*\ ■x. . -y>.*i . 4 •' " .. .?•£ '**£M%? •/-.., ,3" ft-* :. '■■£&$%& ** .'V.:. &?; -.'w\ fc, 9 )GGX2G3C0CCOOCaC •*.) Surg-eon General's Office ^y?lk HO Airorar MMSR¥^ «^ "} PRESENTED BY "I) O ANN. / 11 V705L,. )Y,M. T?*>O.L. i..^'OV^ # li>K.AEs> i . % A SYSTEM OPERATIVE SURGERY: BASED UPON THE PRACTICE OF SURGEONS IN THE UNITED STATES: BIBLIOGRAPHICAL INDEX AND HISTORICAL RECORD OF MANY OF THEIR OPERATIONS, DURING A PERIOD OF TWO HUNDRED AND THIRTY-FOUR YEARS. BY r HENRY H. SMITH, M.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE*©/ SURuTlki IITTHE UNIVERSITY OF PENNSYLVANIA; CONSULTING SURGEON AND LECTURER ON CLINICAL SURGERY IN THE PHILADELPHIA HOSPITAL; SURGEON TO THE ST. JOSEPH'S HOSPITAL; FELLOW OF THE COLLEGE OF PHYSICIANS, PHILADELPHIA, ETC. SECOND EDITION, NUMEROUS ADDITIONS IN BOTH THE TEXT AND ILLUSTRATI MAKING NEARLY ONE THOUSAND ENGRAVINGS ON STEEL IN TWO VOLUMES VOL. II. PHILADELPHIA: J. B. LIPPINCOTT AND CO., 1856. 3L5\ s Entered according to the Act of Congress, in the year 1854, by LIPPINCOTT, GRAMBO, AND CO., in the Office of the Clerk of the District Court of the United States, in and for the Eastern District of the State of Pennsylvania. OPERATIVE SURGERY. PART III. OPERATIONS ON THE FACE AND NECK—Continued. CHAPTER X. OPERATIONS UPON THE CHEST. SECTION I. SURGICAL ANATOMY OF THE CHEST. The extent of the chest as a surgical region is usually regarded by anatomists as limited, above, by a circular boundary formed by the upper extremity of the sternum, the first rib and first dorsal vertebra, or, in other words, by the bony constituents of the thorax; and below, by the curved line formed in the arrangement of the cartilages of the ribs, the chest being at this point completely sepa- rated from the abdomen by the diaphragm. There is, however, a portion of the body of great importance to the surgeon, which is not included in these limits, and which is yet not included in those assigned to the upper extremities, to wit, the structures about the clavicle; and it will, therefore, answer better for the purposes of description, at present, to define the chest as that portion of the body intermediate to the neck and abdomen, the upper portion being intimately connected with the upper extremi- ties, but the lower separated entirely from the abdomen by the diaphragm. As most of the constituents of this section of the body are unimportant, consisting merely of skin and muscle, they do not present any points requiring either a precise regional description, or a minute account of their connections with subjacent parts. The VOL. II.—2 18 OPERATIVE SURGERY. reader may, therefore, be referre] for their description to the ana- tomical account of this part, whi every one gains in the course of a medical education; as its surgu-i details are also limited, such a brief account as may readily be presented in connection with the operations performed upon it, is all that is at present demanded. § 1.—SURGICAL ANATOMY OF THE PORTION OF THE CHEST ABOUT THE CLAVICLE. The Clavicle, being fixed by the articulations at its sternal and acromial extremities, has for its function the preservation of the pectoral space, or the steadying of the shoulder, and the prevention of its approach to the sternum. At each of its extremities is found a perfect joint amply supported by ligaments, in addition to which may be noted two other ligaments, which are upon its under sur- face, and tend to hold the bone in its proper relations to the ribs; to wit, the costo-clavicular or rhomboid ligament, which, arising from the cartilage of the first rib, is inserted into the roughness on the under surface of the clavicle near its sternal extremity, and the coraco-clavicular or conoid ligament, which, arising from the cora- coid process of the scapula, is inserted into the tubercle near the inferior and external surface of the bone. The ligamentum bicorne, or bifid ligament, is so closely connected with the subclavius mus- cle, that it may be regarded chiefly as its fascia, and a further ac- count of it omitted. The Muscles connected with the clavicle above are a portion of the sterno-cleido-mastoid at its sternal extremity, and a part of the trapezius at its humeral end, whilst the pectoralis major and part of the deltoid are in front, and the subclavius muscle below. The latter muscle, arising from the cartilage of the first rib, is inserted into the inferior face of the clavicle, from near the sternum to the conoid ligament, and therefore draws the clavicle towards the rib. The Subclavian Artery and Vein are both placed between this muscle and the first rib, the vein being close to the artery, but in front of it. The Brachial plexus of Nerves extends from the scaleni muscles to the axilla, passing along with the artery between the subclavius muscle and the rib. It has the axillary vein in front of it, but the different nerves surround the artery, as if plaited. The fascia superficialis of the chest and neck, together with the skin, complete the coverings of this part. OPERATION UPON THE CLAVICLE. 19 SECTION II. RESECTIONS OF THE CLAVICLE. The resections practised upon the clavicle are such as are de- manded for the relief of caries, necrosis, or osseous tumors, and may require either a partial or perfect division or resection of the bone. In describing the operation of resection of this bone, as well as in similar operations on other bones of the extremities, the reader should bear in mind that by the term " resection" is gene- rally understood the removal of either a part or the entire structure of the bone, in such a manner as will yet permit the patient to have more or less use of the extremity to which it is attached. Any operation therefore which destroys this use, or also removes the limb, is to be regarded as an amputation and not as a resection. That this definition of the operation of resection is correct, is apparent from the views expressed by the following excellent authorities. Thus, J. Cloquet and A. Berard,' in speaking of the peculiar characters of a resection, state that " the preservation of the soft parts constitutes the special character of this operation, which should be practised so as to avoid all lesion of the arterial or venous trunks, and injure the muscles and tendons as little as possible." Again they say: " It is for this reason that resections of the supe- rior extremity by preserving, to a certain extent, the motions of the limb, are superior to amputations."2 Malgaigne, who is also good authority, remarks, when speaking of resections, that "we comprise under this title the removal of the articular extremities of bones, the resection of the long bones in their continuity, and the extirpation of certain bones entire, without amputation of the soft parts."3 All operations, therefore, which have not been performed with these restrictions should be strictly ex- cluded from this class. 1 Dictionnaire de Med., tome xxvii. p. 402. 2 Ibid., p. 411. 3 Op. Surg., Phil. edit. p. 188. 20 OPERATIVE SURGERY. § 1.—RESECTION OF THE ENTIRE CLAVICLE. The removal of the clavicle, either entire or in part, is an opera- tion that has been occasionally found necessary or expedient, in consequence of the development of osteo-sarcomatous growths upon it, and their encroachment upon adjacent parts; or for the relief of necrosis; the cases of caries, demanding rather the healing of the ulcer than the resection of the bone. Although the function of the clavicle appears to be essential to the proper action of the upper extremity, its removal has been accomplished without materially impairing the utility of the limb. When in this resection it is found possible to retain a portion of the periosteum it should always be left, as in the operation per- formed by the celebrated French surgeon, Moreau, for necrosis; though the entire clavicle was removed, yet at the autopsy of the patient, made several months subsequently, the bone was found to have been entirely regenerated, so as to preserve its relations with both the sternum and scapula. There is, however, reason to think, from the account furnished of this operation, that it was rather the removal of a sequestrum resembling the former clavicle than a re- section; and that the old bone, like the sequestra of other bones in a certain stage of necrosis, had been encased by the new osseous deposit consequent on the efforts of nature to remedy the disease, and hence the formation of the new clavicle. The only cases of entire resection of the bone, not consequent on amputation, that I have been able to find recorded as performed in the United States, is one by Dr. Charles McCreary, of Kentucky,1 who, in 1813, removed the entire clavicle for a scrofulous affection of the bone without impairing the functions of the limb, the patient living for thirty-five years subsequently without any return of the disease; one by Dr. Mott, of New York, in 1819; one by Dr. Warren, of Boston, in 1833; and one by Dr. Wedderburn, of New Orleans, in 1832. In Europe, Travers has removed a large portion of the clavicle, leaving only the sternal end, in a boy who, twelve months subse- quently, had the free use of his arm; and Chaumet, of Bordeaux, has also removed four-fifths of the bone on account of a tumor which originated in it, whilst Meyer and Roux operated on it on 1 Gross, History of Kentucky Surgery, p. 180. RESECTION OF THE ENTIRE CLAVICLE. 21 account of caries. The most perfect and difficult resections of this bone in its continuity unconnected with amputations are, therefore, those just referred to as performed by the four American surgeons there named. Extirpation of the entire Clavicle, by Dr. Mott, of New York.—A young man, nineteen years of age, had a conical tumor to form on the left clavicle, without his being able to assign for it any cause. At the time of the operation, it was about four inches in diameter at its base, of an incompressible hardness, firmly at- tached to the anterior portion of the bone, and with its apex covered with luxuriant fungous granulations, the consequence of former means of treatment, from which profuse hemorrhage took place from time to time. Operation of Dr. Mott.—An incision, being commenced over the sterno-clavicular articulation, was carried in a semilunar direc- tion in the sound integuments to near the junction of the clavicle with the acromion process of the scapula, exposing the fibres of the pectoralis major muscle. These fibres were then carefully divided, so as to avoid injuring the cephalic vein, a small portion of the deltoid muscle being detached from the clavicle, and the vein drawn outward towards the shoulder. It being now found impossible, from the size of the tumor and its proximity to the coracoid pro- cess, to get under the clavicle in this direction, another incision was made from the outer edge of the external jugular vein over the tumor, to the top of the shoulder, so as to divide the skin, platysma- myoides, and a portion of the trapezius, by which means a sound part of the bone was laid bare near the acromion process. A di- rector very much curved was then cautiously passed under the bone from above, great care being taken to keep the end of the instrument in contact with the under surface, and an eyed probe being conveyed along the director, a chain-saw was passed, and, after being carefully moved a little to see that nothing intervened, made to cut the bone entirely through at this point. The dissection being now continued along the under surface of the tumor below the pectoralis major, a number of very large arte- ries and veins were cut and ligated; the first rib exposed under the sternal end of the clavicle; the costo-clavicular ligament divided and the sterno-clavicular articulation opened from below, thus giving considerable mobility to the mass. The sawed end of the clavicle being then elevated by means of strong curved spatulas, the 22 operative surgery. subclavius muscle was divided at its origin, the remainder of it being obliterated in the tumor. The tumor was now separated from the cellular and fatty structure between the omo-hyoid and the sub- clavian vessels, at the upper and outer part of which, a number of large arteries required the ligature, especially a large branch from the inferior thyroid artery. The anterior part of the upper incision being then made from the sternal end of the clavicle over the tumor until it met the other at the external jugular vein, this vein was tied with two ligatures, and divided between them. The clavicular origin of the sterno-cleido-mastoid was also divided about three inches above the clavicle, and, the deep fascia being exposed, the mass was very cautiously dissected until the scalenus anticus was exposed; the subclavian vein, which was firmly adherent to the tumor, being most carefully detached, without injury, by the handle and blade of the scalpel. The external jugular vein being so con- nected with this part of the tumor as again to require two ligatures near the subclavian, and be again divided in the interspace, the whole mass was removed, the hemorrhage throughout being so free as to require more than forty ligatures, and the operation having occupied nearly four hours for its execution. The patient recovered in about eight weeks, and was subsequently enabled to use his arm by means of a mechanical contrivance which kept the shoulder off from the chest.1 Operation of Dr. J. C. Warren, of Boston.2—A man, aged twenty-four, after violent muscular effort, felt a severe pain at the junction of the right clavicle with the sternum. A year afterwards, his clavicle presented a tumor measuring seven inches from the sternal end, in a line with the bone, to its scapular extremity; from the clavicle to the nipple it measured five inches; the tumor being hard, with no evident fluctuation, though a slight pulsation could be perceived by the stethoscope. There was no sensible difference in the pulsation at the wrists; the patient complained of its occa- sionally pressing on his windpipe, and the constitution presented signs of the scrofulous diathesis. Operation of Dr. Warren.—The patient being placed on the table, with the shoulders elevated, an incision was made from the acromial extremity of the clavicle to the sternal end of the opposite bone. This being crossed by another at right angles with it, begin- 1 Amer. Journ. Med. Sciences, vol. iii. p 100, 1828. * Ibid., vol. xiii. p. 17, 1833. RESECTION OF THE ENTIRE CLAVICLE. 23 ning just below the middle of the sterno-mastoid muscle, and ex- tending to the face of the pectoral muscle below the middle of the clavicle, the four flaps were dissected from the surface of the tumor, and the outer extremity of the bone laid bare by dissecting the deltoid from its anterior, and the trapezius from its posterior edge. The coraco-clavicular ligament being then divided, an eyed probe, armed with a ligature, was passed under the clavicle, and a chain- saw attached to the ligature drawn after it under the bone so as to saw it entirely through. A strong band being now passed around the outer extremity of the divided bone, the tumor was partly moved by it so as to give tension to the surrounding soft parts. (Plate XXXVII., Fig. 6.) The pectoralis major muscle being then divided and dissected from the lower edge of the tumor, was drawn so as to expose the pectoralis minor and the cephalic vein. On continuing the dissec- tion under the tumor, the subclavius muscle could be freed from the outer part, but was lost in the tumor at its sternal end, where the dissection necessarily proceeded over the surface of the sub- clavian vein. An adhesion of the tumor to the second rib, in which it was imbedded, prevented also its perfect separation at this part until the close of the operation. The next step being to divide the attachments of the upper or cervical edge of the tumor, the posterior external jugular vein was divided and tied. Being filled with dense lymph, it discharged no blood. The sterno-mastoid muscle was next cut across, and the sheath of the cerebral bloodvessels exposed, the internal jugular vein, which passed into the tumor, being, after much care, separated from it, and the carotid and par vagum drawn to one side. The anterior ex- ternal jugular vein was found imbedded in the internal extremity of the tumor, and, though also filled with lymph, was tied, as a measure of safety, when the sternal end of the tumor was, with great caution, separated from the corresponding parts of the jugular and subclavian veins, the whole extent of the latter vessel, as well as the lower part of the internal jugular and par vagum nerve, being exposed and put in motion by the pulsation of the subclavian, caro- tid, and innominata arteries, when the extirpation was completed. But little blood was lost; only one or two arteries, and the veins just stated, requiring the ligature. The flaps were then brought over and retained by three sutures and adhesive plaster, so as to 24 OPERATIVE SURGERY. cover the wound perfectly. On the thirteenth day after the opera- tion, the patient was attacked with chills, and in the fourth week he died (as far as could be judged from the post-mortem examination) of constitutional irritation, being of a bad habit of body. Operation of Dr. A. J. Wedderburn, of New Orleans.—A man, aged twenty-one years, was admitted, January 21, 1852, into the Charity Hospital at New Orleans, with caries of the clavicle, so extensive as to require the entire removal of the bone by disarticu- lating it at its two extremities. Operation.—An incision being made in the integuments over the entire length of the clavicle, and sufficiently far beyond its extremities to permit the disarticulation, the soft parts over the superior and anterior borders of the bone were dissected off. The clavicle being now disarticulated at its acromial end, the dissection was continued on the under surface by keeping close to the bone, the adjacent structure being kept tense by elevating the clavicle from its scapular towards its sternal articulation. During this, the bone, owing to its being carious, broke in two at about one inch and a half from its sternal end, thus rendering the disarticulation at the sterno-clavicular articulation more tedious than it would have been if there had remained sufficient length of bone to have afforded a purchase. It was, however, safely accomplished. After-Treatment.—After cleansing the wound, the cavity left by the removal of the bone was filled with lint, saturated with a solution of sulphate of quinia, in order to guard against erysipelas, which was then in the hospital, and the parts kept in this condition for twenty-four hours. The next day, the lint being removed, the wound was united with adhesive plaster, over which was placed a compress of lint, also wet with a solution of the quinia, five grains to the ounce of water. No other treatment was resorted to. The shock from the operation was so slight that the patient sat up within twenty-four hours after its performance, and on the 8th of April the patient was discharged, without any deformity, and with the perfect use of the arm.1 Remarks.—In the details of these operations, there may be noted some difference in the methods of operating, caused apparently by the peculiar circumstances of each disease, though in most of the important points they correspond. As such will doubtless be the 1 New Orleans Monthly Medical Register, vol. ii. p. 1, 1852. RESECTION OF A PORTION OF THE CLAVICLE. 25 case hereafter, should the operation be again repeated, any estimate of the advantages of one plan over the other could only be theoreti- cal, and not serve as a guide for future operators. In reviewing the accounts just given of these operations, it must be apparent that they create a great risk of life; but this a competent surgeon will doubtless always be prepared to meet, and if the patient's con- dition can be benefited by a repetition of these rare resections, no experienced operator should for a moment hesitate about their per- formance. A point worthy of being mentioned in connection with these operations as well as others involving the great veins of the neck, is the liability to the entrance of air into the large veins from even a very slight wound of the vessel, and when the constant action ' of the vessel, as affected by the expiration and inspiration of the patient, is recalled, the rapid passage of a bubble of air to the heart may be readily understood. But, though this circumstance has caused most speedy death, yet it has not invariably done so, and the use of anassthetic agents, when judiciously conducted, will, it is thought, diminish very much this danger. When a patient is fully etherized, great tranquillity is obtained in the respiratory move- ment of the chest, and there is, therefore, less risk of a wound being accidentally inflicted; whilst, in consequence of the diminished in- flation of the lungs, absence of all efforts at crying, and also of shock to the system induced by this valuable agent, the risks of the operation, when thus performed, must be less than they were formerly. With the heart beating about sixty in the minute, and the respiration slow and comparatively feeble, as is usually the case in etherization, it may be doubted whether these large veins would not be as free from danger as is possible in any dissection in the neighborhood of their parietes. § 2.—RESECTION OF A PORTION OF THE CLAVICLE. Resection of a portion of the clavicle is an operation that may be occasionally demanded in cases of necrosis of this bone. It may be performed either at its sternal or humeral third, and is illustrated by the operations hereafter described. 26 OPERATIVE SURGERY. Resection of the Humeral end of the Clavicle.—In a case of necrosis of the clavicle, Velpeau operated in the following manner:— Operation of Velpeau.—A crucial incision being made with each branch four inches long, the flaps were dissected back, the acromio-clavicular ligament and some portions of the deltoid and trapezius muscles divided, and the necrosed bone raised by means of a bit of wood which was employed as a lever, until the sequestrum could be detached from the sound parts.1 Resection of the Sternal end of the Clavicle.—The resec- tion of this end of the bone was performed by Dr. Davy, of Bun- gay, England, in order to relieve the pressure upon the oesophagus of a young lady, consequent on a dislocation of this extremity of the clavicle by a disease of the vertebral column. Operation of Dr. Davy, of England.—An incision, two inches long and following the axis of the clavicle, being made on the ex- tremity of the displaced bone, the articular ligaments were divided, and a piece of shoe-leather slipped under the end of the bone, so that it could be divided by sawing upon the leather without involving the deeper-seated parts. The wound healed readily, deglutition was restored, and the patient perfectly relieved by the operation.2 SECTION III. RESECTION OF THE SCAPULA. Resection of the Scapula has been performed, in several instances, for the removal of large tumors, either so as to leave the neck and glenoid cavity of the bone, with the exception of its neck, or so as to retain all the portion above its spine. The entire bone has also recently been removed by Dr. Gross, of Louisville. § 1.—RESECTION OF THE ENTIRE BODY OF THE SCAPULA. Operation of Dr. S. D. Gross, of Louisville.3—A tumor, fifteen inches in its vertical diameter, and fifteen and a half inches 1 Malgaigne, Philadelphia edit., p. 195. 2 Malgaigne, p. 19G. * West. Journ. Med. and Surg., vol. xi. 3d series, p. 420. RESECTION OF THE ENTIRE BODY OF THE SCAPULA. 27 in the transverse, having been developed on the scapula, so as to impair the use of the arm and cause great pain in the limb, Dr. Gross removed it and the scapula in the following manner:— A full dose of chloroform having been administered, an incision, sixteen inches long, was made obliquely downwards and inwards from the superior angle of the scapula to the inferior portion of the tumor. Another, which began about five inches below the upper end of the first was then carried in a curvilinear direction, so as to terminate about the same distance from its lower end, and, the dense integuments being dissected off, first towards the spine, and then towards the axilla, the levator scapulae and trapezius muscles were divided. The acromion process being then sawed through just behind the clavicle, the latissimus dorsi and serratus anticus mus- cles were divided, so that the fingers could be carried underneath; the tumor was elevated so as to sever the connections which existed near the ribs, and the deltoid and other muscles of the arm being next incised, the neck of the scapula was sawn through, and the entire mass removed with comparatively little difficulty. About twenty- four ounces of blood were lost, several arteries near the neck of the bone requiring the ligature after the removal of the morbid growth. The immense wound being now united by sutures and adhesive strips, the parts were supported by a compress and brQad body bandage, and nearly the entire wound healed by the first intention. At the end of three weeks the patient returned home, but, having taken cold on the journey, was attacked by pleuro-pneumonia which was followed by hectic fever, under which he sank in two months. Operation of Hayman.1—A large tumor, which was attached to the scapula, was laid bare by two semicircular cuts through the skin and tendinous expansion, and cut away by rapid strokes of the knife, when the bone was sawn obliquely through its spine, so as to leave only the glenoid cavity and the parts immediately above the spine. This patient recovered, and could move the arm in most directions, except in elevation. Operation of Mr. Luke, of England.—An incision being made through the skin, from the axilla along the axillary margin of the tumor and anterior costa of the bone, and round the inferior angle to within a short distance of the spine of the scapula, a second in- 1 Chelius, Syst. Surgery, vol. ii. p. 762. 28 operative surgery. cision was carried along the lower margin of the spine, from the commencement of the first to its termination. The muscles in the supra and infra spinata fossa being then incised in a direction from a little behind the glenoid cavity to a little above the superior angle, the scapula was steadied and the bone sawed through near the root of the acromion process, when the whole structure was removed. The hemorrhage was very free, twenty or thirty arteries near the armpit requiring the ligature, and about a pint or a pint and a half of blood was lost. The edges of the wound being then closed by adhesive strips, the arm was secured to the side by a bandage, and the forearm placed in a sling. In two months, the wound had completely healed, and in eleven months after the operation "the motions of the arm, forwards and backwards, were perfect, and, in fact, more than ordi- nary, the limb moving with more than the usual pliancy, and yet pos- sessing considerable power. Rotation outwards and inwards was possible, and the patient possessed tolerable strength, being able to lift with ease considerable weights, though elevation of the arm from the side could only be accomplished by the aid of the opposite hand. Remarks.—The resection of considerable portions of the bodv of the scapula has also been performed by Liston, Janson, Syme, Wut- zer, Textor, and Travers, in Europe,1 and are evidences of the pro- gress of operative surgery in a department which has for its especial object the preservation of a certain amount of the usefulness of the limb. With the exception of some variety in the external incisions required by the development of the tumors which demanded the resection, these operations have all had some general points of re- semblance, the preservation of the glenoid cavity being the great object of all of them, in order that the mobility of the limb might be retained. Among American surgeons, the most marked case is that of Dr. Gross, though excisions of the scapula, and even of the scapula and clavicle, have been performed by other surgeons in the United States, either in the act of amputating at the shoulder or in consequence of the development of disease in this region after amputations. As these latter operations are, however, properly amputations of the shoulder-bones, they will be referred to in connection with amputations of the upper extremity, in a subse- quent portion of the work. 1 Chelius, vol. iii. p. 763. LIGATURE OF AXILLARY ARTERY BENEATH THE CLAVICLE. 29 § 2.—RESECTION OF THE ACROMION PROCESS OF THE SCAPULA. The resection of the acromion process of the scapula is an opera- tion so very similar to that of the acromial end of the clavicle, allowance being made for the position of the muscles as well as for the greater facility of access to the part, that it can be readily under- stood without further reference. The resection of the inferior angle of the scapula would require the employment of such incisions as would freely expose the part, after which its removal could be accomplished by bone nippers or strong scissors passed beneath the bone. SECTION IV. OPERATIONS ON THE PARTS ABOUT THE CLAVICLE. In the portion of the chest immediately about the clavicle only one operation of importance is ever requisite, to wit, the ligature of the axillary artery, or, as it is sometimes, though incorrectly, termed, the ligature of the subclavian artery beneath the clavicle. § 1.—LIGATURE OF THE AXILLARY ARTERY BENEATH THE CLAVICLE. The Axillary artery in this portion of its course may be found in the triangular space which is bounded above by the clavicle, below and on the outside by the pectoralis minor muscle, and below and on the inside by the sternal origin of the pectoralis major. Ordinary Operation.1—The patient being laid upon the table, with the shoulders slightly raised, and the elbow carried a little off from the body, so as to stretch the skin, an incision should be made three inches long, and about three-quarters of an inch below the clavicle, parallel with the bone, so as to terminate outside of the line of junction of the pectoralis major and deltoid muscles, dividing only the skin. The superficial fascia of the chest and the fibres of the pectoralis muscle being then carefully cut, and attention given 1 Malgaigne, Philad. edit. p. 147. 30 OPERATIVE surgery. to the position of the cephalic vein, a director should be introduced beneath the posterior portion of the sheath of the muscle; then, after bringing the arm to the side, so as to relax the parts, tear the cellular tissue about the vessels with the point of the director, and carry the index finger behind the upper border of the pectoralis minor muscle, and, pushing it downwards and outwards, the vessels will be seen in the following order: 1st. On the inside, the axillary vein swollen at each expiration, and partly covering the artery. 2d. Outside, and a little behind the vein, the axillary artery. 3d. More externally and behind, the nerves of the brachial plexus. The vein being drawn inwards by a blunt hook, the aneurismal needle should be passed between the vein and the artery from within outwards, above the origin of the acromial and mammary arteries, which would otherwise interfere with the formation of the coagulum. (Plate XXXVL, Fig. 4.) Operation of Lisfranc.—Abducting the arm forcibly from the body, so as to render distinct the clavicular and thoracic origins of the pectoralis major muscle, Lisfranc incised the skin in an oblique direction from the clavicle downwards and outwards. The fascia superficialis being then carefully divided, and the line of separation of these two parts of the muscle apparent, their adhesions were separated by the finger or knife-handle, the arm brought close to the side, and the artery sought for and tied, as in the plan just described. Malgaigne1 gives as a " rule" a direction which I have always found to be a good one, and that is, after the laceration of the posterior part of the sheath of the pectoralis major muscle, to search on the inside of the wound for the vein, which is the first vessel met with, and is an infallible landmark. Carrying it inwards, the artery will be found a little outside and a little behind. Remarks.—The ligature of the axillary artery by either of the above plans will be found to be a very troublesome operation, and in the case of an aneurism or wound lower down, which are the prin- cipal disorders likely to require it, a most difficult one to perform in consequence of the infiltration of the parts, or the enlargement of the thoracic vessels. The after-treatment will also be troublesome and require special attention at each dressing, in order to prevent col- lections of pus within the wound, or the travelling of matter into the axilla, or beneath the pectoral muscles, in consequence of the 1 Philad. edit. p. 148. OPERATIONS UPON THE MAMMARY GLAND OF THE FEMALE. 31 depth of the wound. The position of the brachial nerves, or any anomalous distribution of the vessels, is also liable to lead the ope- rator into error, although the rule laid down by Mr. Malgaigne would obviate this in the hands of a careful surgeon and good anatomist. As the artery may be more readily tied in the axilla (as will be shown in connection with the operations upon the upper extremity), and is not so difficult to ligate above the clavicle as it is below, the latter place is now seldom selected for the application of the ligature. The results attending the ligature of the axillary artery by surgeons in the United States may be seen to a limited extent in the Bibliographical Index, and will be again referred to in connection with the operations on the extremities. In studying all operations, but especially the ligature of arteries, the student will find it much to his interest to practise them upon the subject in the manner that has just been described. The French surgeons are particularly fond of this kind of practical exercise, and it is one reason why their directions in relation to the ligature of arteries are especially valuable. In every operation upon the blood- vessels, those who are accustomed merely to the practice of the dissecting-rooms should, however, recollect the additional difficult- ies that they may have to encounter from the changes in the relative position of the parts in consequence of disease, as well as the in- creased dangers always to be encountered from the thin coats of veins being distended with blood in the respiratory efforts of the patient. CHAPTER XI. OPERATIONS UPON THE MAMMARY GLAND OF THE FEMALE. The mammary gland of the female is peculiarly liable to the de- velopment of tumors of various kinds which may require either to be separated from the gland and removed by themselves, or may be of such a character as will render the extirpation of the entire breast the most advantageous operation. To decide on the extent of an operation of this kind, the surgeon should be perfectly fami- liar with the peculiar tendencies of the different kinds found in this organ. 32 OPERATIVE SURGERY. All tumors of the breast have been divided, by Sir Astley Cooper, into those which are benignant and those which are malignant, the first being often curable by remedial measures, or by the extirpa- tion of the tumor itself; the latter being liable to invade the whole gland and render its entire extirpation proper, except when deve- loped in the breasts of those who from age or other circumstances may find it desirable to retain the bosom, even at the risk of being compelled to submit to a repetition of the operation. The removal of any of the benignant tumors may be accomplished by such inci- sions through the skin as will expose the new growth, when, after passing a ligature through it, or obtaining a good hold upon it,in some other manner, the surgeon should carefully dissect it from the surrounding structure, so as to leave no particle of it. The extir- pation of the entire gland will be more fully detailed subsequently, in connection with the anatomical relations of this part. At present, attention may be advantageously directed to the gene- ral pathology of tumors of the breast, in order to enable the ope- rator to decide which operation may be advisable. SECTION I. PATHOLOGY AND DIAGNOSIS OF MAMMARY TUMORS. In the extended work of Sir Astley Cooper,1 in that of Dr. War- ren, of Boston,2 and in an able article by Velpeau,3 may be found much valuable instruction in relation to this class of complaints, to which those desiring more extended details than can be reasonably anticipated in a work of the general operative character of the present, are referred. In the subdivisions of the benignant class of Sir Astley Cooper, are placed six different species of tumors. 1. The Hydatid. 2. The Chronic Mammary. 3. Cartilaginous and Osseous. 4. Adipose. 5. Large Pendulous Breast. 6. Scrofulous. 