now draws the tumor off from the buttock, whilst the surgeon makes an incision around the external side of its base, so as to free it from its con- nection 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, whilst the other is applied on the mucous surface of the tumor, the latter is perfectly strangulated 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. Scis- sors 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. OPERATIONS FOR PROLAPSUS ANI. 591 Place the patient on the side, with the knees drawn up and the shoulders flexed, so as to relax the abdominal muscles, or, if the parts are sensitive, etherize him thoroughly so as to prevent any re- sistance, and wash the tumor. Then, with the first and second fingers well oiled, press the centre of the prolapsed bowel within the sphinc- ter ani muscle, retain it there with one finger whilst another portion of the bowel is similarly inverted, and continue this manipulation until the entire tumor is replaced, when a compress applied with a T bandage will often suffice to retain it. If the submucous cellular tis- sue and sphincter muscle have been much relaxed, the introduction of an ivory or wax stem, or about two inches of a rectum bougie, will prove useful by supporting the upper folds of the gut until the proper tone of the part is acquired. But if these means fail, a diminution of the bulk of the part, or of the anal orifice may be demanded so as to create a cicatrix that will induce sufficient contraction of the cel- lular tissue to reduce the size of the opening. II. OPERATION OF DUPUYTREN. With the patient in the position just recommended for the restora- tion of the bowel, pick up with a pair of Liston's forceps one of the radiated folds of 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 introduces a little lint into each wound, in order to insure suppu- ration 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 produce such a diminution of the anus as will inter- fere with the subsequent efforts at defecation. III. EXCISION OF A PORTION OF THE SPHINCTER ANI. Operation of Robert.—Remove, either by scissors or the scalpel, a transverse portion of the sphincter ani muscle, and unite the wound by a twisted suture. * Mott's Op. Surgery, vol. iii. p. 1106. 592 operative surgery. IV. cauterization. Operation of Cheselden.—Apply caustic lengthwise upon one or more points of the mucous coat, favor the suppuration, and await the cicatrization. The French surgeons sometimes prefer the actual cautery similarly applied. V. EXCISION OR AMPUTATION OF THE TUMOR. In very bad irreducible cases, the adhesions of the adjacent por- tions of the tumor prevent its reduction; suppuration and sometimes hemorrhage ensue, and the aged patient is exhausted by the dis- charge 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 excise 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 he- morrhage, and obviate excessive contraction by the use of bougies. Remarks.—In the operations just quoted, but 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 an appropriate treatment, without surgical aid. If the prolapsus is so marked and obstinate as to require the adoption of any operation, that of Chesel- den should be first tried, and then, if requisite, resort had to the ope- ration 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. hemorrhoids, or piles. 593 SECTION III. HEMORRHOIDS, OR PILES. Pathology.—Hemorrhoids (a^a blood, and pS« to flow) consist of tumors seated at or near the verge of the anus, which are sometimes liable to bleed at each effort at defecation. Although this complaint has been so long known to the profession, there is yet a diversity of sentiment in regard to its pathology. By some, hemorrhoids are regarded as a varicose condition of the anal veins (Jobert), or as tu- mors resulting from a laceration of the veins and the effusion of blood into the adjacent submucous or subcutaneous cellular tissue (Ribes), or as preternatural cysts, which are sometimes distended with blood and very much swelled, whilst at others they are more empty and flaccid. These different views, as thus expressed by distinguished 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 suppo- sition, and with a knowledge of the minute anatomy of the anus and rectum, it appears to me an easy matter to harmonize these varied conditions, and explain the pathology of the complaint. The mu- cous 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 cellular tissue, and directly con- tinuous with those of the mesentery, it is certainly possible to create precisely such a condition of parts as has been described by Ribes, and yet refer the whole complaint to a varicose condition 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 would first induce fulness of these vessels, then serous or lymphy infiltration of cellular tissue in which the dis- tended veins would freely anastomose, whilst the rupture of the veins would readily lead to effusion of blood, and the formation of a cyst covered by mucous membrane or skin, according as the vessel was above or on the line of the external sphincter ani. If, then, absorption 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, whilst the inflammation and ulceration of either the mucous or cutaneous surface of the tumor might give rise to a hemorrhage, the amount of which would depend on the 594 OPERATIVE SURGERY. size of the vein opening into it. If, then, I 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 cellular sub- stance, or to a varicose condition 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. An internal blind pile being, on the contrary, a varicose enlarge- ment of one or more branches of the same veins higher up the rectum, would consequently be a tumor covered by the mucous coat of the part, which mucous covering would be liable to become elongated by infiltration of its submucous cellular tissue ; whilst if it inflamed, ulcerated, and opened the vein, it would give rise to a hemor- rhage, which would of course be most marked when the efforts at defecation created a congestion of the veins. Such a tumor will, therefore, require to be treated with an especial regard to this in- flammation, 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. § 1.—TREATMENT OF HEMORRHOIDS. The principal plans of treatment proposed by surgeons for the cure of hemorrhoids consist in the ligature and in excision. I. THE LIGATURE. The hemorrhoidal tumor may be strangulated either by threads passed through its base, and then tied so as to surround it, or by encircling the tumor with a wire ligature, drawn tight by means of a double canula (Physick), or by the simple loop of silk thrown over it, so as to constrict its base. (Plate LXIII. Fig. 1.) II. EXCISION. The removal of hemorrhoidal tumors by excision may be effected by seizing them in toothed forceps, and removing them with scissors LIGATURE AND EXCISION OF HEMORRHOIDS. 595 curved on the side (Dupuytren), or by passing a ligature through the tumor, and excising it with a bistoury. Remarks.—The objection to the use of the wire ligature, as above directed, 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; whilst excision, especially of inter- nal piles, by removing the mucous coat, exposes the patient to dan- gerous hemorrhage. The following plan obviates all these objections, and effects a speedy, safe, and permanent cure:— Operation of Dr. Wm. E. Horner, of Philad.*—Calm the ir- ritability of the rectum by cold water injections, employing them several days before the operation. Then, at the time of the opera- tion, empty the rectum, direct the patient to force out the tumors by straining in a squatting position, and place him in bed on the side corresponding to the tumors after they are protruded. Then passing a large needle and strong silk ligature transversely through the upper part of the largest tumor, and removing the needle, form a loop by tying together the ends of the ligature, and direct 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 liga- ture, the assistant should hold this with his other hand so as to pry or elevate the mucous coat from the subjacent parts, when the sur- geon 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 rather into the skin than upon the mucous lining of the anus, and keeping sufficiently close to the mar- gin of the anus to prevent a fold of integument being left upon its edge, as this is apt to swell, inflame, and become exceedingly painful. 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 should now be drawn perfectly tight, or until the tumor becomes dark brown or black, when its end should be fastened upon the canula, and the venous plexus will be perfectly constricted through the mucous coat of the rectum on the inner face of the tumor, and through the cell- * Am. Journ. Med. Sciences, vol. iv., N. S., p. 358. 596 operative surgery. 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 about the anus. 3. The gut. 4. The anus. 5. The structure immediately around the anus. After Bernard and Huette. Fig. 2. A similar Section to show the relations of an Incomplete Fistula. 1. Orifice of the fistula in 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. Hand of assistant supporting the buttock. 2. Left forefinger of 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 downwards, as he withdraws both hands. 4. Fistulous opening. After Nature. Fig. 5. Section to show the Operation of Probing a Fistula. 1. Rectal orifice of fistula. 2. Its anal orifice. 3. Rectum. 4. 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. Rectal orifice of fistula. 2. Its anal opening. 3. The gut. 4, 5. The director. 6. The bistoury passing along it. 7. Portion of the integuments near the anus, which is to be laid open. The drawing re- presents the patient in the position of Fig. 4. Auer Bernard and Huette. Fig. 7. Operation for Fistula in Ano by means of the Ligature. 1. Rectal orifice. 2. Anal opening. 3. Rectum. 4, 4. Ligature in situ. 5. Tissue to be divided. After Bernard and Huette. 'late i'.-; Fig. 1 Vig. 2 FISTULA IN ANO. 597 ular coat of the gut on its outer side. If the hemorrhoid remains large and very tumid, after being constricted, the surgeon may 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, to guard against adhesions, and an anodyne enema given, the thread ligature being left in the tumor for six or eight hours, when it may be used to elevate it, whilst it is snipped off with a pair of scissors, the wire loop being thus freed from its position without creating any loss of blood. Remarks. — The dangers that have been incurred from the excision of piles, and the suffering consequent on the ordinary method of applying the ligature, are facts that every experienced surgeon must have frequently noted. When, therefore, it is neces- sary to select a mode of operating, I would recommend a trial of that proposed by Dr. Horner, as it is one that I have repeatedly performed, and the success of which I have now seen in nearly thirty cases. In but one of these has it been necessary to repeat the operation, whilst many, and some even of the very worst hemor- rhoids that I have ever encountered, have been cured in about two weeks: some patients being able to sit up in bed in seven days. SECTION IV. 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 buttock, internally into the gut, or by both surfaces. From the constant action of the sphincter and leva- tor 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 condi- tion 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 cavity 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. Two principal means are resorted to: 1. The ligature. 2. Incision. 598 OPERATIVE SURGERY. § 1.—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; but by the use of the following instruments of Dr. Wm. Gibson, it is rendered a simple and not very painful operation. Operation of Dr. Gibson, of Philadelphia.*—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, §5) 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 supported by the finger, 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. Then 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 escapes, as during this time the formation of granulations will generally have removed the complaint. § 2.—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, withdrawing 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 * Pract. of Surg., vol. ii. p. 164. OPERATION BY THE KNIFE. 599 charpie or lint until it heals from its upper end by the formation of new granulations. (Plate LXIV. Fig. 4). Remarks.—Among the variety of methods of operating for fis- tula in ano, recommended by surgeons at various periods, there is no difference in the indications to be accomplished, though individual pe- culiarity has suggested a variety of instruments. Of all these but one demands special notice, and that is the sheathed bistoury of Wheatley and Dr. Physick. This instrument resembles 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 plea- sure. 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 etheriza- tion 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, are also better than the position 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 surgeon, 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 scrofulous patients, the ligature is best adapted to the cure; but incision is the most prompt and least troublesome. 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 proceeding only increases the suf- fering of the patient, and delays the cure. In very callous cases, a slight paring of the edges of the incision may expedite the treat- ment ; but in most instances, nature is capable of removing the in- duration. OPERATIVE SURGERY. PART Y. OPERATIONS ON THE EXTREMITIES. PAET V. OPERATIONS ON THE EXTREMITIES. CHAPTER I. GENERAL OPERATIONS ON THE EXTREMITIES. Jhe 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 that have been al- ready described; thus, the removal of tumors, the relief of deformities arising from the cicatrices of burns, the ligature of arteries, or the resection of bones, is very much the same in all parts of the body, and must be regulated by the same general rules, as they differ only in accordance with the anatomical relations of the region in which they are performed. It will consequently be unnecessary, in this part of the volume, to do more than describe such modifications of these operations as are required by the position and functions of the extre- mities, 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 ex- tremities ; one includes all those of a general kind which are per- formed upon the superficial tissues, whilst the other has reference to such as are deeper seated. The class of operations of a general character which may be assigned to the first of these limits embraces such as are required for the relief of diseases of the nails and skin, of the superficial nerves, of the veins, and of the tendons. * 604 OPERATIVE SURGERY. SECTION I. OF INVERTED TOE NAIL. Pathology.—The suffering caused by the inflammation or ulcera- tion of the skin, at the external side of the nail of the great toe, has been such as frequently to attract the attention of surgeons to its pathology and mode of treatment. Authors have, however, differed considerably in their views of the cause of the complaint, some assert- ing it to be due to a deviation or ingrowing of the nail itself, whence the name of "Inverted Toe Nail;" and others contending that it was owing to the uprising of the flesh in consequence of the pressure of the boot. As in many other vexed questions, both opinions are perhaps correct, or rather the trouble is often due to both causes. But whether the original source is in the flesh or in the nail, the lat- ter soon becomes the cause of its continuance. To relieve the trouble created by this complaint, it was proposed by Dionis to elevate the nail by scraping it thin, and packing fine lint beneath its edge; by Dessault to recurve the nail, and elevate its poinf by means of a curved piece of tin; by Dupuytren to slit it up in the middle, and turn out each half, whilst Larrey suggested the same process, combined with excision of the matrix and the ap- plication of the actual cautery or caustic. The latter I have found to be the most effectual, and it may be readily accomplished in the following manner:— § 1.—REMOVAL OF THE NAIL AND ITS MATRIX. Operation.—Place the patient in a perfect state of ansesthesia by the use of ether, and then with a small sharp spatula or scalpel handle passed around the root of the nail and inserted beneath the fold of the skin at its base to the extent of one-fifth of the length of the nail, free the latter entirely from its matrix. Slit the nail down the middle from before backwards; evert each half; cauterize the matrix thoroughly with anhydrous potassa; apply over the surface a pledget of dry lint; allow it to remain until suppuration is induced, and then favor the cicatrization by appropriate treatment. ENLARGED BURSA. 605 SECTION II. CURE OF PARONYCHIA, OR WHITLOW. Pathology.—Four kinds of whitlow have been described by authors: to wit, that where pus is found immediately beneath the cuticle, at the root of the nail after trivial inflammation; that in which it is seated in the cellular substance at the end of the finger; that in which the disease is in the sheath of the tendons; and that arising from inflammation of the periosteum. To relieve the sufferings of the patient, and check the progress of the disease in the first two varieties, Dr. Perkins has proposed the free application of caustic;* and such a treatment may answer for the mild forms. But in the more severe kind (third and fourth varieties) nothing but an early and free incision will prove effectual, and in the cases involving the periosteum prevent the necrosis of the phalanx which is so apt to ensue when the disease is not promptly arrested. Operation of Incision.—Etherize the patient, place the finger well supported upon a table, and with a sharp-pointed straight bis- toury puncture the soft parts at the upper end of the affected phalanx, and then by a rapid motion slit them down to the lower end of the same phalanx, making the incision in the middle of the finger so as to avoid serious injury to the tendon or the division of the digital arteries or nerves, which course along its sides. The case should then be subsequently treated as an ordinary abscess. SECTION III. ENLARGED BURSA. Pathology.—The enlargement of the bursae mucosae, which are seated in the course of the tendons near certain joints, is generally the result of an acute or more frequently subacute inflammation conse- quent upon over-action of the tendon, or upon long-continued pressure on the part. The increased secretion of bursal synovia thus induced leads to the formation of a tumor in the course of the tendon, which * Am. Med. Record., vol. ii. p. 490, 1819. 39 606 operative surgery. is more or less elastic, and caused by the bursal sac being distended with the natural secretion of the part. When seated at the wrist, the term ganglion is generally employed to. designate it, though this is equally applicable to the swellings found near other joints. The principles of the treatment are the evacuation of the con- tents of the bursa, and the production of such action in its cavity as will prevent the reaccumulation of the fluid. These principles have been carried out in various ways; sometimes the cyst has been rup- tured by a blow, and the liquid, after being effused into the sur- rounding cellular tissue, left to be absorbed by nature; or the tumor has been treated as an abscess by laying it open with a bistoury, or by introducing a seton, or by a subcutaneous puncture; or by excit- ing adhesive inflammation in it by injections of iodine; or the sac has been entirely removed by dissecting it out. The close proximity of the joint must necessarily be an objection to any means of treat- ment that is liable to excite severe inflammation, and the least dan- gerous methods should therefore be first tried. § 1.—subcutaneous puncture. Operation.—Puncture the tumor by a tenotome or cataract nee- dle, so that the opening in the cyst and that in the skin shall not correspond; squeeze its contents into the adjoining cellular tissue, and leave it to be absorbed, whilst pressure is employed to prevent its reaccumulation. § 2.—puncture and injection of iodine. Operation.—Puncture the cyst directly through the skin with a narrow bistoury, or, if the tumor is large, by a trocar and canula. Evacuate its contents, and then with a syringe throw in a small por- tion of tincture of iodine, regulating the subsequent inflammation by appropriate treatment. § 3.—incision. Operation of Dr. Geo. Hayward, of Boston.*—In enlarged bursae over the patella, or housemaid's knee, Dr. Hayward operates as follows:— * Am. Journ. Med. Sciences, vol. iv. N. S. p. 513. varicose veins. 607 Puncture the tumor, and evacuate its contents, and if it fills again, as is usually the case, lay it open by a free incision, inserting a piece of lint between the lips of the wound, so as to bring on the proper degree of inflammation, and regulate this by poultices and appropriate treatment. Dr. Hayward has never found it necessary to excise the cyst. SECTION IV. PAINFUL CONDITION OF THE NERVES. The nerves of the extremities are sometimes pricked in bleeding, or so accidentally injured as to induce a neuralgic condition, to relieve which an operation is demanded. This operation is varied, and may consist either in a simple transverse division of the main trunk, or in the excision of a portion of it. For the neuralgia and other evils resulting from the injury of a cutaneous filament in venesection, little more is requisite than a simple incision across the nerve so as to divide it entirely; but in other cases it may be requisite to lay bare the main trunk of the nerve by a regular dissection of its course, and to excise a small portion in order to prevent the reunion of the divided parts, and the restoration of the function of the part. For several interesting papers on affections of the nerves, the reader is referred to the operations of Dr. Warren, of Boston, as quoted in the Bibliographical Index.