7. The Irritable Tu- mor. Of the signs of each Dr. Warren gives the following:— 1st. The Scrofulous Tumor is seen in early life in patients who present all the constitutional signs of scrofula. This tumor is large, 1 Cooper on the Diseases of the Breast. 1 Warren on Tumors. 3 Diet, de Medecine, tome 19me. PATHOLOGY AND DIAGNOSIS OF MAMMARY TUMORS. 33 irregular, indistinct, not painful, varies in size at different times, and corresponds with the tuberculous tumor of Velpeau. 2d. The Chronic Mammary Tumor occurs before the age of thirty-five, in healthy, but feeble constitutions; is circumscribed, of a rounded form, quite movable; not tender or painful; increases slowly, and is not malignant. 3d. The Irritable Mammary Tumor is seen before middle age in delicate and nervous habits; is not large nor well defined; is ten- der, painful, and sometimes accompanied with general swelling of the breast and fever. It is not malignant. 4th. Hydatids, or Hydatid Tumors, appear before middle age; are irregular; occupy the whole breast; are not tender, painful, or discolored; increase rapidly and attain a great size, when they may be readily distinguished by the globular bodies which form on the surface, as well as by their magnitude and freedom from pain. 5th. The Adipose Tumor is seen in healthy females, and easily recognized by it great size, elasticity, freedom from sharp pain, and regular surface. 6th. Cartilaginous and Osseous Tumors, which are rare, may be known by their extreme hardness. 7th. Cancerous Tumors are usually seen between the ages of thirty and fifty; often in those whose relatives have suffered from cancerous complaints. $th. Encephaloid growths occur in young subjects; are large and soft; consist of two or more globular bodies; increase rapidly; ulcerate; create a fungus, and bleed. Velpeau, with the accuracy of detail which is so characteristic of an extended experience, divides all mammary tumors into three classes: 1st. Those arising from simple hypertrophy, either of the gland or its envelops. 2d. Those due to degeneration of the natu- ral tissues; and 3d. Those which are the result of abnormal deposits, as shown in the following table:— f 1. Of the mammary gland. 1. Simple hypertrophy. . -i 2. Of the cellular tissue. [ 3. Of the fat. ( In laminae. Fibrous. . . . \ In mass. [ In radii. 2. Degenerations. . . . -j ^ Of the glandules. | Fibro-scirrhous. \ Of the gland. L L 0f the milk-ducts. VOL. II.—3 34 OPERATIVE SURGERY. 3. Abnormal productions. Liquid cysts. Solid. Serous or hydatid. Gelatinous. Sanguinolent. Fibrinous. Tuberculous. Buttery, milky, or cheesy. Osseous. Scirrhous. Encephaloid. Colloid. Melanotic. In the above well-arranged table may be found a designation of nearly all the tumors of this portion of the body, and the follow- ing description, which is mainly condensed from the information furnished by his valuable paper, will sufficiently fill up this brief enumeration. To those desirous of investigating the views of other surgeons, and especially those describing the microscopical charac- ter of these tumors, I would recommend the works of Walshe, Lebert, Berard, and Birkett; further reference to which my space compels me to omit. § 1.—TUMORS DEPENDENT ON HYPERTROPHY. Hypertrophy of the Mammary Gland is only seen in the unmarried female, is most apt to appear soon after puberty, and sometimes creates such a development of the organ as is almost incredible, some having been reported in which the gland hung down to the knees and weighed thirty pounds, and others having been forty-two inches in circumference. In the only case that I have seen in Philadelphia, the breast reached nearly to the umbili- cus, and was larger than a man's head, as tested by an attempt to surround the gland with a hat. This complaint is universally admitted to be rare, and yields no further inconvenience, in many instances, than such as can be reme- died by stays, and, in many instances, disappears on childbearino-. The natural appearance and feel of the gland will usually prevent diagnostic errors. The Fatty Tumor, or hypertrophy of the adipose and cellular tissues around the breast, is not intended to include the ordinary lipomatous growth which is occasionally seen in the breast, as well TUMORS DEPENDENT ON HYPERTROPHY. 35 as elsewhere, and which is a circumscribed, lobulated, and pedicu- lated tumor, but designates a rare form of disease in which the adi- pose structure of the entire breast is much augmented, creating a mass of considerable size, of a broad base and not pediculated. This tumor is apparently dependent on an extreme development of the adipose cells in the interlobular septa of the breast as well as in the subcutaneous layer of fat. The mass is nearly always lobulated, or as if subdivided into numerous secondary masses, by the fibro- cellular septa which create the lobules of the breast. When incised, there is seen an almost homogeneous mass furrowed by a few whit- ish fibrous bridles, intermixed with many glandular lobules which are greasy and unctuous to the touch, of a yellow color, of the con- sistence of lard, and which may be broken down by the finger. Dr. Warren1 reports an instance of this kind of tumor which he removed, and which weighed eight pounds. No appreciable cause could be assigned for its production. Fibro-Cellular Hypertrophy is an abnormal development of the natural partitions, and fibrous or cellular laminae which separate or envelop the lobes of the breast, and is generally due to some inflammation of the breast which has previously existed, such as an acute or chronic mammary abscess. On examining the breast after this complaint, the gland is often found to be decidedly harder, less elastic, less lobulated, and more homogeneous than is the case in its natural condition. The subcutaneous cellular and fatty tissue, together with the divisions of the lobules, are now found to be con- founded in one regular mass, in the midst of which the natural structure of the gland seems to be lost. This disorder has been described by Sir Astley Cooper and Dr. Warren as the chronic mammary tumor, and is difficult to distinguish from the early stages of carcinoma. It may, however, be diagnosticated from scirrhus by the previous history showing that it was consequent on one or more attacks of inflammation; by the absence of pain, heat, and redness; by its density, by its mobility, notwithstanding the appearance of adhesions between the tumor and the skin; by the good constitu- tion of the patient and their self-satisfied condition, as well as by its remaining stationary, rarely or ever increasing. This fibro-cellular hypertrophy often disappears of itself by a complete and gradual resolution, even after it has existed a long time; seldom or never 1 On Tumors, p. 229. 36 OPERATIVE surgery. degenerates, and does not usually demand operative interference. In a patient, at present under my treatment, the left breast has been thus indurated during a period of four years, as the consequence of an inflammation of the gland, which, in accordance with the advice of Mr. Cusack and other surgeons of Dublin, has been untouched by the knife. During two different lactations, acute inflammation has shown itself about the structure, the first of which was relieved by an antiphlogistic and resolutive treatment, and in the second by a free suppuration, which, though causing some diminution of the surrounding enlargement, did not materially change the character of the original deposit. § 2.—TUMORS DUE TO DEGENERATION OF TISSUE. The class of tumors of the breast, designated as those due to a degeneration of tissue, is intended to include such as present the elements of the gland either in a condition of induration which has been compared to the hardness of wood, or to that of fibro-scirrhous deposit. The first may be found arranged either in laminae, in mass, or in radii, constituting a variety of scirrhus, and deserving of special consideration in order to render the diagnosis of the tumors of this part more accurate, as well as to present a more definite account of the changes of structure than could be furnished under the general term " scirrhous degeneration." I. LIGNEOUS, OR WOOD-LIKE SCIRRHUS. The ligneous variety of scirrhus may be seen either in laminaa mass, or radii. In the laminated class, the disease usually occupies a disk which is more or less regularly circumscribed by a tegumentary envelop and, as a general rule, seated in the skin, though sometimes it con- sists in isolated points which are deep-seated. In the first case the skin is hard to the touch, a little wrinkled, thickened and of a grayish or red color, which is altogether unnatural, looking as if the part had been tanned. In other instances, the disks are much smaller and disseminated, the two varieties occasionally existing in the same patient, a large disk being surrounded by an infinite num- TUMORS DUE TO DEGENERATION OF TISSUE. 37 ber of small ones. Sometimes they rise above the surface of the skin, whilst at others they are disseminated in the subcutaneous layer. This sort of degeneration continues, usually, notwithstand- ing the most judicious treatment; is reproduced with extreme ob- stinacy, and cannot be operated on with any chance of success. At other times, this ligneous degeneration shows itself as small shot or pea-like tumors, in or under the skin, which have their seat in the subcutaneous cellular tissue, and apparently result from the trans- formation of this tissue. These tumors are also reproduced with extreme obstinacy, and are not benefited by an operation. In a paper by Dr. Joseph Parrish,1 the condition of parts, in this form of scirrhus, has been distinctly noted, his attention having been called to it by Dr. Physick. It is there described as giving the sensation of a granulated surface as if the skin were filled with small shot. Dr. Physick considered this as the most dangerous form of true scirrhus, and thought that he had never known an operation to prove ultimately successful, an opinion in which Dr. Parrish coincided. II. FIBRO-SCIRRHOUS DEGENERATION. This class includes most of the tumors which are designated in common language as cancerous. They may be seen either as affect- ing the septa which surround or separate the different lobes of the breast; as extending to the proper structure of the gland, or as con- nected with the milk-ducts. On incising a breast affected with the first (septa), it is seen to be partitioned by hard, pearl-like lamina?, which creak when cut, and this variety is the most difficult to eradicate of all the forms of scirrhus, as these apparent roots, by prolonging themselves in every direction, can seldom be entirely removed. III. THE ORDINARY CANCEROUS TUMOR OF THE BREAST. This tumor, as described by Dr. Parrish,2 commences with a small distinct lump, which runs its course either with great rapidity, or 1 North Amer. Med. and Surg. Journ., vol. vi. p. 295, 1828. 2 Opus citat. 38 OPERATIVE SURGERY. remains indolent for months or years. When it becomes active, the first symptom is generally a lancinating, or an exceedingly dis- tressing burning pain. When the tumor increases in size, it embraces the adjacent parts, and identifies them with its own peculiar structure. As at first perceived,' it is a hard irregular lump without definite limits, is movable, that is, moves with the portion of the gland in which it is situated, but does not move in that portion like the chronic mam- mary tumor before spoken of. As it contracts adhesions with the skin, the latter becomes wrinkled and puckered, or is slightly swollen, and the nipple is retracted or depressed below its ordinary level; whilst, as adhesions form with the pectoral muscle, the whole mass becomes, as it were, a part of the thorax. The skin, changing color, becomes of a dark red, cracks, and gives exit to a thin serum, which is followed by ulceration. Hectic fever comes on, the dis- ease involves the adjacent lymphatic glands, and an operation for its removal becomes unjustifiable. The pain which attends the development of cancerous tumors is evidently due to the compression of the nerves of the part by the scirrhous substance, and usually follows the course of the thoracic nerves into the axilla. This pain, combined with the peculiar ca- chexia, is an important aid in diagnosticating these complaints. § 3. ABNORMAL PRODUCTIONS IN THE BREAST. Of the abnormal deposits in the mammary gland, there are found two kinds, to wit, such as are liquid and such as are solid. The liquid deposits embrace the whole class of encysted tumors and are comparatively simple in their character, requiring either the removal of the cyst and its contents, or the development of such an action as will modify the process of secretion. The solid tumors may be either benignant or malignant. Of the first, we have the fibrinous, tuberculous, cheesy, and osseous, all of which may be extirpated with but little chance of return • whilst the scirrhous, encephaloid, colloid, and melanotic will most frequently be reproduced at some period, or in some other spot, after extirpa- tion. The variety seen in these productions must, however, prevent 1 Warren on Tumors, p. 236. EXTIRPATION OR AMPUTATION OF THE MAMMARY GLAND. 39 a more detailed allusion to them, and the account of the progress and result witnessed in the numerous tumors found in and about the mammary gland may, therefore, be briefly summed up in the following facts:— 1st. All tumors of the breast are, or are not, susceptible of ma- lignant transformation. 2d. Those not susceptible of cancerous transformation are the encysted class, as the hydatids, the serous or sanguinolent effusions, and the fibrinous, tuberculous, cheesy, and osseous tumors. 3. All those included in the preceding table under the head of degenerations, as the ligneous, fibro-scirrhous, &c, are liable to con- version into cancer, whilst the other solid abnormal prod actions^ are well known to be malignant. SECTION II. EXTIRPATION OR AMPUTATION OF THE MAMMARY GLAND. The mammary gland is covered by the integuments in front and adherent behind, by a loose cellular tissue, to the fascia covering the pectoralis muscle, being chiefly supplied with blood from the branches of the external mammary artery, whilst its veins run up into the axillary vein. Its removal may be readily effected by in- cising the skin in such a form as circumstances may demand, but the subsequent dissection of the gland should be conducted in the line of the fibres of the pectoralis muscle, that is, from the sternum towards the axilla. Operation.—The patient being etherized and placed upon a table, rather than upon a chair, with her head and shoulders slightly raised, the arm of the affected side should be carried off from the body, and held by an assistant, so as to keep the skin and pectoral muscle upon the stretch. Then, standing on the side of the disease, or by the shoulders of the patient, place the four fingers of the left hand upon the skin, so as to make it tense, whilst an assistant does the same with the integuments of the opposite side of the tumor. After thus steadying the skin, make a semi-elliptical incision with its concavity upwards and the nipple near its centre, either by cutting from the axillary margin of the gland, or lower portion of the anterior border of the axilla towards 40 OPERATIVE SURGERY. PLATE XXXVIII. OPERATIONS PRACTISED ON THE CHEST. Fig. 1. Extirpation of the mammary gland of the female. The patient is seen lying down with the arm carried off from the body, and the lowest of the two elliptical incisions has been made from the axilla towards the sternum. The parts being intended to heal by granulation, much more of the integument is about to be removed than is usual in the United States. 1, 2, 3. First or lowest incision. 1, 4, 5. Line of second incision. After Bernard and Huette. Fig. 2. Represents the completion of the operation of extirpation of the breast, as usually practised. The left hand of the surgeon grasps the gland and draws it towards the sternum, whilst the thickened cellular tissue or lymphatics are being dissected from the margin of the axilla. After Nature. Fig. 3. A view of the arrangement of the adhesive straps after the ope- ration. The straps should be long, and pass obliquely around the chest, so as to leave intervals between the different strips. A piece of linen has been introduced between the edges of the skin at the lowest angle of the wound, in order to secure a vent for the matter. 1. Line of union of the wound left by the incisions. 2. Mesh to favor escape of the pus. 3, 3. Posterior course of the adhesive strips. After Bernard and Huette. Fig. 4. Operation of empyema upon the right side of a man. The patient is represented lying down, and slightly inclined to the left side, while the surgeon makes an opening between the eighth and ninth ribs. After Bernard and Huette. Fig. 5. Resection of two of the ribs on the left side. The patient lying down and inclined towards the right, a crucial incision has been made over the seat of the disease, the flaps 1, 1 turned back, the ribs 2, 2 sawed across or broken, and the posterior extremities elevated by a bandage previous to their removal. The thickened surface of the pleura 3 is seen behind the seat of the disease. After Nature. Plate 38. Fi£ ^y~~L !*ni&.....,.....x___ fife.4. EXTIRPATION OR AMPUTATION OF THE MAMMARY GLAND. 41 the sternum, if standing on the diseased side, or by beginning on the sternal side and extending the cut towards the axilla if stand- ing at the shoulder of the affected side, holding the scalpel in the first position (Plate II., Fig. 1), and bearing on it with tolerable firmness, so as to divide the integuments thoroughly by the first stroke of the knife. Then, while the breast and skin are drawn in different directions, dissect the integuments free from the gland on its lower portion, and make another elliptical incision with its concavity downwards, on the upper side of the gland, so as to meet the first one at its sternal termination, but not quite reach it at the axilla, including between these two incisions as much integument as will remove any excess of skin (Plate XXXVIIL, Fig. 1). Then, dissect- ing the upper flap off from the gland in the same manner as before, seize the mass firmly, either with the tumor forceps, or by means of a ligature passed through it, or by the fingers, which are usu- ally the best instruments; and dissect it from the sternum to- wards the axilla, either by working from above downwards or the reverse, according as it is found most convenient, though the dis- section from below exposes the operator to the risk of getting beneath the fold of the pectoral muscle in approaching the axilla. As the various branches of the mammary arteries (external thoracic) are divided, the hemorrhage, if profuse, or if the patient is feeble, should be checked, by ligating each vessel as it is cut. But, if this is not the case, the bleeding may be overlooked for the moment, or temporarily checked by compression of the arteries by the fingers of an assistant, when they will often contract and give no further trouble. In prosecuting this dissection, the left forefinger and thumb should constantly examine the surrounding textures, in order to detect any hardened portions, the dissection being always carried so far into the healthy tissue as to leave a margin of the latter to be extirpated along with the breast. On approaching the axillary end of the ellipse, grasp the breast in the left hand (Plate XXXVIIL, Fig. 2), and draw upon it so as to insure the removal of any of the condensed laminae, or fibres of indurated cellular tissue which are connected with it. If the axillary glands also show any signs of hardening, they may now be readily removed, by slightly prolonging the inci- sions into the axilla, and working from above downwards; but this part of the operation requires considerable care in some instances, in order to avoid injuring the axillary vein. To prevent this, it will 42 OPERATIVE SURGERY. be found advantageous not to elevate the patient's arm to any great extent, as this position rather puts the axillary vessels on the stretch, and brings them near to the point of the knife. When any of the thoracic veins appear to be connected with the lymphatic glands or indurated tissues, or when the disease is thought to approach near to the main vein, it will be safer, instead of dissecting it out, to sur- round the axillary portion of the structure with a strong ligature, and cut off the part connected with the tumor on the mammary side of the thread, leaving the remainder to slough or ulcerate out. After being fully satisfied that every diseased particle is removed, the wound should be cleansed, any arteries that continue to bleed ligated, and the ligatures brought out at the sternal extremity of the incisions. The arm being now brought to the side, the edges of the skin may be approximated and held together at the central point by a single suture, supported by long adhesive strips, or the whole may be closed by the interrupted suture without resorting to the use of the plaster. In either case, it is a 'good practice to introduce a little mesh of linen into the lower orifice of the incision (Plate XXXVIII., Fig. 3), in order to secure a vent for the pus by preventing the en- tire union of the skin before the ligatures come away, or before adhesions have formed in the deeper-seated parts. When adhesive strips are employed, they should be applied from below upwards, obliquely across the line of the wound, so as to leave spaces between each strip for the escape of matter (Plate XXXVIIL, Fig. 3). After this, a compress should be firmly retained against the part by a spiral reversed bandage of the chest, so as to prevent the pus collecting within the lower flap, whilst the arm of the side operated on should be supported in a sling, or kept close to the side, so as to preserve perfect rest of the pectoral muscle until union has occurred. If the disease has involved a part of the pectoral muscle this portion should also be removed, though, as a general rule, it is best to avoid incising even the anterior fascia of the muscle, lest it sub- sequently interfere with the free motions of the arm. Should the gland be known to be adherent to the muscle before operating, the chances of the cure will be so much diminished that the surgeon may well hesitate before he advises his patient to submit to the knife. In cases of open or ulcerated cancer, such as are not deemed suitable for an operation, or where the disease returns and creates a painful ulcer in or near the cicatrix, it will prove advantageous to EXTIRPATION OR AMPUTATION OF THE MAMMARY GLAND. 43 dress it by covering the sore from time to time with the coating formed by the application of the solution of gutta percha in collo- dion, as suggested by Dr. Dugas, and spoken of under cancer of the lip (page 355). In the case reported by Dr. Dugas,1 there' was a cancerous ulceration, of several months' standing, of the size of the areola, in the depressed centre of which were seen the remains of the nipple. The axillary glands were alsp much enlarged, and the patient a prey to continual pain, which was especially severe at night. Under the application of a coating of the solution of gutta percha, applied over the whole breast at first every twenty-four hours, and then, as the discharge diminished, once in a week, the patient was gradually relieved of all pain about the breast, and even in the axilla, slept quietly at night, and enjoyed her meals, a change which must have proved highly serviceable in arresting the pro- gress of the disease. Remarks on Amputation of the Breast.—The simplicity of the operation of extirpating the breast is often such that the detailed account of it just given, may by many be deemed unnecessary, and to the man of experience such will doubtless be the case in this as in most other operations; but to others it will, it is thought, prove useful. The frequency of the operation demands also that those whose experience is limited should, if possible, be made aware of the difficulties which are occasionally met with; whilst, in an ope- ration for the removal of a growth which is so very liable to return, too much care cannot be taken to excise every portion that is dis- eased, and this can only be accomplished by following the details of a proceeding similar to that just stated. In what seemed to be a simple case of extirpation of the mam- mary gland, as performed by Dr. Warren, of Boston, everything did well until it became necessary to remove some of the indurated lymphatic glands of the axilla. When the separation of these was nearly effected, "a vein was divided, which gave exit to a small quan- tity of venous blood, when almost instantly the patient struggled, her complexion changed to a livid color, and a bubbling, gurgling noise was indistinctly heard, showing the entrance of air into the vein. The axilla was, therefore, instantly compressed, but the patient became insensible, and breathed as if in apoplexy. The tumor was at once separated, the patient laid down, brandy poured 1 New Orleans Medical Register, vol. ii. p. 7, 1852. 44 OPERATIVE SURGERY. down her throat, and ammonia introduced into her nostrils, but the pulse became less distinct every instant," and although every other possible means of exciting animation were tried, even to opening the larynx and inflating the lungs by a pair of bellows, and con- tinued without intermission for twenty minutes, the patient never breathed again. In the history of this case, Dr. Warren1 suggests that the entrance of air into the axillary vein in this operation may be prevented by keeping the arm towards the side, so as to relax the coats of the vessel, instead of extending them, as is done when the arm is elevated during the progress of the dissection towards the axilla. But when the surgeon is aware of the risk of this accident, and is cautious, he will be better enabled to see the parts that he is about to cut when the axillary dissection is made with the arm slightly elevated. In all such cases it is, however, the safest plan to secure the chain of glands and cellular tissue with a ligature, and leave the pedicle to slough out, instead of dissecting into the axilla, in order to remove them. The selection of the different external incisions, or their direction, is, it is thought, a matter that must be settled at the moment by the peculiar circumstances of the case. The elliptical incision in the line of the fibres of the pectoral muscle is that most frequently resorted to, and answers perfectly well in most instances. The propriety of arresting the hemorrhage as the arteries are divided, or simply twisting or compressing them during the operation, is also a point on which surgeons differ, and must be left to the decision of the operator, who should be guided in his course by the strength of the patient, and by the number and size of the vessels that are divided. I have seen many instances where only from one to four ligatures were demanded, whilst, on the other hand, I have been compelled to apply fifteen or twenty before the bleeding was checked. Statistics.—A very important question connected with this ope- ration is the advantages likely to result to the patient from its per- formance. To decide this point correctly, it is essential that the subsequent history of the cases operated on should be known, and this, from various causes, it seems to be almost impossible to obtain. In order to gain reliable statistics of the results of surgical operations for malignant diseases generally, the American Medical Association recently referred this subject to a committee, of which Dr. S. D. 1 Warren on Tumors, p. 260; also Am. Cyclopedia Pract. Med. and Surg., by Hays vol. i. p. 263, article Air, 1834. EXTIRPATION OR AMPUTATION OF THE MAMMARY GLAND. 45 Gross was chairman. This gentleman accordingly furnished1 a very elaborate and full report, embracing the opinions of surgeons in every section of the globe, and containing a large amount of valu- able details. As the extent of this paper requires that it should be consulted in its unity, I can only express my opinion of its value, and add as illustrative of its results the following brief synopsis of some of the conclusions at which it arrived:— " 1st. Cancerous affections, particularly those of the mammary gland, have always, with a few rare exceptions, been regarded by practitioners as incurable by the knife and escharotics. " 2d. That excision, however early and thoroughly executed, is nearly always, in genuine cancer, followed by a relapse at a period varying from a few weeks to several months from the time of the operation. " 3d. That the profession have always been, and still are averse to any operation for the removal of cancer after it has ulcerated, contracted adhesions, &c, because it then almost invariably returns and progresses more rapidly than when allowed to pursue its own course. " 4th. That extirpation is improper in acute or rapidly develop- ing cancer. "5th. That all operations for encephaloid growths are more rapidly followed by relapses than those performed in hard cancer." ***** " 14th. That life has occasionally been prolonged, and even saved by an operation after a relapse; but that, as a general rule, the second operation is as incompetent to effect a permanent cure as the first." The following points are considered by Dr. Gross as unsettled, opinions being divided in respect to them. " 1st. The propriety of excision is doubtful in cases which are of hereditary origin. " 2d.. It is doubtful whether a very young patient should be operated on, if the disease is of rapid growth, as the operation will only expedite the fatal issue. " 3d. It is doubtful if a case attended by suppression or irregu- larity of the menses should be operated on. " 4th. A quickened state of the pulse, if occasioned by the local irritation, should forbid the operation. 1 Transact. Am. Med. AssolRation, vol. vi. p. 155. 46 OPERATIVE SURGERY. ***** " 6th. It is supposed, but not proved, that the excision of carci- nomatous tumors only tends to hasten the patient's death. " 7th. It is doubtful whether an operation on a recent cancer is more successful than that on an older one, other things being equal." Dr. Gross, therefore, sums up his report, which is chiefly based on the experience of others, by expressing his individual practice to be to discourage a resort to the knife in all malignant diseases, except those of the skin or the cancroid variety. Prior to the appearance of this report, the professional opinion of the result of surgical operations was formed from limited accounts, and from the recollection of operators, that, in the majority of cases of well-marked cancer, the operation did not cure the patient, though it was supposed to prolong her days, and the latter assertion has always been urged by those who advocated the operation in all cases. The prolongation of life is, I think, a doubtful matter, as I have known advanced cases of ulcerated cancer to live months (in one instance three years) under a local antiphlogistic and palliative treatment, combined with the free use of chalybeates, according to the plan directed by Justamond and others. The following seem to be the opinions of the other surgeons here- after quoted, so far as I have been able to collect them, and as they furnish the views of many eminent men, might have been very much augmented if it had seemed desirable. But with the conclu- sions stated in the paper of Dr. Gross, such an enumeration without a digest would have tended to confuse rather than elucidate the subject, and I therefore present them very briefly. Rhazes,1 A.D. 924, opposed all operations for cancer when the tumor was not entirely free from the surrounding parts. Albucasis,2 A. D. 1100, strongly doubted the propriety of ope- rating in cancerous tumors, declaring that he never cured or saw cured a single case. Monro, in England, and Delpech, in France, are believed to have been opposed to the operation. Velpeau,3 on the contrary, regards most of the cancerous, encephaloid, or colloid tumors as a primary local complaint, the rest of the system being only involved second- 1 History of Surgery, p. 20, vol. i. of this work. 2 Ibid., p. 21. 3 Diet, de MeU, torn. ^me, p. 97. EXTIRPATION OR AMPUTATION OF THE MAMMARY GLAND. 47 arily. He thinks, therefore, that every case of cancer should be operated on, and operated on as early as possible, without delaying in order to try remedial measures. Dr. Joseph Parrish, of Philadelphia, admits that, after considerable observation and experience, he was much discouraged by the final success of the operation, and never resorted to the knife (unless at the particular request of the patient) where the disease had pene- trated into the axilla, or fixed upon the parts beneath the breast. When the breast alone was affected, he advised the operation, though believing it to offer but a doubtful prospect of escape. Dr. Warren,1 of Boston, is satisfied that many cases may be cured by the operation, and, according to the best of his information, thinks that one in three has been cured without a relapse, and that when the tumor is not ulcerated, and there are no signs of a consti- tutional disorder, it is best to try the experiment. Dr. Dudley,2 of Lexington, reports to the Committee on Surgery, of the American Medical Association for 1850, "that he never removed a scirrhous breast without a return of the disease at a sub- sequent period." Dr. Paul F. Eve3 "never operated when the diagnosis was un- equivocal, that the affection did not return." Dr. J. Kearny Rodgers,4 of New York, gives, as the result of his experience, that "no two cases survived the operation, in good health, two years; the majority being in their graves in less than twelve, and many in six months." Dr. Mussey,5 of Cincinnati, who was the chairman of the commit- tee of the American Medical Association on these statistics in 1850, in speaking of his own experience, says that he "has operated for cancer of the breast, in many instances, without learning the sequel; but of those ascertained there were only two in which the disease did not return in some part of the system within four years, and most of them within one year." Drs. Twitchell,6 of New Hampshire, entertained the same views; so also did Dr. Knight, of Connecticut; but the latter thought that in some instances life has been prolonged by the operation. 1 On Tumors, p. 278, 1839. 2 North Am. Med. and Surg. Journ., vol. vi. p. 300, 1828. 3 Transact. Am. Med. Association, vol. iii. p. 332. 4 Ibid. 6 Chairman of committee, op. citat. 6 Transact. Am. Med. AssociatiP, vol. iii. p. 332. 48 OPERATIVE SURGERY. Dr. Flint1 has seen one case of undoubted encephaloid disease of the breast, in which the patient was well seven years after the ope- ration. The result of Dr. Mussey's report is, therefore, "that soft as well as hard cancer of the mammary gland is, in some instances, a local disease, and that the operation may prolong life."2 Dr. Gross in his late report to the American Medical Association,3 just referred to, also expresses the opinion as based upon the views of surgeons in every section, that it is improper to operate in any case when the disease is hereditary, as such cases are peculiarly virulent and intractable, and tend rapidly to a fatal termination. Leroy D'Etiolles4 gives, as the result of his statistics, that, in four hundred and twelve cases, the mean result of cancer in women (not limiting the disease to the breast) was three years and six months life, without the operation, and two years and six months after it. "Extirpation of cancer does not, therefore, prolong life." Of can- cerous tumors in the breast alone, Leroy gives the following result: "Of two hundred and four, twenty-two died in the year after the operation, and eighty-seven had a return of the complaint, making the whole number one hundred and nine, or more than one-half." He, therefore, discountenances the operation. Mr. Broca,5 in a prize essay on the pathological anatomy of can- cer, has added other melancholy illustrations of the subsequent position of patients who have been operated on for cancer. In this essay he shows that of 39 really cancerous patients (the tumors hav- ing been examined microscopically), 11 died from the consequences of the operation, and 28 survived these. Of 19 of the latter who were kept in view, every one relapsed; 16 dying within the first twelve months after the operation; 2 in the course of the second year; and 1 at the end of the 25th month. "Sir Benjamin Brodie6 also states that the late Mr. Cline, senior and Sir Everard Home, would scarcely ever consent to the opera- tion under any circumstances." 1 Opus citat., p. 334. 2 /j^ p 337 3 Trans. Am. Med. Assoc, vol. vi. p. 174, 1853. 4 Chelius's Surgery, vol. iii. p. 510, note by J. F. South. s Brit, and For. Med.-Chirurg. Rev. and Charleston Med. and Surg Journ vol viii. p. 413, 1853. fa' 6 Chelius's Surgery, vol. iii. p. 539. REMOVAL OF TUMORS OF THE CHEST. 49 " Bransby Cooper gives, as his recollection of the sentiments of Sir Astley, that he acknowledged there were only nine or ten out of a hundred extirpations that he had performed in which the dis- ease did not return." The same surgeon, however, reports one of his own cases where it was eleven and a half years before the disease-showed itself; and Mr. Callaway, a case where the patient did not die till twenty years subsequent to the operation.1 My own observation, though limited in comparison with the ex- perience of the distinguished men just named, is decidedly adverse to the cure of cancer of the breast by an operation, not one out of ten, to the best of my knowledge, having escaped a return of the disease. On summing up the opinions thus quoted, it seems that nearly four are opposed to the operation for every one who favors it, though, even among those quoted as favoring it, the recommendation is only either as an experiment, or in the hope of prolonging life. Under the statement exhibited in the present statistics, and with the knowledge furnished by the valuable labors of Dr. Gross, a sur- geon had therefore better state to his patient the little danger that is to be apprehended from the performance of the operation, but also state the chances of a return of the complaint, and leave the deci- sion to her own willingness to endure the pain of the wound. As far as can be judged from a somewhat extended research, there is, I think, reason to believe that the course of the disease has sometimes been hastened by the operation in this country, whilst Leroy thinks life was certainly shortened about twelve months in the cases that he operated on in the Parisian hospitals. SECTION III. REMOVAL OF TUMORS OF THE CHEST. In addition to the tumors just referred to in connection with the mammary gland of the female, the surgeon may be called upon to extirpate degenerations of the same gland or its resemblance as found in the male. This, as well as the ordinary lipomatous, fibrous, 1 Chelius's Surgery, vol. iii. p. 540, note by J. F. South. VOL. II.—4 50 OPERATIVE SURGERY. or other tumors found upon the side of the chest, may be readily excised by the means described in connection with the treatment ot 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. § 1. CONGENITAL ENCYSTED TUMOR ON THE RIGHT SIDE OF THE CHEST SUCCESSFULLY TREATED BY A SETON. An infant, three weeks old, of good development and health, had a tumor at birth of a globular shape, six inches in its vertical 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.1—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. Tne 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 reaccumulation, which was drawn off. and a few silk threads 1 Am. Journ. Med. Sciences, vol. xvii. N. S. p. 22. 1846. SURGICAL ANATOMY OF THE THORAX. 51 introduced to act as a seton, as in the treatment of hydrocele. At the end of forty-eight hours, sufficient inflammatory action being excited, the seton was withdrawn, and the patient, after a convul- sion and serious constitutional disturbance, recovered. (See note.1) CHAPTER XII. OPERATIONS PRACTISED 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 1 By an error in the Bibliographical Index, a 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. 52 OPERATIVE SURGERY. as exterior to them, and are mainly concerned either in respiration, or in the motion of the body. 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 mus- cle of the abdomen; which, arising from the eight inferior ribs, are interlocked in its five upper heads with the serratus magnus. The diaphragm, after being attached to the lower edge of the thorax, rises up within the chest by a convex surface, which is on a level with the fourth rib. The Intercostal Arteries pass from behind 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 arte- ries, 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 consequence 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. RESECTION OF THE RIBS. 53 § 1.—RESECTION OF THE RIBS. Resection of the ribs has been demanded in cases of serious dis- eases of these bones. In a patient of Dr. George McClellan,1 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.2 In the systematic description of resection of these bones, usually 1 McClellan's Princ. and Pract. of Surg., note by Dr. J. H. B. McClellan. 2 Bibliography, p. 98. 54 OPERATIVE SURGERY. presented in the various works on operative surgery, the following directions are given:— Operation.1—Lay bare the diseased portions of the bone either by a straight, curved, or crucial incision. (Plate XXXVIIL, 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 a 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,2 and in one by Velpeau,3 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 Encyclo- pedique, 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 extent of four inches, and the thickened pleura also excised, so that the pulsations of the heart in the pericardium could be seen. The patient lived several months, but ultimately died of a return of the cancer, for the relief of which the operation was performed. According to Velpeau, Severin, J. L. Petit, Duverney, David, La- peyronie, and Dessault have all done the same thino- in cases of caries and necrosis. He has also performed the operation himself in three instances with success. Dr. Warren, of Boston, also reports having successfully excised 1 Malgaigne, Philad. edit. p. 207. 2 Diet, de Medecine, tome 9^, p. 147, 3 Operat. Surg., by Mott, vol. ii. p. 738. PARACENTESIS THORACIS. 55 the seventh, and in another case the sixth and seventh ribs success- fully for caries, and Drs. McDowell of Virginia, Mott of New York, and McClellan of Pennsylvania, in three other instances, performed this resection with varying success. As an operation, its execution may therefore be said to be comparatively easy, the thickened condition of the pleura obviating most of the risk likely to arise from opening the pulmonary cavity. But it should be remem- bered that caries and necrosis can both be cured by the mere efforts of nature, or by slight surgical assistance, and nothing can, therefore, justify a repetition of any of these operations, unless the sufferings of the patient, and the effects upon his respiration, should be most urgent. Indeed, in this, as in many other cases, surgical skill and judgment are often best shown when the 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 (sv, in, nvov, pus), though originally employed to designate 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 opera- tion that is required to evacuate it. The operation of paracentesis thoracis being, however, intended especially for the relief of collec- tions of pus within the pleural cavity, or for the removal of the fluid of hydrothorax, a brief reference to the pathological condi- tion of the parts concerned may advantageously be made to pre- cede 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 56 OPERATIVE SURGERY. of abscesses in the liver. When the complaint results from ex- ternal 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 adjoining ribs, the tumor which indicates the collection being made by pus which comes from within the pleural cavity. In most instances, however, whether of external or internal empyema, the pleura exhibits 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 honeycomb-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 occasion- ally strong adhesions to the pleura costalis may retain it much lower, and expose it to be wounded in the operation of paracen- tesis. 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 contents of the part, without admitting air into the pulmonary cavity. To accomplish this, it has been suggested to puncture the parietes of the chest with a trocar and canula, or with a trocar and syringe, or to make a direct dissection, layer by layer, from the skin to the pleura. In all the plans that have been recommended for the accomplishment of this object, surgeons have differed mainly in regard to the best point for the puncture; but, as the patient is usually compelled to sit up, and as the general anatomical relations of the region especially favor a certain point, it is sufficient to state that, when circumstances admit of it, the space between the fourth and fifth, or fifth and sixth ribs, and a little posterior to their mid- dle, 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 PARACENTESIS THORACIS. 57 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 con- dition of the part than on the diseased state, and it is most pro- bable that the weight of the fluid collected within the right pleura will more than counteract any elevation of the liver when the pa- tient is in the erect position. In counting the ribs in a person of ■moderate flesh, but 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 dis- tinguish 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.1 But by directing the patient to take as full an inspiration as possible at the moment of puncturing the pleura, the diaphragm will be secure from injury. Ordinary Operations of Paracentesis Thoracis.—The pa- tient being propped up in bed, and a little inclined to the sound side, so as to separate the ribs as much as possible on the diseased side, divide the skin to the extent of one and a half inches in a direc- tion parallel with the superior edge of the lowest rib on the inter- costal space, that is selected for the puncture. Then, after divid- ing the superficial fascia, and any portion of a muscle of the chest that may intervene, as well as the external and internal inter- costal muscles, the pleura will generally be found to bulge into the wound, and being distinctly felt by the forefinger, so as to establish the fact that only a fluid is behind it, puncture the membrane with the point of a bistoury, and enlarge the opening gradually as the liquid escapes2 (Plate XXXVIIL, Fig. 4). If the pleura is very much thickened, care will be requisite to avoid the error of pushing it before the instrument, for such a case has been seen, as may be found by referring to the Bibliographical Index.3 Velpeau enter- tains the opinion that, in cases which require the operation of para- centesis, the effused liquid, or even an abscess, will remove the lung from the point of puncture, and thus secure it from being wounded. He, therefore, objects to the details just given, and advises that the side of the chest be at once opened by a deep puncture with the bistoury in the same manner as an ordinary abscess. 1 Malgaigne. 2 Velpeau, Op. Surg., by Mott, p. 515, vol. iii. * Bibliography, p. 100. 58 OPERATIVE SURGERY. Operation of Dr. Metcalfe, of New York.'—The patient being placed on a stool of convenient height, an exploring needle was passed between the seventh and eighth ribs immediately be- neath the angle of the scapula, and the presence of serum rendered positive. A bandage being then passed around the chest, a short incision was made in the skin with a lancet, and the trocar of Schuh passed into the chest to the depth of one inch and a half. The cock of the canula being now turned and serum escaping, a flexible catheter was adjusted to the mouth of the canula, and its free end immersed in a little clean water, the fluid being thus al- lowed to escape from the chest without the admission of any air into the pleural cavity. In this manner, seventy-two ounces of serum were evacuated, the steady tension of the bandage prevent- ing any discomfort from the evacuation of the fluid. The operation lasted half an hour, and the patient was then able to take a long, full inspiration, and was temporarily relieved, the object of the operation in the present case being only palliative. The instru- ment employed was a modification of Schuh's instrument, and consisted of a trocar three and a half inches long by about one line in diameter, resembling the ordinary instrument for tapping hydro- cele, which was fitted into a canula in which was a cock at the distance of two and a quarter inches from the end which entered the chest. A roughened handle projected at right angles to the axis of the tube at its external extremity. The canula was of the same diameter throughout, and had no cup as in the ordinary canula, so that an elastic catheter could be readily attached to it. Its simplicity over the trough of Schuh is its chief recommendation in the opinion of Dr. Metcalfe. In order to tell when the serum from the chest passed out of the end of the catheter which was immersed in the water, a crumb of bread, pressed between the fingers to render it heavy, was dropped near the end of the catheter, and by its motion indicated the current caused by the effused liquid. After-Treatment.—If circumstances render it desirable to keep the wound open, a tent may be introduced, and removed from dav 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 1 New York Med. Times, vol. ii. p. 377, 18-33. PARACENTESIS thoracis. 59 with warm water, or warm barley-water; weak astringent washes, or those of an antiseptic character, as dilute solutions of the chlo- ride of soda, 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' 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,1 and has reported numerous instances of the success of this mode of operating, all the patients being immediately more or less relieved, and two being perfectly successful, though the patients were very ill at the time with hectic, &c. This mode of operating by the canula he thinks is preferable to the ordinary mode of in- cising the soft parts. Estimate of the Operation.—In estimating the value of any of these modes of operating, the difficulties or objections applicable to each should not be overlooked. When the intercostal spaces are prominent, and the 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 instrument of Dr. Wyman, of Massachusetts, may prove advan- tageous. In Boston, the experience of the profession is said to be favorable to it. Under all circumstances, the surgeon may antici- pate 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 emploj^ed, 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 accom- 1 Transact. Am. Med. Assoc, vol. iv. p. 245. 60 OPERATIVE SURGERY. panied with thickening of the tunica vaginalis. When the surgeon recalls the constitutional effects liable to result from opening closed cavities, and especially those containing pus, and covered by a pyo- genic membrane, he can readily foresee the consequences of open- ing the pleura in cases of empyema. The natural tendency of such collections is either to be absorbed or discharged by the efforts of nature. If discharged by nature, the inflammation of the surround- ing parts, and the character of the opening made by ulceration, are well known to be more favorable to a cure than is the case when the surgeon punctures it. I would, therefore, express the opinion that this operation should not be resorted to until the latest possible moment; that, when done, air should be prevented from entering the cavity of the chest; that the pus should be slowly and only partially discharged, the wound closed, and the operation repeated, if necessary. If, however, the entrance of air cannot be prevented, it will be better to evacuate the whole of the liquid, and treat the case subsequently like one of cold abscess. The results obtained in the following table show pretty correctly what may be anti- cipated from the operation, when resorted to after the diagnosis has been made with the aid of auscultation:— STATISTICS OF THE OPERATION OF PARACENTESIS THORACIS. CURED. DIED. Of 24 cases treated in the United States,1 there were, counting two reported as relieved, 17 5 Of 72 cases reported by Velpeau2.....41 31 Of 44 " " " Roe3......32 12 Of 26 " " " Roe4 for hydrothorax . 17 9 Of 16 " " " T. Davis5.....12 4 Total, 182 ~I^ ^ From this table it appears that about two-thirds of the cases operated on have been cured. Remarks.—Although the above table shows the results of more recent cases, it is only an evidence of the fact that carefully chosen cases will be attended with fair success. The value of the operation has, however, been very differently estimated at various periods, most 1 Bibliographical Index, p. 99. 2 Velpeau, Me"d. Op6ratoire. 8 Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 38. Paper by Wm. Pepper, M. D. * Ibid. s jiidt EFFUSIONS IN THE PERICARDIUM. 61 of the surgeons, up to the time of the discovery of Laennec, having regarded it as either doubtful or dangerous, and especially from the difficulties attendant on the diagnosis. Since the more general resort to auscultation, many of these difficulties have been removed. Disease 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 certain. But, though the cases can now be better selected than they were formerly, a successful result is not always obtained. The true value of the operation may, it is thought, be correctly stated thus: Paracentesis will always afford temporary relief, and about one-half of the cases will recover; but whether these patients would have died without it, is difficult to tell. The idea is certainly erroneous that paracentesis thoracis is an eminently easy and successful operation, and though its results have sometimes been such as to justify its performance, the prog- nosis should be guarded. In the preceding statistics which I have collected from various sources, it is shown that the mortality has been considerable, and the objections that were raised against the operation in former days should, therefore, not be slightly disregarded. They are thus stated by Velpeau:— If the lung has been forcibly compressed by the liquid, and yet is 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 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, whilst 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. § 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 62 OPERATIVE SURGERY. 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 opinion that doubt may be attached to all except the one performed by Dr. John C. Warren, of Boston, and reported below. His opera- tion has also been reported to me1 as successful, and is, it is thought, the first positively successful case on record. Operation of Dr. Jno. C. Warren2 for effusion in the Pericardium.—A respectable female, aged about thirty-five years, having suffered considerably from palpitation and dyspnoea, with the other signs of hydrops pericardii, Dr. Warren operated as fol- lows: An incision being made on the face of the seventh rib, the integuments were drawn upwards to the sixth intercostal space, and the tumor or prominence, which was very marked, carefully punctured with a small trocar and canula, the pericardium being easily reached. Between five and six ounces of serum being thus evacuated, the wound was carefully closed, the chest bandaged, and the patient recovered sufficiently in a few weeks to leave the Mas- sachusetts General Hospital, but was not heard of subsequently. Operation of Mr. Schuh.—Another successful case of tapping the pericardium is related by Mr. Walshe,3 in which Mr. Schuh introduced the trocar and canula in the fourth intercostal space, or between the fourth and fifth ribs, and drew off upwards of a pint of reddish serum, which flowed in gushes that corresponded with the systole of the heart. This patient was also very much relieved and in the course of the month bid fair to be cured, but six months subsequently died of an encephaloid growth near the trachea. The post mortem showed that the operation had been perfectly success- ful, and that the pericardium was adherent to the heart by thick cellular tissue. 1 Dr. Warren in MS., Nov. 1853. 2 Dr. Warren in MS. 3 Walshe on Cancer, p. 366, Lond. edit. PARACENTESIS ABDOMINIS. 63 CHAPTER XIII. OPERATIONS UPON THE PARIETES OF 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 precisely the same means as those already designated in the account of the neck, this slight allusion to them may be sufficient to preserve the con- tinuous arrangement of the subject adopted as the order of the present work. Within the walls of the abdomen there are, however, such a variety of organs that its contents require a more detailed consider- ation; 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 yet remains to be de- scribed the surgical treatment adapted to the relief of certain con- ditions 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. 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. 64 OPERATIVE SURGERY. 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 tight by assistants, in order to keep up constant pressure upon the abdominal cavity as the liquid escapes; or the same pressure may be effected merely by the pressure of the assistant's hands. The surgeon, being then perfectly satisfied of the correctness of his diag- nosis, 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 eva- cuated, when, removing the instrument, he may close the wound by a piece of adhesive plaster, and cover this with a compress and bandage. Remarks.—Simple as this operation evidently is, surgeons have differed somewhat in regard to the details of its performance. Thus, some have advised that the patient should be seated, others, that he should be lying down; some have recommended the entire evacu- ation of the fluid at the first operation, whilst others direct the re- moval of 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 peculiarities of the case. Dr. Physick1 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 Mr. Fleming, of the Val de Grace,2 though it had, as is shown above, been employed many years before his suggestion was announced. Dr. Physick's Operation.—The patient lying down 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 the linea alba about two inches below the navel, the fluid being allowed to escape through the puncture as soon as it is removed. After the liquid has partially escaped, and the stream begins to diminish a female catheter should be introduced into the peritoneal cavity, in order 1 Dorsey, Surgery, vol. ii. p. 365. » Malgaigne, Philad. edit. p. 387. HEPATIC abscesses. 65 to favor the further evacuation of its contents. 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 evacuation of the fluid permitting the abdominal parietes to accommodate them- selves to the vacuum otherwise liable to be left in the abdomen unless the belly is kept well bandaged. As it^is also well known that incised wounds are less liable to inflammation than punctured, the chances of peritonitis are hereby diminished. Whether the proposal to excite inflammatory action in the sac of the peritoneum by injecting iodine, or similar articles, will ever be generally adopted, is a matter of doubt. Velpeau has long been sanguine of success from this means; but his opinion is based mainly on theoretical views; and no other surgeon, so far as I know, has attempted it, though several have favored a resort to his suggestion. The horizontal posture of the patient throughout the operation, has long been regarded with favor by many in the United States, and I have frequently resorted to it, and so has Dr. Storer, of Bos- ton, during the last ten years. In Europe, however, it appears to be regarded as a novelty, and has been lately advocated by Dr. Simpson, of Edinburgh, as a new 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 disin- tegration of the secretory portion of the gland. This purulent col- lection, 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 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 VOL. II.—5 Q6 OPERATIVE SURGERY. PLATE XXXIX. OPERATIONS PRACTISED 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 intro- duced, enlarge the wound by slightly incising the abdominal parietes up- wards. 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 practised upon an external inguinal hernia of the left side, the surgeon standing on the right side of the patient, and manipu- lating 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 opening, whilst the fingers of the same and opposite hand press the vis- cera vertically upwards towards the femoral ring. After Bourgery and Jacob Plate 39 Fio 1 Ftp. 3 Fig,. Fig,. 7 HEPATIC ABSCESSES. 67 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, care being taken to insure the adhesion of the liver to the abdo- minal parietes, before attempting any puncture. 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 tumors of this region, from the swelling caused by a hepatic abscess, that Rccamier 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 walls. (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 it should be remem- bered that when the patient is well etherized, there is but little 68 OPERATIVE SURGERY. tendency in the bowels to move towards the wound, and that this direction will therefore be seldom needed. On reaching the sur- face 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. I.)1 Operation of Dr. Savery, of New Hampshire.2—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 some time previous to the incision, was then gradually tightened as the swelling dimin- ished, so as to keep the parts in apposition. The discharge con- tinued for a few days, and then ceased; but considerable constitu- tional irritation existed during the first week, and required the free use of wine and quinia, with other appropriate remedies. Remarks.—The opening of an hepatic abscess would be a very simple measure, were it not for the doubts that are often excited as to the actual existence of pus, and the difficulty of judging 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. 1 Diet, de Med., tome 13me , p. 249. 2 See Bibliographical Index, p. 102. HYDATIDS OF THE LIVER. 69 SECTION III. HYDATIDS OF THE LIVER. The occasional development of hydatids of the liver demands that a few words should be said in relation to the operation which is sometimes required for their removal. Although rarely met with, the existence of hydatids in the liver gives rise to a train of symptoms, which, when tested by " ex- clusion," has enabled the surgeon to diagnosticate their presence, and operate for their relief. In a case reported by Dr. J. Edward Weber, of N. Y.,1 a tinsmith had suffered for nine years from an enlargement of the right side, over the region of the liver, which felt hard, and was more apparent when he had abstained from food. Being sometime subsequently attacked with severe pain, he became conscious, during each inspiration, of a sensation in the ride, which gave to his hand an impression similar to that caused by the purring of a cat. The diagnosis of hydatids of the liver having been satis- factorily established, Dr. Weber determined to evacuate the cyst so as to unite its walls, or cause them to shrink, and he decided to do so by an operation, which he performed as follows:— Operation of Dr. Weber, of N. Y.—The bowels having been freely moved, an exploring trocar was thrust a few inches through the integuments into the most prominent part of the swelling, the sensation caused by the passage of the instrument being similar to that perceived in paracentesis abdominis. On withdrawing it, a fluid resembling whey, dropped from its orifice, the microscopical examination of which revealed nothing remarkable. A longitu- dinal incision, two inches long, being then made down to the liver, a direct puncture of the liver with the trocar, gave the same results. As there was no union of the peritoneal surfaces, a well-oiled tent was introduced upon the peritoneum, in order to produce a limited inflammation, the end of the tent being left in the lower angle of the wound. During six days the patient complained of slight pain in a circumscribed space, of the size of the hand. Eight- een days subsequently, as it was supposed that adhesions had taken place, the second operation was commenced. The first incision 1 New York Med. Times, May 1852. 70 OPERATIVE SURGERY. having contracted, it was enlarged upwards of an inch, when, the finger having detected perfect adhesions between the abdominal peritoneum and that covering the liver, an incision was made through the parietes of the liver into the cavity of the cyst, which was thought to be of the size of the adult skull. The contents, which consisted of a fluid and small cyst, being now very cautiously evacuated, another oiled tent was introduced as before, and after a tedious recovery, and the presence of an hepatic fistula, the patient recovered in about twenty two months after the first operation. SECTION IV. GASTROTOMY or enterotomy. Gastrotomy (ya^p, the belly, and tout], 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- tised 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 practised on the intestines, ovario- tomy the removal of ovarian tumors, and herniotomy that employed for the relief of protrusions of the bowels. Either gastrotomy or enterotomy must, however, continue to be very rare operations, the risks of general peritonitis, as well as the possession of less difficult plans of treatment, rendering surgeons indisposed to resort to them. These operations have therefore been chiefly performed in order to remove such foreign bodies as were not likely to pass through the alimentary canal, as in the three cases quoted by Dr. Watson, of New York,1 from the German Epherides, in one of which a knife which had been swallowed with the blade open, and ten inches long, was extracted by a longitudinal incision two inches long in the left hypochondriac region, and the patient recovered; in another, in which a knife seven inches long was also successfully removed by a similar incision, the cure being very prompt; and in a third, a knife of nine inches being successfully re- moved in the same manner. Enterotomy has also been performed in order to overcome the intestinal obstruction in cases of volvulus. 1 Am. Journ. Med. Sciences, vol. viii. N. S. p. 330. GASTROTOMY. 71 § 1.—GASTROTOMY. • Gastrotomy, or the incision of the abdominal parietes, in order to open the cavity of the stomach, is an operation that has been recently suggested in cases of impermeable stricture of the oeso- phagus, in order to permit the introduction of nutriment, and has, as just stated, also been resorted to for the removal of foreign bodies of such size as to preclude all reasonable hope that they could other- wise be evacuated, as in the case reported by Dr. Marcet, where a sailor swallowed a number of clasp-knives. Although gastrotomy is an operation that could seldom be justifiable, yet under such cir- cumstances as have been referred to in the account of (Esophago- tomy,1 and with our knowledge of the wonderful recoveries of patients under extensive wounds of this viscus, of which several cases are cited in the Bibliography,2 it must be admitted that there are instances in which the surgeon might be induced to advise its performance. Operation of opening the Stomach.3—As the mere operative proceedings connected with the exposure of the stomach cannot require any extended detail for the instruction of one who is fami- liar with the anatomical relations of the stomach, it seems to be only requisite to state that the general course of proceeding would be very similar to that just detailed for the treatment of hepatic abscess; or, in more definite terms, cut through the abdominal pa- rietes with caution, over the front of the stomach in the line of the linea alba, extending from an inch below the ensiform cartilage, to an inch and a half above the umbilicus, until the peritoneum is ex- posed ; carefully open the portion which lines the abdomen; hook or seize the front surface of the stomach between its curvature; stitch it fast to the abdominal parietes, and then wait, if possible, for adhe- sion to occur, before puncturing the viscus, lest its liquid contents should escape into the peritoneal cavity, when, if the patient is able to sustain the constitutional shock, or peritonitis that may ensue, it will subsequently be necessary to treat the wound so as to create a fistula, through which food might be introduced, as was done by Dr. Beaumont, in his experiments on digestion, as practised in ' Vol. i. p. 494. 2 Bibliographical Index, p. 102. 3 Chelius, vol. iii. p. 103. 72 OPERATIVE SURGERY. the celebrated case of St. Martin.' Should gastrotomy, however, be attempted for the removal of a foreign body, such as a knife, or other large substance, similar to those that have been accidentally swallowed, and referred to by Dr. Watson, of N. Y.,2 Marcet, and others, the wound should be made to unite as soon as possible, by a treatment analogous to that reported hereafter, in the case which occurred in the practice of Dr. Ashby, of Virginia,3 or in that now quoted. In a case reported by Barnes,4 of a young peasant, who, whilst endeavoring to produce vomiting with the handle of a knife, let it slip into his stomach; it was removed by a surgeon named Shoval, in the following manner:—■ Shoval's Operation in 1635 for the Removal of a Knife from the Stomach.—A straight incision being made in the left hypochondrium, two fingers' breadth below the false ribs, first through the skin and cellular tissue, and then through the muscles and peritoneum; the stomach was exposed, but slipped from the fingers whenever it was attempted to be seized. Being at length caught with a curved needle, and drawn out of the wound, a small incision was made into it, through which the knife was easily ex- tracted, when the stomach immediately collapsed. After thoroughly cleansing the external wound, it was united by five sutures, and tepid balsam poured into the interstices, and tents impregnated with balsam completed the dressing by closing the wound thoroughly. Two sutures being removed next day, and two more on the .follow- ing day, the wound healed on the fourteenth day after the operation and the patient completely recovered. The knife, as seen by Dr. Oliver at Konisberg, in 1685, was six and a half inches long. § 2.—ENTEROTOMY. Enterotomy, or the division of the abdominal muscles, and their peritoneal lining, so as to permit the opening of a portion of the intestinal canal, has also been resorted to for the removal of foreign bodies, as in the case of Dr. White, of Hudson, hereafter reported » See Bibliography, p. 101. 2 Ibid p 10Q 5 Am. Journ. Med. Sci., vol. viii. N. S. p. 330. 4 Chelius, vol. iii. p. 106. ENTEROTOMY. 73 for the cure of volvulus, and in some instances for the relief of obstinate constipation, or for obstruction of the rectum in the form- ation of an artificial anus. Like the operation of gastrotomy, that of enterotomy can only be thought of in very desperate circumstances, although the success which has attended the instances in which it has been employed, has been sufficiently marked to have attracted attention. In a paper published by Mr. Phillips, of England,1 it is stated that of 27 patients operated on for the establishment of arti- ficial anus, 13 recovered. Of 53 cases referred to as operated on, for obstruction of the bowels, including both infants and adults, 17 were cured. Mr. Phillips, therefore, advocates the operation in obstruction where three or four days have passed without relief from other means. In cases of volvulus, the difficulty of the diagnosis must render the resort 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 these operations, as a general rule, and would urge^he utmost caution in respect to diag- nosis on the part of any surgeon who might be placed in such circumstances as apparently demanded it, I am convinced that it presents some chances of success; and as such a concatenation of circumstances may occur as will demand its consideration here- after, there seems to be a good reason for exhibiting the few facts that have been presented in connection with the subject. By refer- ring to the Bibliographical Index,2 several cases may be found in which the intestinal canal has been most rudely treated without causing death. In the case reported by Dr. Brighamnof Utica,3 a patient survived the removal of seventeen inches of the intestinal canal; in one reported by Dr. Dugas, of Georgia, the intestines were cut in two by a bowie-knife and sewed up, yet the patient recovered; and in the others there referred to, they sustained the rudest handling, and were even severed without causing death. But, though success followed these cases, it is presumed that no judi- cious surgeon would take any of them as a precedent for an opera- tion which is universally regarded as a forlorn hope, except under 1 Brit, and Foreign Med. Review, April 1849. 2 Bibliography, p. 100. * Am. Journ. Med. Sciences, vol. ix. N. S. p. 355. 74 OPERATIVE SURGERY. the urgent circumstances in which an operator is fully satisfied that the patient's chances of life are less before than they would be after the performance of the operation. Enterotomy successfully performed by Dr. J. E. Manlove, of Tennessee.1—In July, 18-44, 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 enterotomy promised but little benefit, yet the certainty of death without it justified its performance. Manlove's Operation of Enterotomy.