* SECTION V. VARICOSE VEINS. Pathology.—The morbid enlargement or dilatation of any of the veins of the body has long been regarded as constituting a varix, and, to relieve this, surgeons have suggested various operations. The failure of many of these plans to effect a cure, as well as the serious loss of life that has in some instances ensued upon their per- formance, should induce a close examination of the anatomical rela- tions of these vessels, as well as the pathological changes noted in * Part I. p. xxxiv. 60S OPERATIVE SURGERY. them. My present limits will, however, simply permit a reference to the coats of these veins, without entering upon their surgical anatomy. The veins of the extremities, in which the varicose condition is most often seen, are, like the arteries, composed of three coats— a cellular, muscular, and serous or arachnoid one—these coats being generally much thinner in these vessels than in the arteries, the tenuity of the veins being so great as to permit the circulation of the blood to be distinctly seen through them, in consequence of which they are more liable to expansion or rupture upon the application of force. All the superficial veins of the extremities communicate with the deep veins by numerous-anastomoses. In an elaborate paper upon the Pathology of Varices, by Dr. Jno. Watson, of New York,* may be found many excellent observ- ations connected with their condition. Speaking of the stages in the progress of varices, Dr. Watson refers to the first as being cha- racterized by a simple dilatation of the vessel, which leads to inter- stitial development or hypertrophy; the second, by an increase in their length, which leads to the formation of folds and serpen- tine convolutions, these being most common where the vessel is under least restraint; the third, by an increase in the thickness of their elastic or muscular coat; and the last, by a change in the inner coat, which becomes so thickened as to resemble delicate muscular tissue. Terminations.—Varicose veins may, under favorable circum- stances, contract upon themselves, and diminish in calibre so as to contain less blood than is natural to them. Or the inner membrane may inflame, throw out coagulated lymph, and thus close its channel, or it may run on to suppuration, as in suppurative phlebitis, or the disease may terminate in death by loss of blood. Operations upon the veins, by inducing inflammation, may cause death from phlebitis; or the recession of the blood from the vari- cose vessels into the course of the general circulation, in persons of a plethoric habit, may induce pleurisy and pneumonia; whilst, under the most favorable circumstances, the most that can be obtained is a temporary relief, the return of the circulation through the anastomosis, between the deep and superficial vessels, often re- developing similar evils to those which it had been attempted to * Am. Journ. of Med. Sciences, vol. v. N. S. p. 36. tenotomy, or division of the tendons. 609 relieve. From considerable observation of many of the plans of operating heretofore employed and recommended, I am induced to think that the patient's life is often exposed without obtaining any permanent good, and I shall therefore omit all mention of the ope- rative proceedings usually described as applicable to this complaint. Those desirous of full information on these plans are referred to the excellent and extended paper of Dr. Watson, to whom I am indebted for much additional information, and to a confirmation of views ob- tained in Paris in 1840.* Coinciding in the correctness of his opin- ions as to the danger resulting from incisions, and similar means of treatment, the following plan, as pursued by him, is the only one to which I will refer. Treatment of Varicose Veins, by Dr. Jno. Watson, of New YoRK.f—The patient, having the limb bandaged, and having been kept in bed for twenty-four hours, several small pieces of a common wax bougie should be applied over the course of the varices, some being placed longitudinally, and others transversely along the veins, and secured in their position by a roller. Over this apply the starch bandage,^ and allow it to remain undisturbed as long as it causes no inconvenience, and does not become deranged. Remarks.—After the references already made to the treatment of this complaint, the reader must be aware that I deem little more requisite in the way of an operation upon varices, than such pressure as can be obtained by pursuing the judicious plan advised by Dr. Watson. It or the laced stocking, or both, are capable of accom- plishing quite as much in the treatment of varices of the limbs as either caustic, excision, incision, perforation, or any of the nume- rous other plans usually referred to. SECTION VI. tenotomy, or division of the tendons. Under the heading of "contracted tendons," surgeons have some- times placed a class of deformities which are due to a contraction of the muscle, instead of the tendon, to which it belongs; but in the * Philada. Med. Exam., vol. ii. p. 821, 1839. f Loc. citat., p. 57. X Smith's Operative Surgery, p. 282, 3d edit. 610 operative surgery. cases of burns or ulcers, an actual loss of the substance of the tendon sometimes ensues upon the injury. From muscular contraction, the tendons in the neighborhood of different joints are, however, some- times rendered so prominent and distinct, that they appear to be contracted, as they can be felt like tense bands or cords immediately beneath the skin, interfere with the motion of the part, and retain the limb in a deformed position. To obviate this, the division of the tendon has been practiced with considerable success, especially when seconded by such mechanical contrivances as may restore and pre- serve the limb in its ordinary position. This division of a tendon may be readily accomplished in any case by means of a tenotome (Plate XXXV. Fig. 13), which should be passed beneath the skin, and made to act on the tendon as directed in torticollis.* As an operation, the division of a tendon is sufficiently simple; but, unless the consequences are well understood, much evil may result from its performance, or from the too early application of mechanical means to remedy the contraction. In studying the result of the operation, it should therefore be recollected that when a tendon has been divided without contact with the air, as is accomplished in its subcutaneous section, or in its laceration, the following changes may be anticipated: 1. A slight effusion of blood at the seat of injury between the divided ends. 2. The exu- dation of soft gelatinous plastic matter. 3. Its conversion into a sort of lamellated or fibrous tissue, which in its early condition is susceptible of a certain amount of elongation. Perfect rest for a day or two is therefore essential to success in ope- rating for tenotomy, the mechanical means being gradually applied and persevered in until the elongation of the part is sufficient. In deformities of the foot (club-foot), and of the hand, or in false anchy- losis, the operation of tenotomy may prove serviceable, care being taken, by reference to the surgical relations of the part, to prevent injury to the adjacent nerves and bloodvessels. For the mechanical treatment of these complaints, the reader is referred to my volume on minor surgery, f * Part III. p. 286. t P. 435, edit. 1850. LIGATURE OF THE AXILLARY ARTERY IN THE AXILLA. 611 CHAPTER II. LIGATURE OF THE ARTERIES OF THE EXTREMITIES. The arteries of the upper extremity may be ligated at any point from the shoulder to the fingers, and are to be operated on by the same rules as have been already stated in the chapter on Aneu- risms in general.* The present account will, therefore, be limited to the operative steps required in the special application of the ligature to the arteries of this member, the anatomical relations of each vessel being given in connection with the operation practiced upon it. SECTION I. LIGATURE OF THE AXILLARY ARTERY IN THE AXILLA. Anatomy.—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 clavicle, and others, among whom is Dr. E. Geddings, of Charleston,f limiting it to the triangular depres- sion included between the upper part of the arm, shoulder, and side of the chest, which is formed by the edge of the pectoralis major in front, the latissimus dorsi, and teres major muscles be- hind, as they tend to their insertion into the humerus, and by the ribs covered by the serratus 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 it, or sometimes renders it convex, and when the patient is * Part III. p. 317. t Amer. Cyclop, of Med. and Surg., vol. i. p. 559. X Part III. p. 345. 612 OPERATIVE SURGERY. PLATE LXY. LIGATURE OF THE ARTERIES OF THE ARM. 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 axillary artery. 9. Pectoralis minor muscle. 10. Pectoralis major. 11. Anterior margin of axilla drawn back by a hook. 12. Cut edge of brachial fascia. 13. Biceps muscle. 14. Coraco-brachialis. 15. Lymphatic. After Bernard and Huette. Fig. 2. Ligature of the Axillary Artery in the Axilla. 1, 2. Incision in the skin and fat. 3. That in the fascia. 4. Axillary artery raised on a director. 5. Axillary vein drawn back by a blunt hook forceps. 6. The median nerve. 7. 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 artery at the elbow by expansion from biceps tendon. 10. Median basilic vein. 11. Cephalic vein. After Bernard and Huette. Fig. 4. Anatomical Relation 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 ex- ternal cutaneous nerve. 12. Main trunk external cutaneous. 13. Branch of median nerve. 14. Branch of internal cutaneous. 15. Its main trunk. After Bernard and Huette. Fig. 5. Anatomical Relations of parts about the Wrist. 1. Posterior annular ligament. 2. Tendon extensor primi internodii. 3. Tendon ex- tensor secundi internodii. 4. Radialis indicis artery. After Bernard and Huette. Fig. 6. Ligature of Radialis Indicis Artery. 1. The skin. 2. The fascia. 3. The artery with the ligature beneath it. After Bernard and Huette. -atoire. 614 OPERATIVE SURGERY. which is the second indication; and inside and beneath it is the artery, which should be ligated as before directed. Remarks.—Ligature of the axillary artery in the axilla may be demanded in case of an aneurism or wound of the brachial artery high up; the primary hemorrhage in the case of wounds being re- strained by pressure of the subclavian upon the first rib, whilst, 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, with- out injuring either the nerves or the vein, has therefore generally prevented its 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 permissible. Occasionally, fainting from loss of blood will deprive the operator of the aid to be obtained from noting the pulsation of the vessel in its full force, whilst the interlacing of the numerous nerves will add to his embarrassment; but it should be remembered that usually the median nerve is next to the coraco-brachialis muscle, that inside of it is the internal cutaneous, and that behind this we have the ulnar and radial nerves, so that, by following the directions of Malgaigne, even the ordinary amount of anatomical knowledge, possessed by those long absent from the dissecting-rooms, will suffice for the operation. SECTION II. LIGATURE OF THE BRACHIAL ARTERY. Anatomy.—At the lower border of the latissimus dorsi, and upon the anterior face of its insertion, the axillary artery takes the name of Brachial, which it continues as far as the bend of the elbow. Throughout its length its course is down the arm on the inner side, winding gradually forwards to reach the middle of the anterior face of the bend of the forearm. 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. (Plate LXV. 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 LIGATURE OF THE BRACHIAL ARTERY. 615 elbow it perforates the fascia, and passes beneath the expansion from 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. 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. The radial, ulnar, and internal cutaneous nerves are also upon its inner side, high up, but lower down they advance towards the posterior and internal face of the arm and recede from the artery. The brachial artery is, how- ever, liable to great varieties, sometimes giving off the radial and ulnar as high up as the axilla. § 1.—LIGATURE OF THE BRACHIAL ARTERY AT THE MIDDLE OF THE ARM. Lying on the inner side of the coraco-brachialis high up, and on the inner edge of the biceps lower down, the median nerve is ex- ternal and anterior to the course of the artery. Four indications point out the line of the incision : 1, the external 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), the incision being made parallel with, and inside of them (Lisfranc); 4, the pulsation of the vessel.f Operation.—Carry the limb a little off from the body, flex the 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, pick it up, nick it, insert a director, and slit'it up to the extent of two and a half inches, so as to expose the inner edge of the biceps mus- cle, when the thick yellow sheath of the vessel will be readily seen. Incise this on its inner edge, and the median nerve, which is the * E. Geddings, Amer. Cyclop. Med. and Surg., p. 346. f Malgaigne, Philad. edit., p. 145. 616 OPERATIVE SURGERY. first white cord on the inside of the muscle, being found, the artery may be exposed beneath it, and easily ligated from without inwards, by drawing the nerve a little to the outside. (Plate LXVI. Fig. 2.) The internal cutaneous nerve is internal to, and the ulnar half an inch behind the artery. § 2.—LIGATURE OF THE BRACHIAL NEAR THE ELBOW. 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, and the median nerve will be found about a quarter or half an inch on the inside of the vessel, when a ligature should be carried around the artery from within outwards. (Plate LXVI. Fig. 2.) Two inches above the epitrochlea, the median nerve passes underneath the artery, so 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 ligature of the brachial artery at any point is not a difficult operation to one familiar with the general relations of the median nerve to the artery, a*id though these vary a little at dif- ferent points, 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 anomalies are not very common. When the ligature is applied upon the ves- sel, one end should be cut off, the wound closed by adhesive strips, and the arm kept moderately warm for a few hours until the circu- lation is established through the muscular and anastomosing branches. When, in ligating the artery, the arm is much swelled, the line de- scribed by Sabatier will furnish the best direction for the incision; but, when it is not, the course of the biceps or coraco-brachialis mus- cles will suffice. The rapid enlargement of the anastomosing arte- ries, though soon advantageously restoring the circulation sometimes, creates trouble in cases of aneurism at the bend of the elbow, and occasionally necessitate the application of two ligatures, one above and the other below the tumor. * Malgaigne. LIGATURE of the radial artery. 617 SECTION III. LIGATURE OF THE RADIAL ARTERY. Anatomy.—At the upper third of the forearm, the radial artery is placed in the groove that separates the supinator radii longus from 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 from 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. Malgaigne's Operation at the Upper Third of the Forearm. —By an incision in the line just mentioned, the skin is 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). If the artery is not met with, draw the muscle outwards 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 be found unless there is an anomaly. Ligature 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; open the fascia upon a director; and the artery will be found on the outer or radial side of the tendon.f (Plate LXVI. Fig. 3.) Remarks.—The ligature of the radial at the points mentioned may be required in cases of wounds, and readily accomplished under * Malgaigne. t Ibid. 618 OPERATIVE SURGERY. PLATE LXVI. LIGATURE OF THE ARTERIES OF THE UPPER EXTREMITY Fig. 1. Surgical Anatomy of the Bloodvessels of the Forearm and Hand. 1. Brachial artery. 2. Radial artery. 3. Ulnar artery. 4. Position of radial artery at wrist. 5. Position of ulnar at wrist. 6. Palmar arch. 7. Radialis indicis. 8. Basilic vein. 9. Cephalic vein. 10. Venae satellites of radial artery. 11. Venae satellites of ulnar artery. 12. Median nerve. 13. Radial nerve. 14. Ulnar nerve. 15. Biceps tendon. 16. Supinator radii longus. 17. Flexor carpi radialis. 18. Flexor carpi ulnaris tendon. After Bernard and Huette. Fig. 2. Ligature of the Brachial Artery—Upper Incision. 1. Skin. 2. Fascia. 3. Brachial vein. • 4. Median nerve. 5. Artery raised on a director. Second Incision near the Elbow. 1. Skin. 2. Fascia. 3. Inner edge of biceps. 4. Median nerve. 5. Artery on director. After Bernard and Huette. Fig. 3. Ligature of the Radial and Ulnar Arteries. Upper Third—1. Skin. 2. Fascia. 3. Radial artery. 4. Radial nerve. 5. Director under artery. 6. Inner edge supinator radii longus. At Wrist.—1. Skin. 2. Fascia. 3. Artery on director. 4. Radial nerve. Ligature of the Ulnar Artery at the Middle of the Forearm.—1. Skin. 2. Fascia. 3. Artery. 4. Vein. Ligature of the Ulnar Artery at 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. Anterior tibial artery. 2. Anterior tibial nerve. 3. Anterior annular ligament. 4. Tendon extensor proprius pollicis. 5. Extensor brevis digitor pedis. After Bernard and Huette. Fig. 5. Ligature of the Anterior Tibial Artery on the Foot. 1. Skin. 2. Fascia. 3. Director. 4. Artery raised on it. After Bernard and Huette. : '> 4 v y LIGATURE OF THE ULNAR ARTERY. 619 the directions just given. The fondness of many of the French surgeons for practicing the ligature of arteries in the dissecting- room makes them excellent authorities, and I therefore have resorted, and shall freely resort to their directions, as considerable personal experience has tested the value of those that have been given. The ligature of the magna pollicis, or of the radialis indicis, at the root of the thumb, can seldom be required in practice; compression, or the ligature of the radial at the wrist, answering a better pur- pose. The operation is, however, shown in Plate LXV. Fig. 6. SECTION IV. LIGATURE OF THE ULNAR ARTERY. Anatomy.—The thickness of the flexor muscles near the elbow placing the ulnar artery very deep at this point, no operation is usu- ally attempted here, and it is therefore unnecessary to study its rela- tions at its upper third. In its middle and lower third, it lies upon the flexor profundus 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 rein upon its outside, but it is subject to many anomalies, in some of which it is quite superficially placed. Operation at the Middle Third of the Forearm.—A line drawn from the internal condyle to the radial side of the pisiforme bone will indicate the usual course of the vessel. Upon this line make an incision three inches long, and not extending higher than three fingers' breadths from the internal condyle; open the fascia upon a director; carry the inner lip of the wound inwards with the fore- finger until the internal edge of the ulnar can be felt, and 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 flexor sublimis. 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 (ulnar nerve), with the artery and its two venae satellites on its radial side, when the ligature may be passed from within outwards, the hand being strongly flexed to relax the muscles. (Plate LXVI. Fig. 3.) Ligature of the Ulnar above the Wrist.—Make an incision two inches long and one inch above the joint parallel with the tendon of the flexor carpi ulnaris ; divide the fascia, draw the tendon a little 620 operative surgery. inwards, and the artery will be found on its external side beneath the deep fascia, the ulnar nerve being on its inside and posteriorly. Open the deep fascia, and pass the ligature from within outwards. (Plate LXVI. Fig. 3.) Remarks.—The ligature of the ulnar at its upper third is now never attempted, on account of the difficulty of finding the artery, as well as on account of the subsequent suppuration of the wound. It is also better to avoid, if possible, ligating this vessel in its middle third, for the same reason, the ligature near the wrist being sufficient for wounds of the palmar arch, which most frequently demand the operation. CHAPTER III. LIGATURE OF THE ARTERIES OF THE LOWER EXTREMITY. The main artery supplying the lower extremity is the continua- tion of the External Iliac, and is at different points named Femoral, Popliteal, &c, according to its position, and may be ligated at any point. SECTION I. LIGATURE OF THE FEMORAL ARTERY. Surgical Anatomy.—The line of the groin, or that caused by the attachment of Poupart's ligament to the bones of the pelvis, consti- tutes the upper boundary of the Femoral artery, whilst below it takes the name of Popliteal, at a point which is about one-third of the whole length of the os femoris, above the knee-joint, or as soon as it has traversed the insertion of the adductor longus muscle. In the space thus circumscribed, the femoral artery runs a winding course, being first on the anterior, then on the interior, and lastly, near the poste- rior face of the thigh, following the direction of a line drawn from the middle of the crural arch to the posterior and internal part of the condyle of the femur, and being inclosed in a common sheath with the femoral vein, the latter being on its inner or pubic side near the LIGATURE OF THE FEMORAL ARTERY. 621 groin, behind it in the middle of the thigh, and a little to its outer side below. (Plate LXVII. Fig. 1.) The anterior crural nerve lies upon the external side of the artery outside the sheath of the vessels, whilst 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 pelvis; 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 again to its outer side low down the thigh. The regular course of the muscle makes it a most useful point of reference when attention is given to its relations at the different points of the limb. The 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. § 1.