—An incision being 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 peritoneum and bowels along the lower half of the incision were found adherent. An opening of about a fourth of an inch in length was therefore made into the bowel nearest the wound, from which there escaped large quantities of flatus and liquid feces, as well as some of the medicine which had been taken a short time previously. A further examination showing that the intestines were united to the peritoneum by extensive adhesions at various points, within reach of the finger and probe, and that there was therefore but little probability of the escape of any liquid into the peritoneal cavity, the wound was closed by sutures and adhesive strips, except at the intestinal opening. The amendment in all the symptoms was prompt, the extremities becoming warmer, and the pulse fuller and slower within an hour 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 thus made until the seventeenth day, when he had an evacuation per vias naturales, the wound having nearly closed. Nine months after this, he was presented to the Tennessee State Medical Society for inspection, being perfectly well. The adhesions were supposed to have been the result of a contusion of the abdomen received six months previously. Remarks.—In the paper just quoted, Dr. Manlove also states Boston Med. and Surg. Journ., vol. xzxii. p. 492. enterotomy. 75 another marked instance of the success of this operation, in which Dr. Wilson, of the same county, performed enterotomy in a case of volvulus, drew out the intestines until he reached the obstruction, dissected the adhesions found at the invaginated portion, overcame the obstruction, replaced the bowels, and the patient rapidly reco- vered.1 Successful Enterotomy, and Removal of a Silver Tea- spoon, by Dr. Samuel White, of Hudson, New York.2—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 tea- spoon, with some fruit jelly, and forcing the spoon down his throat in the absence of his nurse, was enabled to swallow it, by pressing his fingers against the handle. 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 fifteen minutes with stupor, showed itself, during which he would throw himself violently about. This lasted during two hours, while the spoon probably passed the pylorus, when he 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 ileum near the line dividing the right iliac and hypogastric regions. It remained fixed in this position, with increased heat and irritation in the adjacent parts, till August 7th, when, fearing the 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 intestine, which contained the spoon-handle, protruded; the intestine pierced with the lancet over the end of the handle, and the spoon extracted by forceps. The divided edges of the intestine were then secured by the Glover's suture, and the external wound closed with adhesive strips and lint. Under simple dressings, the wound healed by the first intention, and the patient recovered. 1 Boston Med. and Surg. Journ., vol. xxxii. p. 495. 2 New York Repository, vol. x. p. 367, 1807. 76 OPERATIVE SURGERY. SECTION V. 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 fistulas 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.1—A widow lady, set. thirty-nine years, had been attacked with constipation and violent pain at the pit of the stomach, which resisted every remedy until the nine- teenth day, when a fistulous orifice showed itself. Six months sub- sequently, 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 exco- riated and inflamed the abdomen, and rendered it intolerably pain- ful. On drinking a glass of water, the whole of it was discharged through the fistula in twenty seconds, and an examination, by a catheter introduced into the opening, therefore, led to the conclusion that the opening was in the stomach near the pylorus. Treatment.—A beef-bladder being cut open longitudinally, was spread with adhesive plaster and applied over linen spread with cerate, so as to cover the excoriated part, an opening being made in the dressing corresponding to the fistulous orifice, after which a firm bandage and compress were applied and the diet limited, nou- 1 Am. Journ. Med. Sciences, vol. xiv. p. 271, quoted from Western Journ. Med. and Phys. Sciences, Jan. 1834. WOUNDS OF THE ABDOMEN. 77 rishing enemata being resorted to in order to sustain the patient. The external irritation soon healed; the bandage was gradually tightened, and a cylindrical compress employed, under which treat- ment the fistula was completely healed in thirty days, and the patient subsequently regained her health. Remarks.—Should the orifice of such a fistula fail to heal under similar measures, the surgeon might derive advantage from the use of escharotics. As the experiments connected with digestion, per- formed by Dr. Beaumont upon St. Martin, who also labored under one of these fistulas, have long been before the profession, the refer- ence to his paper1 before given will furnish sufficient evidence of the powers of nature under such circumstances, as well as the means employed by Dr. Lovell, U. S. army, to obviate the inconvenience resulting from the creation of the opening. As there is a marked tendency in the mucous membrane of the stomach or bowels to become everted and strangulated at the orifice either of the fistula, or of the wounds which open at this protrusion, it should always be guarded against by appropriate pressure during the treatment of the case, and especially in its early stages. CHAPTER XIV. WOUNDS OF THE ABDOMEN. Incised wounds of the abdomen, 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 apposition 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 im- portant of these wounds are those complicated with a protrusion of some of the abdominal contents, as the latter, when once protruded, are with difficulty replaced, not only in consequence of the contrac- tion of the muscular fibres around the wound, creating strangulation, but also from the peristaltic action of the bowels, causing the pro- truded intestines to be filled with solid or gaseous deposits. 1 Am. Med. Record., vols. viii. and ix., 1825. 78 OPERATIVE SURGERY. SECTION I. WOUNDS WHICH CAUSE PROTRUSION OR STRANGULATION OF THE STOMACH, INTESTINE, OR OMENTUM. In treating such abdominal wounds as are followed by a protru- sion of any of the viscera, it should be adopted as a universal rule of practice that, before resorting to any incision to facilitate the restoration of the protruded viscus, the surgeon should en- deavor to replace it by manual means, aided by such a position of the patient, use of anaesthetics, and other constitutional measures, as will induce perfect relaxation of the tissues which form the ante- rior abdominal walls. Since the discovery of ether, the restoration of the stomach, intestines, or omentum which have protruded through an abdominal wound is much more easily accomplished than was the case formerly. The following plan of treatment 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 thoroughly from all foreign matter by squeezing water upon them from a sponge, and then gently seizing, between the thumb and fingers, that portion of the viscus which had last protruded, com- press it lightly so as to force back its contents, endeavoring to carry it into the cavity of the abdomen by pressing upon it with the forefingers. The peristaltic action of the digestive canal being entirely arrested during anaesthesia, the muscles of the abdomen perfectly relaxed, and the diaphragm partly quiescent, success will often crown these efforts. When the protruded portion is returned, it then remains to unite the sides of the wound by a few points of the twisted suture, and support them by adhesive strips and a bandage. But if it should be found impossible to 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 WOUNDS OF THE INTESTINE. 79 case it may become necessary to treat it as is done in a similar con- dition in hernia. In cases in which the protruding viscus has been wounded, as has frequently happened, the opening in it should be carefully approxi- mated by one or two points of the interrupted suture, so placed as not to include the mucous coat, and then leaving the ends of the threads attached to the viscus, its opening may be made to corre- spond with that in the abdominal parietes. Operation of Dr. Ashby, of Alexandria.—In a very marked case reported* by Dr. C. W. Ashby, a boy, six years of age, fell upon the points of a pair of sheep-shears, which he had in his hand, and drove the instrument into the stomach obliquely from above down- wards, so as to graze the left side of the sternum and edges of the ribs. The external wound was flap-shaped, and through this nearly the entire stomach protruded, discharging its contents through an aperture nearly three-fourths of an inch long. Having placed a single suture in the middle of the wound in the stomach, nausea and vomit- ing ensued from the handling of the viscus, and the boy became so unruly as to prevent the restoration of the stomach, although the abdominal wound was several times enlarged. At this period, anaesthesia was induced by chloroform, and, after slightly enlarging the abdominal wound, the stomach was readily replaced, although the boy vomited freely, as before, from handling the organ. The wound in the stomach being then brought directly opposite that in the abdominal parietes, it was gently retained within the verge of the external wound by a single stitch, lint, wet with cold water, and retained by a bandage, completing the dressing. A large dose of opium being then administered, the patient rapidly convalesced. On the fifth the wound discharged freely, and on the sixth the liga- ture came away, after which the recovery was rapid. SECTION II. WOUNDS OF THE INTESTINE. When an intestine is wounded in such a manner that the injured part can be seen through the opening in the abdominal parietes, it becomes necessary to treat it by such means as may induce union, 1 Stethoscope, vol. i. p. 660, 1851. 80 OPERATIVE SURGERY. PLATE XL. SUTURES OF THE INTESTINES AND ARTIFICIAL ANUS. Fi«r. 1. Continued Suture for Longitudinal Wounds. 1, 1. Ends of the thread. 2, 2. Points perforated by the first stitch, showing the dis- tance from end wound. 3, 4, 5, 6. Subsequent points, showing the dis- tances to be observed between the several stitches, and their relations to the edges of the wound. After Bcrnard and 1Iuette- 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. After Bernard and Huette. Fig. 3. Suture of Jobert for Transverse Wounds. 1. First thread passed through the intestine. 2. Second suture. 3. Edges of transverse wound of intestine. 4. Mesentery. 5. Point at which it has been incised in order to favor the union of the two ends of intestine. After Bernard and Huette. Fig. 4. Suture of Lembert for uniting Transverse Wounds of the Intes- tine by approximating the adjacent serous surfaces. 1. The first insertion of the thread. 2, 2. Its point of exit and re-entrance, or the second su- ture. 3. The third point. After Bourgery and Jacob. Fig. 5. Profile of this Suture. A. The suture as first formed. 1. End of the thread. 2. First loop. 3. Portion of thread over the wound. 4. Second loop. 5. Termination of thread. B. Profile of this suture as finished. 1. Exterior kuot. Fig. 6. Artificial Anus, in which the ends of the intestine open upon the groin by separate orifices. 1, 2. Ends of the intestine. 3. Mesentery between them. 4, 5. The two anal orifices. After Bourgery and Jacob. Fig. 7. Artificial Anus where the two ends of the bowel open by a single orifice. 1, 2. Upper ends of intestine. 3. Septum formed by union of 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 artificial 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 septum. 4. Mesentery. After Bernard and Huette. Fig. 11. A view of the Enterotome of Dupuytren as applied. 1. Ab- dominal parietes. 2. Instrument. After Bourgery and Jacob. Fig. 12. Enterotome of Liotard applied. 1. Septum. 2. Instrument. After Bourgery and Jacob. Plate 40. WOUNDS OF THE INTESTINE. 81 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 consequent 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. When a wounded intestine presents itself, so that the injured point can be readily reached, the extent of the wound is the first point to which attention should be directed, the means of treatment being necessarily varied according to the nature of the injury. In small punctures, or those less than a third of an inch in extent, or those openings through the intestinal coats which are consequent on the strangulation and ulceration that ensue upon certain 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. This loop gradually ulcerating through the coats of the viscus, whilst lymph is effused upon the peritoneal surface, will be soon discharged by stool, without exposing the patient to the risks consequent on the escape of its liquid contents into the abdominal cavity. But if the opening is more extensive, then resort must be had to some of the various sutures that have been recommended by sur- geons at different periods: Albucasis, A. D. 1100, Guy de Chau- liac, A. D. 1360, Le Dran, Eamsdohr, Shipton, Travers, Thos. Smith, Gross, and others, having advised peculiar methods of treat- ment. 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 VOL. II.—.6 82 OPERATIVE SURGERY. wound; the looped suture of Palfyn; that of Le Dran; and the continued or interrupted suture, as recommended, with various modifications, 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 assistant (Plate XXXIX., Fig. 3), the surgeon should pro- ceed to reduce the intestine, and then drawing the ends of the thread towards the abdominal parietes, cause the outer coat of the intes- tine to approximate 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.1 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 transversely to the line of the wound, at a distance of about a quarter of an inch from each other. The threads on each side being then tied together, the two bundles were collected together and twisted into one, so as to pucker up the edges of the wound (Plate XXXIX., Fig. 5.) Loop Suture of Palfyn.—A ligature being passed through the 1 Malgaigne. SUTURE OF TRANSVERSE WOUNDS. 83 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.1—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 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.2 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 further on, continue them in the same direction to the other end by a series of equal stitches. The intestine being reduced, fasten the end upon the ab- domen, and three days subsequently cut off one end of the thread near the wound, and draw out the other.3 (Plate XL., Fig. 1.) § 2.—SUTURE OF TRANSVERSE WOUNDS. Suture of Ramsdohr.—Invagination of the two ends of the in- testine being accomplished, this surgeon stitched them together by 1 Mott's Velpeau, vol. iii. p. 623. 2 Malgaigne, p. 399, Philad. edit. 3 Ibid. 84 operative surgery. 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 abdomen. (Plate XL., Fig. 3.) Suture of Lembert.—After preparing as many threads, each armed with needles, as seemed requisite, one needle was pushed through the coats of the intestine as far as the mucous membrane, from without 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 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.1 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 import- ance of the subject, and the numerous experiments that have been performed 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 pre- sent 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. 1 Malgaigne, p. 404. SUTURE OF TRANSVERSE WOUNDS. 85 Travers,1 it appears that sutures of every description, when applied to an intestine and left unconfined at the external wound, ulcerate through into the bowel and are discharge©^ 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,2 Gross, of Louisville, Kentucky,3 as well as 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 surfaces be brought in contact in order to promote adhesions; that the bowels be kept as still as possible, and that every means be employed to keep down general peritoneal inflammation. Under proper treat- ment, and with the exhibition of sound judgment, moderate wounds of the intestine are by no means a hopeless class of injuries, vari- ous cases having been reported, in which patients recovered after most extensive injuries, and even the loss of seventeen inches of the intestinal canal.4 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 favorable kind than might be the case if he trusted solely to general ideas on 1 Inquiry into the Process of Nature in repairing Injuries of the Intestines, by Benjamin Travers. London, 1812. 2 An Inaugural Essay on Wounds of the Intestines, for the degree of M. D. in the University of Pennsylvania, by Thomas Smith, Member of the Philadelphia Medical Society, 1805. 3 An Experimental and Critical Inquiry into the Nature and Treatment of Wounds of the Intestines, by Samuel D. Gross, M. D. Louisville, 1843. * Bibliographical Index, p. 102. 86 OPERATIVE SURGERY. the subject, and induce him to exert his skill towards the preserva- tion of life in even the most desperate cases. Estimate of these different Sutures.—For a small punctured wound, there can be no question that the application of the ligature as advised by Sir A. Cooper, is the most advantageous; that the loop suture of Palfyn and Ledran comes next, according to the extent of the wound, and then the process of Jobert. In the union of trans- verse wounds, the interrupted suture is probably equal to any other. The plan of Ramsdohr 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 seri- ous 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. CHAPTER XY. hernia in general. By the term "Hernia," is usually understood the formation of a tumor in consequence of the protrusion of some portion of the abdominal contents through a natural or preternatural opening, into some tissue which naturally covers it, or into an adjacent cavity, as that of the thorax. In order to relieve the symptoms which supervene on the occurrence of this complaint, it is neces- sary so to act, that the return of the viscus may obviate the effects of its displacement upon the life or comfort of the patient. Hernial tumors may form at any portion of the abdominal pa- rietes, that is, either above, through the diaphragm; below, through the openings about the pelvis; in front, through the abdominal mus- cles; in the course of the bloodvessels to the lower extremities or through the muscles of the loins or of the perineum when wounded. HERNIA IN GENERAL. 87 When the displaced viscus can be returned simply by manipula- tion, the complaint is said to be relieved by " Taxis;" but in other cases, where this manipulation fails, it will require more or less divi- sion of the tissues which cover it, in order to reach the seat of the obstruction, and this division is the object of the cutting operations termed "Herniotomy," and practised for its cure. The cases of hernia that most frequently require the performance of Herniotomy, are those in which the return of the tumor is ob- structed, or its contents 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 laudable 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 also been conducted with a degree of minuteness that has hardly left any shred or portion of the tissue concerned without a name. These details have conse- quently thrown a mist around the descriptions, that has confused and puzzled the brains of many students, who, under a less artificial account of the parts, would promptly have seized on all the facts possessing a practical value. The anxiety that has thus 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 that surrounds this complaint as first presented to the mind of a young student; and though by subsequent study he may find that the various names, given by different writers, often desig- nate 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 from the details furnished by the distinguished men whose names are identi- fied with the subject of hernia, 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 88 OPERATIVE SURGERY. to the wants of the surgeon, may also be seen in the tendency of anatomical teachers to adopt the descriptions furnished by normal anatomy, instead of those presented in the pathological changes of the complaint; whilst, instead of describing the alterations of struc- ture produced by disease, they present a perfect and minute detail of the disposition of the parts as found in 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 anatomy of these parts. No one qualified for the study of operative surgery can be presumed to be ignorant of the principal facts in special anatomy; and in the effort which will now be made to pre- sent a concise account of the pathological and surgical anatomy of hernia, it will be assumed that the reader is familiar with the great points of reference usually described by the anatomist. In the fol- lowing account there will, therefore, 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, Fe- moral, 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 omentum. These viscera being so situated within the cavity of the abdomen as to have the great sac of the peritoneum in front and around them, it follows that their protrusion at any point will also generally involve a prolapse of this membrane, as well as of such other tissues as may be so situated as to be acted on by the mass. The envelops of every protrusion become, therefore, the first por- tion of the structure to be examined. ENVELOPS OF HERNIA. 89 § 1.—ENVELOPS OF HERNIA. The coverings of any hernia, which protrudes in front through the abdominal walls, necessarily consist of a portion of every tissue which is to be found between the skin and the peritoneum, unless violence has destroyed the continuity of the layers, or nature left in them a deficiency or opening through which the tumor could pass; or unless the 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, therefore, 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 very much increase or diminish its density from that seen in the normal condition of parts. Outside of the peritoneum is generally found a cellular layer of greater or less thickness, according to its position, which varies somewhat in its attachments to the peculiar region in which it is placed; thus, at the sides of the pelvis and groins it is loose and movable, whilst in front its adhesions are firmer and less easily overcome. In this extra-peritoneal cellular substance, 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 moderate pressure is made upon it, it becomes more deve- loped, thickened, and laminated, acquiring a density and fibrous appearance which qualify it for the name of "fascia," which it has received; but when the pressure is very great, it becomes thinner and atrophied. In the protrusions which are found to escape at the groin, this cellular 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 90 OPERATIVE SURGERY. PLATE XLI. SURGICAL ANATOMY OF THE PARTS CONCERNED IN nERNIA. 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 linea alba. 2, 2. Rectus abdominis muscle, and lineae transversse. 3. External oblique. 4. Its tendon, also the position of the internal abdominal ring. 5. Round ligament of the uterus at its exit from the external abdominal ring. 6. Epi- gasti|ic artery. 7. Peritoneum covering the intestines. 8. Section of fascia transversalis everted. 9. Transversalis abdominis muscle. 10. In- ternal 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. Perforations in the superficial fascia of the thigh, for the passage of the superficial vessels. 3,3. Extension of the superficial fascia over the cord and testicles. 4,4. Superficial arteries. After Bernard and Huotte. Plate 41 H£3 ftg-..4 Fig. 2 SEAT OF HERNIA. 91 spread around them, or by the condensed cellular structure which fills up the spaces left around the vessels. Outside 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, all these layers, which, in the normal con- dition, are easily distinguished, will be found so blended and thick- ened as to have lost most of their ordinary characters and position, being fused, as it were, into one, or they may have their laminae so increased that nearly twice as many can be made over a hernia, as might be looked for in 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 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 tissue outside of the peritoneum, and that un- derneath 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 connec- tion with the particular class to which it belongs. § 2.—SEAT OF HERNIA. The abdomen being a closed cavity, accurately filled by its con- tents, 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 mo- bility, though some of the intestines have occasionally been forced through it into the cavity of the chest.1 When it occurs, it is of course beyond the relief of operative means. Below, the abdominal contents are sustained by the bones of the pelvis and their connec- tions, 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, 1 See Bibliography, page 99. 92 OPERATIVE SURGERY. as at the obturator foramen, or at the opening for the thyroid artery (thyroidal hernia); at the sacro-sciatic notch (ischiatic her- nia), where the gluteal artery passes out, and also alongside of the vagina of the female (vaginal hernia), or through a laceration of the perineum of the male (perineal hernia). 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 contents to press against the anterior parietes of the abdomen when the patient is in the erect position, and as many weak points exist in 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 spermatic cord or of the round ligament of the uterus as well as of the femoral vessels, and it is at this point the Inguinal and Femoral herniae are 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 umbilical vessels of the foetus, seldom or ever is 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, through which the vessels of the cord are transmitted; and whilst the latter exist, or shortly afterwards, a hernia may pass directly along the course of these vessels, but in the adult it is otherwise. At the latter period, the former aperture is so closely contracted, and the vessels which occupied it so perfectly solidified, that this point offers greater resistance than the linea alba itself, and a hernia through the umbilicus proper 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 former umbilical vessels, a weakness of the structure around the EFFECTS OF THE FORMATION OF HERNIA. 93 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 pregnancies or to such other causes as produce distension of the part, the tumor may be designated as an umbilical hernia, because occurring in the neighborhood of the um- bilicus, though, unless the aperture is 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 di- rectly 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 portion 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 reference is made, thus its " mouth" is the portion which is continuous with the abdomen; the "neck" that which adjoins the opening in the abdomi- nal 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 middle, 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 94 OPERATIVE SURGERY. its protrusion, 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-perito- neal 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 symptoms designated as those of strangulated hernia. It is for the relief of the latter that the operation of her- niotomy, as it is sometimes termed, or the incision of the parts around the protrusion, is demanded. Before proceeding to the details of this operation, it will prove useful to refer to the general symptoms of each variety of hernia as they are most frequently noticed. § 4.—REDUCIBLE HERNIA. All herniae, whether reducible, irreducible, or strangulated, are composed either of intestine or of omentum, or of both, and give rise to tumors which vary in shape, size, and position. When the tumor can be restored simply by the taxis, it constitutes the variety of the complaint which is designated as " Reducible Hernia." Symptoms of Reducible Hernia.—The constitutional disturb- ances caused by reducible hernia are such as may be chiefly referred to derangement of digestion, as constipation, belching, rumbling, dragging pains in the belly, and occasionally a disposition to nausea or vomiting, all of which are relieved when the contents of the tumor are replaced in their natural position, as sometimes hap- pens when the patient lies down, or when pressure, or the taxis, is properly exercised 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. § 5.—IRREDUCIBLE HERNIA. A prolapsed intestine, or portion of omentum, or both, which can- not be restored to its proper position, but continues as a permanent tumor, constitutes the form known as the " Irreducible Hernia." STRANGULATED HERNIA. 95 Symptoms of Irreducible Hernia.—The tumor caused by this class of hernia is more or less permanent, varying in size and symp- toms according to circumstances; 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 giv- ing 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 consequence of the fixed position of the omentum or intestine interfering with the distension and upward movements of the stomach, especially 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 detailed as the result of strangulation. § 6.—STRANGULATED HERNIA. When, from any circumstances, a reducible or irreducible hernia is constricted by the surrounding structures to such a degree as to interfere with the passage of the contents of the bowels through it, or when the circulation becomes interrupted either in the bowel or in the omentum, a certain class of symptoms are induced which are regarded as positive evidence of the existence 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 of Strangulated Hernia.—The symptoms of stran- gulated hernia will be found to vary with the tightness of the con- striction, 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, or when it is the result of inflammation. When the consequence of simple obstruction, the patient expe- 96 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 ves- sels. 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. Envelops of an oblique Inguinal Hernia. 1. Skin and super- ficial fascia. 2. Tendon of external oblique distended by the hernia. 3. Cremaster and tunica vaginalis communis, or the fascia propria of the hernia. 4. Sac. 5. Omentum. 6. Intestine. After Bernard and Huette. Fig. 3. Yiew of a direct Inguinal or a Ventro-Inguinal Hernia. 1. Integuments 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 tascia lata. After Bernard and Huette. Fig. 4. Plan to show the relation of the parts of the Sac. 1. Abdo- minal parietes and ring. 2. Neck of sac. 3. Its fundus. 4. Its mouth. 5. Peritoneal cavity. After Bernard and Huette. Fig. 5. Peculiar form of a Sac, as occasionally seen. 1. Abdominal parietes and ring. 2. Fundus of sac. 3. Body of the sac above an hour- glass contraction. 4. Cavity of the peritoneum. After Bernard and Huette. Fig. 6. Commencement of the changes seen in the formation of a Her- nial 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 IIuette< Fig. 7. Next step of the formation, as seen in a recent Hernia. 1. Abdominal 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. Abdominal parietes. 2, 2, 2. Intestine. 3, 3, 3. Continuous line of pe- ritoneum. After Bernard and Huette< fid 1 Fio 3 Fieo i //^\ liofl f J^\- W'rf >&&& ), ^ / 53 / % STRANGULATED HERNIA. 97 riences a sense of uneasiness, fulness, or constriction, in the part or in the abdomen, as if a cord was drawn around the latter, accom- panied with flatulence, more or less violent colicky pains, a desire to go to stool or to strain, but without any, or at least slight evacua- tions. This is followed by nausea and vomiting of the contents of the stomach, then of mucus and bile, and subsequently by dis- tressing retching, restlessness, moisture of the skin, irritation and excitement of the pulse, and the other usual symptoms of a bad attack of colic. If promptly relieved by a reduction of the tumor, these symptoms will all 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 abdomen. But if the obstruction remains, and inflammation is induced, then the symptoms just detailed will be* followed by others of a more serious character. In some cases of strangulation, these violent symptoms may be the first indications given of the existence of constriction, patients often suffering from some of those just detailed without deeming them more than the ordinary incon- venience likely to result, or which has previously resulted, from their complaint. The symptoms of strangulation, in very marked cases, consist in a greater tension and tenderness of the tumor; in increased tender- ness and swelling of the abdomen; in increased vomiting, which often brings up stercoraceous matter, accompanied or followed by hiccough, and in a change in the color of the tumor, which becomes dark red or livid, and gives a doughy or crackling sensation to the touch. The pulse becomes more frequent, small, and wiry; the skin more wet, cold, and sodden; the countenance expressive of dis- tress and suffering; the mind desponding and anxious, though pre- senting 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 intestine; but, the adjacent parts being glued to the side of the seat VOL. II.—7 98 OPERATIVE SURGERY. of the protrusion by the lymph resulting from the inflammation, the peristaltic action of the bowel forces its contents out at the opening thus made, and gives the patient the complaint designated as Arti- ficial 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 must be resolved into either a prevention or removal of this constriction. In every case, therefore, it becomes the surgeon's duty to attempt the restoration of the contents of the tumor at as early a period as possible, bearing in mind, in all 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. § 1.—REDUCTION OF HERNIA. The manual treatment requisite for the reduction of hernia is, as has been stated, designated by the term Taxis (rasjw, to arrange), this word signifying the replacing of the contents of the tumor in the abdominal cavity. General Plan employed in practising Taxis.—The details of the taxis, as required by each form of hernia, being hereafter given, this account will be restricted to such means as are applica- ble as adjuvants to the taxis in all cases. 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 the position of the pa- tient and 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 REDUCTION OF HERNIA. 99 or constitutional treatment likely to facilitate the reduction of all hernia, where difficulty is experienced, can alone claim attention. The earliest causes of difficulty in the reduction of most hernia being the accumulation of either fecal, gaseous, or vascular pro- ducts within the protruded portion, the first point to be attended to is, to empty the bowels by enemata, and relieve the stomach by emetics, especially if a full meal has preceded the difficulty, in order that a freer circulation may be established in the protruding por- tion. At the same time, 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 portion to inflame, blood should be freely drawn from the arm, and will prove useful, 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 con- striction is supposed to be the result of muscular contraction, per- fect relaxation of the whole system should be produced, and the patient placed in such a condition as will tranquillize the action of the diaphragm and respiratory muscles. To accomplish this, no- thing, in my experience, is comparable to perfect etherization, espe- cially in the hernia of children, as these patients, when etherized, always lie perfectly quiescent, and have a respiratory movement of so slight a kind (compared with the efforts which they usually make to resist the taxis, either in consequence of pain or fear), that the facility of the reduction is much increased. Indeed, a resort to ether is often sufficient, of itself, to accomplish the reduction of adult hernia without the abstraction of blood, the warm bath, or any of the other means usually employed; but the entire evacuation of the contents of the stomach should always precede the employ- ment of the anassthetic. Should the want of ether prevent a resort to this powerful adj uvant to the taxis, then the practitioner must em- ploy some of the other means of inducing the same degree of mus- cular relaxation, such as the warm or hot bath, or the use of tobacco or tartar emetic. The employment of tobacco, in the form of infu- sion, in the proportion of a drachm to the pint of water, one-third or one-half of which is thrown into the rectum every hour, is a very powerful means of inducing general relaxation, but is liable to the objection of exciting a longer and more thorough depression of the system than is desired, in consequence of the continued absorption 100 OPERATIVE SURGERY. of the infusion if the rectum does not expel it, as will sometimes happen in consequence of the relaxation of its muscular coat, even though the sphincter ani muscle offers no impediment to its escape. A much safer and more controllable method of applying tobacco will be found in the 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 it out by means of the string which has been left pendulous at the anus. Various local means have also been recommended as adjuvants to the taxis, such as warm applications to relax the cause of the constric- tion or cold articles to favor the contraction of the protruded portion; but as the three principal varieties of hernia escape most frequently through aponeurotic openings, which are attached to muscular fibres, little or no relaxation near the seat of stricture can be anticipated from the application of heat, whilst by causing an afflux of blood to the part, it must tend to increase the local congestion in the ves- sels of the tumor, especially if omentum constitutes a part of it. Cold, on the contrary, will diminish this congestion, and reduce the size of the protruding tissues, by exciting contraction of the fibres of the cremaster muscle, or peristaltic action in the muscular coat of the bowel, so as to favor the reduction of the tumor, whilst it cannot affect the condition of a tissue so purely fibrous in its cha- racter as that found in the usual position of the hernial rings. In applying cold as a means of restoring hernial protrusion, or as an adjuvant to the taxis, it will be found most useful when its action is limited to the contents of the tumor. To effect this, apply it aa follows: Take a cold cloth or small lump of ice and apply it directly to the lowest portion of the tumor, without permitting it to touch the upper portion, or that near the neck of the sac, so that it may induce a contraction of the contents of the sac from below upwards when, if the case is one of scrotal or inguinal hernia, the effect will be promptly apparent, the scrotum and fibres of the cremaster muscle contracting so rapidly as to render the change in the position of the tumor very apparent. If the hernia contains intestine, the cold thus applied, by hastening the peristaltic movement, will also tend to PALLIATIVE TREATMENT OF REDUCIBLE HERNIA. 101 empty the bowel of its contents or of its blood, thus diminishing its size and aiding very materially in its restoration. When the cold is applied to the largest portion of the tumor, or a lump of ice is so placed upon it, that its weight may aid the effect of the cold, or when it is indiscriminately applied all over the tumor, it is liable to produce contraction of the muscular parietes of the abdomen, and by thus constricting the parts near the mouth of the sac, to do more harm than good. When a hernia has been reduced, a good truss should be well adjusted to the opening, in the manner directed in the special forms of hernia, in order to prevent future protrusions. § 2.—PALLIATIVE TREATMENT OF REDUCIBLE HERNIA. The removal of the weight of the intestines from a hernial tumor having enabled its contents to return to the cavity of the abdomen, as frequently happens when the patient takes the horizontal posi- tion, or when pressure is made on its contents in order to replace them in the abdomen, as in the operation of Taxis, their future descent should be prevented by resorting to some of the bandages capable of making constant pressure at the point of exit. These bandages are very varied, and, under the name of " Trusses," have received every possible modification in the means of attaching them to the part, composition of the pad, or variety of adaptation to particular seats of hernia. From a very early period, the employment of the form of a truss best adapted to the treat- ment of hernia has been governed by the peculiar views of the sur- geon at the moment, or by other accidental circumstances. As the manufacture of these bandages has also led many unprofessional men to study the complaint, great ignorance, and often a want of common honesty, have been exhibited in the formation and lauda- tion of such instruments as it is apparent cannot possibly accom- plish the object that is desired, namely, the perfect retention of a hernia within the abdominal walls. In the United States, the variety in the instruments recommended for this retention has been fully equal to, if it has not exceeded, that found in Europe, and it would be a useless labor to attempt either an enumeration of the different kinds, or an examination of their merits and defects. Nearly all trusses are liable to the serious professional objection of 102 OPERATIVE SURGERY. being patented, in consequence of which an unnecessary cost is charged upon those who require them. I am, therefore, unwilling, in a professional treatise, to specify any one truss as being a better or more scientific instrument than another, lest improper advantage be taken of the recommendation. I. THE GENERAL CHARACTER OF TRUSSES. A good truss is an instrument formed of a spring of sufficient elasticity to retain a "pad" at the seat of the hernial protrusion, and resist the action of the diaphragm and abdominal muscles. To pre- vent its chafing the skin, it should be well stuffed, and, if it is not well fitted to the patient's pelvis, so arranged with straps attached to the spring that the latter may be readily adjusted, or prevented from slipping when once placed in a proper position. In order to adapt a truss to a patient, the surgeon should pass a piece of tape or soft wire directly around the pelvis at the seat of the protrusion, and, allowing one additional inch for the stuffing of the spring and thickness of the pad, select an instrument of the length of the string or wire. The spring of a truss will be strong enough when it will press firmly on the hernia and yet not cause the pad to indent the tissues after it has been worn a few hours. If it does more than this, it will do harm by leading to atrophy of the structures; or, if the pad is incorrectly shaped, it will favor the recurrence of the hernia when the truss is omitted, by enlarging the "rings." The pad of a truss, being the most important point, has generally received the most attention, and been made of every conceivable shape and material; some being round, oval, oblong, pyriform, pyra- midal, conical, truncated, and square, and composed of horsehair, or cork, wood, ivory, metal, glass, and wire-springs, covered by kid, buckskin, leather, caoutchouc, linen, or cloth. A good pad should have the following characters: A perfect adaptation to the shape of the region that it is to cover; sufficient firmness to maintain its proper surface without variation; and be either composed of, or covered with, some substance that is capable of preventing irritation of the skin or its excoriation from the constant absorption of the perspiration causing the pad to macerate the cuticle like a poultice. If the pad and spring are well adapted to the part, a simple circular PALLIATIVE TREATMENT OF REDUCIBLE HERNIA. 103 strap will retain them in position; but if they are not, or the patient is very thin, a vertical or perineal band may also be demanded. My own preference is for a spring of moderate strength, and well stuffed to fit the bony projections of the vertebrae or edge of the pelvis, whilst for the pad I prefer cork or light wood, covered by a thin layer of finely polished calfskin, between which and the skin there should always be worn, and especially in warm weather, a fold of linen.1 When a patient desires to bathe, a similar truss covered with oil-silk may be employed, or an oil-silk sheath be slipped over the truss as usually worn. The pad should generally be permanently attached to the end of the spring, or be so fastened by screws that it can only be shifted by the use of a screwdriver. The much lauded "movable," "self-adjusting," "self-regulating," "ball and socket" trusses I regard as among the follies of the day, and worse than useless. Every pad should have its surface so bevelled as to adapt it to the natural inclination of the abdominal or femoral pa- rietes ; or, if the patient is very corpulent, the pad should be so inclined upon the end of the spring as to enable it to press gently from below upwards. AVith the knowledge possessed by every reputable cutler in the United States, any surgeon can have a proper truss constructed for each case as it is wanted; and it is to be hoped that the profession, by pursuing this plan generally, and giving their attention to the subject, will be able to do away with the prac- tice of employing such instruments as are patented and sold by "bandage-makers." The hair-stuffed pads so often sold for the treatment of hernia have two serious objections: 1st, the hair yields to the pressure, and the pad loses its proper shape; and 2d, it and its covering, by absorbing perspiration, often become exceedingly foul. II. FITTING OF TRUSSES. To apply a truss accurately to the retention of an inguinal hernia, the patient should be first placed in the position for the taxis, and the entire contents of the tumor restored to the cavity of the abdo- men; then, whilst a finger is applied at the internal ring in an "oblique inguinal hernia," or at the external ring in a "direct hernia," place the pad at this point by slipping the spring under the patient's 1 Similar trusses may be obtained of Rorer, cutler, Sixth Street, above Market, Philadelphia. 104 OPERATIVE SURGERY. back and around the pelvis, fasten the circular strap, and, letting the patient rise, notice whether any portion of the hernia escapes by the side of the pad. If it does not, direct the patient to move about a little and cough, so as to see if the pad retains its place, or whether it is disposed to slide up, as is sometimes the case. If it does, then apply the perineal strap to bold it down; but otherwise it will not be required. Some caution is also necessary in applying a truss to the male, lest the pad be so shaped or so placed as to touch the pubis and compress the cord, thus exposing him to the danger of having one testicle atrophied. Except in a direct inguinal hernia, there is no occasion for a pad to touch the pubis; on the contrary, it should close the internal rather than the external ring. In the direct variety, or the more rare form of inguinal hernia, as the ex- ternal ring must be the point for the pressure, the pad should be always so rounded or curved on its inferior edge- that, whilst it approaches the pubis, it shall not be able to compress the cord against it. In employing a truss for the retention of hernia, some surgeons have experienced the following evils which may occasionally re- sult from the use of this instrument: thus, if a portion of the hernia escapes and is compressed by the truss, the patient will be exposed to the risks of strangulation; if it presses very firmly on the rings, it may lead to absorption of the adipose and cellular tissue around them; if it produces excoriation of the skin, it may necessitate the removal of the instrument, and do away with the possibility of making any pressure, whilst if it compresses the spermatic cord against the pubis, it will induce the atrophy of ,the testicle just referred to. A truss that is well made and properly applied will, however, be free from these objections. It may be said to be well applied if the patient feels comfortable under all movements, and has the sensation of increased strength in the part, and it will be well made if its spring is strong enough to support the hernia, without making such pressure as would indicate the position of the pad by the in- dentation left on the skin after the truss has been removed. Nor should the truss, as a general rule, be applied with the idea of in- ducing adhesive inflammation in the subjacent structures. Its object is mainly that of a supporter, which, by preventing the descent of the bowel into the inguinal canal, affords an opportunity PALLIATIVE TREATMENT OF REDUCIBLE HERNIA. 105 to the tissues to contract towards their original condition. A truss that possesses the characters that I have detailed,1 and which is constantly worn night and day, will render a patient perfectly secure from strangulation, and though I believe it will be unable, in most adult cases, to cure a hernia radically, it yet presents us with the following advantages. 1st. The pad may be readily and accurately shaped to fit the anatomical relations of the region. 2d. From its being formed of firm materials, its shape is never changed, as is the case in trusses with soft pads. 3d. The screws upon the neck, by fastening the pad of the instrument to the spring, except when shifted by a screwdriver, materially facilitate its ac- curate adjustment to the part, and insure the safety of adjacent bloodvessels. But in choosing any instrument, the surgeon should be especially observant of the force of the spring; generally they are too stiff, the cutlers having no idea but that of sufficient force " to push up the bowel," whereas a good instrument should have only sufficient power in the spring to prevent the descent of the contents of hernia, after it has been replaced either by the fingers of the patient or of his surgeon. If a spring seems to be too stiff, its power may be diminished by gently bending it backward, or from its natural curve, care being taken to apply the pressure near the neck of the instrument, and not to bend it so far backward as to break it. The selection of a truss is a subject that deserves, and has re- ceived, careful attention from a large number of surgeons, and whether we entertain a high opinion of its efficacy in effecting a radical cure, or only believe in its utility in the palliative treat- ment of this complaint, it should be well made and accurately fitted, or it will do neither. In treating hernia by a truss, I would advise, under any circum- stances, that the instrument should be applied in every case except when the complaint is met with in children under eighteen months, as from this term to eighteen years of age, the truss alone will often effect a cure, whilst the more advanced adult will be safe from the dangers of strangulation whilst wearing one, and may perhaps, after a few years, be able to lay it aside. But when a truss is once applied, the patient should be directed to wear it constantly, and especially cautioned against taking it off at night, lest he suffer from sudden strangulation, such as I once saw in a patient, who, having removed 1 See page 102. 106 OPERATIVE SURGERY. his truss on going to bed, was attacked with strangulated hernia during sexual intercourse. The further consideration of the truss will be found in connec- tion with the radical cure Of hernia, whilst the other points con- nected with the treatment of hernia will be detailed in the special account of each of the three principal classes of this complaint. CHAPTER XVI. OF INGUINAL HERNIA. In inguinal hernia, the tumor is found at the external or internal abdominal rings, after having, as in the class known as " oblique hernia," passed along the line of the spermatic cord, or of the round ligament of the uterus (inguinal canal); or at the external ring without having passed through the inguinal canal, as in the variety designated as direct or ventro-inguinal hernia, in consequence of the protrusion occurring more directly through the parietes of the belly. Inguinal hernia, when reducible, may be treated either by the palliative or by the radical plan of treatment, the entire con- tents of the sac, in either case, being carefully restored by the taxis, as hereafter directed in strangulated inguinal hernia. § 1.—RADICAL CURE OF REDUCIBLE INGUINAL HERNIA. Although after the reduction of a hernia and the application of a good truss, the patient is for the time secure from the dangers of strangulation, yet his liability to omit the use of the instrument as well as the inconvenience which sometimes ensues upon its employ- ment, has frequently induced surgeons to search for some means of closing the opening, so as to secure him permanently against the recurrence of the complaint. These means have, of course, been very varied, though generally predicated on the development of such an inflammatory action in the part as would create adhesions of the sides of the opening, or plug up the orifice through which the hernia escaped, by such articles as would remain in consequence RADICAL CURE OF REDUCIBLE INGUINAL HERNIA. 107 of their fusion with the structures around the rings. Reserving an opinion of the value of these plans of treatment until they have been enumerated, I shall now present a brief account of a few of such American and European suggestions as seem plausible or have been attended with some success. Operation of Dr. Pancoast, of Philadelphia.1—Having noticed that benefit accrued from making one or two rows of punctures with an acupuncture needle across the neck of the sac, Dr. Pancoast decided to employ some more positive means of excit- ing inflammation, which he accomplished in the following manner:— A minute trocar and canula being prepared together with a small graduated syringe well fitted to the end of the canula, and capable of containing a drachm of fluid, as well as a good truss for making compression; place the patient on his back, and, restoring the con- tents of the tumor, apply a truss accurately over the internal abdomi- nal ring, so as to keep up the hernia, and prevent even the small quantity of liquid that is to be employed as an irritant, from enter- ing the cavity of the abdomen. Then pressing with the finger at the external ring so as to displace the cord inwards, bring the pulp of the finger to bear on the spine of the pubis, and enter the trocar and canula with a drilling motion at the outer side of the finger, until the point is felt to strike the horizontal portion of the pubis near the inner side of its spine. The point being now slightly retracted and turned upwards or downwards, introduce the instru- ment further, until the freedom of its movements shows that it is fairly lodged in the cavity of the sac. Then turning it into the inguinal canal, scarify the inner surface of the upper part of the sac as well as that just below the internal ring, and withdrawing the trocar, and ascertaining by a probe that the canula is not disengaged from the cavity of the sac, apply the syringe to the end of the canula and throw in slowly and cautiously half a drachm of either Lugol's solution or of the tincture of cantharides, or of some other stimu- lating liquid, so as to lodge it just below the orifice of the external ring, when, on removing the canula, a compress should be applied above the upper margin of the ring and retained there by the appli- cation of the truss. The patient being now placed in bed for ten days, with his thighs and thorax flexed, keep him in this posi- tion, whilst as much pressure is made with the truss as can be borne 1 Op. Surg., 3d edit. p. 285. 108 OPERATIVE SURGERY. without increasing the pain, in order to prevent the viscera descend- ing and destroying the new-formed adhesions. Remarks.—Of thirteen different cases in which this plan was tried by Dr. Pancoast, there was only one who had sufficient peri- toneal inflammation to excite apprehension, and in this one it yielded to leeches and poultices. In several cases, a single operation appeared to be perfectly successful; in others, where the sac was large, or the patient less careful in using the truss, the effect was merely to nar- row the sac, a repetition of the operation being necessary, but Dr. Pancoast states that he is unable to testify to the permanency of the cure during several years, in consequence of the patient's being lost sight of. In the few who remained near him a few months, he did not see the return of the tumor though they did not wear a truss. Operation of Dr. Bowman, of Kentucky.1—A puncture being made, a syringe with a very fine nozzle was introduced, and inflam- mation of the parts around the abdominal canal and ring by the use of Lugol's solution or other articles. Dr. Bowman has employed this treatment in six or eight cases, about one-half of which were successful. Jobert, of Paris, has recently reported2 the cure of a patient by this means. Operation of Dr. John Watson, of New York.3—The patient lying on his back, with the scrotum and left spermatic cord drawn slightly to the right side, and with the integuments over the left external abdominal ring slightly on the stretch, the point of a deli- cate bistoury was introduced directly down to the crest of the pubis so as to touch without dividing the insertion of Poupart's ligament. Being then made to work freely in the loose tissue immediately in front of the ring, but without wounding the spermatic cord, the nozzle of a small syringe, charged with about a drachm of tincture of cantharides was introduced, and the liquid injected to the bottom of the cut, the hand of an assistant pressing in the meantime over the inguinal canal so as to prevent the fluid from entering it or passing through the sac into the abdomen. A compress and spica bandage being then applied and an anodyne administered, the pa- tient was kept on his back, and in a few minutes began to complain of pain, which was most severe along the spermatic cord, but by the 1 Gross, History of Kentucky Surgery, p. 90. 2 Med. News, vol. xii. July, 1854, p. 127. 3 New York Journ. Med., vol. ix. p. 200. radical cure of reducible inguinal hernia. 109 next morning had nearly subsided. Eighteen days subsequently, he was able to walk without his truss, no tendency to the protru- sion being noticed, but as he left the hospital, the future result was unknown. Operation of Dr. W. II. Roberts, of Alabama.1—Dr. Roberts employed a small silver syringe, whose canula was an inch long and terminated in a trocar-shaped steel point, near which were two small orifices for the exit of the fluid from the syringe, which would hold about fifty drops. After purging the patient freely, and administer- ing an anodyne, the operation was performed as directed by Dr. Pancoast, oil of cloves being, however, the liquid employed. In six cases reported by Dr. Roberts as treated by this operation, most of them were subsequently as bad as before. 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 removed 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 to admit three fingers to pass into the abdomen, was only reduced by the operation to about half its breadth. The integuments were now united by suture, &c. The wound suppurated very profusely, and was about six weeks in closing, owing to peculiar difficulties. Two months after the operation, a hard, insensible lump occupied the seat of the external ring, where the wire had been placed, and four months subsequently 1 Southern Med. and Surg. Journ., vol. ix. N. S. p. 133. 110 operative surgery. the patient, though engaged at hard labor, had had no return of his hernia. Operation of Dr. Jameson, of Baltimore.—Having operated for crural hernia on a lady, who subsequently had a return of the protrusion, and begged to be relieved at all hazard, Dr. Jameson operated as follows: Having, by an incision similar to that re- quired for strangulated femoral hernia, exposed the crural ring, a flap of integuments, two inches long and ten lines wide at its base, was dissected from the adjacent parts, reverted on itself, and intro- duced into the ring so as to plug it up, the wound being closed by several points of the interrupted suture. This operation cured the patient in this instance, but has not, so far as I know, ever been repeated. Operation of Gerdy, of Paris.1—A curved needle, pierced with an eye near its point and fastened to a handle, several quills for the quilled suture, some strong aqua ammonia, together with ligatures and a camel-hair pencil, being prepared, the operation is thus performed:— "Whilst the patient is lying down, the surgeon places his left forefinger under the anterior edge of the scrotum, pushes back the 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 Malgaigne. radical cure of reducible inguinal hernia. Ill first, a camel-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. The other plans of treatment are very varied; thus, Velpeau, at one period, revived the old plan of scarifying the sac, but has since abandoned it, and Bel mas introduced strips or bags of gelatine into the cavity of the sac, though it proved to be a very imperfect plan of proceeding. Bonnet, of Lyons, and Mayer, have also attempted the constriction of the canal by pins and ligatures (as in cases of varicocele), but have obtained only occasional and temporary success. The following operation is among the more recent of those pro- posed, and presents some points which are worthy of notice:—■ Operation of Dr. T. Wood, of Cincinnati.1—Having prepared a needle with the eye in the middle, and a spear-point at each end so as to enable it to pass readily in any direction without becoming entangled, place the patient on his back in bed with the pelvis ele- vated, so as to relax the tension of the abdominal parietes. The hernial sac with all its contents being then returned through the ring, pass the little finger of the left hand into the ring so as to carry before it the thin structure of the scrotum. After thus ascer- taining the condition of the ring, and being satisfied that there is nothing between the columns but the spermatic cord, carry the latter downwards and inwards, and hold it by the pressure of the finger in the angle of the ring, which is next to the symphysis pubis, and, whilst it is thus retained, thrust the point of the needle through the integuments so as to strike the inner column of the ring about one-eighth of an inch from its margin, and as near the pubes as is possible without endangering the cord either by wounding it with the needle, or by constricting it, twhen the sides of the ring are approximated by the ligature. The point of the needle being then passed through the tendon in many points, so as to excite more action, and carefully directed upwards, pass it through and across the canal (so as to avoid the cord, and also prevent its becoming entangled in that portion of the scrotum which caps the finger), until it reaches the opposite column of the ring at a similar distance from its margin, when, the side of the needle being 1 Western Lancet, vol. xii. p. 281. 112 OPERATIVE surgery. pressed strongly against the abdominal ring, the finger should be gradually withdrawn until the point of the needle can be made to reach a proper point for puncturing the tendon, when it should be thrust through and made to appear on the external surface of the integuments opposite its point of entrance. The point of the needle being now seized, and drawn carefully through until the ligature has passed through both the punctured columns of the ring, make it retrace its course as soon as its eye escapes from the tendon, so as to carry the end of the ligature through and out of the first opening made in the skin, thus placing the first end of the ligature at the puncture first made, and the last end at the opening made by the exit of the needle; after which the two ends should be tied over a compress placed between them, so as to bring the opposite columns of the ring in contact and cause their union by adhesive inflammation. After the ligature is applied and the columns ap- proximated, the patient should be kept constantly on his back, and the ligature not removed for eight or ten days, the free suppura- tion usually seen at this time facilitating the escape of the ligature, when gentle traction is made on it. Remarks.—The three cases operated on by Dr. Wood were, ap- parently, cured at the time of his report, though he desired a longer period to test the cure. The first case had then been operated on eighteen months, the second eight, and the third three months, but each continued to wear his truss. The discussion in the Medico- Chirurgical Society of Cincinnati, on Dr. Wood's paper, led to the expression of sentiments which all familiar with hernia will pro- bably admit to be reasonable, viz: that his operation, like that of Gerdy, only closes the external ring, and does not act on the internal ring or on the inguinal canal, and that though applicable to direct hernia, it is not equally so in the oblique variety. But even if this operation should accomplish nothing more than a closure of the external ring, it must prove useful in many cases, and therefore appears to me to be worthy of further examination. Its true value can only be established by its trial in numerous instances. OBSERVATIONS ON RADICAL CURE OF INGUINAL HERNIA. 113 § 2.—GENERAL OBSERVATIONS ON THE RESULT OF THE MEANS RE- SORTED TO FOR THE RADICAL CURE OF INGUINAL HERNIA. A strong desire to ameliorate the condition of those who labor under the evils of hernia, having led surgeons, as has just been shown, to investigate the possibility of effecting a radical cure of this complaint, their conclusions in respect to the results of one plan of treatment (trusses) have, in some instances, been so favor- ably received as to have led a great number of patients to believe that radical cures of hernia can be accomplished solely by the use of these bandages. The report of a committee of the Philadelphia Medical Society, appointed with a special view to the investigation of the truss of Dr. Chase,1 has often been quoted as indorsing the opinion that his truss will accomplish a radical cure; but such has never seemed to me to be the true verdict of the committee. Though believing in the advantage of employing Dr. Chase's truss in preference to many others, their report says: "That the success, in cases of umbilical hernia in young children, is almost general . . . that success in other varieties of hernia, affecting subjects (children) of similar ages, is by no means rare under the operation of trusses with soft pads; that, in children over ten years of age, it (a radical cure) becomes rather uncommon; that in youths between the age of puberty and twenty years, it (the radical cure) becomes rare, and after the latter period very rare." This committee defined a radical cure as follows: "A cure is radical when the tendinous and fascial barriers to the egress of the bowels are brought or restored to their normal or original firmness and power of resistance," to which I would add, and capable of permitting the ordinary actions of life, during three years, without the reappearance of the hernia. Under this definition, there are few cases of adults over twenty years of age that are shown to have been cured in the many works which I have consulted, and I therefore respectfully reiterate the opinion that a radical cure of a hernia (not congenital) in a patient over twenty years of age, has very rarely been accomplished by a truss. Tempo- rary relief has enabled some patients to go without the truss for a few months, but in the majority of instances, I think it will be found that the complaint has or will reappear in about eighteen months. 1 Report of Committee of Philadelphia Medical Society, Philad. 1837. VOL. II.—8 114 OPERATIVE SURGERY. Nor is this opinion solely that founded on my individual observa- tion of many of the late Dr. Chase's patients, as well as those treated by myself with his truss. Dr. T. Wood, of Cincinnati, who was a private pupil of Dr. Chase, and specially instructed in his opinions and mode of treatment, and who also saw numbers of patients treated by him, says, in an extended article on the radical cure of hernia:1 " I have seldom met with a patient who had not a hernia at the end of two years' treatment. I have much more rarely met with one that remained cured at the end of three years, and I have never knOwn one to be radically cured of a hernia at the end of four years' treatment by any means whatever. The conviction is therefore indelibly stamped on my own mind that no truss will effect a radical cure of hernia any* more than indigo will cure epilepsy, or the thousand and one corn salves will radically cure those troublesome customers that torture your toes." In thus expressly advancing the opinion that hernia is not radi- cally cured by a truss in the majority of instances after the age of eighteen years, or after the period when the patient's frame is well developed, I am fully aware that others entertain somewhat less decided sentiments on the subject, and the reader will therefore view the opinion as that based chiefly upon individual experience. It rasij be that I have been unfortunate in the selection of cases, or that I was wanting in surgical skill, but as others may be similarly situated in this respect, I humbly desire to prevent any young sur- geon from accidentally misleading his patients into the belief that the use of a truss will cure them, lest the result cause them to charge him either with ignorance or wilful deceit, and induce them to place him in the same class with the miserable characters who profess to cure all disorders. Although decided in my own views on this subject, I desire it to be understood that my opinion and that of Dr. Wood also differ from that of the committee appointed by the American Medical Association in 1852, to report on the radical cure of hernia. This committee (composed of Drs. Hayward, J. M. Warren, and Parkman, of Boston) "regard compression, when properly employed, as the most likely means of effecting a radical cure in the greatest num- ber of instances," and some of the French surgeons coincide with them. Many, however, both of the French and English school, 1 Western Lancet, vol. xii. p. 277, el supra. OBSERVATIONS ON RADICAL CURE OF INGUINAL HERNIA. 115 have dissented from this opinion; and the reader will, therefore, see that the question is by no means settled, and should so regulate his opinion as to protect himself from the suspicion of wilfully misleading his patient, by candidly stating to him the uncertainty of the result. Let the adult fully understand that whilst he wears a truss that is accurately fitted, he is as secure as he can be against the dangers of strangulation ; that his hernia will not be so liable to give him trouble as it was before the application of the truss, no matter what he may do; that whilst he wears it there is a chance of a cure, but that, in all probability, he will find it essential to his safety to wear a truss for many years, if not for life. The other means which have been resorted to in the attempts to cure 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 accomplishing it. Few, how- ever, seem to have presented unexceptionable facts, as each period appears to' have been dissatisfied with the acts of its predecessors, and to have endeavored to remedy their operations, or suggest others. The application of a ligature around the sac was advised especially by Guy de Chauliac, A.D. 1360, who directed that the sac should first be laid bare, in order to strangulate it with greater certainty at its root. The use of a leaden ligature, and the approxi- mation of the sides of the ring, as advised by Dr. Nott, present a modification of this operation, which may prove to have several ad- vantages over the old-fashioned thread and the strangulation of the neck of the sac, and, as it does not constrict the cord (being placed below it), is worthy of further trial. Of the operation of Mr. Gerdy, I have only to. say that my personal observation of some of his cases, several years since, did not induce any confidence in its ulti- mate success, whilst the plans of Velpeau, Belmas, and others, have not been sustained by general professional experience. The modi- fication of the plastic operations, also, tried many years ago bv Dr. Jameson, of Baltimore, has been well thought of, but, though the patient was benefited, I am not aware that the operation has been repeated. Summary.—Upon the whole, I incline to the opinion that though any of these operations, when followed by the use of the truss for two years, will be more likely to effect a radical cure than the truss alone, yet that the result of the operations by themselves will also be doubtful in the majority of cases. As they have, however, succeeded, 116 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 Cre- master 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 mtscles. 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 perito- neum. 4. The cord. 5. Mouth of hernial sac. After Bernard and Huette. Fig. 4. Relative position of the coverings of an old Scrotal Hernia, aa 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 albu- ginea. 