—LIGATURE 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 incision in the skin, so as to expose the internal border of the sartorius mus- cle, which may be recognized by the course of its fibres. Then care- fully 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, and pass the aneurismal needle from within outwards (Plate LXVII. Fig. 2). If the needle is passed in the opposite direction, its point may wound the vein and the escape of even a little blood will materially interfere wi.th the sight of the surgeon and delay the operation. * Bernard and Huette. 40 622 OPERATIVE SURGERY. PLATE LXVII. LIGATURE OF THE ARTERIES OF THE LOWER EXTREMITY. Fig. 1. Anatomy of the Femoral Vessels. 1, 1. Femoral artery. 2, 2. Femoral vein. 3. Internal saphena vein. 4. Muscular branch of artery. 5. Long saphenous nerve. 6. Branch in front of sheath of vessels. 7. Arteria profunda. 8. Opening in adductor muscle. 9. Musculo-cutaneous nerves. 10. Anterior crural nerve. 11, 11. Hooks holding aside sartorius muscle. After Bernard and Huette. Fig. 2. Ligature of the Femoral Artery. At its Upper Third.—1. Skin. 2. Fascia. 3. Sheath of vessels. 4. Artery raised on the director. 5. Femoral vein. 6. Long saphenous nerve. 7. Inner edge of sartorius muscle. At its Lower Third.—1. Skin. 2. Fascia. 3. External edge of sartorius muscle. 4. Femoral vein. 5. Long saphenous nerve. 6. Artery exposed in its sheath. After Bernard and Huette. Fig. 3. Anatomy of the Popliteal Artery. 1. Artery. 2. Vein. 3. Semi-membranosus muscle. 4. Gastrocnemius. 5, 5. Hooks holding aside the muscles. After Bernard and Huette. Fig. 4. Course and Relations of the Popliteal Artery to the Joint. 1,1. Artery. 2. Femur. 3. Tibia. 4,4. Posterior face of knee-joint. 5, 6, 7. Articulating arteries. After Bernard and Huette- Fig. 5. Ligature of the Popliteal Artery in its Upper Half. 1. Skin. 2. Fascia. 3. Fat. 4. Peroneal nerve. 5. External saphena vein. 6. Popliteal vein. 7. Artery as shown by 8, the hook holding aside the yemg After Bernard and Huette. Fig. 6. Ligature of the Posterior Tibial Artery—At its Upper Third. 1. Skin. 2. Fascia. 3,3. Gastrocnemius muscle held aside by a blunt hook. 4. Artery on the needle. 5. Soleus muscle. At its Middle Third.—1. Skin. 2. Fascia. 3. External edge of soleus. 4. Artery. 5. Needle under it. 6. Posterior tibial nerve. At the Ankle.—1. Skin. 2. Director under artery. 3. Posterior tibial nerve. Afler Bernard and Huette. LIGATURE OF THE FEMORAL ARTERY. 623 § 2.—LIGATURE OF THE FEMORAL ARTERY AT THE UPPER PART OF THE THIGH. Scarpa's Operation.—At this point, the artery is quite superficial, and may be readily felt pulsating in the triangular space formed by the junction of the sartorius, adductor brevis, and Poupart's liga- ment, 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 per- formed as follows:— Feel for the pulsation of the artery, and note the spot where it is faintest, which will indicate the point where it is crossed by the sartorius muscle, and commencing at this part incise the skin ob- liquely downwards to the extent of three inches, taking care to push the saphena vein inwards. On exposing the fascia lata, pick up a fold at the lower point of the incision ; nick it, introduce a director, and slit it up to the same extent as the skin; open the sheath in the same manner, and expose the artery, the nerve being on its outside, and the vein still at its inner side, and tie it by passing the needle from within outwards so as to avoid the vein. Remarks.—The oedematous condition of the thigh, sometimes seen in cases demanding the ligature of the femoral artery, adds materi- ally to the difficulties attending its ligation when required upon the patient. As above described, these operations are chiefly adapted to the dissecting-room, or to the natural condition of the parts. When, therefore, any difficulty is experienced 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 anterior 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 gan- grene, the origin of the profunda favoring the course of the circu- lation when the ligature is applied in the middle of the thigh. The * Malgaigne. 624 operative surgery. ligature of the femoral, as practiced in the lower third of the thigh, is shown (Plate LXVII. Fig. 2); but, as it requires the division of the arterial canal through the adductor magnus, and also makes a deep wound, it is seldom resorted to on the patient. SECTION II. LIGATURE OF THE POPLITEAL ARTERY. Surgical Anatomy.—The popliteal artery is a continuation of the femoral, and extends from 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, also cover it. The artery is first on the inner side of the femur, then approaches its posterior face, and passing between the condyles is in contact with the back of the knee- joint.* Lisfranc's Operation.—The patient being laid upon his face, with the limb extended, feel for the interval between the two heads of the gastrocnemius 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, intro- duce 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 inwards, and pass the needle under the artery from within out- wards.f (Plate LXVII. Fig. 5.) Remarks.—The ligature of the popliteal, as above described, is an operation that is seldom or never undertaken, 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 travelling beneath the fascia of the leg, inducing surgeons to avoid it. In all cases of aneurism, or wounds of the * Bernard and Huette, Med. Operatoire, p. 42. ■f Malgaigne. LIGATURE OF THE POSTERIOR TIBIAL ARTERY. 625 tibial arteries 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 would render it abso- lutely necessary to place the ligature higher up. This operation is one, therefore, which is seldom practiced except in the dissecting- room. SECTION III. LIGATURE OF THE POSTERIOR TIBIAL ARTERY. Surgical Anatomy.*—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 tendo-Achillis. At its upper third, it lies very deep, being beneath the tibialis posticus, 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 digitorum 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 beneath the tendons of the tibialis posticus and flexor longus digi- torum pedis, and is almost parallel to the posterior margin of the malleolus internus. It may*be ligated at its upper, middle, or lower third. § 1. Operation of Malgaigne at its Upper Third.f—Make an incision at least four inches long, entirely through the skin, cellular tissue, and fascia, commencing about half an inch from the inner margin of the tibia; introduce the forefinger, and detach and carry outwards the internal head of the gastrocnemius as well as the soleus. Then, whilst an assistant holds these muscles backward and out- wards, open the deep fascia upon a director, and look for the artery ; on finding it, separate it from its accompanying veins, and ligate it. (Plate LXVII. Fig. 6.) * Bernard and Huette, p. 38. f Ibid., p. 39. 626 operative surgery. PLATE LXVIII. ligature of the arteries of the leg. Fig. 1. Anatomical Relations of the Popliteal Region, as shown after removal of the integuments. 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 yejns After Bernard and Huette. Fig. 2. Anterior View of the Knee-Joint. 1. Femur. 2. Patella. 3. Tibia. 4. Fibula. 5. Tendon of patella. 6. External and internal lateral ligaments. After Bernard and Huette. Fig. 3. 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 arterv After Bernard and Huette. Fig. 4. Anatomical Relations of the Posterior Tibial Artery. 1. The posterior tibial artery. 2, 3. Its two vense comites. 4, 4. Section of the internal saphena vein. 5. Fascia of the leg. 6, 6. Hook holding back the fascia anteriorly, and the soleus muscle posteriorly, so as to expose the deep-seated parts. 7. Tibialis posticus muscle. 8. Flexor longus digitorum. 9. Internal malleolus. 10. 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. Anterior tibial veins. 3. Anterior tibial nerve. 4. Peroneal artery and vein raised on a director. 5. Flexor longus pollicis. 6. Fibula. 7. Peroneus longus and brevis cut across. 8. Tibialis anticus, held back by the hook. 9. Extensor proprius pollicis. 10. External malleolus, covered by the fascia. After Bernard and Huette. Fig. 6. Ligature of the Anterior Tibial and Peroneal Arteries. Upper In- cision.—Ligature of the Anterior Tibial, near its Upper Third. 1. Skin. 2. Fascia. 3. Tibialis anticus muscle. 4. Extensor proprius pollicis. 5. The vein. 6. The artery raised on the needle. Middle or Posterior Incision. —Ligature of Peroneal Artery below its Middle. 1. Skin. 2. Fascia. 3. Peroneus longus. 4. External border of soleus. 5. Needle under. 6. The Peroneal artery. Lower Incision.—Ligature of the Anterior Tibial at its Lower Tbird.—1. Artery. 2. Anterior tibial nerve. After Bernard and Huette. LIGATURE OF THE ANTERIOR TIBIAL ARTERY. 627 Remarks.—This operation is an exceedingly troublesome one, in consequence 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 encountered in the patient. It is, therefore, rarely resorted to. § 1.—LIGATURE OF THE ARTERY AT ITS MIDDLE THIRD. Velpeau's* Operation.—Make a straight incision, about three inches long, at an equal distance from 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.) § 2.—LIGATURE OF THE ARTERY BEHIND THE MALLEOLUS INTERNUS. Lisfranc's Operation.—Make a longitudinal incision in the skin parallel to the internal malleolus, but two lines posterior to it, ex- tending 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 venae satellites. The nerve lies posteriorly and externally to the artery. (Plate LXVII. Fig. 6.) Remarks.—Ligature of the posterior tibial artery near the mal- leolus, is a simple operation, and one that is well adapted to the treatment of wounds of the plantar arteries. That in the middle of the leg is somewhat more difficult, owing to the depth at which the artery is placed. SECTION IV. LIGATURE OF THE ANTERIOR TIBIAL ARTERY. Surgical Anatomy.—The anterior tibial artery, after passing through the interosseous ligament in the upper part of the leg, lies v * Operat. Surgery, by Mott and Townsend, vol. ii. p. 127. 628 operative surgery. 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 this course on the leg, it follows a line which is drawn from the middle of the space between the head of the fibula and spine of the tibia to the middle of the inter-malleolar space, and from this space to the middle of the first metatarsal interosseous space of the foot. Owing to its depth, this artery is seldom tied high up, though it may be accomplished, and, 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. § 1.—LIGATURE 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 posticus to become prominent, and following the course of the ten- don when it can be felt, or the line above described when it cannot, make an incision three inches long through the skin and foot; open the fascia freely, and seek for the first tendon, or the first inter- muscular space from the spine of the tibia. 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 artery lower down. Pass the needle from the fibula towards the tibia, and from below upwards, and apply the ligature. (Plate LXVIII. Fig. 6.) Should the operator carry the incision too far outwards, 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 outwards, and the error will soon be indicated. * Malgaigne, Philad. edit. p. 157. OPERATIONS ON THE BONES OF THE UPPER EXTREMITY. 629 § 2.—LIGATURE OF THE ANTERIOR TIBIAL ON THE DORSUM OF THE FOOT. Ordinary Operation.—Draw a line from the middle of the space between the two malleoli to the first metatarsal interosseous 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 tendon of the extensor communis, which may be made prominent by causing the patient to extend his toes. After which, the sheath of the extensor communis, or the deeper 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 outer 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. It may be required in the treatment of aneurism, as once happened to myself, or for wounds, though most frequently pressure suffices for the latter. The spica of the instep* will be the proper dressing. 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 neces- sary by their relations to surrounding parts. Certain general rules are, therefore, applicable to both extremities, and will be referred to under one general head, the special operative proceedings being detailed in connection with the extremity to which they belong. * Smith's Minor Surgery, p. 101. 630 OPERATIVE SURGERY. SECTION I. RESECTIONS IN GENERAL. By resection of the bones of the extremities, is usually meant such an operation as removes a sufficient portion to create a void or destruction of continuity. In many instances, resection of the heads of these bones results in more or less shortening of the limb, though even then the member will be much more serviceable than an artificial limb; and it is, therefore, an operation by which the surgeon can remove a disease, and yet not destroy the use- fulness of the member. Without entering into the question of the advantages of resection over amputation in disorders limited to the articulations, it must suffice in this account to give expres- sion to the opinion that the experience of surgeons is now gradually establishing its superiority over amputation, and the propriety of attempting the relief of the diseases of the joints by its means should, therefore, be always thought of before resorting to ampu- tation. The general conditions which are essential for the proper perform- ance of a resection may be divided into such as concern the patient, and such as pertain to the surgeon. It is essential on the part of the patient 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 en- tire complaint. The surrounding soft parts should also be in a con- dition favorable to the healing of the wound, without being liable to such contraction, suppuration, or ulceration as might 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 bloodvessels in the neighborhood must all be left untouched, if possible. Especially is it important to avoid un- necessary 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. RESECTIONS IN GENERAL. 631 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 care- fully superintended by the operator. For the performance of any resection, various saws, chisels, gouges, bone-nippers, &c, 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 instru- ments resorted to in operations upon the bones is nearly indefinite, the reader is simply referred to Plate VI. for a view of such as are most frequently wanted. SECTION II. RESECTION OF THE BONES OF THE UPPER EXTREMITIES. The resection of the bones of the upper extremities may be prac- ticed either upon their diaphyses or upon their articulating extremi- ties. In operating 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. § 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, which may be accomplished by exposing the articulation, and removing them with the saw or gouge. Syme's Operation.—Whilst an assistant compresses the subclavian artery, make a longitudinal incision, three and a half inches long, in the middle of the deltoid, and a shorter one from its inferior extremity upwards and backwards, towards the posterior border of the axilla, so as to form a triangular flap. Raise it up, and whilst it is held by the assistant, carry the elbow in towards the side of the 632 OPERATIVE SURGERY. 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 as in his amputation of the shoulders, the head of the bone luxated, sawed off, and treated as above directed. Operation of White, of England.—Make an incision down to the bone, parallel with the fibres of the deltoid muscle, and extend- ing from the apex of the acromion four or five inches downwards; open the capsule on the outer side of the joint; carry the elbow into the body; luxate the head of the bone through the muscle, and saw it off. 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 re- moval 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 con- tact after the performance of this resection, a considerable amount of motion has been preserved at the shoulder, and in a case reported by Mr. Syme the use of the arm was almost completely established. Resection of the head of the humerus has not, I think, been per- formed by surgeons in the United States, except in the case reported by Dr. Hunt, of Washington ;f and in one of a partial character by Dr. Pinkney, U. S. Navy,J though amputation of the shoulder for disease of the bone has often been resorted to. It is, however, one which is well worthy of a trial. In selecting a method, that of White should be preferred, if the induration and other changes in the soft parts do not forbid it, as it preserves the more perfect action * Smith's Minor Surgery, p. 39. f Med. Record., vol. i. p. 365, 1818. X Am. Journ. of Med. Sciences, vol. xii. N. S. p. 330, 1846. resections in general. 633 of the deltoid, and thus facilitates the subsequent motion of the shoulder; but the section of the deltoid, as advised by Syme and Lis- franc, 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.—FALSE JOINT IN THE HUMERUS. Resection of the ends of a false joint in the Humerus have been cured by the introduction of a seton, as suggested by Dr. Physick ;* by the application of caustic by Dr. Rhea Barton, of Phila. ;f by resecting the ends of the bone, by Dr. J. Kearney Rogers, of N. Y. ;| and by many others. Operation of Dr. Physick, of Philadelphia.—In the year 1802, a patient afflicted with a false joint in the middle of the hu- merus was cured in the following manner:— A long seton-needle, armed with a skein of silk, being prepared, extension and counter-extension of the limb was made by two assist- ants, and the seton passed between the fractured ends of the bone in such a manner as to avoid 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 bending at the seat of fracture became less apparent, and in about five months the arm was as strong as ever. Several other surgeons in the United States have since been equally successful.§ § 3.—resection of the elbow-joint. Resection of the bones of the elbow-joint, like that of the shoulder, is also among the more recent operations of surgery, having been suggested by Park, of England, in 1781, and performed in 1782 by Moreau.|| The process of Moreau is that which has been most * Med. Repository, vol. vii. p. 122, 1804. f Med. Record., vol. ix. p. 275, 1826. X N. York Med. and Phys. Journ., vol. vi. p. 521, 1827. § Bibliographical Index, p. xc. || Velpeau, Op. Surg. 634 OPERATIVE SURGERY. 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, whilst with 2, the fingers of his left hand, he holds up the triangular 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 subclavian artery is compressed by one assistant, whilst the surgeon transfixes the soft parts near the end of the bone by a catlin, and cuts down- wards, 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 replaced and held in position by the sutures. After Bernard and Huette. Fig. 5. Resection of the Radius. 1, 2. Incision. 3. Hand of 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 extirpation of the ulna, which has been accomplished by Dr. Butt, of Vir- ginia, in a similar manner. Afler 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. Vertical incision. 2, 3. The transverse cut. This transverse incision is wrongly represented, as it should have been carried across from 1, 1, so as to revert the flap downwards. After Bernard and Huette. RESECTIONS IN GENERAL. 635 generally approved, and it has been selected with occasional modi- fication as the plan of most of the operations performed in the United States. Operation of Dr. Thomas Harris, of Philadelphia.*—In the case of a woman, twenty-six years of age, laboring under hectic with suppuration in the elbow-joint, the following operation was per- formed :— The operating table being covered by a mattress, the patient was placed on it with her face downwards, and with the posterior internal portion of the elbow presenting to the surgeon, whilst the point of a strong bistoury was passed transversely so as to divide the skin, cellular 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 sido, including the ulnar nerve, being now drawn to one side, by means of curved spatulae, the olecranon process was removed by the common ampu- tating saw. (Plate LXIX. Fig. 3.) The condition of the joint was then carefully examined, and all the articulating surfaces being found in a carious condition, the head of the radius and the diseased sur- faces of the ulna and humerus were perfectly removed with the bone- nippers, two branches of the articulating arteries tied, the joint care- fully cleaned, and the parts closed by sutures, and dressed with an- gular splints. The patient ultimately recovered with considerable motion of 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 Dr. Harris this was increased by the thickening and adhesion of the soft parts. To obviate this, Du- puytren proposed to open the sheath of the nerve cautiously behind the internal condyle, as soon as the upper flap was dissected, and have it held inwards and forwards by an assistant during the opera- tion. A reference to the bibliographical index will show the reports of the operations performed by Dr. Gurdon Buck, Jr., of New York,t * Am. Journ. Med. Sciences, vol. xix. p. 341. t Ibid., vol. v. N. S. p. 299. 636 OPERATIVE SURGERY. and by Dr. J. Pancoast, of Philadelphia. In that of Dr. Buck, for the removal of the olecranon process, the longitudinal incision was substituted for that of the II, the sides being dissected up so as to expose the bone without dividing the attachment of the triceps tendon, and is a valuable improvement where it is admissible. § 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 belongs, however, to the operation as detailed in the resection of the elbow- joint, whilst the removal of the lower constitutes resection of the wrist. I. RESECTION OF THE BODY OF THE ULNA. The ulna or radius, when diseased to a considerable extent, may be removed from the arm without necessarily destroying the useful- ness of the limb. Operation of Dr. Butt, of Va.