2. Tunica vaginalis testis. 3. Cremaster muscle and tunica va- ginalis communis 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. 43 Fig. 3 l 4 fig. 7 -^N, ^ ; STRANGULATED INGUINAL HERNIA. 117 at least for some few months, other surgeons may deem it proper to repeat the trial. If called on to select any one method of operating, I should prefer the plan of Dr. Wood, of Cincinnati, or the use of a leaden ligature below and around the ring and neck of the sac, in a manner somewhat similar to that reported by Dr. Nott, whilst, if a more simple operation was desirable, I should resort to the use of the injection as practised by Drs. Pancoast, Watson, Roberts, &c. Many of those most experienced in the result of these operations are, it will be seen, like myself, far from being satisfied of their ability to effect a radical cure, Dr. Robert expressing the opinion,1 based on the record of his cases, that, "so far as the danger of the operation is concerned, he has yet to learn that any existed, having seen the intestines come down the day after the operation and returned without bad consequences. He has also seen the oil of cloves thrown into the sac when the omentum was there, and re- tained without trouble. Yet, since the latter part of 1847, he has had so little confidence in the operation as to have given it up, pre- ferring to rely upon the introduction of a small seton at the external ring. Dr. Wood, also, it will be seen, was not so satisfied with his success, at the date of his report, as to recommend his operation as a certain radical cure; and Dr. Pancoast was unable to testify to the permanency of the cure, owing to his losing sight of his patients. CHAPTER XVII. STRANGULATED INGUINAL HERNIA Oblique or Indirect Inguinal Hernia, in the male, consists, as before stated, in a protrusion of some of the abdominal contents through parts which have been left in a weakened condition, by the descent of the testicle from the loins to the scrotum. In the female, this form of hernia passes through the openings left for the passage of the round ligament of the uterus in its course to its insertion. When, the protrusion occurs directly through the abdominal parie- tes behind the external abdominal ring, and without following the course of the inguinal canal, it constitutes the form of the com- 1 Southern Med. and Surg. Journ., vol. ix. p. 136. 118 OPERATIVE SURGERY. plaint which has been designated as "Direct Hernia." As the oblique hernia is the most common, a reference to the changes induced upon the parts by the descent of the testicle will facilitate the comprehension of the anatomical relations of such portions as are directly connected with the operation required for its relief when strangulated. SECTION I. SURGICAL RELATIONS OF INGUINAL HERNIA. The anatomical details of the abdominal parietes belonging to special anatomy, and being generally among the elementary studies of every medical student, I shall not now enter upon a description of the muscles, fascia, &c, which compose the abdominal walls, but limit this account to a few of the points especially connected with the surgical relations of inguinal hernia. The split or opening in the tendon of the external oblique mus- cle of the abdomen, or the "External abdominal ring," is found at the point where the tendon, or ligament of Poupart, is attached to the spine and symphysis of the pubis. This opening or ring being somewhat triangular in its shape, has its base resting upon the pubis, whilst its summit is lost in the general fibres of the tendon of the external oblique. It is covered by the skin and fat as well as by the fascia superficialis abdominis of Camper, whilst the space or opening contained between its sides is filled with loose cellular tissue in the normal condition, though the existence of hernia may so thicken it as to justify the name of " intercolumnar fascia." Through this ring the spermatic cord of the male, and the round ligament of the uterus in the female are transmitted, either to the scrotum or pubis, both of them inclining very much to the outer side (outer column) of the ring. In the integuments over this ring we find a small artery and vein (arteria et vena ad cutem abdominis of Haller). Behind the ring is the common insertion of the rectus abdominis and pyramidalis muscles, which tend very much to strengthen the part and prevent, except in ventro-inguinal hernia, the descent of the bowels at this spot. Extending obliquely upwards and out- wards from this ring—for the extent of an inch and a half in the normal condition—is the space or flattened passage designated as SURGICAL RELATIONS OF INGUINAL HERNIA. 119 the inguinal canal, though, except when distended by a hernia, it cannot properly be spoken of as a canal. Behind, it is bounded by the rectus abdominis muscle and fascia transversalis, to which it chiefly owes its strength; below, by the crural arch; whilst its an- terior and inferior boundaries are chiefly due to the imperfect fibres of the internal oblique and transversalis muscles, to the tendon of the external oblique, and to the fascia superficialis and skin. Throughout its length, we find the spermatic cord of the male and the round ligament of the female, and when an oblique hernia descends through it, these structures will generally be found behind, below, and within the hernia. The upper, posterior, or external orifice of this canal is designated as the "Internal abdominal ring," or opening in the fascia transversalis, though such an opening never exists in the normal condition of the parts, as a process of the peri- toneum as well as of the fascia transversalis is extended into the canal in its healthy condition; the presence of the internal ring is therefore always due either to dissection, or to the pressure of a hernia from which its edges have become defined. On the inner side of the internal ring, when it exists, or on the inner side of the cord or round ligament, is found the Epigastric Artery, which, running vertically upwards, or nearly parallel with the fibres of the rectus muscle, has the peritoneum behind it, and the fascia trans- versalis in front of it. Through these structures, the foetal testicle and oblique inguinal hernia descend in their course from the abdo- men to the skin, and in the course of this canal must the taxis be practised, when the effort is made to restore it. 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 fascia transversalis; next, a few fibres of the transversalis muscle; then, a few of those of the internal oblique muscle, the two together constituting the cremaster muscle. Passing then through the external abdominal ring, it extends the portion of the cellular tissue which is between the sides of the ring and the fascia superficialis, and, lastly, drops into the pouch of°the skin known as the scrotum. When in the scrotum, this gland is, there- fore, covered by the skin, fascia superficialis, cremaster muscle, condensed cellular tissue (tunica vaginalis communis), and by the peritoneum (tunica vaginalis testis), and the cord has the epigastric artery bet^en the linea alba and the line of its descent (inguinal canal). 120 OPERATIVE SURGERY. Shortly after taking its position in the scrotum, the tube-like pro- cess of the peritoneum, which then extends from the scrotum to the 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 diminished 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, especially in old hernia, and take on a defined shape, thus constituting the in- ternal ring, whilst the centre is either absorbed or converted into a reticulated structure (fascia propria), and then the tumor, passing on, takes a position in front of the cord, but also a little towards the median line of the body. Being here beneath the fibres of the transversalis and internal oblique muscles (cremaster), it escapes through the external ring, pushes before it the cellular tissue which usually fills up this ring (intercolumnar fascia), and, pressing it against the superficial fascia, the two become blended in one, and there only remains the additional covering of the skin. In ope- rating upon an inguinal hernia, there are, therefore, usually found the skin, superficial fascia, cremaster muscle, fascia propria and sac, all of which must be divided before the contents of the tumor can be made apparent. The only bloodvessels about this class of tumors are the small artery and vein, before spoken of as being found directly beneath the superficial fascia, and the epigastric artery and vein, which is directly beneath the peritoneal fascia. The arteria ad cutem abdo- TAXIS IN STRANGULATED INGUINAL HERNIA. 121 minis is therefore between the fascia superficialis and the external oblique tendon, whilst the epigastric artery is between the fascia transversalis and the 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 her- nia, or that in which the protruded part does not fdllow the entire course of the spermatic cord, it may be upon its outer side. (Plate XLIL, Fig. 3.) But as the pressure of the hernia upon the peri- toneum and fascia transversalis elongates the first, and causes a thickened margin to the second, this artery is removed a line or two from the 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 iis about an inch and a half, the internal ring being about this distance exterior to the external ring, or about as much nearer to the anterior inferior spinous process of the ilium. But, in hernia, the traction caused by the protruded parts, especially in old hernia, approximates these two rings, so that one is often very nearly in contact, and also behind the other, and the epigastric artery is 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 or inter- nal 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 IN STRANGULATED INGUINAL HERNIA. Taxis, as employed for the purpose of replacing an inguinal her- nia within the cavity of the abdomen, consists in manipulating the tumor so as# to press the portion which was last protruded, first 122 OPERATIVE SURGERY. through the ring or opening at which it has passed, the remaining 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 strangulated inguinal hernia, it is essential to success that the parts concerned should be in a state of perfect relaxation, and that the patient should offer no resistance to the manipulation of the surgeon; but, as a strangu- lated hernia soon becomes painful, some little opposition may always be anticipated, unless means are taken to prevent it. The use of anaesthetics in these cases, as in those of children, before referred to, is, therefore, especially demanded, in order to obviate this resistance, as well as to relax the muscles generally. As the position of the patient also materially facilitates the operation of Taxis, he should, before being etherized, or when the latter agency is not em- ployed, 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 the portion last protruded upwards and backwards, compress the lower part of the swelling with the fingers and thumb of the other hand, in the same manner that he would squeeze a caoutchouc bottle to empty it of air. If, after a short time, the tumor diminishes in size, its base may be approximated to the sum- mit, 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 ring, and then retaining it there a few seconds. (Plate XXXIX., Fig. 6.) If, after moderate manipulation in this manner, no diminution of the swelling is perceptible, the taxis should cease, the patient be allowed to rest, or his position be changed to such a direction as might induce the intestines within the abdomen to gravitate in a different direction TAXIS IN STRANGULATED INGUINAL HERNIA. 123 from the hernia, and thus facilitate its return. If, however, a very small portion of the tumor can be replaced, the rest will usually follow; and when the protruding portion is intestine, a distinct gur- gling 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. New Method of making Taxis.1—After vainly employing the usual means of reduction, as just detailed, Dr. Wise, of India, suc- ceeded in restoring a strangulated hernia by the following plan, it having been suggested by a Mussulman gentleman, who had seen it successfully applied: "Place the patient on a table, and having folded a long sheet several times on itself, carry it around the lower part of his pelvis, twisting it on itself in front, and again at the sides, so as to enable the assistants, who stand on each side, to bold the extremities of the sheet, and pull them gently upwards, or towards the patient's head, whilst a third assistant holds the feet, and the surgeon makes the taxis. As the gut immediately above the strangulated portion is often superficial, and distended with flatus and liquid, it will be drawn upwards from the hernial sac, whilst the return of the protruded portion is favored by the taxis practised by the surgeon." If, after one or two trials of either or both of these means of making the taxis, no change is effected, then it may become a ques- tion whether it is better to resort to herniotomy 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 em- ployment 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 contents have occasionally been down before, but were reduced with some trouble, the repetition of the trial may succeed, espe- cially if cold applications are made, as before directed, to the tumor in the interval of the attempts. In recent and small 1 Western Journ. of Med. and Surgery, 3d series, p. 207, from London Journ. of Med. 124 OPERATIVE surgery. 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 cor- rectly practised, 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 re- sort to the operation is not so urgent, as it has more than once hap- pened 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 Jaas suddenly caused the tumor to disappear. With young surgeons, there is apt to be too much delay before resorting to the knife, and the force employed in the taxis is often too great. It should, therefore, be remembered that delicacy of ma- nipulation will generally succeed better than force, and that the ultimate success of the operations for the relief of the 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,"1 and was 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 moderate pressure, such as that produced by placing a pound weight on the tumor, when continued for a half hour, has frequently succeeded even when judicious taxis had failed; and it may be readily accomplished by the application upon the swelling of any substance of this weight. But the dangers of delay should always be borne in mind, even when these means are employed, though they are less likely to excite inflammation than the repeated pressure of the fingers in the taxis. 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."2 In making taxis for the relief of strangulated hernia, whether before or after the incision of the tissues, it is important that the symptoms of strangulation should disappear when the reduction is accomplished. Should they not do so, and yet the restoration of » ffiuvres Chirurgicales, as quoted by Parrish on Hernia, Philad. 1836. ' Parrish on Hernia, p. 28. REDUCTION OF STRANGULATED HERNIA IN MASS. 125 the hernia within the abdomen be certain, it may become necessary to incise the canal and seek for the constricted tumor in the abdo- men as the condition of the parts concerned in the reduction " en bloc" or "en masse" as the French describe it, requires prompt relief. In the work of Dr. Parrish, and in an article by Dr. Geo. C. Black- man,1 of New York, in the works of Cooper, Lawrence, and others, will be found many valuable details in relation to this troublesome and dangerous accident as connected with the treatment of strangu- lated hernia. | 2.__REDUCTION OF STRANGULATED HERNIA IN MASS. As death has sometimes ensued upon the employment of the taxis, in certain cases of strangulated hernia, in which, though the contents of the tumor were evidently returned into the abdomen, the symptoms of strangulation yet existed until the termination of life, the attention of surgeons was given at an early period to the investigation of the cause, and from the post-mortem appearances of these cases, it was discovered that the symptoms were the result of the return of the whole tumor into the abdomen, whilst the stric- ture existed in the neck of the sac. This condition of things was how- ever so rarely met with, that when it was first reported by Le Dran, Scarpa, Louis, and many of the surgeons of his time, denied the possibility of the occurrence. Closer investigation has, however, shown that such an accident is not so exceedingly rare as was at first supposed. Dupuytren, Breschet, and Jobert, among the French surgeons; Sir Charles Bell, Cooper, Lawrence, and Luke, among the English, and Dr. Joseph Parrish, of Philadelphia, and Cheese- man and Blackman, of N. Y., having, at different periods, noted similar cases, and called professional attention to it. Treatment.—In order to relieve a patient under these distress- ing circumstances, whether resulting from the taxis, or from an ope- ration in which the sac has not been opened, the first efforts should be directed to obtaining, if possible, the reproduction of the hernial tumor. Sometimes this is said to have been easily done; but in most of the cases reported by those whose attention has been di- rected to this complication of hernia, it has proved difficult, or even impossible; and nothing has therefore remained but to open the canal 1 Am. Journ. of Med. Sciences, vol. xii. N. S. p. 386, 1846. 126 OPERATIVE SURGERY. freely, draw out the sac, and divide the stricture which existed at its neck, an operation which has rarely terminated successfully. In order to guard against the reduction "en masse" during the opera- tion of herniotomy, the finger should be passed around the inner side of the neck of the sac, before restoring the hernia. § 3.—HERNIOTOMY IN STRANGULATED INGUINAL HERNIA. 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 sub- sequently unnecessarily exposed to a further escape of the viscera. Preliminary Measures.—Before commencing the operation, the surgeon should properly prepare such instruments as may be required, as well as the dressing. In most cases, he will find it useful to select one good scalpel, one sharp-pointed bistoury, one director, one pair of dissecting forceps, one Cooper's bistoury (Plate XXXV., Fig. 16), or one probe-pointed bistoury wrapped to within an eighth of an inch of its point, and not sharp; a tenaculum, liga- tures, 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.1 Then the hair should be shaved from around the tumor, so as to prevent its interfering with the subse- quent 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 after sunset, as is often the case, several sperm candles should be added to the other general arrangements. Three assist- ants will prove useful; one to aid the operator in his incisions, one to sponge blood from the wound, and one to attend to the etheriza- tion or to the wants of the patient. Ordinary Operation for Strangulated Inguinal Hernia.— In commencing the operation of herniotomy for strangulated ingui- nal hernia, the selection of a mode of incising the skin must depend upon the abilities of the operator. If he is dexterous, its division may ' See Smith'B Minor Surgery. herniotomy in strangulated inguinal hernia. 127 be effected by holding the scalpel in the third position, or like a pen (Plate II., Fig. 5), and cutting in the axis of the tumor from the upper "to'the lower portion. But if this is not the case, and espe- cially 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 (Plate II., Fig. 4), 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 ele- vated from the subjacent parts. Then puncturing this fold in its middle, with a bistoury, incise it by cutting from within out- wards, or the reverse, 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 the forceps, so as to form a little fold at the most prominent point of the tumor (Plate XLIV, Fig. 5), and this being nicked by pressing the scalpel against it, 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. Next, picking up another layer in the same manner, treat it likewise (Plate XLIV, Fig. 6), and proceed to divide the laminae until the contents of the tumor can be distinctly felt, or perhaps indistinctly seen beneath the serous layer or sac, the latter being more or less thickened, accord- ing to circumstances, although it never presents the shining ap- pearance of peritoneum on its outside, owing to the changes pro- duced 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 generally show the position of the cremasteric lamina, and serve as a most import- ant 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, intro- duce the director, and slit it up (Plate XLIV, Fig. 6), when the bowel or omentum will be fully displayed, the first presenting a 128 operative surgery. PLATE XLIV. A VIEW OF THE OPERATIONS PERFORMED FOR INGUINAL IIL'RXIA. Fig. 1. The first step in Gerdy's. operation for the radical cure of re- ducible 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 Iluetto. 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 scal- pel from without inwards. It may be incised from within outwards with safety, if the integuments are very thick, or there is a deposit of fat in the Cellular tissue. 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. T. 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. 8. Relations of the Intestine and Omentum in an Entero-epiplocele. 1. Intestine. 2. Omentum. 3. Director in the act of depressing the tumor so as to pass between the contents and the stricture. After Bernard and Huette. Fig. 9. Mode of dividing the stricture upon a broad director, when the constriction is too tight to permit the passage of the finger beneath it. 1. The director. 2. The bistoury. After Bernard and IIuette> Plate 44 Fig. Fig. 2 7* M Fig. 3 7 iLvlk. 'if^l Kg. Kg-8 HERNIOTOMY IN STRANGULATED INGUINAL HERNIA. 129 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 iutestines 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 sometimes difficult to tell whether the hernia has been direct or oblique, and, of course, whether the epigas- tric artery is on the outer or inner side of the neck of the sac, pass the forefinger as far up as possible, and endeavor to get the.finger- nail between the constriction and the bowel, depressing the latter by bearing 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 substituted 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 stric- ture by passing the blade flatwise along the palmar surface of the fore- finger, or along the groove of the director (Plate XLIV. Fig. 9), and carrying the point beneath the stricture, when, having accomplished this, it only remains to turn its edge directly upwards, so that it shall be parallel with the external margin of the rectus abdominis mus- cle. 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 sensa- tion of rending, turn the knife again flatwise, withdraw it, and en- deavor 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 VOL. II.—9 130 OPERATIVE SURGERY. 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 import- ant that the operator should see that the stricture is not continued by the neck of the sac, or by a cord of omentum, &c, as is some- times the case, and an instance of which is related by Dr. Parrish.1 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 in- testine, when, by ulcerating through the coats of the latter, they will be discharged per anum, whilst the opening that would other- wise have resulted, will 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 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 arti- ficial anus, the healing of which will often be accomplished by nature, or may be effected by some of the means hereafter directed. Many experienced surgeons have, however, regarded the use of this suture with distrust, Dessault and others having shown that the in- flammation which preceded the gangrene caused sufficient effusion of lymph to retain the bowel at the neck of the sac:2 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 the former have become spha- celated, then the mortified part should be ligated, and the portion beyond the ligature cut off, the remainder being left as a plug in the opening, after which the dressing may be made as before directed. Dressing.—If the operation has been promptly done, and the intestine is simply congested, the middle and upper angle of the integuments should be united by a point or two of the interrupted suture, leaving the sac in its place, a morsel of lint beino- introduced 1 Parrish on Hernia, p. 147. 2 Rid., p. 104. REMARKS ON STRANGULATED INGUINAL HERNIA. 131 into the lower angle of the wound to prevent the skin healing, and also to preserve a vent for the subsequent suppuration. The adhe- sive strips, cerate, compress, and spica bandage being now applied, the patient should be carefully placed in bed, the thigh being flexed on the pelvis by folding a pillow, and placing it beneath the ham. After-Treatment.—When the parts have been returned into the abdomen, and freed from the constriction, it generally happens that the circulation is restored, and the structure resumes its ori- ginal 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 essen- tial 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, the diet during the first week being strictly restricted to light and farinaceous articles. When three or four days have elapsed after the operation, the con- dition 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 confined to the supine posture until the part has healed sufficiently to bear the pressure of a light truss "over the compress and bandage. § 4.—GENERAL REMARKS ON THE OPERATION OF HERNIOTOMY IN STRANGULATED INGUINAL HERNIA. In the account just furnished of the operation required for the relief of strangulated inguinal hernia, the effort has been made to limit the description to such details as are most frequently demanded. Several complications have, therefore, been intentionally omitted, lest reference to them should tend to embarrass the mind of the young surgeon, and render the operation unnecessarily difficult. A few of them may however be briefly mentioned, as illustrative of the difficulty occasionally met with. Among the most common of the complications for strangulated hernia, are those which are due to the changes that take place in the sac; thus, the sac may be con- 132 OPERATIVE SURGERY. cealed by coagulated blood, especially when the taxis has been employed violently for a long period; or the distinction between the sac and the intestine may be rendered difficult by their close adhesion, or by the presence of gangrene; or the cellular tissue out- side of the sac may be heavily charged with fat, so as to add very materially to the thickness of the covering of the hernia. In one case, I estimated the thickness of the tissues through which I cut at half an inch, before I found the sac. At other times the testicle has been found involved in the tumor, or hydatids have been formed in the sac, or the omentum has been forced out and stran- gulated by a cancerous tumor of the mesentery. Sometimes there have been two sacs; sometimes a very large amount of serum, and a very small portion of intestine, &c. &c. In fact, every possible variety or departure from the formal relations of the parts, or those usually given by anatomists, in their account of the position and appearance of this region in the healthy condition, will be met with in operating. It should, therefore, be remembered that all hernias are liable to peculiarities, arising either from the duration of the com- plaint, the size of the tumor, the peculiar habit of the patient, or the means employed in the treatment (as violent taxis), or from the ex- istence of other diseases, as hydrocele, or from the hernia being con- genital, or from adhesions, or from the formation of bands at the mouth of the sac: but an examination of any of the valuable mono- graphs that have been presented on this complaint, will soon enable any medical man who contemplates the possibility of performing this operation, to obtain a knowledge of these peculiarities. I must now pass them by. 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 prac- titioner. 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 REMARKS ON STRANGULATED INGUINAL HERNIA. 13d 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 tendency to sphacelus. The division of the stricture without opening the sac, has been sanctioned by Mr. Key, Liston, Gay, Teale, Luke, and many of the English school who have reported very favorably of it; thus, Teale reports 32 cases operated on without dividing the sac, of which 27 recovered; and Mr. Gay reports1 125 operations in which the sac was not opened, and of these 73 recovered; whilst in 73 in whom it was opened, 13 died. The dangers likely to result from reduction in mass, should however be remembered as militating against the advantages of this mode of operating, and the propriety of it, as an operation to be adopted by an inexperienced surgeon, is deemed by many others a matter of doubt. Thus, Chelius* says " that the mode of operating in which the hernial sac is not at all opened, is in general to be rejected, or specially confined to cases in which it is certain the strangulation is seated in the abdominal ring, as in a recently produced, or very large rupture." Sir Astley Cooper, though advising this practice in large ruptures, after divid- ing the stricture at the neck of the sac, does not recommend it as a general rule. Lawrence prefers opening the sac, and Mr. South3 does not think any great advantage gained by not opening the sac, as he coincides with Mr. Lawrence in the opinion that the perito- nitis originates in the congestion near the seat of stricture, and that its dangers are not enhanced by the incision made into the sac in the restoration of hernia. The greatest objection to it is the risk that is always run of reducing the hernia "in mass," when, if stran- gulated 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, as stated by Mr. South, and only to be thought of in ruptures with recent strangu- lation from the ring. In strangulation by the sac, it is not appli- cable. It has, however, been accomplished in recent cases of stran- gulation at the external ring by Dr. Pancoast, of Philadelphia.4 1 Brit, and For. Med. Chirurg. Rev., No. IV. p. 167. 2 Chelius's Surgery, by South and Norris, vol. ii. p. 303. 3 Ibid., p. 307. 4 Trans. Am. Med. Assoc, vol. iii. p. 373, 1850. 134 OPERATIVE SURGERY. § 5.—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 HERNIOTOMY IN STRANGULATED INGUINAL HERNIA. South' Astley Cooper2 Geoghegan3 Lawrence4 Brand5 Percival Pott6 Scarpa7 Richter8 reports ...... 8 cases. 11 3 9 2 1 7 1 42 CURED. DIED. ARTIF ANUS 6 2 8 2 1 2 1 5 4 1 1 1 0 6 1 1 0 30 11 From this it appears that, out of forty-two cases of strangulated inguinal hernia, which were operated on, more than two-thirds recovered. CHAPTER XVIII, FEMORAL OR CRURAL 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 under Poupart's ligament. On reaching this 1 Chelius, by South, vol. ii. p. 312. 2 Treatment and Anat. of Inguinal Hernia. 3 Commentary on Treatment of Ruptures, by Ed. Geoghegan. 4 Treatise on Ruptures. 6 Chirurgical Essays. 6 Treatise on Ruptures. 7 Treatise on Hernia ; also Arnaud. 6 See Scarpa, anatomical relations of femoral hernia. 135 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 apon- eurotic expansion which covers the muscles of the thigh (fascia lata femoris), it takes a position a little below the line of the groin. The contents of this tumor, like that described in the preceding chapter, may be either intestine or omentum, the latter being the least common, though, from the position of the caecum, a portion of the large intestine has occasionally been found in the sac on the right side, and in one case, reported1 by Dr. Van Buren, of New York, even on the left side, instead of the smaller bowels, as was the case in inguinal hernia. Femoral hernias are most common in females—are usually smaller than inguinal tumors—are always found beneath, and not above, the line of Poupart's ligament- spread sideways as they increase, and have their greatest diameter to correspond with the oblique line of the groin. 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 mus- cles, covered by a condensed fascia, which, as it follows the course of the first named muscle, is hence called the iliac fascia. Anteriorly, we find the portion of the 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 this insertion (Gimbernat's ligament), forming the boundary of the opening for the passage of the femoral vessels (femoral or crural ring). The attachment of the anterior parietes of the abdomen to Poupart's ligament, and the continuity of these parts with the fascia of the thigh, constitute the remainder of the structures forming the front of this region. Of these, the extra-peritoneal fascia (fascia transversalis), in its course behind the abdominal muscles, is brought so closely in contact with the fascia covering the iliae muscle, as to adhere to it, the two (iliac and transversalis fascia) sending a pro- 1 See Bibliographical Index, p. 106. 136 OPERATIVE SURGERY. longation of their structure upon the course of the femoral vessels, and thus forming the commencement of their sheath. As the ab- domen 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 of the fascia transversalis in front, has given to the portions of these tissues which surround the vessels, the name of "infundibular fascia." It will, now, be readily seen that, as Poupart's ligament forms an arch in stretching from the anterior superior spinous process of the ilium to the pubis, there would be a considerable space between it and the bones (Plate XLV, Fig. 1), were it not filled up by the iliacus internus and psoas magnus muscles, and their fascia. These parts, by diminishing the distance between the anterior spinous process and the pubis, leave merely an opening for the vessels (crural ring), which is bounded behind and exter- nally by the iliac muscle and fascia, internally by Gimbernat's liga- ment, 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 adhesions of the surrounding parts, together with the 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 lym- phatic glands of the part, and when the tumor thus formed escapes from the abdomen into the course and sheath of the femoral vessels, it has no other covering except the integuments. As the psoas and iliacus 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 ANATOMICAL RELATIONS OF FEMORAL HERNIA. 137 beino- next to it, and the femoral artery outside of the vein. (Plate XLV, Fig. 4.)' If the sheath of the femoral vessels was perfect, the tumor would continue to be covered by it, but in order to admit lymphatic 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 opening), where this vein enters, the tumor escapes (Plate XLV, Fig. 3), and thus getting outside the fascia lata, lies directly be- neath 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 Fascia, 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, there- fore, 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 apparent to any one who will look for them. From the looseness of the cellular tissue between the fascia su- perficialis and the fascia lata femoris near the pubis, this hernia is most apt to rise upwards towards the groin, instead of following the downward course of the saphena vein, and it therefore approaches the outer and lower edge of Poupart's ligament. The relations of the different parts in this region are usually simple. At the crural ring, counting from the outside of the pelvis- 138 OPERATIVE SURGERY. (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 di- rectly beneath Poupart's ligament, we also usually find the epigas- tric 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. These arteries have, however, sometimes arisen by a common trunk, and passed anterior to the sac before they divided.1 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. In twenty-one preparations of crural hernia, Sir Astley Cooper found the obturator artery pass- ing into the pelvis on the outer side of the neck of the sac, and therefore entirely out of the risk of injury. " The femoral vein runs on the outer side of the sac, about half an inch from the centre of its orifice. Half an inch beyond the vein and exterior to it is the centre of the External Iliac artery. The Epigastric artery arises from the external iliac, about three-quarters of an inch from the centre of the sac, and, as it passes forwards and up- wards, it approaches this point about a quarter of an inch nearer." The spermatic cord, or the round ligament, passes about half an inch anterior to the mouth of the hernial sac, being first situated on the outer side, and afterwards crossing its forepart.2 The divi- sion of any stricture at these parts should, therefore, be made very slightly, but directly upwards, and at the middle of the ring, espe- cially 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. AVomen being, however, by far more subject to this form of hernia than men, the division of the stricture upwards, and a very little in- 1 Cooper on Hernia. 