*—In consequence of a long- continued necrosis of the ulna, it was determined to remove the en- tire bone in the following manner :— Operation.—The patient being seated in a chair, and the tourni- quet applied as usual, a transverse incision was made down to the bone, about four inches and a half below the olecranon, and extend- ing to a little more than half the diameter of the arm. A longitu- dinal 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 as to protect the soft parts from the action of the saw. The ulna being now divided transversely j 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 ena- ble an assistant to elevate it, after which the bone was disarticulated * Philad. Journ. Med. and Phys. Science, vol. i. N. S. p. 115, 1825. resections in general. 637 from the wrist and removed. (Plate LXIX. Fig. 5.) The wound being cleansed, the tourniquet was loosened, the ulnar and interos- seous arteries tied, and the edges of the longitudinal wound 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 uninterrupted as ever, declaring subsequently that he had as much strength in this hand (the left) as most people had in the right. II. RESECTION OF THE INFERIOR EXTREMITY OF THE ULNA. Operation.—" The hand being carried outwards, make a longi- tudinal 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 be- neath the end of the bone, it may be readily sawed through."* (Plate LXIX. Fig. 6.) Remarks.—The success attending resection of the ulna has cer- tainly been such as may induce others to repeat the operation in similar cases rather than amputate the limb, and in the variety of diseases of this bone which are met with from time to time, the surgeon should hesitate before consenting to such a mutilation, espe- cially if the arm is the right one. A case of resection of the middle two-thirds of the ulna has lately been reportedf by Dr. Carter Johnston, of Richmond, Virginia, which resulted most fortunately. In quoting the case of Dr. Butt, which is, I believe, unique in its character (though smaller portions have frequently been extirpated), the French surgeons have been misinformed, both Malgaigne and Velpeau referring to it as a resection of the radius, whereas it was the removal of the lower two-thirds of the ulna. Dr. Pancoast, of Philadelphia, seems also to have fallen into the same error.J In operating upon the radius, the same steps would be required, as are described for the resection of the ulna, but the subsequent use- * Bernard and Huette. f Philadelphia Med. Examiner, vol. vii. N. S. p. 644, 1851. X Operative Surgery, by Joseph Pancoast, M. D., Philad. p. 125. 41 638 OPERATIVE SURGERY. fulness of the limb would be necessarily much more impaired, as the hand would be thrown out of its line with the arm, and prona- tion and supination destroyed. III. 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, as, under such circumstances, the bones of the carpus would proba- bly participate in the complaint. Operation of Velpeau.*—By an incision on each side of the forearm, reaching from the root of the thumb, and from the last metacarpal bone upwards for two inches above the level of the sty- loid process of the radius, and united by a transverse incision, a flap is formed and turned from above downwards 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 not 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 pres- sure will unite it to the anterior surface, and the hand be ultimately useful to some extent. IV. RESECTION OF THE METACARPUS. One or more of the last four metacarpal bones may, occasionally, require resection in their middle, in consequence of a limited caries, or badly-treated fracture. When needed, the bone should be care- fully exposed from the back of the hand, the soft parts protected, and then the portion excised by the bone-nippers. Resection of the metacarpal bone of the thumb is to be accom- * Velpeau, Op. Surg. RESECTION OF THE FEMUR. 639 plished 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 por- tion of the thumb. V. RESECTION OF THE BONES OF THE HAND. The phalangeal articulations 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 parts allowed to heal in this posi- tion. CHAPTER V. OPERATIONS ON THE BONES OF THE LOWER EXTREMITY. The success attending the resection of the bones of the lower ex- tremity has been even more brilliant than that ensuing upon the operations performed on the thoracic limbs, and it is to the surgeons of the United States, and especially to Dr. J. Rhea Barton, of Philadelphia, that the world is indebted for a most happy illustra- tion of the advantages to be gained from a scientific application of mechanical principles when aided by the efforts of nature in the formation of a new joint. SECTION I. RESECTION OF THE FEMUR. The femur has been resected at its head, trochanters, shaft, and condyles, either for the removal of such portions as were diseased, or to restore the usefulness of the limb. 640 OPERATIVE SURGERY. § 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 sup- puration and hectic which supervened, and these few were children about fourteen years of age, who were afflicted with caries. This operation should, therefore, be considered as a most dangerous one, especially as the natural tendency of the complaint is to a cure, and anchylosis is as apt to follow the resection as the progress of the disease. A reference to Plate LXX. Fig. 2, will sufficiently ex- plain 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 Dr. Jno. Rhea Barton, of Philadelphia.*— A young man, 21 years of age, having his thigh immovably fixed at a right angle with his pelvis, and carried across the opposite thigh, whilst the foot rotated inwards, was operated on as follows:— The patient being laid partially on the opposite side, a crucial in- cision, seven inches long, was made over the prominence of the tro- chanter 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 LXXI. Fig. 12), the bone was then nearly divided through the upper part of the great trochanter; and the neck—when the limb which 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 Dessault's splints.f The patient subsequently recovered, and by the formation * North Amer. Med. and Surg. Journ. vol. iii. pp. 279, 400, 1827. f Smith's Minor Surgery, p. 252, 3d edit. resection of the knee-joint. 641 of a false joint produced at the resected portion had during six years a limb upon which he could walk without apparent lameness. Dr. J. Kearney Rogers, of New York, about four years afterwards suc- cessfully performed a similar operation.* SECTION II. INTRODUCTION OF A SETON FOR FALSE JOINT IN THE FEMUR. Physick's Operation for false joint in this bone was similar to that reported under false joint in the humerus, but was not suc- cessful. The operation has also failed in other cases in the femur, and was not thought by Dr. Physick to be adapted to the treatment of the disease in this bone.f SECTION III. RESECTION OF THE KNEE-JOINT. In cases of anchylosis of the knee-joint, resection of a V-shaped piece of the femur was also suggested by Dr. Barton as a means of furnishing a useful limb, especially when the joint was flexed. As this operation has since been successfully performed, and repeated by various surgeons in the United States, it is now justly regarded as a standard one in cases of true anchylosis resulting in permanent flexion of the knee. Operation of Dr. Jno. Rhea Barton, of Philadelphia.;};—A physician, having his leg permanently flexed and anchylosed upon the thigh, to a degree somewhat less than a right angle, as the re- sult of inflammation which had existed in childhood, determined to obtain relief, and underwent the following operation in the hands and at the suggestion of Dr. 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 com- menced also on the outer side about two and a half inches above the * Am. Journ. Med. Sciences, vol. i. N. S. p. 507, 1840. Reference to this paper has been overlooked in the Bibliographical Index. f Dorsey's Surgery, vol. i. p. 135. X Am. Journ. Med. Sciences, vol. xxi. p. 332,1837. 642 OPERATIVE SURGERY. PLATE LXX. RESECTION OF THE BONES OF THE LOWER EXTREMITY. 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. Flaps of integument formed by a crucial incision, and turned back. 2. In- cision of muscles over 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. Semilunar incision through the soft parts, convex above, and exposing 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 limb 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. Retrac- tor applied to the soft part. 2. Strips beneath the bone. 3. Portion of the femur to be excised. 4. The amputating saw. After Bernard and Huette. Fig. 5. Resection of the External Malleolus. 1. 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. 8. A small saw, dividing the bone before it is reverted and disarticulated. After Bernard and Huette. Fifc.l. Kg-z RESECTION OF THE KNEE-JOINT. 643 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 includ- ing 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 backwards, these fibres were now gently broken, and the operation, which lasted about five mi- nutes, entirely completed. No bloodvessel being injured, the flap was restored to its place, the wound lightly dressed, the patient placed in bed upon his back, and the limb supported 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, and changed from time to time until the limb had attained a position 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 constitu- tional 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 touch- ing the floor, although a slight angle had been designedly 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 per- fectly. Remarks.—In the observations of Dr. 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 espe- cially 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 ad- vantageous to resort to the rule proposed by Dr. Goddard, of Phila- 644 OPERATIVE SURGERY. delphia,* and practiced by Dr. Mutter, which is as follows: " Take the angle of deformity, and then remove from the bone the comple- ment of the angle." The use of Stromeyer's splint, as employed by Dr. Mutter in his case, would also be an improvement on the ori- ginal dressing, as the popliteal space will thus be left entirely free from pressure, and the limb may be readily and gradually extended, as required. This operation has also been successfully performed by Dr. Piatt Burr, of Louisiana, and by Drs. Gibson and Pancoast, of Philadelphia. § 1.—REMOVAL OF A PORTION OF THE PATELLA, CONDYLES, AND ARTICULATING SURFACES OF THE TIBIA. Operation of Dr. Gurdon Buck, Jr., of New YoRK.f—A pa- tient, 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 deve- loped in every respect than its fellow. By modifying the operation of Dr. 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 before, 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 from the outer to the inner condyle, across the middle of the patella, and a second incision from the middle of this, perpendicularly, downwards 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 articulating sur- face of the tibia, the ligament of the patella and fibro-ligamentous 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 sec- tion of the tibia was then made, three-fourths of an inch below the joint anteriorly, and directed obliquely upwards so as to terminate * Philad. Med. Examiner, vol. vii. N. S. p. 39,1851. f Am. Journ. Med. Sciences, vol. x. N. S. p. 277. RESECTION OF THE KNEE-JOINT. 645 at the margin of the articulating 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. The wedge- shaped piece being removed, it was found that the section had not divided the posterior portion of the condyles, which still re- mained 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 sec- tions met, and directed more obliquely upwards and backward. The remaining points of connection being then cautiously ruptured by flexing the leg, the rough prominences were pared away with the forceps. On attempting to extend the leg, it was found that the bony surfaces could only be brought to within a finger's-breadth an- teriorly, 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 sur- faces in contact. The section of the condyles now exceeding that of the tibia in its antero-posterior 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. 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 recovered, 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 defective development of the limb subsequent to the inflamma- tion of the joint. Remarks.—The selection of this plan of operating having pro- bably been caused by the peculiar difficulties of the case, it is difficult to make a just comparison between these two methods. .The opinion of a want of strength in the support afforded by the 646 OPERATIVE SURGERY. operation of Dr. Barton, which seems to have originated the plan pur- sued by Dr. Buck, is, however, an erroneous one, as has been proved in several instances, whilst the section above the condyles, as prac- ticed by Dr. Barton, can be made to remove the difficulties connected with contractions about the ham. Except under peculiar circum- stances, 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 usually by incising the soft parts, turning out the ends of the bones, sawing them off, and then treating the case as a com- pound fracture. It is, however, a very serious operation, and 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 use of splints applied so as to enable the patient to walk about, as I have succeeded in doing in two instances,* in one of which an ununited fracture of several months' standing recovered simply in consequence of the stimulus of motion. In no case, there- fore, would I attempt this operation until these or similar splints had been worn for a twelvemonth. SECTION IV. 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 performed in cases of severe wounds of the joint complicated with dislocation, as well as in those of compound fracture. These operations have, in a few instances, been attended with more suc- * On the treatment of Pseudarthrosis by an apparatus which permits the use of the limb, and obviates the necessity of the amputation. (Am. Journ. of Med- Sciences, vol. xxi. p. 106, 1851). EXTRACTION OF THE FIBULA. 647 cess than might have been anticipated 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 an- other 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."* Such cases must, however, be regarded as wonderful in- stances rather than as ordinary examples of success. More fre- quently, the patient will suffer from severe constitutional disturbance, and if he recovers will 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 bet- ter than the natural one. When, however, it is desired to perform this resection, 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 over 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, avoiding the vessels and nerves ; insinuate a chain-saw between the tibia and fibula from with- in outwards, divide the bone, raise up its lower extremity and disar- ticulate it. Then place the leg on its external side, and make a longitudinal incision on the tibia from the internal malleolus, about three and a half inches upwards, and from its extremity make a transverse cut as far as the tendon of the tibialis anticus. Dissect up the flap and isolate the surrounding 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 fibulaf (Plate LXX. Fig. 6). § 2.—EXTRACTION OF THE FIBULA. 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 ante- rior tibial nerve, where it winds round the neck of the bone.| * Velpeau, Op. Surgery, by Mott and Townsend, vol. ii. p. 822. f Bernard and Huette, Med. Operat. p. 103. X Malgaigne. 648 OPERATIVE SURGERY. § 3.—RESECTION OF THE ASTRAGALUS. The removal of any of the bones of the tarsus must be the result of circumstances, and the only directions which can be given in re- lation to them is to open the integuments freely at the most promi- nent point of the bone, and then free its attachments. The astragalus has been successfully removed in cases of com- pound dislocation, by Drs. William A. Gillespie, of Virginia ;* Bar- ton, of Philadelphia, in 1831 ;f Alexander H. Stevens, of New York; and in a few other instances. There is, therefore, sufficient evidence to show that, in compound dislocations of this bone, it is desirable to attempt its resection or extirpation before resorting to amputation of the leg. § 4.—RESECTION OF THE METATARSAL BONES AND PHALANGES. The resection of these bones is to be conducted on the same prin- ciples as those of other parts, and the incisions to expose the bone will be similar to those described under Amputations. CHAPTER VI. GENERAL REMARKS ON AMPUTATIONS. The amputation of a large limb necessarily destroying the equi- librium which had previously existed in the forces of the economy, should always be regarded as a serious operation, and liable to involve the life of the patient. As it also removes a part which is often essential to the daily maintenance of the individual, and, in too many instances among the poor, 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 * See Bibliographical Index, p. xci. f Liston's Pract. Surgery, Philad. edit. p. 141, 1842. GUNSHOT WOUNDS. 649 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 ; and the eclat 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 amputate a limb without having a consul- tation with two or more other 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 to be impossible. 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 advantageously be allowed to occupy several pages. I shall, however, be compelled to confine its consideration to a very brief statement of the opinions of distinguished authorities in a few of the more serious cases. § 1.—GUNSHOT WOUNDS. The necessity of amputating in these injuries, it has been gene- rally admitted, should be regulated by the fact of their producing a compound fracture opening into a large joint, or the mutilation of the principal bloodvessels and nerves; but, in all these cases, the position and circumstances of the patient should not be overlooked, as in- juries 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 m gunshot fractures differ somewhat, according to the position of the injury. In the femur, it is nearly universally admitted to be 650 OPERATIVE SURGERY. PLATE LXXI. INSTRUMENTS FOR AMPUTATION, ETC. Fig. 1. Trocar for Tapping the Bladder through the Rectum. Schively's pattern. Fig. 2. Petit's Tourniquet. " " Fig. 3. A Large round-bellied Scalpel for dissecting back the integu- ments in the circular amputation. Schively's pattern. Fig. 4. A Small Catlin for the interosseous space. " " Fig. 5. Large Amputating Knife, for the circular operation. " " Fig. 6. The Long Ten Inch Catlin, for the flap " " " Fig. 7. An Eight Inch " " " " " Fig. 8. Bone-Nippers, for removing any sharp points left by the action of the saw. Schively's pattern. Fig. 9. Dissecting Forceps, to hold the integuments whilst they are dis- sected from the fascia before they are reverted, as in the circular operation. Schively's pattern. Fig. 10. Spring Forceps of Dr. Nathan R. Smith. " " Fig. 11. Artery Tenaculum. " " Fig. 12. Barton's Metacarpal Saw. " " Fig. 13. Ordinary " " " " Fig. 14. The Large Amputating Saw. " " RAILROAD ACCIDENTS. 651 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; and Percy, Thompson, Larrey, Guthrie, and Hennen ex- press nearly the same views.* Mr. Guthrie, however, states that in the upper extremity it is very different, and that " this limb should not be amputated for almost any accident that can be produced in this way."f § 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 fractures of the most serious kind. These injuries, together with those resulting from the use of thrashing-machines, as well as those created in mills, are the result of the application of force to the limb, in such a manner as to produce extensive contusion of neighboring parts as well as laceration at the seat of injury. It is, therefore, not uncommon, in amputations after 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 Dr. George Hayward, of Boston,| " from a condition of parts resembling that which has been spoken of by military surgeons as a local asphyxia, and is a state of sus- pended 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 be de- layed until the reaction is established, though on this point there is a diversity of sentiment. * Velpeau's Op. Surg, by Mott, vol. ii. p. 454. t Velpeau, loc. cit. X Paper on Amputations in Massachusetts General Hospital, p. 16, Boston September, 1850, 652 OPERATIVE SURGERY. For the consideration of other injuries requiring amputation, the reader must refer to the more general surgical treatises, as the sub- ject is too extended for a work of a purely operative character. § 3.—THE PERIOD FOR AMPUTATING. The advantages of a primary over a secondary amputation are also a serious question, and one with respect to which there is diver- sity of sentiment. Larrey* asserts that, in the American war, the French surgeons lost almost all their patients by deferring their amputations, whilst the Americans, by immediate amputation, saved nearly all of theirs. Velpeau,! after a careful and learned examination of this ques- tion, states that amputation should in these cases be performed within the first twenty-four hours after the accident. Sir George BallingallJ is, however, " satisfied that in civil hospitals primary amputations 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." Dr. Norris,§ in a paper published in 1838, furnishes the sta- tistics of the amputations in the Pennsylvania Hospital for the seven preceding years, and 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 operations 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 3T2T, and in the latter 1 in 2«." Dr. George Hayward, of the Massachusetts General Hospital at Boston, in some valuable statistics from that Institution,!) affords * Clinique Chirurg. tome 3»e, p. 518. f Op. Surg, by Mott, vol. ii. p. 470. X Ibid. 471, note by Dr. Townsend. § Am. Journ. of Med. Sci. vol. xxii. p. 356. II Ibid. vol. i. N. S. p. 38, 1840. f Am Journ. of Med. Sci. vol. i. N. S. p. 64, 1840. A reference to this paper, as well as a second one by Dr. Norris, has been accidentally omitted in the Bibliographical Index, owing to an error of the press. THE PLACE OF ELECTION. 653 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 fourteen primary ampu- tations, ten were cured and four died; but he fears that the ope- ration in recent injuries is often resorted to too early.* Dr. Buel,t 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 amputations was 27.77, of others 30.76 per cent. The mortality after amputations for chronic affections was 20.67. Judging from these statements, as well as from personal experi- ence, I should therefore advise the performance of amputation in such accidents as require it, as soon after the injury as reaction is fairly established, that is, as soon as warmth and a free circulation have returned, the patient being fully etherized before the perform- ance of the operation, so as to escape the shock. 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 circu- lar, 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 advan- tageously performed is a point which the character of the limb, the occupation of the patient, and the probable substitute for the * Opus citat., p. 70. f Am. Journ. of Med. Sciences, vol. xvi. p. 39 42 654 OPERATIVE SURGERY. limb subsequently to be obtained, must chiefly decide. As a gene- ral rule, where the pecuniary circumstances of the patient admit of his obtaining an artificial limb, the surgeon should 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, the stump should, on the contrary, be made at least within four fin- gers' breadth of the tubercle of the tibia, in order to prevent the protrusion of the stump behind, when the knee is bent upon the Peg- Surgeons of all countries yet differ widely in regard to the advan- tages of amputating through a joint in preference to above it. But when it is recollected that every articulating surface is covered by a synovial membrane, which is liable to keep up a secretion, prevent the healing of the flap, and create a fistula, and that, as a general rule, the joints present prominences of bone which often can only be covered by the integuments, and that the latter will subsequently sustain friction very badly, it must, I think, be admitted that the trifling increase in the length of the stump is more than compensated by its subsequent ability to resist pressure and the creation of ulcers. " The place of necessity knows no law." 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 operation. § 1.—THE CIRCULAR OPERATION. This ancient method of operating has been described by all sur- geons from the earliest periods, especially from the time of Celsus, though it has been modified at different times, in order to guard against a "conical stump," or to prevent such a retraction of the muscles as would diminish the amount of covering to the bone. Without specifying these modifications, it must suffice to state that THE OVAL METHOD. 655 the plan of operating at present generally pursued by the profession, appears to have been adopted with a full knowledge of the views of surgeons of a preceding period, in respect to the advantages of each, and may therefore be presumed to be the best. Ordinary Operation.—After applying the tourniquet, or some other means of arresting the circulation, the skin should be divided by a circular sweep of the amputating knife, held so that the in- cision may commence with the heel of the blade, and terminate with the same point. The attachment of the skin to the fascia being then divided so as to enable the integuments to retract, or to 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, and the divi- sion of the fibres which adhere directly to the bone 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, the surgeon usually has to decide whether he will bring the sides of the integuments together vertically or transversely to the thickness of the limb. This point, though chiefly dependent on the peculiar circumstances of each case, may generally be decided by the posi- tion in which the limb is to be placed in bed during the cure, 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 intention, and it is under such circumstances that the line of union in a circular operation may become a matter of importance. § 2.—THE OVAL METHOD. The oblique or oval form of the flap is the result of such an inci- sion 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 cir- cular wound, and is especially applicable to amputations through the joints. In performing it, the knife should be carried around the limb in a direction which is oblique to its perpendicular diameter, 656 OPERATIVE SURGERY. so as to divide all the parts down to the bone and form a wound which is 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 integument, 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. § 3.—the flap operation. In the formation of a flap of the integuments to cover the end of the bone, two methods have been employed, the difference being the formation of one or two flaps. When two flaps are desired, they may be formed either by cutting from the skin to the bone, or from the bone outwards. In operating from without inwards, the cut is made through all the tissues, at an angle capable of furnishing a sufficient amount to form a cushion for the end of the bone. This flap being held by an assistant, a second is formed on the side of the vessels of the limb, by commencing at the bone, and cutting outwards, 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. 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. Sometimes, however, it is the result of necessity, as in cases of laceration, where the integuments are destroyed on one side of the limb. SECTION IV. ESTIMATE OF THE DIFFERENT FORMS OF AMPUTATION. The variety of cases requiring amputation, and the different re- sults obtained under such circumstances, has apparently cliised a ESTIMATE OF THE DIFFERENT FORMS OF AMPUTATION. 657 want of harmony among experienced surgeons in deciding this ques- tion, which it is difficult to credit. 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 am- putation that might be instantly demanded on a field of battle and without assistants, might be performed very differently, when the operator was in a civil hospital, and with every convenience, so that, if two surgeons were similarly situated, they would doubtless coin- cide 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 suppu- ration; that there is greater difficulty in finding the vessels that are to be tied, owing to their being obliquely divided; and that secondary hemorrhage is, therefore, 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 hemorrhage is rare; and that, by giving the wound a conical shape with the bone in the cen- tre, 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 dissect- ing back the cuff-like portion of the skin, when anaesthetics are not employed, and to the excessive and irregular contraction of the va- rious layers of the muscles when transversely divided. Chelius,* 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." VELPEAUf thinks, " too much importance has generally been ac- corded to the flap operation; that it has many partisans in the dis- secting-room, but is seldom resorted to for amputation in the con- tinuity of the limb." Fergusson,! although performing the flap operation most fre- quently, owing to special circumstances, states " that, at the present day, more amputations are done by the circular than by the flap * System of Surgery, by South, vol. iii. p. 652. f Operat. Surg., by Mott, vol. iii. p. 484. X Practical Surgery, p. 152. 658 OPERATIVE SURGERY. operation, and that, fifteen 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." Hayward! savs " 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 Hospital, 24 were performed by the double flap operation, and 25 by the circular method. Of the flap operations, the mortality was 17.66 per cent., and of the circular, only 12 per cent." Dr. Buel, however, thinks that the greater mortality of the flap operation may have been due to the greater proportion of thighs in which it was performed. Dr. 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, and his own opinion is decidedly in favor of the circular method. Personal experience has long induced me to think that, in at- tempting to settle this question, there has been too much ascribed to the defects of each method of operating; that the circular opera- tion is the best in the middle of the limb, but that the flap is best adapted to the extremities or to the articulations; and that the rapidity with which one can be performed instead of the other, is owing rather to the greater 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 (laceration), the flap is the only *. Practice of Surg. vol. ii. pp. 488, 489. f Am. Journ. Med. Sciences, vol. xxii. p. 359. X Ibid. vol. i. N. S. p. 65, 1840. § Ibid. vol. xvi. N. S. p. 38. || Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 24, 1852. PREPARATORY MEASURES. 659 means of forming a covering to the stump without removing a large amount of the limb. SECTION V. GENERAL MEASURES REQUISITE IN AMPUTATION. The mere division and removal of the limb being the simplest por- tion of an amputation, the surgeon should pay special attention to the other measures connected with the operation, as these are mainly conducive to its prompt 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.* The necessary instruments, which may be seen in Plate LXXI., should all be in perfect order. The ligatures should be carefully made; the bandage and compress 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 retractorf 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 ren- ders it desirable to prevent the loss of even a moderate amount. The dressings for an amputation were formerly very varied; but a wiser 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, Maltese cross, tow, bandages, &c, which were prepared to envelop the stump, many surgeons now resort to the water dressing, and require, therefore, a few needles and 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. * Part I. page 21. f Smith's Minor Surgery, p. 39, 3d edit. 660 OPERATIVE SURGERY. PLATE LXXII. AMPUTATIONS OF THE ARM. Fig. 1. View of the Head of the Humerus, showing its Hemispherical Character.—1. Greater tuberosity. After Bemard and Huette- Fig. 2. Side View of the Bones forming the Shoulder-Joint.—1. Head of the humerus. 2. The clavicle. 3. Acromion process of the scapula. 4. Coracoid 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. Shape of the posterior flap. After Bernard and Huette. Fig. 5. The same Operation, showing the Formation of the Anterior or Internal Flap.—1. The long catlin. 2. Hand of the surgeon. 3. Anterior angle of flaps, or point of exit of the catlin. 3, 4, 5. 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. Wound left by the preceding Operation.—1, 2, 3, 4. 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. 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 bra- chial and profunda arteries. After Bernard and Huette. AFTER-TREATMENT. 661 § 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 carefully watch its effects; the second control the hemorrhage, either by pressing on the main artery or by the appli- cation of the tourniquet; the third should support 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 instrument, nor depressing it so as to snap and splinter the bone; whilst the fourth should hand the instruments, attend to retracting the soft parts, so as to protect them 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, whilst the third warms the adhesive strips when they are required. § 3.—AFTER-TREATMENT.* The dressing of an amputation may be advantageously performed as soon as the hemorrhage is entirely checked, in the following man- ner: 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 this angle and between the edges of the skin, as was the practice of Dr. Physick. Then with the needle and ligature make two or three stitches of the interrupted suture, in order to close the stump, 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 band should be carried over the limb above * See Part I. p. 28, et supra. 662 OPERATIVE SURGERY. 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 bed-clothes. 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 in a patient in good health, the diet may consist of light nutritious articles and broths, and then if fever or a tendency to active inflam- mation is not apparent, he may be allowed to eat meat and resume his ordinary diet. But if the patient 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, 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 stump 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 supported by long adhesive strips, or by the turns of a bandage. About the sixth or tenth day, one or more of the ligatures will be loosened, and may be quietly drawn away ; but, should they adhere too long, and delay the cure, then the means before referred tof 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 inflammation, warm cloths may be substituted, if suppuration seems likely to re- lieve it; but whenever the latter is freely established, the stump should be placed horizontally, or slightly inclined downwards, so as to favor the escape of the matter, and prevent its burrowing in the muscular interspaces. Although the water dressing, as thus prac- ticed, 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 frequently changed and fresh ones substituted, so as to pre- vent decomposition of the pus and consequent irritation. By these means, the secretions never become offensive, and both patient and * See Part I. p. 29. f Ibid., p. 61. ACCIDENTS DURING OR AFTER AMPUTATION. 663 surgeon obtain a degree of comfort that was impossible under the old method of dressing the stump. § 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 operator. This carelessness may be shown: 1. In the occurrence of hemorrhage. 2. In cutting openings in the flaps. 3. In splintering the bone. The occurrence of hemorrhage during an amputation may arise from breaking of the tourniquet, or from failure to compress the artery, by the assistant intrusted with it, both of which ought to 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; whilst 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 compression; but, if more profuse, it may be re- quisite 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 occur- rence after an amputation, and is due to the irregular contraction of the muscles, sometimes caused by the pressure against the sharp end of the bone, and sometimes due to nervous irritation. Gentle circular compression of the limb, and the free use of opiates inter- nally will usually afford relief. Should the recurrent bandage of stumps have been applied, the turns should be examined to see that 664 OPERATIVE SURGERY. PLATE LXXIII. AMPUTATION AT THE ELBOW-JOINT IN THE FOREARM. Fig. 1. A Front View of the Articulating Surfaces of the Bones compos- ing 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. Articulating 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 upwards. 4. The knife in the act of completing the division of the anterior ligament 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 re- tracting 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. Sawing the Bones of the Forearm in the same Operation.__ A retractor has been passed through the interosseous space and around the bones, so as to protect the soft parts from the action of the saw. 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. PL •■ ■'" AMPUTATION AT THE SHOULDER. 665 they do, not compress the end of the soft parts of the stump against the freshly sawed edge of the bone. Inflammation of the stump, abscesses, or exfoliation of a lamina of bone may also complicate the after-treatment, but they may be re- lieved on the ordinary principles of the treatment of such affections elsewhere. When the removal of the ligature is delayed beyond the proper time (three to four weeks), a resort to the means before referred to* is all that is necessary. Neuralgia of the stump may arise, either from the inflammation and enlargement of the end of the 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. CHAPTER VII. AMPUTATIONS OF THE UPPER EXTREMITY. In describing the various methods of amputating the extremities, I shall have nothing new to offer, and having learned in the Parisian schools the methods of the French surgeons, I am merely prepared to present them as described by themselves, and to offer the results of personal experience. Most of the methods, hereafter detailed, may, therefore, be found in the various works of the day, though I have selected the manuals of Bernard and Huette, and of Malgaigne, as the best authorities. SECTION I. AMPUTATION AT THE SHOULDER. Lisfranc's Operation.—The patient being seated, or propped up in the bed near its edge, the arm should be placed close to the side, and the head of the humerus pushed upwards and outwards as much as possible, by carrying the elbow upwards and inwards by the sur- * Part I. p. 61. 666 operative surgery. geon grasping the humerus near its middle; then feeling for the acro- mion, and coracoid processes, or for the acromio-coracoid triangle, plunge an eight-inch catlin in at the external side of the posterior mar- gin 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 pro- cess. 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, coracoid, and acromion. Let an assistant now raise the arm from the side, and carry it off from the body, whilst the surgeon grasps 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 cap- sular 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 in- troduced, it may now be effected by incising it with its heel, whilst the assistant holds up the flap. On again carrying the elbow a little towards 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 downwards 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 acromio-coracoid 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 form- ation 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 the point, make two * Bernard and Huette, Med. Op. p. 70. AMPUTATION OF THE ARM. 667 oblique incisions, one anteriorly and the other posteriorly, so as to divide the integuments and flesh on the anterior and posterior pa- rietes 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 com- pressed by an assistant. The wound which is left is perfectly oval, and well adapted to healing. (Plate LXXII. Fig. 7.) Remarks.—The plans above stated presenting two excellent methods of amputating at this joint, it is unnecessary to enter into the description of the various modifications that have been proposed by others. The circular operation presents us at this joint with no- thing peculiar. Sanson, of Paris, who, in connection with Velpeau, recommended it strongly, divided all the structures at one sweep of the knife applied one inch below the acromion, and then disarticu- lated the bone. The objection to this mode of amputating, or rather the advan- tages possessed by either that of Lisfranc or Larrey, is that, as the artery is not divided until the last moment, it can then be promptly seized and tied as the arm is out of the way. Amputation at the shoulder-joint has been frequently performed in the United States, having been done by Dr. John Warren, of Boston, as early as 1781; by Dr. Bayley, of New York, in 1782; and subsequently by Drs. Bowen, of Providence; Whitridge, of South Carolina; William E. Horner, of Philadelphia; N. Pinkney, U. S. Navy; D. Gilbe/t and Page, Philadelphia; and by Dr. Eve, of Georgia; as well as by many others, whose cases cannot now be re- called. Of those, above mentioned, a large proportion proved suc- cessful. SECTION II. AMPUTATION OF THE ARM. The amputation of the arm may be accomplished at any point, either by the circular or flap operation. Circular Operation.—The patient being etherized, and then 668 operative surgery. 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 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. Flap of skin reverted. 4. The catlin dividing the front of the ioint. After Bernard and Huette. Fig. 3. Denonvillier's Operation at the Wrist.—1. The radius. 2. The ulna. 3. 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. Anterior flap. 4. The knife, which, hav- ing 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 sec- tion. 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. AftemEernard and Huette. Fig. 9. Union of the Wound, showing the Line of the Cicatrix and the Appearance of the Hand after the Amputation. After Bernard and Huette. AMPUTATION AT THE ELBOW-JOINT. 669 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, whilst 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 being supported by an assistant, and stooping down, carry the knife so far round the arm that he may 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 so as to bring the heel of the blade to terminate the incision. The loose- ness of the attachment of the skin to the fascia permitting con- siderable motion, it is only necessary for the assistant to retract it (Plate LXXII. Fig. 9) until the surgeon again, by one sweep and firm pressure, 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 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 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 divi- sion of the muscles, as in the circular amputation of the leg. The flap operation, as shown in Plate LXXII. Fig. 8. SECTION III. AMPUTATION AT THE ELBOW-JOINT. Velpeau's Operation.—The hand being strongly supinated, and the forearm slightly flexed, a circular cut should be made through the integuments about three fingers' width below the bend of the 43 670 operative surgery. PLATE LXXV. amputation OF the fingers. Fig. 1. Amputation of all the Fingers at once.—1, 2, 3. 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 gap After Bernard and Huette. Fig. 3. Circular Amputation through the Metacarpal Bones.