2 Ibid. TAXIS IN FEMORAL HERNIA. 139 wards, may be practised without injuring any artery, unless the obturator is very peculiarly placed. But as variations are occa- sionally 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 fo be nicked, or the tissues around it, before making any incision at the ring. SECTION II. OPERATIONS FOR THE RELIEF OF STRANGULATED FEMORAL HERNIA. The operations for the relief of strangulated femoral hernia, like those described in the other forms of hernia, consist in the Taxis, in those attempted for the radical cure, as in the operation of Jameson, quoted in the Badical Cure of Inguinal Hernia, p. 129, and in the division of the stricture, or herniotomy. § 1.—TAXIS IN FEMORAL HERNIA. The general details of the performance of the taxis having been already given in connection with inguinal hernia, it is only neces- sary 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, permitting the tumor to expand more readily towards the anterior inferior spinous process of the ilium, than in any other direction, 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 behind. By adducting the limbs or carrying the affected limb a little towards 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 140 OPERATIVE SURGERY. favorable a position as possible. Therefore, when the patient is thus placed, and well etherized, it only remains for the surgeon to press the tumor gently downwards and inwards, in the line of the saphena vein, in order to free the hernia from the projecting edge of the falciform process of the fascia lata, or that portion which, after covering the sartorius muscles, is extended towards the pubis in order also to cover the pectineus muscle, and then, with the fingers of the other hand, to push it upwards in the line of the femoral vessels. (Plate XXXIX, Fig. 7.) The tightness 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. Less effort should also be made in the taxis of this form of hernia than in the preceding class, and when the tumor does not readily yield to the judicious application of the means before mentioned, the operation of herniotomy should be promptly resorted to in order to divide the stricture. § 2.—TRUSSES IN FEMORAL HERNIA. The directions for the application of a truss for the retention of a femoral hernia do not differ materially from those already fur- nished in connection with all classes of hernia, and detailed in the general account of them.1 Every truss should possess the cha- racters there given, and be applied on the general principles there laid down. As the shape of a pad for femoral hernia differs, how- ever, from that required in the inguinal class, it may prove useful to -call attention to the variations noticed between these two kinds of trusses. In the truss for femoral hernia, as the spring has to go round the pelvis in the same position which it occupied in inguinal hernia, whilst the seat of the protrusion is somewhat lower in the groin, and also a little more outwards, it becomes necessary either to bend the point of the spring more downwards and outwards, or to attach the pad to it by means of a different shaped neck. As femoral hernia also protrudes beneath Poupart's ligament, whilst the ingui- nal variety was found above it, the force which acts upon the femoral 1 Page 103. HERNIOTOMY IN STRANGULATED FEMORAL HERNIA. 141 pad must be applied more directly upwards. The femoral pad should, therefore, be so shaped as to fill in the depression in the line of the groin as well as adapted to the inequalities of the thigh between the pectineus and sartorius muscles. With a pad formed as directed for inguinal hernia, but with its long diameter rather vertical or oblique than transverse, and so attached to the spring that it will press more directly upwards than backwards, the thigh strap may be dispensed with and the hernia retained with much less difficulty than in inguinal hernia, as there are in this spot less bony inequalities than are found nearer to the pubis. The radical cure of femoral hernia by an operation has seldom been attempted, owing to the proximity of the femoral and epigas- tric vessels, as well as the other peculiarities of the sac, &c, in this region. § 3.—HERNIOTOMY IN 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 nearly corresponding with the line of the groin, the incision being extended from the groin to a point a few lines below the lowest part of the tumor, either by picking up a fold of integument and dividing it with the bistoury by transfixing it, or if the 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 J., so as to dissect off the two flaps laterally. The saphena vein being behind and at the outside of the tumor, is not likely to be involved in this manner of operating. 142 OPERATIVE SURGERY. PLATE XLV. PARTS CONCERNED IN THE OPERATION OF FEMORAL HERNIA. Fi5op water, and xs%r} a tumor) is one strictly applicable to any accumulation of serum within the scrotum. A serous infiltration of the scrotal celullar tissue, such as is seen in dropsy, might, therefore, be considered as a Hydrocele were it not that usage has limited the name to such collections of serum as are entirely within the sac of the tunica vaginalis. When, by a careful examination, the presence of serum in this sac has been positively established, its evacuation may be readily accomplished, by a puncture of the cavity with a trocar or lancet; but, as the simple evacuation will not prevent the reaccumulation of the secretion, it is generally necessary to combine with it the pro- duction of such inflammatory action as will lead to the obliteration of the cavity by adhesion of its sides. The first, or the simple eva- cuation of the liquid, constitutes the palliative operation; the other is designated as the curative. I. TREATMENT OF HYDROCELE BY INJECTION. To accomplish the cure of Hydrocele by this means, there should be prepared two bowls, one empty, and the other containing the sub- stance to be injected; a moderate-sized trocar and canula; a syringe with a nozzle capable of fitting the canula; and such an irritating fluid as may be deemed most appropriate for the injection, such as HYDROCELE. 235 port-wine and tepid water, a solution of sulphate of zinc, or corro- sive sublimate and lime-water, or a solution of nitre, the latter hav- ing proved effectual in the hands of surgeons from an early period. The experiments of Velpeau' having shown the great advantages possessed by the diluted, or even the pure tincture of iodine, over most of the other articles, most surgeons now resort to it alone, and obtain a cure in about twelve days. Operation.—After being satisfied of the position of the testicle and the presence of the fluid, the patient should be made to sit upon the edge of a bed, table, or chair, with his thighs widely separated, or else permitted to lie on his back in bed with the limbs in the same position. The surgeon, then seizing the tumor with his left hand, and compressing it so as to render the tissues perfectly tense (Plate LIL, Fig. 11), takes the trocar and canula, and punctures the swelling in front, but a little below its middle, directing the point of the instrument upwards and obliquely backwards and outwards, in order to avoid the testicle, which is generally situated behind, below, and towards the raphe-, though occasionally it is in front or at the top of the swelling, where its position may be readily told by the sensibi- lity shown on compression of the part. As soon as the free motion of the point of the instrument shows that it is within the cavity of the tunica vaginalis, the assistant should hold the empty bowl, and the surgeon, retaining the canula in his left hand, should withdraw the trocar with the right, and allow the liquid to escape. After the evacuation is completed, the nozzle of the syringe, charged with the injecting fluid, should be adapted to the canula, and the liquid in- jected by an assistant, whilst the surgeon, retaining the end of the canula in its position, takes especial care that the liquid is not thrown into the cellular tissue of the scrotum instead of the vaginal cavity. After creating sufficient pain to render the patient slightly faint and cause uneasiness in the lumbar region, the liquid may be allowed to escape, the canula withdrawn, and the patient placed in bed with the testicle supported. After-Treatment.—As the object of this operation is to induce adhesion of the sides of the tunica vaginalis, care is required to guard against too much inflammation, and a moderate antiphlogistic treatment may therefore occasionally be demanded. After the lapse of about ten days, moderate compression by a bandage, or by ad- 1 Velpeau, Op. Surg., by Mott, vol. iii. p. 717. 236 OPERATIVE SURGERY. hesive strips, will prove useful by approximating the sides of the inflamed cavity and favoring adhesion. Should the lymph, which is sometimes effused into the adjacent parts, leave the testicle con- siderably enlarged after the operation, the induration may be made to yield to the use of iodine or mercurials. II. CURE OF HYDROCELE BY THE SETON. Operation.—Puncture the tumor with a seton-needle and strand of silk; allow the silk to remain until it excites sufficient inflamma- tion ; and then withdrawing it by a few threads at a time, so as to leave one or two to secure the continuance of the opening, pursue the treatment just referred to. Sometimes the trocar and canula are made to enter the tunica vaginalis from belowr, and pass out of the scrotum above, when, the trocar being withdrawn, a probe, armed with silk, will readily carry the seton through the canula; and, the latter being withdrawn, the seton will be left in position. III. TREATMENT BY INCISION. Operation.—Puncture the tumor from above downwards with a sharp-pointed bistoury, and, introducing the forefinger or director into the cavity, enlarge the opening downwards. After which, charpie, lint, or balls of dough may be placed in the cavity to excite irritation, and left there until discharged by suppuration. IV. TREATMENT BY EXCISION. This is the same operation as the preceding, except in the removal of a portion of the vaginal tunic either with the scissors or knife. Remarks.—The operation for the relief of hydrocele, though apparently simple, occasionally fails to evacuate the liquid, or does not accomplish a cure. The first is usually the result of carelessness on the part of the operator, and may arise from an error of diagnosis, or from his not rendering the tumor sufficiently tense to cause the trocar to punc- CASTRATION. 237 ture all the tissues instead of passing between the scrotum and the tunica vaginalis; and such an accident is by no means rare, as I have more than once seen the puncture made, the trocar withdrawn, and yet no fluid escape. If the tunica vaginalis is thickened, or slightly ossified, or if the sac is not rendered tense by compression, or if the trocar is not sharp at its point, or if the canula is not well adapted to the shoulder of the trocar, the perforation of the sac may fail, and the tunica vaginalis be pushed back before the instrument instead of being punctured. The evacuation of the fluid, and the consequent contraction of the scrotum, are also liable to displace the point of the canula, so that, on attempting the injection, the fluid passes with difficulty, and, instead of affecting the vaginal cavity, infiltrates the scrotum, and induces sloughing or gangrene. Every precaution should, therefore, be employed to prevent such mishaps in this apparently easy operation. In the selection of a plan of treatment, I usually prefer a combination of the injection with the seton, leaving a single thread in the cavity for several days in order to insure a vent for any liquid which may accumulate, and thus prevent the approximation of the walls of the cavity. By this method, I have never had occasion to repeat the operation, and when aided by the subsequent application of adhesive strips, as em- ployed in orchitis, have usually obtained a speedy cure. § 2.—CASTRATION. The removal of the testis, although a comparatively easy opera- tion, is one that should not be performed without serious deliberation, and only resorted to when such degeneration is found as establishes the uselessness of the organ beyond a doubt, or the risk of further contamination of the system by its existence. In order to avoid the removal of the gland, ligature of the spermatic artery, or the excision of the vas deferens, has been practised by Maunoir and Morgan, of Europe, and Jameson, of Baltimore; but in the cases where these means would be advisable, it may be doubted whether castration would not be preferable, because it accomplishes the same object more effectually. Operation of Castration.—The operation of castration consists in incising the scrotum so as to free the testicle, and in the division 238 OPERATIVE SURGERY. of the cord. The exposure of the gland may be effected either by a simple linear incision, or by an elliptical cut so as to permit the removal of a portion of the skin. The division of the cord may be accomplished either by inclosing all its structure in a ligature, and excising the portion below it, or by separating the vas deferens, ligating the cord, and then dividing it by a sweep of the knife. As the selection of either mode must be regulated by circumstances, I shall refer only to the following one, which is adapted to the ma- jority of the cases which demand the operation, and especially to those where the tumor has attained some size, or where the skin is either diseased or superabundant. Operation.—The patient being placed upon his back, and the parts shaved of hair, the surgeon should seize the tumor in his left hand, with the palm presenting anteriorly, and force it towards the front of the scrotum, or an assistant may hold it so as to render the skin tense. Then, commencing an elliptical incision through the skin a little below the inguinal ring, let him continue it below the tumor, or to the inferior part of the scrotum, so as to insure the escape of pus, the two halves of the incision being made to include as much of the scrotum as it is desired to remove. Then, seizing the margin of either half, dissect off its loose cellular tissue from around the tumor, until the latter can be turned out of the pouch (Plate LIL, Fig. 10). After isolating the cord from the surrounding parts, feel for the vas deferens, which may be told by its cartilaginous consistence, and with a few longitudinal touches of the scalpel, separate it from the cord. Pass a ligature around the remaining portion, draw it firmly, tie it in a double knot, allow the ends to remain, and then divide the entire cord below this ligature. Dressing.—In order to insure a vent for the pus that will subse- quently collect in the scrotum, introduce a small piece of lint or linen into the lower angle of the incision, unite the centre of the wound by a stitch, and close its upper angle by adhesive strips. STONE IN THE BLADDER. 239 CHAPTER II. STONE IN THE BLADDER. Pathology.—The development of urinary calculi in the bladder of the male may be the result of various causes, though most fre- quently it is due to such derangement of the general system, and especially of the function of the kidney, as leads to the formation and deposit of sabulous matter in the bladder, till, by the continual increase and agglomeration of particles, it results in the production of a mass termed a Calculus. These calculi may vary in size from a bullet to that of the diameter of the pelvis, though most commonly they weigh from two to sixteen drachms, those which are heavier than this being rare, and those which are smaller being designated as "pebbles." As all calculi differ in size, so they also differ in composition and hardness; those containing a large proportion of oxalic acid being the most resisting. The scientific treatment of these formations requires a minute investigation of all the functions of the body, as the permanency of the cure depends upon the correctness of the surgeon's knowledge of the cause. Every possible means should therefore be resorted to, in order to learn all the peculiarities of the case, the microscopic and chemical characters of the stone being examined with the utmost accuracy. At present, however, I can only hint at this, and must refer those desirous of information on the more detailed pathology of the complaint to the elaborate trea- tise of Dr. Gross, of Louisville,1 or to that of Civiale.2 Two operations have been suggested for the removal of calculi from the bladder, and the relief of the symptoms created by its pre- sence, the one (Lithotomy) consisting in making an incision through the neck of the bladder by perforating the perineal structure; the other (Lithotripsy) being accomplished by instruments introduced into the viscus through the urethra, by means of which the stone 1 On Diseases of the Urinary Organs, Philad. 1851. 2 On the Medical and Prophylactic Treatment of Stone and Gravel, by Civiale, M. D. Translated from the French by Henry H. Smith, M.D., Philadelphia, 1841. 240 OPERATIVE SURGERY. PLATE LIII. INSTRUMENTS EMPLOYED IN LITHOTOMY. Fig. 1. A strong round-bellied scalpel for the first incisions of the peri- neum. Schiveley's pattern. Fig. 2. A sharp-pointed bistoury, to open the membranous portion of the urethra, and expose the groove of the staff, as it will do it better than the scalpel. In using it, the membranous portion of the urethra should be punctured as near to the prostate as possible, and then laid open from behind forwards. Schiveley's pattern. Fig. 3. Dupuytren's double Lithotome cache. 1. The beak adapted to the groove of the staff. 2,3. The blades expanded laterally, but shutting up in the body of the lithotome. 4. The lever for expanding the blades. 5. A screw to regulate the expansion of the blades. Charritre's pattern. Fig. 4. A side view of Physick's Cutting Gorget, the blade being de- tached at pleasure from the handle. 1. The handle. 2. The stem-beak. 3. The cutting edge. 4. The screw to fasten the blade to the beak and handle. Schiveley's pattern. Figs. 5, 6, 7, 8 represent other blades, which may be adapted to the same handle, and selected in reference to the width of the perineum in each patient; they vary from one-fourth of an inch to one inch, increasing by fourths or eighths, at the option of the operator. The size and angle of the blade and handle are similar to that of the common gorget. The length from the beak to the angle of the handle is four and a half inches, and the handle is four inches. As the blade can be readily detached, it may be perfectly and readily sharpened, and made to cut directly up to the beak of the instrument. Fig. 9. Barton's Stone Forceps with fenestra to diminish the expansion of the blades when holding the stone. Schiveley's pattern. Figs. 10, 11. The ordinary Stone Forceps, of different sizes. Figs. 12, 13. Different forms of the Scoop. Schiveley's pattern. Fig. 14. Earle's Forceps, for crushing calculi, which are too large to be extracted whole. 1. The screw to close the handles. Schiveley's pattern. Fife- 4- SURGICAL ANATOMY OF THE MALE PERINEUM. 241 is broken into particles of such a size as permits their being voided with the urine. In the selection of either, the surgeon should be mainly guided by the peculiarities of the case. If the patient is in feeble health, with disordered digestion, with a diseased bladder, and thickened, muddy, or muco-purulent urine, lithotomy may present the best chance; but if the stone is soft and friable (as may be told by the sensation given to the sound), if the bladder is apparently healthy, and the general constitution not much impaired, lithotripsy should be selected, as being attended with less risk, and also as least likely to give rise to trouble in the execution of the function of the blad- der and testicles, at a subsequent period. The operation of incising the male perineum and extracting a calculus has always been regarded as one of the most important efforts of an operator, and the anatomical relation of the parts cannot, therefore, be too often referred to by those contemplating its execution. SECTION I. SURGICAL ANATOMY OF THE MALE PERINEUM. The Perineum (*?pt around, and v«>; a temple) is formed entirely of such soft tissues as fill up the inferior outlet of the pelvis, and has in the male no openings except those for the urethra and rectum. In its general outline, the perineum may be limited to the space included between the bones forming the inferior strait of the pelvis, though for the purposes of regional anatomy, it has sometimes been circumscribed yet more, by being described as " the isosceles tri- angular space formed by the bones of the arch of the pubis, and by a line drawn transversely from the tuberosity of one ischium to the other in advance of the anus." The tissues entering into the composition of the perineum are the skin, superficial fascia, loose cellular tissue, loaded with fat, and varying very much according to the general condition of the patient, the perineal muscles, the triangular ligament or middle perineal fascia, and the deep or pelvic fascia. In the middle of this region, as thus bounded, we should notice that the larger triangular space above described can be readily VOL. II.—16 212 OPERATIVE SURGERY'. subdivided into two equilateral triangles by the raphe", this line being the boundary of the symmetrical organs found on each side. Of these organs we should note the root of the corpus caverno- sum, the erector penis muscle, the transversus perinei, and some- times the transversus perinei alter, part of the levator ani, or muscle of Wilson, as well as the branches of the internal pudic vessels and nerves. In the middle line of the perineum, we also find, in addition to muscle, the skin and fascia, the accelerator urina3, the sphincter ani, the bulb of the urethra, its membranous portion, the triangular ligament, the rectum, prostate gland, and orifice of the neck of the bladder. The dimensions of the perineum in man have been carefully stu- died by surgical anatomists in order to decide how large a calculus can be extracted through this part. According to Dupuytren, the transverse diameter of the perineum varies from two to two and a half inches, whilst its depth, or antero-posterior diameter, is about four. The distance of the peritoneum from the skin on a level with the recto-vesical depression between it and the verge of the anus varied from two inches and eight lines to three inches and six lines, as examined upon twelve subjects, and from the mucous surface of the neck of the bladder to the raph£, ten lines in advance of the anus, it was from two inches to two inches and eight lines.1 The relative position of the prostate gland, and its capacity for dilatation, have also been accurately studied in consequence of its necessary division in the extraction of calculi through this region. According to Velpeau,2 the prostate gland is situated about eight lines from the symphysis pubis, and its sides about an equal dis- tance from the rami of the pelvis. " The transverse incision on one side of the prostate, as ascer- tained by the measurement of the gland by Mr. II. Bell, in more than forty subjects, can only be about ten lines in length, give an entire opening of two inches and nine lines in circumference, and allow of the exit of a spheroidal body ten or eleven lines in dia- meter. The oblique incision downwards may be from eleven line3 to an inch long, create an opening three inches and a line in cir- cumference, and be large enough for a calculus one inch in dia- meter. 1 Blandin, Anat. Topograph., p. 383. 2 Anat. Chirurg., tome 2mt, p. 236. OPERATION OF PERINEAL LITHOTOMY. 243 " When the prostate is incised on both sides, the transverse inci- sions being each nine or ten lines long, there will be an opening four inches five lines and a half in circumference, which will, there- fore, permit the extraction of a calculus one inch and a half in dia- meter. Two perfectly oblique incisions form an isolated triangular flap, the base of which is one inch and three-fifths in extent, lays bare, when the flap is lowered in front, a triangular opening alto- gether a little less than four inches, and consequently less than the transverse opening. An oblique incision to the left side eleven lines, or an inch long, and another transverse one to the right ten lines long, permits the largest opening, and with the dilatation of the urethra, give an opening of four inches and eight lines, whilst it is one which can be easily expanded. This last is the incision preferred by Mr. Senn."1 The membranous portion of the urethra is ten lines long, and is situated behind the triangular ligament, and in front of the pros- tate. The bulb of the urethra is attached to the anterior face of the triangular ligament, is formed by a spongy or erectile tissue, which is nearly deficient in children, fully developed at puberty, and is longer than its width in old men.2 The transversus perinei artery supplies the bulb of the urethra, and passes to it fourteen lines in advance of the anus. The branches of the venous vesical plexus, which surround the neck of the blad- der, lie outside of the prostate in the thickness of its sheath. SECTION II. OPERATION OF PERINEAL LITHOTOMY. Perineal Lithotomy may be performed in three ways: in one, the incision opens the membranous' portion of the urethra and the pros- tate on the left side of the perineum, and is called the Lateral ope- ration; in the second, both sides of the prostate gland are divided, constituting the Bi-Lateral operation; and in the third, it is divided in the line of the raphe', and is, therefore, termed the Median operation. 1 Malgaigne, Op. Surg., Philad. edit. p. 497. * Blandin, p. 386. 244 OPERATIVE SURGERY. § 1.—PREPARATORY STEPS. Before proceeding to employ any of the means that are proper, as preliminary measures, in the operation of lithotomy, it is essen- tial that the presence of the stone be positively established. I. DIAGNOSIS OF STONE IN THE BLADDER. Various symptoms have been recorded by surgical writers as pathognomonic of the existence of a calculus; but, though useful as aids in diagnosis, they cannot be relied upon by themselves; sounding, or the direct contact of an instrument with the stone, being the only certain sign of its presence. Sounding.—To prove the existence of a stone by sounding, the surgeon should select two steel sounds of different curves, and with smooth polished handles, warm and oil them, and then introducing first one and then the other into the bladder in the manner directed for catheterism, move its point about until he can cause it to touch the calculus, when the sensation which will be communicated to the fingers will prevent a mistake. The advantages of employing sounds with different curves will be found in the facility with which the smaller curve may be made to sweep the bas-fond of the blad- der, when the greater convexity of a more curved instrument might enable it to pass over the stone without touching it. When a sound is in the bladder, its point should be gently turned from side to side as well as to the top and bottom of the viscus, lest the stone be encysted. In order to obtain an accurate touch, the broad handle of the sound-should be perfectly smooth, and held between the thumb and forefinger, so as to obtain as great a surface of contact as possible. By attaching a flexible stethoscope to the handle of the sound by means of a little clamp, the sense of hearing may also be made to aid materially the diagnosis. On the part of the patient, there are also certain circumstances which are favorable to the establishment of a diagnosis by these means. Thus the bladder, at the time of sounding, should hold sufficient water to keep its sides moderately distended. When, therefore, the patient has urinated a short time previous to the visit PREPARATORY STEPS IN PERINEAL LITHOTOMY. 245 of the surgeon, a silver catheter should be first introduced, and about twelve ounces of tepid water slowly injected, so as to distend the bladder, and prevent its closing on the instrument. If, after sounding with the bladder in this condition, a stone cannot be felt, the fluid may be allowed to escape, or be voided by the patient, in order that the contraction of the bladder may bring the stone in contact with the instrument. Small calculi in patients with dis- eased prostate are also sometimes difficult to detect, unless the finger is introduced into the rectum; and the same manoeuvre will often prove useful in other cases. A change in the position of a patient sometimes renders the presence of a stone apparent, by causing it to touch the sound; thus, after lying on the back, a po- sition first on one side and then on the other, cautiously taken, will often cause the instrument to touch it; and, in two instances, Dr. Physick succeeded in thus detecting a stone where other means had failed, the patient being placed in one instance so nearly on his head that the fundus of the bladder became the most depending part.1 The record of cases in which patients have been cut, without the operator finding any stone, as well as the history of those whose bladders contained large calculi, the presence of which had not been detected during life, are sufficiently numerous to lead every ope- rator to use the utmost caution in sounding his patient. Thus, a fibrous tumor, attached to the prostate gland by a slender pellicle, is reported by Velpeau2 to have been mistaken for stone; whilst Dessau It, Cheselden, S. Cooper, and Velpeau3 cite other cases where even large stones existed without being recognized. By a resort to Anaesthetics, many of the former sources of difficulty can now be removed, so that one familiar with the changes of structure liable to be produced in the bladder by disease can hardly fail, with proper care and repeated examinations, to satisfy himself fully of the attual condition of the viscus. In addition to the knowledge gained, by sounding, of the pre- sence of a stone, the operator should also learn the probable size, consistence, number, and position of the calculi, all of which will materially aid him in deciding upon the kind, as well as the steps of the operation, that may be required for its removal. 1 Dorsey's Surgery, vol. ii. p. 179. 2 Mutt's Velpeau, vol. iii. p. 888. a Qp ci[aLf vol> ^ p g91_ 246 OPERATIVE SURGERY. § 2.— CONSTITUTIONAL TREATMENT. The presence of the stone being in most instances the cause of much of the suffering and general constitutional disturbance seen at this period of the complaint, it might be supposed that its prompt removal would afford the best chances for a recovery; but expe- rience has firmly established the fact that the greatest success attends such operators as have first carefully watched the prepara- tion of their patients. To accomplish the proper preparation of a patient for the opera- tion of lithotomy requires a correct judgment and the combination of the highest medical with the best surgical experience, as the means must vary in different cases: but in every instance the pa- tient should be placed in as healthy a condition as possible. He must, therefore, neither be too much depleted nor stimulated, whilst every secretion should be noted, in order to tell the proper condi- tion of his whole system. As a general rule, it is beneficial to evacuate the bowels thoroughly, but gently, before operating; to obtain perfect rest; to have the mind free from anxiety, and to place the digestive and thoracic viscera in a good condition by means of alteratives, sedatives, and diaphoretics. No better means can be resorted to for the relief of the train of symptoms that have been termed a "fit of the stone" than the free use of alkaline and diluent drinks; the hip-bath; anodyne enemata; and the occasional inhalation of ether. I have in several instances afforded much relief simply by administering boluses of the following alkalies and diuretics:— B. Saponis Hispan., Carb. sodae exsiccat., aa 3j; 01. juniperi gtt. lx. M. Et ft. mass dein in pil. xii dividend. S. One every four hours. In cases of gravel, the same formula, by neutralizing the uric and lithic acid, has caused the evacuation of such an amount of sand as induced patients to think the stone was being dissolved. LOCAL PREPARATORY MEANS IN LITHOTOMY. 247 § 3.—LOCAL PREPARATORY MEANS. The local preparatory measures required in lithotomy refer both to the part of the body to be operated on, and to the apartment selected for the performance of the operation. The perineum of a patient about to be cut for stone should in all cases be perfectly cleansed and shaved, in order to avoid the irritation liable to be caused after the operation by the adhesion of unhealthy discharges to the hair of the part. The rectum should also be thoroughly emptied by a laxative enema, and then put at rest by the use of an anodyne, but the bladder should be kept nearly full, either by inducing the patient to retain his urine, or if this cannot be done, or if the secretion is deficient, by injecting tepid water as directed in sounding. In selecting a room, it is important to have one that is well venti- lated, and with a good light falling either from above or from one side; to have a firm narrow table, and sufficient stands or tables for the reception of instruments, &c. After selecting the table, it should be covered by a mattress and pillows, the end of the mattress being doubled under and tied or pinned firmly together, so as to elevate and support the hips. Over this should be placed a thick blanket, and over this a sheet, the end of which should hang down to the floor, in order to protect the clothes of the surgeon. The resort to a shallow box or pan of sawdust at the foot of the table, and placed just beneath the end of the sheet, will also aid in preserving the cleanliness of the apart- ment. In addition to such instruments as may be required for the special mode of operating selected by the surgeon, there should also always be a large syringe and catheter; a pitcher of barley-water to wash out such fragments of the calculus as may be created in extracting the stone, together with a little cup of sweet oil, sponges, basins, water, towels, and stimulants should the occasion require them. Five assistants may be required to aid the operator. The first should hold the staff and scrotum of the patient, according to the directions furnished by the surgeon. Two others should place the patient's knee in their axilla, whilst their forearms should be passed round his leg, so that by bearing their weight upon his pelvis they may steady it upon the table, and by keeping his thighs sepa- 248 OPERATIVE SURGERY. PLATE LIV. LATERAL OPERATION FOR LITHOTOMY. Fig. 1. A view of the position of the patient, surgeon, and assistants, as far as they could be shown upon one figure, in the lateral operation for" stone. 1, 2. Hands of first assistant holding the staff vertically, and holding up the scrotum. 3. Left forefinger of surgeon depressing the rectum in the deep incision in the perineum. 4, 4, 5, 5. The hands and arms of the assistants. Their arms are, however, represented as placed upon the thighs of the patient instead of nearly parallel with his legs, as they ought to be; but this position was incompatible with the view. 6. The appearance of the incision in a deep perineum, immediately after punc- turing the membranous portion of the urethra. After Nature. Fig. 2. Manner of holding and passing the knife in the groove of the staff when the bladder is opened by it instead of the gorget, its handle being gently depressed so as to keep its point in the groove of the staff as it enters the bladder. 1. The staff. 2. First position of the knife. 3. Its final position in the neck of the bladder. After John Bell. Fig. 3. The right forefinger passed into the bladder along the staff, so as to recognize the position of the stone before passing in the forceps. 1. The staff. 2. Hand of the surgeon. After John Bell. Fig. 4. An outline to show the manner of enlarging the wound by means of the probe-pointed bistoury. 1. The staff in position. 2. The forefinger of the surgeon introduced into the opening in the neck of the bladder with its palmar surface pressing against the back of 3, a probe-pointed bistoury in the act of enlarging the incision in the prostate gland. After John Bell. Fig. 5. Outline representing the forceps as grasping one stone, whilst a second is represented below it. 1,1. Improper line in which to attempt extraction, as it exposes the neck of the bladder to contusion against the arch of the pubis. 