—1, 1. Re- tractors 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. Line of incision. After Bernard and Huette. Fig. 5. Amputation through the Fifth Metacarpal Bone.—The bone has been sawed through obliquely, whilst 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. Anatomical Relations of the Palmar Surface of the Phalanges of a Finger.—1. The metacarpal bone. 2. The first phalanx. 3. Its lower ex- tremity. 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 pal- mar 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. A"er Bernard and Huette. Fig. 14. The Flap turned up to show the Disarticulation. After Bernard and Huette. Figs. 15, 16, 17. Different Stumps resulting from the flap, oval, and cir- cular operations. AUer Bernard and Huette. amputation of the fingers. 671 below; then, dissecting up and reverting this flap (Plate LXXIII. Fig. 6), cut through the muscles at one sweep, divide the lateral liga- ments, 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. SECTION IV. AMPUTATION OF THE FOREARM. In amputating this portion of the upper extremity,, every effort should be made to preserve as great an amount of the member as possible, in order to facilitate its subsequent usefulness, whether the patient contemplates using an artificial limb, or merely a hook. This amputation may be best accomplished by the ordinary circu- lar method (Plate LXXIII. Fig. 8), a retractor of two tails being prepared in order to protect the parts more effectually by 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 per- formed in preference to the amputation at the upper third of the forearm, whenever the injury is confined to the hand. SECTION V. AMPUTATION OF THE FINGERS. Amputation of the various phalanges may be accomplished by either 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 672 OPERATIVE SURGERY. adapted to the operation through the body of each phalanx, and the oval to the removal of the finger at the metacarpo-phalangeal articu- lation, as shown in Plate LXXV. Fig. 7. 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 limb 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 when the patient walked. 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. Amputations of the femur 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 diffi- cult 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. In the United States, this operation was first performed by Dr. Walter Brashear, of Kentucky, now of New Orleans, in 1806,* and * Trans. Am. Med. Association, vol. iv. p. 269, 1851. AMPUTATION AT THE HIP-JOINT. 673 by Dr. Mott, of New York, in October, 1824,* by disarticulating the bone after ligating the femoral artery. It has since been performed by Dr. Brainard, of Chicago, f and Van Buren, of New York,J in a case in which the shaft of the femur had been previously amputated; by May, of Washington; and by Drs. Richards and Clagget, of Maryland. § Of the various methods of operating, the flap and oval are the best, the circular being objectionable on various grounds. In either method, it is, however, essential that the anatomical relations of the articulation should be kept distinctly in view by the operator. As these are figured in Plate LXXVI. Fig. 1, the repetition of them may be omitted at present. When the flap operation can be attempted, the methods by the formation of one flap, as shown in Plate LXXVI. Figs. 2, 3, will prove the best. Lalouette's Operation.||—The patient lying on the sound side, make a semicircular incision from the upper and external part of the great trochanter 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 inwards, 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 Dr. Van Buren, of New York.T[—Having ampu- tated the thigh two years previously, near its middle, in consequence of the formation of a "true osteo-cartilaginous exostosis," and the * Phil. Journ. Med. and Phys. Sciences, vol. xiv., or v. N. S. p. 107, 1837. f Am. Journ. Med. Sciences, vol. xxii. p. 37, 1838. t Trans, of New York Acad, of Medicine, vol. i. p. 123. § Trans. Am. Med. Association, vol. iv. p. 270. || Malgaigne, Phil. edit. p. 266. fl Trans. New York Acad, of Medicine, p. 135. 674 operative surgery. 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. Iliac fossa. 2. Shaft of femur. 3. Po- sition of its head in the joint, 4. External iliac artery. 5, 6. Anterior, superior, and inferior spinous processes. 7. Trochanter minor of the femur. 8. Ischium. 9. Pubis. After Bernard and Huette. Fig. 2. Amputation at the Hip-Joint by the Flap Operation.—1, 2, 3. An- terior flap. 4. The long catlin about to cut the anterior flap. After Bernard and Huette. Fig. 3. Amputation at the Hip-Joint by Lateral or External and Internal Flaps.—1. The long catlin transfixing the limb directly behind the head and neck of the femur. 2, 3, 4. Line of external flap. 2, 5, 6. Line of internal flap. After Bernard and Huette. Fig. 4. Continuation of this Operation, when it only remains to Disar- ticulate 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 assistant raising the anterior flap. 2. The head of the femur disar- ticulated. 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 upwards, in order to show the posi- tion of the vessels, as well as the acetabulum. 1, 3, 4. 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 with- drawal of the catlin.—1. Right hand of surgeon. 2. Position of the catlin in the posterior or circular incision. 3. Left hand of the surgeon abducting the thigh so as to disarticulate the bone. 4. Hands of the first assistant hold- ing up the anterior flap, and compressing the artery in it. 5. Hands of the second assistant. After Van Buren. H-z- V ■/ ^T\T^ .BflKS*1**^.! amputation at the hip-joint. 675 disease having subsequently returned, Dr. Van Buren advised ampu- tation at the hip-joint, to which the patient consented. Operation.—The patient, being in a perfect state of anaes- thesia 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 his left hand, and 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 pushing its point through the integuments near the anus, at a point diametri- cally 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 upwards 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 oppo- site 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 ace- tabulum ; the round ligament and the rotator muscles near the tro- chanter divided; and the limb removed. A large compress or folded towel being then immediately applied to the surface of the posterior flap by the assistant who lays down the amputated limb, the arteries are to be secured in detail, the gluteal and ischiatic being tied be- fore the femoral and profunda if the latter are well controlled in the anterior flap. The wound is then closed, as before directed. Remarks.—Various modifications of the amputation at the hip- joint have been from time to time suggested, among which is that of Dr. Ashmead, of Philadelphia, in which flaps are formed by cut- ting from the surface inwards, and then disarticulating the bones. But I should prefer the method of Lalouette to all of them, when circumstances permit it, as the hemorrhage can be more readily and 676 operative surgery. PLATE LXXVII. amputations of the thigh. Fig. 1. The Circular Operation.—1. The knife dividing the muscles. 2. Hand of assistant favoring their retraction, and holding back the skin. 3. Hand of another assistant compressing the femoral artery when the tourni- quet is not employed. 4. 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. 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 outwards. 5, 6. Line of incision for the inner flap. After Bernard and Huette. Fig. 3. Sawing the Bone in the Circular Operation.—1. A retractor pro- tecting 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. Line of anterior incision. After Bernard and Huette. Fig. 5. Circular Amputation through the Knee-Joint.—1, 2, 3. Line of the incision below the joint. 4. The integuments turned back. 5. The knife opening the joint in front. After Bernard and Huette. Fig. 6. Amputation by the Oval Method.—1, 2, 3. Line of the incision below the joint. 4. 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. Line of incision for the formation of the posterior flap. 4. Front of the condyles of femur. 5. The catlin. 6. Hand of the surgeon holding the tibia so as to favor the formation of the flap. After Bernard and Huette. Plate 77 circular amputation of the thigh. 677 coolly arrested by tying the vessels in the outer incision before divid- ing 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 surrounding parts. SECTION II. CIRCULAR AMPUTATION OF THE THIGH. As usually performed, this operation corresponds with the circular operation, described upon the humerus. In a large and muscu- lar limb, the following operation may, however, be made to form quite as good a stump, and be more quickly performed, as it removes the necessity of dissecting up the cuff of the skin. Operation of Alanson.—The limb being carried off from the other, and the artery compressed, the surgeon should place himself between the limbs or upon the outer side, as he finds most con- venient, and then, whilst the skin is 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 cellular attachments of the skin to the fascia, so as to favor its retraction by the assistant (Plate LXXVII. Fig. 1), and again applying the knife with its edge directed obliquely upwards, divide the muscles to the bone; have them also retracted by the hand; divide the few fibres adherent to the bone, a little higher up; apply the retractor; and saw the bone close to the muscles, when a conical hollow stump will thus be formed with the bone in the end of the cone. Ligate the femoral and other arte- ries ; see that the ischiatic 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 to the axis of the limb by two sutures and adhesive strips, applying subsequently the water dressing. ^ Flap Operation.—The flap operation may be performed either by forming an anterior or posterior flap, or by an external and in- ternal one (Plate LXXVII. Fig. 2). 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 to the back of the 678 OPERATIVE surgery. PLATE LXXVIII. AMPUTATIONS OF THE LEG. Fig. 1. The Circular Amputation of the Leg, as usually performed below the Knee.—1, 2, 3. Line of circular incision through the skin. 4. The cuff of skin reverted. 5. 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. Line of incision in the skin. 4. The retractor protecting the soft parts. 5. The large ampu- tating 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. Hand hold- ing up the integuments. 2, 2, 2. Position of the bloodvessels in the stump. 3. Section of the tibia. 4. 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. Tibia. 2. Fibula. 3. Posi- tion 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. First position of the knife. After Bernard and Hutuf. Fig. 6. Appearance of the Wound after Lenoir's Amputation of the Right Leg.—1, 2. Lateral angles of the flap. 3. Tibia. 4. Fibula. - After Bernard and Huette. Fig. 7. Changes made by Nature in the Femur after an Amputation. —1. The shaft. 2. 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 stump. 2. Integuments on its end. 3. Muscle cut across. 4. The artery. 5, 5. The veins. 6. The nerve. 7. Muscular branch of the artery. After Bourgery and Jacob. Fig. 9. Appearance of the Tibia after Amputation.—1. Its head.—2. Portion 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 Opera- tion.—1. The leg. 2. A cushion. 3. A cork to fill up the toe of the boot. After Bourgery and Jacob. Piatt AMPUTATION AT THE KNEE-JOINT. 679 thigh. The operation by the external and internal flaps is shown in Plate LXXVII., and the antero-posterior flaps may be formed as follows:— Operation of Vermale.—Seize the muscles on the front of the thigh with the left hand, elevate them from the bone, and, transfix- ing them with the long catlin, cut a flap of proper length by passing the catlin from within outwards, and from above downwards. Then insert the point of the knife at the same spot, working it around the bone; bring it out at the spot where it first appeared; 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 pil- low, so as to guard against collections of pus. SECTION III. AMPUTATION AT THE KNEE-JOINT. Amputation at this articulation has been accomplished by all the methods before mentioned, the flaps being differently formed by different surgeons, and Plate LXXVII. explains these methods sufficiently well without further reference. Remarks.—Amputation at the knee-joint is an operation that has been variously estimated by different surgeons; but, without referring to their views in detail, in relation to the greater mortality consequent upon the amputation through or above the articulating surfaces, I may mention that one serious objection to it is the diffi- culty of obtaining a stump that will subsequently sustain pressure without leading to ulceration of the soft parts. The shape of the condyles unfits them for this, and, as an artificial limb can be quite as readily applied to a stump formed by amputating a few inches higher, where the parts are fully able to bear pressure, I should always prefer the amputation above the joint to that through it. There are other serious objections that might be urged against this operation; but my space compels me to pass them by. 680 OPERATIVE SURGERY. SECTION IV. AMPUTATION OF THE LEG. The circular operation for amputation of the leg is so similar to that of the forearm as not to require a special description, except to mention that, in sawing the bones, it is best to saw through the fibula first, and at a point a little above that selected for the tibia (Plate LXXVIII. Figs. 1, 2). Flap Operation of Verduin.—The artery being compressed on the thigh, and the leg carried somewhat off from its fellow, the sur- geon, standing on the inner side of the limb for the left leg, and on the outer for the right, unless the operator is ambidexter, should feel for the fibula, and, drawing 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 them, 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 it punctured the skin, and form an anterior semicircular flap, by drawing it towards you, terminating the incision at the internal point of puncture. Perfo- rate 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. Remarks.—This operation usually forms a well-covered stump, and may, with a little practice, be very promptly performed. 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. SECTION V. amputation of 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 suggested, and often practiced. Either of these amputations requires an accurate knowledge of the relations of the articulating surfaces of the bones, and should not be attempted without a recent AMPUTATION OF THE FOOT AT THE TARSUS. 681 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 methods of amputating ever resorted to. To facilitate reference, the parts have been fully shown in Plates LXXIX., LXXX.; and their anatomical relations may, therefore, be omitted here. 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. In the right foot, the thumb would rest against the cuboid, and the forefinger on the scaphoid bones, whilst in the left foot it would be the reverse. Then carry a small catlin across the top of the foot from the thumb to the point of the forefinger, making a semicircular incision which shall descend about half an inch in front of the articulation. Let the assistant draw up the skin, and then divide the extensor tendons and the dorsal ligaments, rendering the latter tense by pressing the toes downwards (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 shav- ing it off from the sole of the foot (Plate LXXIX. Fig. 3). Lisfranc's Operation.—Amputation at the metatarso-tarsal articulation was suggested by Mr. Hey, of England, who accom- plished it by sawing off the ends of the metatarsal bones; and the amputation is, therefore, now often spoken of as Hey's operation. The disarticulation is, however, the operation of Lisfranc, and should be so called. To find the joint,* " 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 tube- rosity of the fifth metatarsal bone, and the index or second finger half an inch in advance of the internal side of the joint at the cu- neiforme internum (Plate LXXIX. Fig. 9). Then, with a strong short catlin, make a semicircular incision on the dorsum of the foot, Malgaigne. 682 OPERATIVE SURGERY. PLATE LXXIX. AMPUTATIONS OF THE FOOT. Fig. 1. A View of the Bones composing the Tarsal Articulation, as con- cerned in Chopart's Operation.—1. Astragalus. 2. Os calcis. 3. Cuboid. 4. Scaphoid. 5. Internal point of joint, or tuberosity of scaphoid bone. 6. External point of the articulation. 7. Head of fifth metatarsal bone. 8. Fibula. 9. Tibia. 10, 10. Two pins to show the direction of the articu- lating surfaces or line in which the knife must be passed. After Bernard and Huette. Fig. 2. Position of the Hand of the Surgeon, and Line of Incision in Chopart's Operation.—1, 2, 3. Line of incision. After Bernard and Huette. Fig. 3. Continuation of same Operation.—The joint being opened, the knife is about to form a flap from the sole of the foot. 1. Anterior tibial artery. 2. The knife. After Bernard and Huette. Fig. 4. Sedillot's Operation.—1, 2, 3. Line of incision. After Bernard and Huette. Fig. 5. 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 Os calcis. 2. Cuboid. 3. Pin in the joint. 4. 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. Astragalus. 2. Scaphoid. 3, 4. Pins in the joints. After Bernard and Huette. Fig. 7. Dorsal View of the Bones of the Entire Foot.—1. Tibia. 2. Fibula, 3. Astragalus. 4. Os calcis. 5. Scaphoid. 6. Cuboid. 7. Internal cuneiforme. 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. Anterior portion of the external lateral ligament. 3. In- * ternal calcaneo-scaphoid. 4. External calcaneo-scaphoid. 5. Astragalo-sca- phoid. 6. Calcaneo-cuboid. 7. Scaphoideo-cuneiforme. 8. Cuboideo- metatarsal. 9. Cuneiforme-metatarsal. ligaments. After Bernard and Huette. Fig. 9. Lisfranc's or Hey's Operation on the Right Foot.—1, 2, 3. Line of incision in the skin. 4. 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 Cuneiforme Bone.—1, 2, 3. Arch of the circle formed by the knife in its different positions. 4. Second metatarsal bone. 5. First meta- tarsal bone. 6. End of the fifth metatarsal bone. After Bernard and Huette. ORGANIC CHANGES RESULTING FROM AMPUTATION. 683 cutting from the thumb towards the finger half an inch in front of the articulation, and by a few touches of the point of the knife upon the adhesions facilitate the retraction of the skin by an assistant. Then placing the point of the knife close to the end of the fifth me- tatarsal bone, divide the lateral and dorsal ligaments, and open the joint as far as the third metatarsal bone. At this point, carry the point of the knife half an inch backwards, or near the ankle; cut the dorsal ligaments; and expose the second metatarsal bone. Then cutting only with the point of the knife, and holding it perpendicu- larly (Plate LXXIX. Fig. 10), graze the tibial surface of the first metatarsal bone, and by a sawing motion open the joint between it and the internal cuneiforme. Divide the interosseous ligament, press upon the metatarsus, and complete the division of the remaining liga- ments, when the flap should be formed out of the integuments on the sole of the foot by shaving them off close to the metatarsal bones. SECTION VI. AMPUTATION OF THE TOES. Amputation of the Toes (Plate LXXX.) may be usually accom- plished by the same methods as the fingers, with the exception of the articulation at the metatarsal bone of the first toe. In this amputa- tion, whether performed 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 if the hard skin of the under surface of the foot can be made to cover it thoroughly, I think it is better not to do so, as this end of the bone is of great service in giving the patient a firm step, and preventing an inclina- tion of the foot inwards. The other amputations of the toes are sufficiently explained in Plate LXXX. Figs. 5 to 12. SECTION VII. ORGANIC CHANGES RESULTING FROM 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 684 OPERATIVE SURGERY. PLATE LXXX. AMPUTATION OF THE TOES. Fig. 1. The Dorsal Ligaments opened by the Puncture of the Knife in Lisfranc's Operation, as shown in Fig. 10, Plate 79.—1, 2, 3. Points opened. 4. Hand of surgeon. After Bernard and Huette. Fig. 2. Manner of forming the Flap from the Sole of the Foot in Lisfranc's Operation.—1. Anterior tibial artery. 2. Resection of hand of surgeon on the foot whilst forming the flap. 3. Position of the knife. After Bernard and Huette. Fig. 3. Wound left after Lisfranc's Operation.—1,2, 3. Shape of plantar flap. 4. Dorsal flap. After Bernard and Huette. Fig. 4. Wound left in Chopart's Operation.—1, 2, 3. Plantar flap. 4, 4. Bloodvessels. After Bernard and Huette. Fig. 5. Amputation of all the Toes through the Metatarsal Bones.—1. The retractor passed in each interosseous space. 2. The saw. After Bernard and Huette. Fig. 6. 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. Line of the dorsal inci- sion 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. Wound left by the preceding Operation. After Bernard and Huette. Fig. 10. Disarticulation of the Third and First Toes.—1, 2, 3, 4. Wounds resulting from the oval method on the great toe. 1, 2, 3. Wound formed by two flaps on the third toe. After Bernard and Huette. Fig. 11. 1, 2, 3. Line of 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. Line of incision in the oval operation. After Bernard and Huette. ORGANIC CHANGES RESULTING FROM AMPUTATIONS. 685 the general health of the patient within a short period after the operation. In the stump, the approximation of the superficial to the deeper- seated parts produced by closing the wound naturally leads to a general matting together of the skin, fascia, muscles, bloodvessels, and nerves, whilst the inflammatory changes connected with the process of healing often create bands of condensed cellular tissue, which, when thickened by pressure, become almost cartilaginous in their density. The division of the nerves of the part is most fre- quently 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 them, 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. For a few weeks after the healing of the 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 absorp- tion and deposition equalizes the surface to a considerable 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 cancellated structure of the bone becoming also more or less inflamed after its section, effusion of lymph ensues, and this becom- ing organized a new deposition of bone follows, 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 which are forced against it. The constitutional 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 imme- diately ensuing on the operation, whilst the fever will sometimes dis- appear promptly. When the portion of the extremity that has been removed is considerable, there is apt to be considerable disturbance of the equilibrium of the system, the process of nutrition goes on rapidly and the patient increases in size to a remarkable degree. At the same time, there is a liability to plethora which may require treatment. 44 686 OPERATIVE SURGERY. SECTION VII. , SUBSTITUTES FOR THE NATURAL LIMB. After the cure of an amputated limb, the surgeon should make it a point of duty to direct the patient in the attainment of some use- ful 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 should be made to strap on to the stump, will answer the purposes of prehension, whilst those of larger means can now obtain excellent substitutes for the arm and hand from various ingenious mechanics. In one instance, a patient, for whom I obtained one of these artificial limbs, was able to grasp his hat and hold other light articles by a neat mechanism that caused the fingers to approach the palm of the hand. Many varieties of artificial legs can now also be readily obtained, in which the support is furnished by a graduated pressure around the stump. In Plate LXXVIII. Figs. 10,11, are represented two boots, which will prove useful in affording support to the foot after the per- formance of Lisfranc's or Chopart's operations. The common peg or wooden leg, usually employed by laboring men as a substitute for the natural leg, requires no further reference, as it is universally known. INDEX. Abdomen, operations on 381 Physick on paracentesis of 383 Abernethy's operation for ligature of external iliac 456 Abnormal productions in breast 361 Accidents connected with lithotomy 532 railroad 651 Adams's operation for ectropium 99 Adipose tumor 245 Alae nasi, restoration of 189 American operations for ovario- tomy 577 Amputation of penis 484 Amputations 648 place of election 653 kinds of 654 cases for 649 period for 652 circular 654 oval 654 flap 655 .estimate of 656 general measures in 659 after-treatment 661 accidents in 663 organic changes after 683 of upper extremity 665 at shoulder 665 of arm 667 at elbow 669 of forearm 671 of fingers 671 of lower extremity 672 of hip-joint 672 of thigh 677 of knee-joint 679 of leg 680 of tarsus 680 of toes 683 Analogous tumors 291 Anatomy of chest 344 of ear f^ of eyeball 114 of muscles of eye 109 Anatomy of face 87,185 of neck 321 of male perineum 511 of female " 545 Anaesthetics in volvulus 387 use of 22 administration, mode of 23 Aneurism 321 Aneurisms in general 315 diagnosis 316 palliative measures 317 Barton's case of 317 of carotids 321 Ankle, resection of 646 Ankyloblepharon 93 Anterior tibial artery, ligature of 627 Anus, artificial 444 Physick's operation for 445 Dupuytren's " 445 Lotz's operation 446 J. M. Warren's operation 447 fissure of 588 imperforate 589 prolapsus of 589 fistula in 597 Arm, amputation of 667 Arteries, division of small 46 of mouth 174 of extremities 611 Artificial pupil 131 modes of operating 132 anus 451 Littre's operation 452 Amussat's operation 454 limbs 690 Assistants, selection of 40 Astragalus, resection of 648 Axillary artery, ligature of 351, 611 B Back, operations on 467 Ballard's operation in spina bifida 311 Bandage in cataract 121 Barton's operation on scalp 73 operation for harelip 161 688 INDEX. PAGE Barton's operations on the jaw 197 on bronchocele or goitre 309 case of aneurism 317 operation for recto-vaginal fis- tula 565 operation for resection of hip- joint 640 operation for resection of knee- joint 641 Bayle on oedema of glottis 249 Beaumont's experiments 391 Begin's operation on abdomen 385 Bellocque's instrument 153 Bertrand's loop suture 397 Bigelow's ligature of internal iliac 465 Bilateral operation of lithotomy 524 statistics of 539 Blandin's operation for harelip 165 Brodie on extirpation of mamma 369 Blepharoplasty 95 "Wharton Jones's operation 96 Dieffenbach's operation 96 Graefe and Fricke's operation 97 Bloodvessels of neck, anatomy of 321 internal carotid 322 external " 323 superior thyroid 323 Bogros's ligature of external iliac 457 Bond's forceps 269 Bones of leg, resection of 646 of extremities, operations on 629 Brachial artery, ligature of 614 Brainard—iodine injections in hy- drocephalus 83 operation for ectropion 99 operation in spina bifida 473 amputation at hip 673 Brashear's amputation at hip 672 Breschet's operation for varicocele 504 Bretonneau's operation for cataract 125 Bronchocele or goitre 307 scrofulous goitre 308 lymphatic " 308 scirrhous " 308 diagnosis 308 Griffith's case 308 Gibson on 309 Barton on 309 subcutaneous ligature 311 Ballard and de Gaillac's operation 311 Brown's yoke 289 Buck's operation for oedema of glot- tis 250 operation for resection of elbow 636 operation for resection of knee 644 Bulb of urethra 513 Burns, deformities from 281 PAOG Burns on tumors of neck 297 Bursal tumors 605 C Caesarian operation 579 Cancer of lip 165 of mouth 177 ligatures 177 double canula and wire 177 of Levret 179 Caries of sternum 375 Carotids, ligature of 327 Castration, operation of 508 Cataract, operations for 117 diagnosis 118 extraction of 127 treatment, preliminary 119 Catoptric test 118 Catheterism of Eustachian tube 218 of male urethra 485 of female " 594 Caustic in stricture 493 Cauterization of larynx 246 Trousseau's operation 247 of prolapsus ani 592 Cautery, actual 54 Cephalaematoma 75 Cervical fascia of Burns 230 Cheeks, removal of tumors from 171 Cheiloplasty 167 Pancoast's operation 167 Chopart's " 167 Malgaigne's " 169 Cheselden's knife for cataract 127 operation 132 Chest, surgical anatomy of 344 tumors of 369 Chew's instrument for strictures 492 Cicatrices from burns 281 cases for operation 282 Dupuytren's mode 282 salient cicatrices 282 Delpech 283 Mutter's operation 283 Circular amputations 654 Circumcision, operation of 479 Cloquet's operation for 479 Cullerier's " 481 Clavicle, extirpation of 346 Moreau's case 346 Mott's operation 346 Warren's " 348 Collodion 57 Columna nasi, restoration of 149 Liston's operation 149 Cook's case of gastric fistula 390 Cooper's operation on ear 217 suture in wounds of intestine 398 INDEX. 689 Cooper's operation for ligature of external iliac 457 Corectomia 132 Wenzel's operation 132 Physick's " 133 Beer's " 133 Velpeau's " 133 Coredialysis 133 Scarpa's operation 133 Langenbeck's " 134 distortion of natural pupil 134 Hays's operation 134 Coretomia 132 Cheselden's operation 132 Costal region 371 Couching 125 Malgaigne's operation 125 Bretonneau and Velpeau's 125 Cranium, operation on bones of 77 for caries and necrosis 78 for exostosis 78 Crystalline humor 117 D Deep lymphatics of neck 297 Desmarres's forceps 91 Dieffenbach's operation for enlarge- ment of mouth 166 operation for blepharoplasty 96 operation for ectropium 99 operation for genioplasty 170 operation for strabismus 112 operation for otoplasty 212 operation for laceration of pe- rineum 551 Diet after operations 29 Dilatation of puncta lachrymalia 104 Dissections 46 Division of masseter 172 Schmidt's operation 173 Mott's " 173 of fraenum of penis 483 Dorsey's operation for entropium 101 operation for ligature of exter- nal iliac 457 operation for removal of tumor from back 467 Dressings, tray for, &c. 37 variety of 55 Duct of Steno I59 Dupuytren's bilateral operation 524 instruments for 524 operation for artificial anus 445 Dura mater 65 tumors of °° E Ear, anatomy of 209 Ectropium, Horner's operation for 9, Ectropium, Brainard's operation for 99 Sir Wm. Adams's operation 99 Dieffenbach's operation 99 Desmarres's operation 100 Effects of ligating carotid 326 Mott's dissection of carotid 326 Key's case 327 Effusion in chest 375 diagnosis 376 operation 376 ordinary operations 377 Wyman's pump 378 estimate of the operation 379 statistics of 380 in pericardium 380 Elbow, amputation at 669 resection of 633 Harris's operation for 635 Buck's " 636 Pancoast's " 636 Elevator of Pellier 121 Encanthus 93 Encysted stone 532 rectum 587 Enlarged bursa 605 Enlargement of mouth 166 Enterotomy 389 White's operation 389 Entropium 100 operation by excision 101 Janson's operation 101 Dorsey's operation 101 Saunders's operation 101 Envelops of hernia 403 Epicanthus 93 Von Ammon's operation 93 Ether, Warren on effects of 24 Eustachian tube 212 Excision of neck of womb 582 of prolapsus ani 592 Ricord's operation for 592 External incision in stricture 493 Extirpation of eyeball 113 of mamma 361 operation 363 Warren's case 365 statistics 366 opinions of Rhazes, Albu- casis, Velpeau, Parrish, Warren, and Dudley 367 opinions of Eve, Rodgers, Mussey, Twitchell, Flint, and Leroy D'Etiolles 368 opinions of Brodie and B. Cooper 369 of tumors of mouth 179 of parotid 237 of ovarium 569 M'Dowell's operation for 570 690 INDEX. Extirpation of ovarium, Atlee's operation for 571 statistics of 573 American operations 577 of womb 583 Essellman's operation for 583 Eve's " 583 Extraction of cataract 127 Daviel's scoop 127 curette 128 Cheselden's knife 127 Lawrence's operation 127 ordinary " 128 Extraction of foreign bodies from ear 213 Sims's operation 214 Paulus iEgineta's plan 214 from oesophagus 267 Extremities, general operations on 603 Eye, operations on humors of 114 Eyeball, operations on 108 extirpation of 113 Eyelids, anatomy of 88 Face, surgical anatomy of 87 resection of bones of 183 False joint in femur 641 in humerus 633 Physick's operation 933 Fascia propria 403 Fatty tumor of mamma 357 Female genito-urinary organs, ope- rations on 545 perineum, anatomy of 545 vesico-vaginal septum 546 recto-vaginal " 546 operations on external organs 547 hypertrophy of nymphae and clitoris 547 cysts, &c. of labia 549 catheterism, operation of 549 Femoral artery, ligature of 620 Femur, resection of 639 resection of head of 640 false joint in 041 Fibrous tumors 295 Fibula, resection of 646 extraction of 647 Fingers, amputation of 716 Fissure of anus 588 Boyer's operation for 588 Fistula lachrymalis 105 bougie, style, canula 105 Haxhall's plan 106 after-treatment 107 in perineo, pathology 497 operation for 497 Horner's operation for 498 PAGE Fistula, vesico-vaginal 557 Hayward's operation on 557 Mettauer's " 559 Sims's " 560 recto-vaginal 564 Roux's operation for 565 Velpeau's " 565 Barton's " 565 in ano 597 Forearm, amputation of 671 resection of 636 Foreign bodies in pharynx 266 in oesophagus and stomach 267 Bond on 267 operation with Bond's for- ceps 269 Weever's forceps 269 Dorsey on 271 in rectum 586 Formation of hernia 406 Frere Cosme's single lithotome cache 523 Frontal sinus, trephining of 82 Fungoid tumors of dura mater 85 Warren's operation 85 Fungous growths 108 G Gastric and intestinal fistulae 390 Cook's case—pressure 390 Beaumont's experiments 391 Gastrotomy 387 General operations on extremities 603 General pathology of hernia 401 Manlove's operation 388 Genioplasty 170 Mott's operation 170 Dieffenbach's " 170 Mutter's " 171 Genito-urinary organs in man 475 in the female 545 Glands of mouth 175 Glover's suture 395 Gross's operation for encysted tu- mor 370 Gunshot wounds 649 H Hand, resection of 639 Hands, advantage of using both 37 Harelip, simple 160 operation 1G0 Barton's operation 161 Mirault's operation 163 Malgaigne's " 163 Warren's mode 164 Double harelip 164 ordinary operation 164 Blandin's plan 165 INDEX. 691 PAGE Hays's operation for strabismus 112 operation for distortion of na- tural pupil 134 Hayward's operation on vesico-va- ginal fistula 557 operation for enlarged bursa 605 on amputations 652 Head, surgical anatomy of 65 Hemorrhage, arrest of 48 by compression 48 by Spanish windlass 49 by tourniquet of Petit 49 ' special tourniquet for 49 ligatures 51 styptics for 54 Physick on 49 Parrish's mode of arresting 54 from nose 152 Bellocque's instrument 152 operation 153 Hemorrhoids 593 Jobert on 593 Ribes on 593 treatment of 594 ligature in 594 excision of 594 Horner's operation for 595 Hepatic abscesses 383 diagnosis 385 Begin's operation 385 Savery's " 386 Hernia in general 400 radical cure of 413 reducible 407 envelops of 403 formation of 406 strangulated femoral 430 anatomical relations of 430 infundibular fascia 431 Gimbernat's and Poupart's ligaments 430 falciform process 432 Hey's ligament 432 Heterologous growths' 291 Hip-joint, resection of 640 Barton's operation for 640 Rodgers, J. Kearney's opera- tion for 641 amputation at _ ou Mott's operation 0(6 Van Buren's " 67-3 Lalouette's " 673 Hodgson-compression of jugular 325 Horner's operation for ectropium 97 operation for salivary fistula 172 operation for resection of up- per jaw . il operation for extirpation of parotid 240 Horner's operation for hemorrhoids 595 operation for fistula in perineo 498 plastic operation for laceration of perineum 553 Hosack's operation for extirpation of parotid 243 operation for staphyloraphy 205 Humerus, false joint in 633 Hydrocele of neck 314 operation for 314 Hydrocele—operation 505 after-treatment 506 treated by the seton 506 incision in 507 excision in 507 Hydrocephalus, puncture in 83 Dugas and Whitridge's cases 83 operation 83 Brainard, iodine injections in 83 Hypertrophy of mamma 357 of tongue 179 Harris—amputation of 179 Newman's case 180 Hypospadias and epispadias 499 Mettauer's operation for 499 I Iliac arteries, ligature of 455 anatomy of 455 internal iliac 456 external " 456 ligature of external iliac 456 Abernethy's operation 456 Cooper's 457 Bogros's " 457 Dorsey's " 457 Post's " . . 459 statistics of external iliac 460 Norris on 461 ligature of common iliac 461 Mott's operation 462 Gibson's case 463 Peace's operation 463 Gibson's needle 463 statistics of ligature of iliac 465 ligature of internal iliac 465 Stevens's operation 465 White's " 466 Bigelow's " 466 statistics 466 Imperforate anus 589 Incisions, shape of 45 in stricture 491 Inflammation, and its uses _ 29 Innominata and subclavian, surgi- cal anatomy of 330 Innominata 331 ligature of 334 Mott's operation 334 692 INDEX. Instruments, selection of sharpening of grinding of for puncture arrangement of cleaning of place of deposit oiling of for stricture Internal nose, anatomy of Inverted toe nail Iris anatomical relations of Irreducible hernia symptoms K Keratonyxis Knee-joint, resection of Barton's operation for Buck's amputation at Laceration of perineum Horner's operation Mettauer's " Dieffenbach's " Lachrymal apparatus, operations on gland Lalouette's amputation at hip Laryngotomy Default's operation estimate of different opera- tions Laryngo-tracheal and supra-sternal regions arteries of this region veins " " Larynx and trachea, surgical ana- tomy of bloodvessels of part Lateral operations for stone operation with the cutting gor- get _ statistics of Lawrence's seton Ledran's loop suture Leg, amputation of Leroy's instrument for urethra Ligatures, Jones on application of effects of removal of manufacture of of arteries Lisfranc on Mott on PAGE PAGE 31 Ligature of arteries, Parrish on 321 32 of both carotids 327 35 Mott's case 327 36 Post's case 329 37 of thyroid artery 311 39 Jameson's operation 311 39 of carotids 323 39 primitive carotid 324 492 Velpeau's operation for 324 150 of axillary beneath clavicle 351 604 ordinary operation 351 117 Lisfranc's " 352 129 Malgaigne's directions 352 407 after-treatment 353 407 of the innominata 334 of subclavian 336 Keate's priority 336 124 Lisfranc's operation 337 641 Roux's suggestion 338 641 of subclavian between scaleni 338 641 Dupuytren's operation 338 679 Rogers's operation 340 statistics 343 of subclavian within scaleni 339 551 Mott's operation 339 553 of spermatic artery 500 553 Maunoir's operation for 500 551 of spermatic veins 501 of arteries of extremities 611 103 of axillary artery 611 89 of brachial " 614 673 of radial " 617 256 of ulnar " 619 256 of arteries of lower extremity 620 of femoral artery 620 257 of popliteal " 624 1 of posterior tibial artery 625 229 of anterior " " 627 230 Ligneous scirrhus 359 231 Limbs, artificial 690 Lip, cancer of 165 245 ordinary operation 165 246 Lipomatous tumors of nose 141 519 Lips, operation on 160 Liquor Morgagni 117 520 Lithotomy 514 538 in female 567 93 Lithotripsy 540 396 preliminary treatment 541 680 Randolph's operation 543 152 after-treatment 543 51 anaesthetics in 544 52 in female 567 53 Lithotome 523 61 Lithontriptor 541 53 Loop suture, Jobert's 396 317 Lower extremity, resection of 639 318 amputation of 672 319 ligature of arteries of 620 INDEX. 693 354 355 355 356 360 360 360 185 172 237 M Mammary gland, operations on pathology and diagnosis of 1. Scrofulous tumor 2. Chronic mammary 3. Irritable mammary 4. Hydatid tumors 5. Adipose " 6. Cartilaginous & osseous 7. Cancerous tumors 8. Encephaloid growths fibro-scirrhous degeneration ordinary cancer of breast Parrish on Masseter muscle division of McClellan's operation for extirpa- tion of carotid operation for resection of ribs 373 May's amputation at hip 673 Median operation for lithotomy 527 Vacca Berlinghieri's operation 528 Metacarpus, resection of 638 Metatarsal bones, resection of 648 Metoplasty 137 Watson's operation for 139 Mettauer's operation for hypospa- dias 499 operation for laceration of perineum 553 staphyloraphy 205 Mott's curved spatula 321 mode of removing polypi from nostrils operation for genioplasty operation for division of mas- seter 173 operation for extirpation of carotid 239 dissection of carotid 326 case of ligature of both caro- tids 327 operation for ligature of inno- minata 332 operation for extirpation of clavicle 346 operation for ligature of com- mon iliac 462 amputation at hip 158 170 Mouth, anatomy of external parts 158 bloodvessels of salivary glands enlargement of Dieffenbach's operation Mouth, anatomy of parts within half arches muscles of part Mussey's bilateral operation 159 159 166 166 174 176 170 525 N Naevi materni 71, 93 pathology of 71 operations for 71 vaccination in 72 heated needles in 72 caustic threads in 72 seton in 72 ligatures in 73 Barton's operation 73 Brainard—collodion in 73 excision of 73 partial incisions in 74 Physick's operation 74 Warren—excision of 74 Nasal cavities, operation on 151 Neck, surgical anatomy of 223 arteries of 228 Neck, tumors of 290 general pathology of 291 classification of 292 diagnosis ' 293 character of tumors 294 position of tumors 295 Needle, curved 51 Nose, anatomy of external 140 operations on " 141 removal of foreign bodies from 151 O Occlusion of the vulva 547 03dema of glottis 249 pathology 249 Bayle on 249 Buck's operation 250 Lisfranc's " 251 statistics of 251 CEsophagotomy 277 modes of operating 277 Guattani's mode 277 Eikholdt's " 277 Boyer's " 277 Watson's operation 278 (Esophagus, foreign substances in 267 Operations, diagnosis of 18 Operating, general duties before 22 Operation, prognosis of 20 Operations for cataract 122 by absorption 123 on ear 212 on external nose 141 on integuments of face 87 on oesophagus 267 for strangulated ingui'l hernia 419 on muscles of eye 109 on the nasal cavities 151 of circumcision 479 for spina bifida 470 Trowbridge's operations 470-1 694 INDEX. Operations for spina bifida Skinner's operation for 472 Stevens's " 472 Brainard's operation 473 on deep-seated organs of fe- male 566 on uterus 567 on rectum 584-586 of ligature in fistula 598 by knife in fistula 598 on bones of extremities 629 Organic changes of amputations 687 Organs of female, operations on 566 Otoplasty 212 Dieffenbach's operation 212 Pancoast's " 212 Ovariotomy 569 statistics of 573 subjects for 575 dangers in 576 American operations 577 Palate 175 operations on 199 Palfyn's loop suture 396 Pancoast on length of penis 477 operation for strabismus 112 modification of Taliacotian ope- ration 147 on cheiloplasty 167 operation of tracheotomy for croup 253 operation for resection of elbow 636 Paraphymosis, pathology of 482 compression in 482 incision in 483 Paronychia 605 Parotid region 227 diseases of 235 superficial lymphatics 235 pathology 236 Parotid gland, extirpation of 237 McClellan's operation 237 Mott's " 239 Randolph's " 240 Horner's " 240 Hosack's " 243 statistics of 241 Parrish—ligature of arteries 321 on cancer of breast 360 mode of arresting hemorrhage 54 on strangulated umbilical her- nia 442 test for position of artery 332 knife for arteries 335 on ligneous scirrhus 359 Paracentesis abdominis 382 ordinary operation 382 PAGE Paracentesis thoracis 375 Parts, closing of 56 Pathology, surgical 18 Paulus ASgineta on polypi in mea- tus externus 214 Peace's ligature of common iliac 463 Pellier's elevator 121 Perforation of membrana tympani 215 Sir A. Cooper's operation 217 Deleau's instrument 217 Horner's " 217 operation 217 Perineal lithotomy, operation of 514 after-treatment of 535 putting to bed 536 treatment of the wound 537 constitutional treatment 537 Perineum, laceration of 551 Dieffenbach's operation for 551 Mettauer's operation for 553 Horner's plastic operation for 553 anatomy of male 511 dimensions of 512 Period for amputating 652 Petit's tourniquet 49 Pharynx and oesophagus, surgical anatomy of 263 operations on 265 hypertrophy of follicles of 265 foreign bodies in 266 Philadelphia needle 321 Physick on hemorrhage 49 on iris * 131 on polypi in nostrils 157 on excision of uvula 181 on removal of tumors from neck 298 on artificial anus 445 operation on scalp 74 operation for ptosis 132 operation for excision of tonsils 182 stomach tube 272 forceps for deep arteries 205 canula 382 operation on abdomen 383 Physick's catheter 487 bougie catheter 489 stylet catheter 492 forceps and needle 533 Piles 593 Plaster, adhesive 56 Plastic operations on face 136 Polypi in meatus externus 215 Paulus iEgineta on 214 Fabrizj's operation 215 in nostrils 153 pathology 153 Dupuytren on 153 Watson on 155 seat of 156 INDEX. 695 r, i . PAGE rolypi, operations for 156 Levret's double canula 157 removal by forceps 157 strangulation 157 Physick's mode 157 Mott's " 158 excision 158 Polypus of uterus 568 Popliteal artery, ligature of 624 Porter's tracheal fascia 254 Posterior tibial artery, ligature of 625 Post's ligature of external iliac 459 Prolapsus ani 589 Dupuytren's operation for 591 Velpeau's " 591 Ricord's " 592 Robert's " 591 Prostate, relative position of 512 Pterygium 108 Ptosis 95 Hunt's operation 95 Punctures 47 Puncture of uterus 568 Pupil, dilatation of 120 narcotics for dilatation 120 R 617 413 413 414 415 415 Radial artery, ligature of Radical cure of hernia Gerdy's operation Nott's " Guy de Chauliac—ligature Nott—leaden ligature Jameson's modification of plas- tic operation 415 Railroad accidents 651 Randolph's operation for extirpa- tion of parotid 240 operation for imperforation of vagina 550 operation for lithotripsy 543 Recto-vaginal fistula » 564 Rectum, operations on 584-586 surgical anatomy of 584 removal of foreign bodies from 586 encysted Reducible hernia Reduction of hernia Regions of face Removal of tumors from neck Stevens on Physick's practice Warren's operations Mott's operation of foreign bodies from nose of substances from stomach operation Resection of inferior maxilla of one side of jaw 587 407 411 88 298 300 300 301, 303 304 151 271 272 193 195 Resection of jaw, Barton's operation 197 Deaderick's operation 195 Gibson's operation 196 ordinary " 196 of sternal end of clavicle 350 Velpeau's operation 350 Davy's " 351 Warren's " 348 Mott's " 346 of upper jaw 186 Gensoul's operation 186 Warren's " 187 Horner's " 190 Stevens's " 191 Mott's " 192 statistics 193 of ribs 372 McClellan's operation 373 Antony's case 373 ordinary operation 373 Richerand's case 374 of inferior extremity of ulna 637 of metacarpus 638 of hand 639 of lower extremity 639 of femur 639 of head of femur 640 of hip-joint 640 of knee-joint 641 of bones of leg 646 of ankle 646 of fibula 646 of astragalus 648 of metatarsus 648 of bones of extremities 630 of shoulder 631 of elbow 633 of forearm 636 of ulna 636 Reybard's loop suture 396 Rhinoplasty, Watson on 142 modes of operating 143 Taliacotius's methods 143 Graefe's modification 143 Warren's " 143 Indian method of 144 Warren's operation 144 Taliacotian operation 146 Pancoast's modification 147 Ribs, resection of 372 Ricord's operation for varicocele 501 operation for prolapsus ani 592 Sac of hernia Salivary fistula Horner's operation Sarcomatous tumor Scalpel, positions of 403 171 172 295 42 696 INDEX. Scalp, structure of 68 operations on 69 tumors, encysted 69 naevi materni of 71 Scissors, action of 36 for dividing parts 45 Scleroticonyxis 123 Seat of hernia 404 Seton in encysted tumor 370 Gross's operation 370 in false joint 633 Physick's operation 633 Shoulder, amputation at 665 resection of 631 Sinus, superior longitudinal 67 Slippery elm bougies 491 Sounding for stone 514 anaesthetics in 515 Spermatic cord 477 artery 468 Spina bifida 479 Chaussier's observations 480 complication with hydrocepha- lus 474 iodine injections in 473 Sponges 56 Staphyloplasty 207 Warren's operation 207 Velpeau's " 208 Pancoast's " 209 Staphyloraphy 199 Roux's operation 201 instruments 201 Warren's operation 202 American " 203 Stevens's " 205 Mettauer's " 205 Wells's " 205 Gibson's " 205 Hosack's " 205 Physick's forceps 205 transverse incisions 206 Statistics of operations on cranium 82 of staphyloplasty 209 of ligation of carotid 329 of extirpation of carotid 241 of ligature of common iliac 465 of ligature of external iliac 460 of ligature of internal iliac 466 of ligature of subclavian 343 of operations for artificial anus 448, 454 of paracentesis thoracis 380 of resections of jaw 198 of strangulated femoral hernia 439 of strangulated inguinal hernia 429 of strangulated umbil. hernia 443 of supra-pubic operation for lithotomy 528 Statistics of tracheotomy for croup 260 tracheotomy for foreign bodies 262 of ovariotomy 573 Stone in the bladder, pathology 509 diagnosis of 514 constitutional treatment of 516 local preparatory means for 517 instruments required for 519 general remarks on perineal lithotomy 529 extraction of the stone 530 Barton's forceps 531 Earle's " 531 the scoop 531 Strabismus 109 sub-conjunctival fascia 111 Gibson's operations 111 Stromeyer's " 111 Dieffenbach's " 112 Sedillot's " 112 Pancoast's " 112 Hays's " 112 Guerin's 113 Strangulated hernia 409 symptoms 409 post-mortem appearances 410 Strangulated femoral hernia 430 taxis in femoral hernia 434 operation 435 statistics of 439 Strangulated inguinal hernia 417 operations for 419 taxis 419 anaesthetics 420 cold applications 422 operation for dividing stricture 422 preliminary measures 422 Cooper's bistoury 423 division of stricture 425 dressing 427 statistics of 429 Strangulated umbilical hernia 441 operation for 441 artificial anus 442 statistics 443. Strangulation of intestine or omen- tum 392 Stricture of oesophagus 273 pathology 273 Velpeau on 273 dilatation of stricture 275 instruments, Horner's 275 caustic—operation 276 Strictures of urethra, pathology of 489 diagnosis of 490 Subclavian, anatomy of 331 ligature of 336 ligature between scaleni 338 ligature within scaleni 933 INDEX. 697 Subclavian, ligature of left within scaleni 340 Rogers's operation 340 Crampton's needle 341 Submaxillary, operations on 244 Supra-clavicular depression 223 region 233 lymphatic glands 233 arteries 233 external jugular vein 234 nerves of the part 234 Supra-hyoid region 225 muscles of 225 Supra-orbitar nerve, division of 75 Warren on division of 77 Supra-pubic operation for lithotomy 528 Sir Everard Home's operation 528 statistics of 539 Supra-sternal fossa 223 Superior and inferior maxillary 185 Surgery, history of xvii history of American xxiii Surgeon, positions and manoeuvres of 28 duties after operations 28 Surgical anatomy of rectum 584 Sutures 57 interrupted 57 twisted 59 pins for harelip 60 quilled 60 in wounds of intestine 393 in longitudinal wounds of in- testine 395 Suture of transverse wounds 397 Ramdohr's suture 397 Jobert's " 397 Lembert's " 397 Travers's experiments 398 Cooper's " 398 Symblepharon 94 Von Ammon's operation 94 T Tarsus, amputation of Chopart's operation Lisfranc's " Hey's Taxis 680 681 681 681 411 in strangulated inguinal hernia 419 in femoral hernia 434 Tenotomy . 609 Thigh, amputation of on Thorax, surgical anatomy of 371 Tobacco injection 412 Toe nail, inverted ou* operation for Toes, amputation of Tongue, operations on Tonsils, excision of 687 177 182 PAGE Tonsils, Physick's operation 182 Fahnestock's instrument 182 Charriere's modification 182 operation of excision 183 after-treatment 183 Torsion 53 Torticollis 286 operation 286 J. C. Warren's 288 J. M. Warren's 287 mechanical means 289 Tracheotomy for croup 252 preliminary measures 253 Pancoast's operation 253 Porter's tracheal fascia 254 statistics of 260 for foreign body 255 Liston's operation 255 statistics of 262 Transversus perinei artery 513 Treatment of goitre 309 by compression 310 Dwight's operation for 310 Mayor's operation for 312 Warren's " 312 of hernia 410 causes of difficulty 411 etherization 411 local means 412 of stricture 491 Trephining the cranium 78 Tumors on back 467 Dorsey's operation 467 of chest 369 of eyelids 91 in orbit 114 dependent on hypertrophy of mamma 357 due to degeneration of mamma 358 lipomatous, of nose 141 encysted 69 pathology of 69 ordinary operation for 69 dressing 71 of bursa 605 of nerves 607 Tunica vaginalis testis 477 U Ulna, resection of 536 Butt's operation for 636 resection of inferior extremity of 637 Ulnar artery, ligature of 619 Umbilical hernia 440 surgical anatomy of 440 operations for 441 strangulated 441 Upper jaw, resection of 186 698 INDEX. Upper extremity, amputation of 665 Urethra, membranous portion of 513 Uterus, operations on 567 puncture of 568 polypi in 568 Uvula 176 excision of 181 Physick's views on 181 ordinary operation 181 Vacca Berlinghieri's median ope- ration for lithotomy 528 Vagina, imperforation of 549 Meigs's case 550 Randolph's operation 550 narrowing of 554 Varicocele 501 Breschet's operation for 504 Ricord's " 501 Velpeau's " 501 Varicose veins 607 Van Buren's amputation at hip 675 Vault of cranium 65 Veins, varicose 607 Watson's operation 608 Velpeau's operation for corectomia 133 operation for ligature of primi- tive carotid 324 operation for resection of ster- nal end of clavicle 350 operation for staphyloplasty 208 operation for varicocele 501 operation for resection Of wrist- joint 638 Vesico-vaginal fistula 555 pathology of 555 palliative treatment 556 Meigs's instrument for 556 Mettauer's operation 559 Sims's " 560 Hayward's " 557 Vidal du Cassis's operation for va- ricocele 503 quadrilateral operation of 529 Vitreous humor 117 W Warren's (J. C.) operation for re- moval of fungoid tumors 85 on effects of ether 24 on division of supra-orbitar nerve 77 operation for resection of up- per jaw 187 operation for resection of cla- vicle 346 operation for staphyloraphy 202 operation for torticollis 288 operations for removal of tu- mors from neck 301, 303 operation for goitre 312 case of extirpation of mamma- ry gland 365 Warren's (J. M.) operation for harelip 164 operation for rhinoplasty 144 operation for staphyloplasty 207 operation for artificial anus 447 operation for torticollis 287 Watson on rhinoplasty 142 operation for metoplasty 136 on polypi in nostrils 158 operation on varicose veins 606 White—ligature of internal iliac 459 operation of enterotomy 398 Whitlow 605 Womb, excision of neck 582 extirpation of 583 Wounds in abdomen 392 of intestine 393 Wrist, action of 53 joint, resection of 638 Velpeau's operation for 638 Wyman's pump 378 THE END. To all Physicians and Medical Students, NEW AND VALUABLE MEDICAL BOOKS, JUST PUBLISHED BY LIPPINCOTT, GRAMBO & CO,, SUCCESSORS TO GRIGG, ELLIOT & CO., No. 14 North Fourth Street, Philadelphia, AND FOR SALE BY BOOKSELLERS GENERALLY IN THE UNITED STATES. THE DISPENSATORY OF THE UNITED STATES: NINTH EDITION, IMPROVED. CONSISTING OF 1st. A TREATISE ON MATERIA MEDICA, or the Natural, Commercial, Chemi- cal, and Medical History of the Substances employed in Medicine, and recognized by the Pharmacopoeias of the United States and Great Britain; 2d. A TREATISE ON PHARMACY: comprising an account of the preparations directed by the American and British Pharmacopoeias, and designed especially to illustrate the Pharmacopoeia of the United States; and 3d. A copious APPENDIX, embracing an account of all substance^ not contained in the officinal catalogues, which are used in medicine or have any interest for the Physician or Apothecary. BY GEORGE B. WOOD, M. D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania, $c. 4"C AND FRANKLIN BACHE, M.D., Professor of Chemistry in the Jefferson Medical College of Philadelphia, 8(C. S(c. The work has been thoroughly revised, with many alterations and additions, so as to bring it fully up to the level of the present state of Materia Medica and Pharmacy. < It embraces the substance of the recently revised United States and British Pharmacopoeias, with a commentary on all that is new in those publications. Nothing, indeed, has been omitted in the revision, which could tend to render the work worthy of a continuance of the public confidence which it has so long enjoyed. DR. WOOD'S PRACTICE. A TREATISE ON THE PRACTICE OP MEDICINE. IN TWO VOLS. OCTAVO. THIRD EDITION, IMPROVED. BY GEORGE B. WOOD, M. D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania. UNITED STATES PHARMACOPOEIA. THE PHARMACOPCEIA OF THE UNITED STATES OF AMERICA, ^^ nv i nTnnutTV flir THE BY AUTHORITY OF THE NATIONAL MEDICAL CONVENTION, HELD AT WASHINGTON, A. D. 1850. IN ONE VOLUME OCTAVO. MITCHELL'S THERAPEUTICS. MATERIA MEDICA AND THERAPEUTICS, WITH AMPLE ILLUSTRATIONS OF PRACTICE IN ALL THE DEPARTMENTS OF MEDICAL SCIENCE, AND COPIOUS NOTICES OF TOXICOLOGY; THE WHOLE ADAPTED TO THE WANTS OF MEDICAL PUPILS AND PRACTITIONERS, BY THOMAS D. MITCHELL, A.M., M.D., Professor of the Theory and Practice of Medicine in the Philadelphia College of Medicine, formerly Professorof Chemistry and Pharmacy in the Medical College of Ohio, Professor of Chemistry and Materia Medica in Lexington, Ky., Lecturer on Obstetrics and the Diseases of Women and Children, Author of Elements of Chemical Philosophy, &c. IN ONE VOLUME, OCTAVO. NOTICES OF THE PRESS. From the Boston Medical and Surgical Journal, Sept. 1850. " We take much pleasure in noticing this able work of Dr. Mitchell, and can assure our readers, it ia one of the best works on Materia Medica and Therapeutics that has been published. It is written in a style that interests and instructs at the same time." From the New York Medical Gazette, November, 1850. " This new work upon an old subject, will be found to embody a variety and amount of practical in- struction in this department, which are not to be met with in any one of the numerous treatises on Materia Medica or Therapeutics, or both, with which the profession has been favored. The ample il- lustrations of practice in all the departments of medical science, with the very copious notices of tox- icology, &c, render it a valuable book for students, and also adapt it for reference by practitioners, both of which purposes are subserved by its alphabetical arrangement." From the Western Lancet, Cincinnati, Oct. 1850. " On the whole, we do not know a better work on Therapeutics. It is copious without tediousness, condensed without incompleteness, and embraces as much reliable information on the treatment of dis- ease as any work of similar size. We are very much deceived if medical students will not find this treatise more to their taste and wants than any hitherto published in this country; and practitioners will find many references to Therapeutics which will prove interesting and valuable. We hope it may be extensively circulated among the profession. The style of the work is terse, agreeable, and always interesting; dullness being no part of the author's composition." From the Transylvania Medical Journal, 1850. " To express the opinion which we have formed of it as a complete record of the knowledge of the author, acquired by years of study, and in a lengthened course of teaching, would only be to add our tribute to the testimonials sent in to him from all directions. " To those who have heard the lectures of Dr. Mitchell, we need say nothing of the style of his book ; and to all who have not enjoyed that privilege, we offer the assurance, that out of the usually dry mate- rials of such a work, the author has produced a most pleasant and entertaining treatise. We cheer- fully recommend it as an excellent text-book." Extract of a letter from Prof. Lawson, of the Medical College of Ohio, Cincinnati, dated Oct. 1850. " It was a source of pleasure, I assure you, to receive the volume on Therapeutics. It reminded me forcibly of Old Transylvania, which, although virtually dead, is like bread cast upon the waters, to be seen many days hence. This volume is an evidence, that the old school may yet do great good for the profession. I have glanced through the work, and it affords me pleasure to say, it merits liberal praise and will prove attractive to medical students. You speak of having other works in preparation. Go on and let them see the light." Extract of a letter from Prof. E. L. Dudley, of the Kentucky School of Medicine, Louisville, Ky. "Allow me to thank you for your friendly recollection, and to express the opinion (formed after hearing the views of many persons in relation to your Therapeutics), that it will be a very popular text- book in the West and South." EBERLE AND MITCHELL ON CHILDREN. A TREATISE ON THE DISEASES AND PHYSICAL EDUCATION OF CHILDREN, BY JOHN EBERLE, M. D., &c. &c. Fourth Edition, with Notes and large Additions BY THOMAS D. MITCHELL, A.M., M. D., &c. &c.'&c. One volume 8vo. From the New York Medical Gazette, November, 1850. " A cursory examination of the notes and large additions made bv Dr MitoKoii I,-*. j he has greatly enhanced the value of the work', and has introduce? a ^e y 1 va etv"^ ^ valuable matter, so that it now comprises a full exhibit of the state of existing knnwi.,^1- • .1 J" and ment, and deserves a place among our standard books " g knowledge ln this depart- 2 AN ILLUSTRATED SYSTEM OF HUMAN ANATOMY, SPECIAL, MICROSCOPIC, AND PHYSIOLOGICAL, Principally designed for the Use of Practitioners and Students of Medicine. In One Volume Royal Octavo. BY SAMUEL GEORGE MORTON, M.D. ^TThis Work is invaluable to the Medical Profession, and one of the most splendid, as to En- gravings and Typographical execution, ever issued from the American press. The following are a few of the many notices of Dr. Morton's Anatomy: In point of elegance of form, as well as exactness and completeness of execution, the Illustrated System of Human Anatomy, Special, General, and Microscopic, by Dr. Samuel George Morton, sur- passes all the works which have proceeded from American medical authors within the last year. This celebrated savant, whose reputation has been carried abroad to a wide extent, and whose name is familiar to the profession at home, through his Crania Americana, Crania iEgyptiaca, and Pulmonary Consumption, has, in his last work, conferred additional renown upon our literature.—Transactions of the American Medical Association. Dr. Morton, with happy felicity, has compressed within the limits of a single volume the most recent microscopic results, an acquaintance with which has led to the truest exposition of anatomical and phy- siological science. And Dr. Morton's distinguished position as an investigator in this department of Anatomy has gained for him a reputation which the appearance of his excellent Anatomy has served to increase.—Charleston Med. and Surg. Journal, March, 1849. We freely recommend the work of Dr. Morton to the whole profession, particularly students, who, we are certain, will not fail at once to recognize the superior merits of this book, a thorough knowledge of which will lay the foundation of anatomical science—without which they cannot be successful or scientific practitioners—deep in their memories. We shall call attention to this volume again in a future number : meantime, we would say to all, purchase it.—New York Journal of Medicine, March, 1849. The title of this work, and the reputation of its author, led us to expect no ordinary amount of pleasure and information in its perusal. So far as we have been able to examine, we have not beea disappointed. Without pretending to go fully into the merits of the volume, we will simply say to our patrons, and the members of the profession in general, that they can here have, in a condensed manner, all that is known in regard to the important and interesting subjects embraced in the above title. It it truly a valuable work.—St. Louis Med. and Surg. Journal, March and April, 1849. Louisville, Ky., April 11, 1849. The book (Dr. Morton's Anatomy) is really a magnificent one. The paper, typography, and cuts, are perfect. Altogether, it is the most beautiful work that has ever been issued by the medical press of this country. That it will meet with a ready sale is unquestionable. The work takes well in the West, and will, I doubt not, be well received by the profession everywhere.—S. D. Gross, M.D. DR. MeCLELLAN'S SURGERY. PRINCIPLES AND PRACTICE OF SURGERY, In One Volume Octavo. Containing the Recent Novelties and Improvements in that Important Branch of Wuiduuu6 Medical Science. By the late GEORGE McCLELLAN, M.D. Trip Publishers have received numerous recommendatory notices of the great practical value of this work to the Medical Profession. Most of the Medical Journals m this country have spoken in the highest terms of the importance to the American Pracfitumer of the work. eberle's practice of medicine. a treatTse ON THE THEORY AND PRACTICE OF MEDICINE, TWO VOLS. IN ONE, OCTAVO. NEW EDITION. BY JOHN EBERLE, M.D., Late Professor of Materia Medica and 0**™%*^%*$?$*" °f Philadd*>hia> Cincinnati, 0^ *n4 WITH NOTES AND ADDITIONS, BY GEORGE McCLELLAN, M.D., AND OTHER DISTINGUISHED PHYSICIANS. Embracing all the late improvements and discoveries in Practice. ~ t>.<» most valuable works on the Practice of Medicine that has ever isaued from This is one among tne musi vaiuau »he American or English press. JUST PUBLISHED, A SYSTEM OF OPERATIVE SURGERY: BASED UPOJT THE PRACTICE OF SURGEONS IN THE UNITED STATES: AND COMFIUSING A BIBLIOGRAPHICAL INDEX AND HISTORICAL RECORD OF MANY OF THEIR OPERATIONS, FOR A PERIOD OF 20O YEARS. BY HENRY H. SMITH, M. D. Illustrated with upwards of 1000 Engravings on Steel. The whole forming one large octavo volume. CONTENTS. Paets 1 & 2.—GENERAL AND ELEMENTARY OPERATIONS, as well as those upon the HEAD AND FACE. r Part 3.—OPERATIONS UPON THE NECK AND TRUNK. Part 4.—OPERATIONS ON THE GENITO-URINARY ORGANS OF THE MALE AND FEMALE. Pakt 5.—OPERATIONS PRACTISED ON THE EXTREMITIES. A BIBLIOGRAPHICAL INDEX Of most of the Surgical Papers connected with the subject is attached to each Par% THE PLATES WILL BE PRESENTED EITHER TINTED OR IN COLORS. V Price $7 50 tinted—$15 colored to nature. EBERL E'S NOTES FOR STUDENTS. NEW E,D ITION. One volume, 12mo. COSTILL ON POISONS. A PRACTICAL TrIItTsE ON POISONS? THEIR SYMPTOMS, ANTIDOTES, AND TREATMENT. BY 0. H. COSTILL, M. D. 18mo. Cloth. Price 50 Cents. KTThis, although a small work, contains all the important information on the subject and is highly approved by the Medical Faculty. , » WE HAVE FOR SALE ALL THE TEXT-BOOKS TOGETHER WITH AS COMPLETE AN ASSORTMENT OF ' STANDARD MEDICAL WORKS AS CAN BE FOUND IN THE COUNTRY. MEDICAL STUDENTS AND PHYSICIANS Will find it much to their advantage to call upon or write us before purchasing LIPPINCOTT, GRAMBO & CO,, Publishers, Booksellers, and Stationers No. 14 North Fourth Street N. B. Particular attention will also be paid to all orders for MFmr at taw . , MISCELLANEOUS BOOKS forW anoI Pnb£I"an'd ntlrfNI> will be spared to complete Suoh orders on the most libS terms NATIONAL LIBRARY OF MEDICINE ?■ wMM ^^^ftS 1MUJ NLfl D10bflM7fl 3 mm li i NLM010684783