2. Forceps seizing the stone. 3, 4. Proper direction of the forceps in the last efforts for extraction of the calculus. After John Bell. Fig. 6. A view of the mode of retaining the stone in the scoop during its extraction by this instrument. 1. The scoop. 2. Left forefinger of the surgeon. After John Bell. Plate 54. Fig 3. 9/ INSTRUMENTS THAT MAY BE WANTED DURING THE OPERATION. 249 rated, render the perineum tense. The fourth should stand at the patient's head and shoulders, to administer the anaesthetic, watch its effects, and furnish drink or such other attentions as the circum- stances may call for ; the fifth should remain in the room to wait upon all. SECTION III. THE LATERAL OPERATION. The division of the perineum upon the left side of the raphe', so as to open the bladder through the left half of the prostate gland, is an operation of considerable antiquity, and by many regarded as the best mode of operating where the stone is not excessively large. Although those selecting it have from time to time deemed it ad- vantageous to modify the various instruments by which the division of the prostate was to be effected, there is but little difference in the other steps of the operation, and this account will therefore be limited to the operation as practised by Cheselden, Abernethy, Cline, and others in Europe; by Drs. Physick, Dudley, Barton, McDowell, and Norris, in the United States; and by such surgeons of the present day as prefer the use of the cutting gorget. § 1.—INSTRUMENTS THAT MAY BE WANTED DURING THE OPERATION. In order to meet all the contingencies that may arise in the lateral method of lithotomy, the surgeon should prepare and place upon a tray the following articles, which are mostly shown in Plate LIIL, to wit: one large and deeply grooved staff, to pass into the bladder; one large round-bellied scalpel with which to incise the perineum; one sharp-pointed bistoury to open the membranous part of the urethra, if the scalpel is not sufficient; a gorget or knife to incise the prostate; forceps of different sizes, with and without fenestra; a scoop; Earle's crushing forceps, or Heurteloup's lithontriptor; a tenaculum; Physick's forceps and needle, in case of wound of the internal pudic artery, and ligatures, needles, and lint for arresting the hemorrhage, or plugging the wound, if requisite. Introduction of the Staff.—The patient being etherized, and 250 OPERATIVE SURGERY. placed as before directed, the surgeon should oil and introduce a sound into the bladder to render the presence of the stone evident to his assistants, and, having done so, withdraw the sound and intro- duce the staff; or, the sounding may be practised the day before the operation, and verified simply by the staff at the time of the ope- ration. The latter being then accurately adjusted in the median line of the body, the first assistant should hold it, whilst the patient's hands and feet are bandaged together, if the assistants are not men of experience, but with the employment of anaesthetics and with good assistants this is not necessary, though some deem it a safer practice. The patient being now in position, with the perineum fully exposed, the surgeon should feel for the ramus of the ischium, the bulb of the urethra, and the body of the staff, so as to recognize these points of reference, and, being satisfied with the position of the latter, direct the assistant how to hold it. On this point there is much difference of sentiment, such surgeons as prefer to be guided in their incisions solely by the staff, liking it to bulge out in the perineum and incline well towards the left side; while others, relying upon their anatomical knowledge, prefer having its point kept accurately in the bladder, with its concavity close under the arch of the pubis, and its handle turned a little to the right groin, so as merely to present its groove towards the left side of the raphe*. Of the two methods, I prefer the latter, relying upon the staff rather in cases of error or deviations in incising a deep perineum than for the primary incisions. In my opinion, any surgeon who cannot open the membranous portion of the urethra without the aid of a staff, is but badly qualified for the performance of the operation of lithotomy. § 2.—LATERAL OPERATION WITH THE CUTTING GORGET. The surgeon being conveniently seated on a moderately low stool or chair without a back, or else kneeling on one knee, should com- mence his operation by placing the first and second fingers of his left hand upon the perineum near the raphe", so as to steady the skin, and then holding the scalpel in his right hand like a pen, puncture the skin and fat by a perpendicular pressure, at a point near to the left side of the raphe, and immediately behind the scro- tum, that is, at one which corresponds with the lower side of the LATERAL OPERATION WITH THE CUTTING GORGET. 251 arch of the pubis, or is about one inch in advance of the sphincter ani muscle. Commencing at this point, let him now, by a steady pressure, continue the incision in a straight line to a spot corre- sponding nearly with the middle of the fibres of the sphincter ani muscle, and about half way between it and the tuber ischii, the incision being about three inches long in the adult, and boldly made, so as to divide the parts neatly, whilst it should be of suffi- cient depth, especially in its middle, to reach the membranous part of the urethra. The beginning and end of this first incision need not, however, be deeper than the skin and fat, whilst the greater depth of its middle should be such as would make a conical wound, the apex of which should be towards the bladder (Plate LIV., Fig. 1). If the first incision is not deep enough in its centre, two or three touches of the scalpel may be made, so as to divide the transversalis and levator ani muscles with the triangular ligament and expose the membranous portion of the urethra. The left forefinger should now be thrust into the wound, whilst the hand is in extreme pronation, so that the radial edge of the finger may be turned downwards, the ulnar side of its pulp and the point of the nail being made to touch the staff, whilst its back presents to the left descending ramus of the pubis. Then laying down the scalpel and taking up the sharp- pointed bistoury, pass it flatwise, or with its back to the rectum, along the left forefinger as a director; carry its point to the bottom of the wound; puncture the membranous portion of the urethra so as to enter the groove of the staff, as may be told by the escape of a little urine and the contact of the instruments; and then cutting from behind forwards, lay bare the staff by one stroke, from the prostate to the bulb, when more urine will follow, and the staff will be clearly felt and seen. Then promptly taking the gorget, dip its point into oil, place its beak in the groove of the staff; stand up; take the handle of the staff from the assistant; balance the two together, the edge of the blade being inclined downwards and out- wards, and then by a steady movement press the gorget along the staff into the bladder. As its cutting edge progresses, the handle of the instrument should be made to descend in front of the anus so as to keep the beak perpendicularly applied to the staff, and prevent its slipping, when a gush of urine will follow and show that the bladder has been opened. Then withdraw the gorget promptly, but leave the staff in the bladder; again pass in the left forefinger; touch the stone with it (Plate LIV., Fig. 3); direct the 252 OPERATIVE SURGERY. assistant to withdraw the staff; and taking the forceps in the right hand, with the thumb and fore or second finger thrust through the •rings in its handles, pass the point of the forceps into the bladder along the left forefinger, with the blades closed; touch the stone, and endeavor to seize it in the forceps, so that its longest diameter shall not be transverse to the wound; or if this cannot be readily done by the right hand alone, take one handle of the forceps in each hand, turn the instrument flatwise, so that it may act as a scoop, and then fishing about, get the stone into the grasp of the instru- ment. After the stone is properly grasped by the forceps, withdraw the left forefinger, slide it along the forceps to the centre screw, and, by a gentle lateral and up and down movement, extract the calculus by such a moderate amount of force as may be necessary to dilate the wound, but not bruise it (Plate LIV., Fig. 5). The calculus being removed, introduce the right forefinger and feel for others, or for fragments;' then pass into the bladder, through the wround, a large catheter; adapt to its free end the nozzle of the syringe containing barley-water, and wash out the clots of blood, fragments, &c. that may be left behind; after which it only remains to arrest any severe hemorrhage that may show itself, and to dress the wound in the manner hereafter stated. Remarks on the Lateral Operation.—The section of the pros- tate gland, as accomplished by Physick's gorget (Plate LIIL, Fig. 4), is .one of great certainty and cleanness, creating a wound which is admirably adapted to healing, in consequence of the accuracy with which the two surfaces may be approximated. The advantages of the ordinary gorget have been variously esti- mated at different periods, some surgeons asserting that its opera- tion was too mechanical, and its division of tissue a " stab in the dark;" whilst others have highly lauded it. In the United States, the English cutting gorget was the favorite instrument of Dr. Phy- sick, who modified it so that its blade could be separated from the beak, and thus made to receive a perfect edge—a modification of great value, and one which really gave this instrument a new cha- racter, making it a perfectly firm and keen knife. The gorgets that have since been made in the United States have been mostly of this pattern, and have been employed by Drs. Gibson, Rhea Barton, Randolph, and McDowell, as well as by most of the lithotomists of Philadelphia. The venerable Dr. Dudley, of Kentucky, whose success as a lithotomist is so widely known, having operated more LATERAL OPERATION WITH THE CUTTING GORGET. 253 frequently with success than any other surgeon, always employs the gorget, though he prefers that of Mr. Cline, of England. An examination of the objections that have been urged against the use of the gorget shows that the faults charged upon it are chiefly due to the old English gorget, or that known as the gorget of Haw- kins, as this cannot be sharpened close to the beak, and, in passing along the staff, is therefore apt to leave a portion of the prostate uncut at the sides of the staff, in consequence of which the gorget is liable to be thrown out of the staff, and made to cut towards the rectum. Many of the instances referred to by the opponents of the instrument are also rather examples of the want of skill in the ope- rators than of defects in the instrument, as a good surgeon could hardly fail to lithotomize a patient with any instrument. There are, however, many operators in the United States who do not use the gorget, preferring a beaked knife, of various kinds and shapes, most of which are apparently favorites, from personal pecu- liarities in operating, and some of which having been designated by the name of the inventor. In many instances such knives are only poor modifications of a gorget, act in the same manner, but do not make so accurate an incision, and are liable to create an opening in the pelvic fascia by leading the operator to incise the prostate to too great an extent laterally. In a deep perineum, it is always difficult to judge of the position of the point of a knife, even when apparently directed by the left forefinger; but with a staff held in the median line of the body, with its curve close under the pubis, and with the beak of a gorget well placed in it, it is impossible to extend an incision beyond the limits of the width of the blade. The advantages and disadvantages of the gorget is, however, a subject which has engaged powerful advocates on both sides, and I shall therefore dismiss it with the simple statement of individual preference for the gorget of Physick, though at the same time I should not hesitate to cut for stone with a staff and pocket bistoury, if nothing else could be obtained, nor doubt the possibility of any skilful surgeon operating neatly and properly with any instrument when a correct anatomical knowledge of the structure concerned was made to direct it. The choice of a knife is the least important part of any operation, and the discussions spent on the shape of instruments would be much more valuable if more closely con- nected with the anatomy of the region, and less with the mechani- cal ideas of the cutler. 254 OPERATIVE SURGERY. § 3.—OPERATION WITH THE SINOLE LITHOTOME CACHE OF FRERE COSME. The single lithotome cache or concealed lithotome of Frere Cosme resembles that of Dupuytren (Plate LIIL, Fig. 3), and has but one blade. It is introduced into the bladder by passing its beak into the staff when the latter has been exposed as in the pre- ceding operation; when carrying its point into the bladder and then opening the blade by pressure against the handle, the prostate and neck of the bladder are to be incised whilst the instrument is being withdrawn in a perfectly horizontal direction. If the handle of the lithotome is too much elevated, the lower surface of the bladder will be exposed to injury; whilst, if it is much depressed, the inci- sion will be too small. If the blade is directed outwards, the pudic artery may be wounded, and if too much downwards, the rectum1 may be opened. Remarks.—In very many instances, I have operated in Paris upon the subject with this instrument, as well as with that of Du- puytren, in the manner usually directed by the French surgeons, but have always felt the uncertainty of the extent of the incision thus effected. The liability of the blade to spring; the difference in the resistance offered to its escape by different perineums; the liability to too great expansion, &c, have satisfied me that it cannot bear a comparison either with the gorget of Physick or with what has been termed the " beaked knife of Liston." Its chief recom- mendation appears to be the difficulty of wounding the rectum. Such an event would certainly be a strong recommendation of the instrument, if lithotomy was to be performed by every individual, but can not prove so to an accomplished surgeon—and none but good surgeons should attempt this operation. SECTION IV. THE BILATERAL OPERATION. In the bilateral operation of lithotomy, the bladder is opened by an incision through each half of the prostate gland, and a wound 1 Malgaigne, Philad. edit. p. 505. THE BILATERAL OPERATION. 255 made through which a calculus may be extracted, of somewhat larger dimensions than is possible by the lateral section. From having been revived and brought into notice, as well as modi- fie4 by Dupuytren in 1824, it is often spoken of as his operation, though Celsus, it is well known, was also familiar with a similar method. Operation of Dupuytren.1—Instruments.—The instruments employed by Dupuytren were: 1. A sound, which was lighter than the ordinary sound, sloped off at the end of its grooves, and expanded for two inches in length, at the point where it is most curved, so that it might the better distend the urethra. 2. A double-edged scalpel fixed in a handle, and sharp on each edge for about one-third of an inch from its point. 3. A double lithotome (Plate LIIL, Fig. 3), the two blades of which opened in one handle, and were so acted on by two levers as to separate in a curved direction, and divide each side of the prostate in its oblique diameter. Operation.—The patient being placed as before directed, and the position of the various points of reference accurately recognized (Plate LV, Figs. 1, 2), the staff should be introduced and held in a perfectly perpendicular direction, whilst the surgeon extends the integuments of the perineum with the fingers of his left hand, and makes a semicircular incision with the double-edged scalpel held in his right, commencing on the right side at a point half way between the tuberosity of the ischium and the anus, passing half an inch in front of the anus, and terminating on the left side of the perineum at a point corresponding with the starting-point on the right. (Plate LV., Fig. 3.) By continued, but rapid incisions, the superficial fas- cia, anterior point of the sphincter ani muscle, and the cellular tis- sue are divided, and the membranous part of the urethra laid bare, when the nail of the left index finger enables the surgeon to feel the groove in the staff, which may then be exposed, as before di- rected, by means of a bistoury. The forefinger, during all this period, should be made to depress the rectum in order to prevent its injury. After opening the urethra for one-third of an inch, use the left forefinger nail as a guide to the lithotome cache, and intro- duce the instrument by holding it in the right hand with the thumb beneath and the two fingers above, presenting it to the staff, so that its convexity may look downwards. The contact of the two instru- 1 Malgaigne's Operative Surgery, Philad. edit. p. 507. 256 operative surgery. ments being now recognized, the surgeon should take the handle of the sound in his left hand, and, elevating it so as to place its curve close under the symphysis pubis, slide the lithotome along its groove into the bladder. Then withdrawing the staff, turn the lithotome so as to present its concavity downwards, or towards the anus, and, grasping the lever, depress it to the handle of the instrument so as to unsheath the blades, withdrawing the instrument progressively downwards until it cuts its way out. (Plate LV., Fig. 4.) The left index finger, being then introduced through the wound into the bladder, should examine the extent of the incisions, and if they are not sufficiently large, direct a probe-pointed bistoury so as to enlarge them. (Plate LIV., Fig. 4.) But if they are large enough, the forceps should be introduced, and the stone extracted as before directed. The width of Dupuytren's incision, when widest, was not more than two inches, so that the incision did not pass the circumference of the prostate. Operation of Dr. T. S. Ogier, of Charleston.1—A boy, thir- teen years of age, with a large calculus, was operated on as follows, in 1835. The rectum being emptied, and a staff placed in the bladder, a semilunar incision was made in the perineum just under the bulb of the urethra, commencing about half way between the anus and the tuberosity of the ischium on the right side, and termi- nating at the same point on the left side, so as to divide the skin and perineal fascia. This being rapidly increased in depth at its centre, the staff was soon felt with the point of the scalpel, a small puncture made in the membranous portion of the urethra, and then Dupuytren's double lithotome being introduced into the bladder, the staff was withdrawn, the lithotome turned with its concavity downwards and the neck of the bladder divided from within out- wards by expanding the blades of the instrument so as to make it cut as it was drawn out. The stone having been then seized with the forceps, was readily extracted, though it measured two and a half inches in length, three and a half in circumference, and weighed one ounce three drachms. Operation of Dr. R. D. Mussey, of Cincinnati.—With a rather narrow scalpel, the superficial crescentic incision is made with its convexity anterior, so as to expose the staff at the membranous • Am. Journ. Med. Sciences, vol. vii. N. S. p. 504. THE BILATERAL OPERATION. 257 portion of the urethra. (Plate LV., Fig. 3.) A straight probe-pointed narrow bistoury being then passed along the groove of the staff, with its edo-e turned towards the left side until it enters the bladder, the point of the left index finger is slid along the back of the bistoury, and made to press it against the prostate so as to divide the latter sufficiently to admit the point of the finger into the bladder, when the staff should be withdrawn and the prostate further divided, if necessary. The finger being then rotated, the palmar surface of its point should be made to rest upon the right side of the prostatic portion of the urethra, the bistoury be turned upon the finger to the opposite side, and the right side of the prostate also divided as far as is necessary, the stone being afterwards extracted as usual.1 Operation of Mr. Fergusson, of England.2—Under the im- pression that a straight line in the course of the raphe with diverg- ing slips on each side of the anus, like a A Y reversed), would permit more expansion of the wound than any other form of external incision, Mr. Fergusson employed it with satisfaction in a case of lithotomy, after having tried it in the operation of lithec- tasy, or extraction of a calculus by opening the membranous portion of the urethra, and dilating the neck of the bladder, as proposed by Dr. Willis. Dr. Eve, of Nashville, Tennessee, has also recently adopted this incision in preference to the semicircular cut of Dupuytren. Operation of Dr. Paul F. Eve, of Georgia.—The staff being introduced into the bladder, a short incision is made directly in the raphfc at the bulb of the urethra, the direction being changed at a very oblique angle at the end of about three-fourths of an inch, in order to terminate at a point midway between the anus and the left tuber ischii. With the edge of the knife now turned upwards, penetrate the tissues, and commence the other leg of the A at a point on the right side corresponding to the one just terminated on the left. This incision being deepened as the instrument ascends, arrives at the middle of the perineum with its edge turned directly upwards, when the urethra is opened and the staff exposed, after which the operation is completed by the lithotome in the usual way. Remarks.—Of twenty-three cases operated on by Dr. Eve with the double lithotome, four died, three of which were from the ope- 1 Am. Journ. Med. Sciences, vol. xi. N. S. p. 265. 2 Fergusson, Pract. Surg., 4th Am. edit. p. 607. VOL. II.—17 258 OPERATIVE SURGERY. PLATE LV. THE OPERATION OF LITHOTOMY AS PERFORMED BY THE BILATERAL SECTION, WITH THE LITHOTOME CACHE OF DUPUYTREN. Fig. 1. Position of the patient, with lines drawn on the perineum to show the points of reference and the direction of the incision. The sub- ject being in the position of lithotomy, the testicles and penis have been turned up and the perineum divided into two equilateral triangles, the angles of which are made to touch the bones around the perineum. 1, Pubis. 2, 3. Tuber ischii. 4. Coccyx. 2, 8, 5. Line of external inci- sion. From Froriep, but after Dupuytren. Fig. 2. Dissection of the same subject. The fascia superficialis has been turned up from the edge of the incision, so as to show the accelerator urinae muscle, and the transversus perinei arteries. The sphincter ani is seen below, and the divided fibres of part of the levator ani are shown in the cut. 1. The skin. 2. Fascia superficialis. 3. Sphincter ani muscle. 4. Line of median incision through the anterior fibres of the levator ani muscle. 5. Accelerator urinae muscle. 6. Perineal arteries. 7. Perineal fascia dissected up, and turned over the body of the penis. From Froriep, but after Dupuytren. Fig. 3. External Incision in Bilateral Lithotomy. 1, 2. The hands of the first assistant holding the staff vertically, and elevating the scrotum. 3. The left forefinger of the surgeon depressing the rectum. 4. Right hand about terminating, 5, the incision. The external incision should be made from left to right, with its convexity forwards, so as to form an arc of about 100°. After Bourgery andJacob. Fig. 4. Section of the prostate with the double lithotome cache upon a subject which had been dissected, so as to show the incision, the anterior portions of the sphincter and levator ani muscles having been removed. 1. Accelerator urinae muscles. 2, 3. Internal pudic artery and nerve. 4. Transverse perineal artery. 5. Hand of the surgeon. 6. Levers which regulate the blades of the lithotome. After Bourgery and Jacob. Fig. 5. Lateral section of the prostate as made by the single lithotome cache, a portion of the sphincter and levator ani and anterior end of the anus being removed in order to show the prostate gland. 1. Bulb of ure- thra. 2. Membranous portion of urethra. 3. Prostate gland. 4, 5. Lithotome in position. 6. Corpus cavernosum. 7. Symphysis pubis. 8. Vesicula Seminalis. 9. Rectum. After Bourgery and Jacob. i'l..ti' 35. *. ?** THE BILATERAL OPERATION. 259 ration, two indirectly and one directly; and seventeen were well in two weeks after the operation.1 Operation of Dr. J. F. May, of Washington.—The patient being etherized, was cut as in the operation of Dupuytren, and a large stone readily extracted. Its longest diameter was two inches and a fraction, its shortest diameter one and five-eighths of an inch, and its circumference five and five-eighths inches. Remarks.—Among American surgeons, the bilateral operation was first performed by Dr. Ashmead, of Philadelphia, in 1832, and by Dr. Ogier, of Charleston, in 1835, since which there have been many who have advocated and practised it, among whom may be mentioned Drs. Stevens, Hoffman, and Post, of New York; Warren, of Boston; Mussey, of Cincinnati; May, of Washington; Pancoast, of Philadelphia; Eve, of Nashville; Pope, of St. Louis; Dugas and Campbell, of Georgia, with many others; though several of them prefer the use either of a special instrument or of a probe-pointed bistoury to the lithotome of Dupuytren. My own experience, as gained upon the subject, corresponds entirely with this, as even with a lithotome, selected by the hands of Charriere, of Paris, I have found the blades to spring and yield to such an extent as to interfere with the accuracy of the section. The mode of operating, described by Dr. Mussey, is therefore, I think, preferable to that advised by Dupuytren. As the incision of Dupuytren permits a very free dilatation of the perineal integuments, and also corresponds with the arch of the pubis through which a large calculus must pass, I cannot think there is any material advantage gained in the size of the wound made by the incision resorted to by Mr. Fergusson and Dr. Eve, whilst the central portion of it, except in very skilful hands, would expose an operator to much greater risk of wounding the bulb of the urethra than is the case in Dupuytren's operation. A median incision through the skin and perineal fascia, in the line of the raphe-, will readily expose the bulb, though of course a skilful operator might expose it without wounding it. The points of recommendation claimed for the bilateral opera- tion over either of the others, are a more direct and free access to the bladder without injuring the vesical plexus of veins, as well as less risk of dividing important bloodvessels; but, on the other hand, Report to Med. Association, 1852. 260 OPERATIVE SURGERY. the rectum is more exposed in the primary incisions, and perineal fistula, irnpotence, and a tendency to stricture near the prostatic portion of the urethra are said to be increased. Statistics alone can settle a question of this kind, though at present it is generally ad- mitted that in cases of very large calculi, or in a case attended by anchylosis of the hip, as in that reported by my friend Dr. Pope, of St. Louis, or in analogous difficulties, the bilateral is preferable to the lateral section. The lateral incision is, however, fully capa- ble of removing a large stone, and I have extracted one by this method that weighed two ounces and seventeen grains, and was six inches in circumference. The increased fondness of American surgeons for the bilateral rather than the lateral operation, seems, however, to indicate that experience proves its special advantages, though fashion occasionally regulates surgery to a certain extent as it does less important subjects. SECTION V. THE MEDIAN OPERATION. Lithotomy having at one period been the especial province of one family, or class of individuals, it is not surprising that various plans of accomplishing it should have been each highly lauded, and handed down as perfect from generation to generation. Among all these methods, that in which the perineum is incised in the median line, and the stone extracted by opening the urethra in the same direction, at first sight would appear to be the safest. But this ope- ration, though very ancient, has, in truth, nothing to recommend it, and is only now referred to because some of its steps may occasion- ally be found useful in extracting such fragments of calculi as lodge and become fixed in the urethra, or for the removal of such pebbles as are developed in the prostate gland. The operation of Giovanni di Romanis, as published in 1520, and since repeatedly modified, is as follows:— Operation of Vacca Berlinghieri.1—The patient being placed as before directed, an incision is to be made in the median line of the perineum from the origin of the scrotum to the anterior border 1 Malgaigne, p. 503. LITHECTASY. 261 of the anus, so as to divide the skin, superficial fascia, and anterior fibres of the sphincter ani muscle, and lay bare the groove of the staff in the membranous portion, without exposing the bulb. The knife, or probe-pointed bistoury, being then passed along the groove of the staff into the bladder, the neck was divided to the extent of four or five lines in a direction parallel with the median line. § 1.—LITHECTASY. The term Lithectasy has been employed to designate the modi- fication of this operation recently revived by Dr. Willis, of Eng- land.1 In the operation of Romanis, as advocated by Marceaux, or the major apparatus (so called from the number of instruments em- ployed in its performance), the membranous portion of the urethra was opened by an incision made near to, but on the side of the raphe. After which a probe was passed along the staff into the bladder, and then two conductors being passed along the probe, the prostate gland and neck of the bladder were forcibly dilated, or, perhaps, torn. As modified by Dr. Willis, this operation now con- sists in opening the membranous portion of the urethra by an inci- sion in the line of the raphti above the anus. After thus opening the urethra, a sponge tent, or some similar dilator, is introduced and the opening dilated, in twenty-four hours, sufficiently to permit such forceps as will remove a small calculus. Remarks.—This operation has but little to recommend it. The dilating process is slow and apt to be a serious source of irritation to the patient. Owing to the difficulty of accurately deciding on the size of calculi, there is also the risk of having an opening which will not permit the stone to pass until the wound is further enlarged by the knife. It will, therefore, be but seldom adopted by any surgeon who is familiar with the performance of the ordi- nary lateral operation. Small calculi, to which it is chiefly adapted, had better be crushed, and in the event of these, or fragments, be- coming lodged in the urethra, it will be better to attempt by skil- ful manipulation to replace them again in the bladder. 1 Willis on Stone. 262 OPERATIVE SURGERY. SECTION VI. OF THE SUPRA-PUBIC OPERATION. As the process of peritoneum which lines the abdominal muscles is reflected from above the pubis to the superior and posterior por- tions of the bladder, there is a space left anteriorly through which it is possible to open the bladder without incising the peritoneum, and it is at this point that the extraction of calculi by the Supra- Pubic or Hypogastric operation has been occasionally practised; though the majority of operators have preferred incising the peri- neum. Operation of Sir Everard Home.1—An incision being made four inches long, between the pyramidales muscle in the direction of the linea alba, the tissues were divided down to the tendon, which was then pierced close to the pubes, and divided by a probe- pointed bistoury to the extent of three inches, a portion of the origin of the pyramidales being detached, so as to increase the size of the opening near the pubes. The forefinger being now passed into towards the pelvis, the fundus of the bladder was recognized, and a silver catheter, open at both ends, being carried into the ure- thra, its point could be felt pressing upon the fundus of the bladder. A stylet, which had been concealed in the catheter, being then forced through the coats of the bladder, was followed by the end of the catheter, and the stylet being withdrawn, the puncture in the blad- der was enlarged sufficiently to admit two fingers, by means of the probe-pointed bistoury. The stone being now felt by one finger whilst the superior fundus of the bladder was held up by the other, a pair of forceps, with a net attached, was passed down into the bladder, and the stone directed into them and retained there by the finger till extracted. A slip of linen being then introduced into the bladder, one end was allowed to hang out of the wound, and the edges of the latter closed by adhesive plaster, a catheter being kept in the urethra in order to draw off the urine. Remarks.—This operation, which was assigned to Franco, in 1561, and afterwards practised by Rousset in 1581, has seldom been 1 Gibson's Surg., vol. ii. p. 259. GENERAL REMARKS ON PERINEAL LITHOTOMY. 263 deemed advisable by surgeons, except for the removal of very large calculi, or in consequence of a diseased prostate. In the United States, it was first performed by Dr. Wm. Gibson, of Philadelphia, but it has since been repeated by Drs. Carpenter, Van Valzah, and George McClellan, of Pennsylvania.1 In a case reported by Dr. Wm. D. Johnson, of Georgia, the lateral operation was first performed, and then the supra-pubic, in consequence of the great size of the calculus, its weight being nearly six ounces, its longitudinal circumference seven inches, and its lateral circum- ference five inches and three-quarters.2 The chief recommendation of the high operation appears to be the safety arising from the absence of hemorrhage; but this is more than counterbalanced by the risks of peritonitis, urinary infiltration, and abscesses. § 1.—THE QUADRILATERAL OPERATION. Vidal du Cassis having suggested the incision of the prostate in several directions, like the radii of a circle, so as to admit of the greater distension of the opening, his mode of operating has been designated as the quadrilateral operation. Except in the very rare instances of enormous calculi, such incisions must, however, be un- necessary, and, when required, could be easily added to any of the other plans of operating, though originally suggested in connection with the bilateral operation. SECTION VII. GENERAL REMARKS ON PERINEAL LITHOTOMY. In the consideration of the different methods of performing pe- rineal lithotomy, little has been said in reference to the mode of extracting the stone; in relation to the accidents likely to occur during the operation; or in respect to the dressing and after-treat- ment, all of which demand special consideration. 1 Gibson, vol. ii. p. 260. Gross, p. 500. 2 Southern Med. and Surg. Journ., vol. vii. p. 893, 1851. 264 OPERATIVE SURGERY. | 1.—EXTRACTION OF THE STONE. In extracting a calculus, after the bladder has been opened by either of the preceding methods, much care and skill are necessary this part of the operation being, in many instances, the most difficult and tedious step of the proceeding. The wound may apparently be free, and the primary incisions rapidly and neatly made, with every appearance of a speedy termination to the operation ; and yet the mere extraction of the stone through the wound will occupy more time than would suffice for several incisions. In order pfomptly to accomplish its removal, the operator should, therefore, first endeavor to learn its position and mode of presentation, and in this he may be materially assisted by recalling the shape of the bladder, its relations to surrounding parts, and the tendency of the stone to gravitate to the most depending point. Most calculi, espe- cially when single, lie at the posterior inferior part, or bas-fond of the bladder, in consequence of their weight, or because the contrac- tion of the muscular coat forces them to occupy such a position as is most favorable to the escape of the urine by the urethra, pre- senting, therefore, their longest diameter longitudinally, and their flattened side downwards. In order to seize a stone thus placed, the curved forceps should be introduced, so that the convexity of their blades may correspond with the posterior angle of the wound, their handles being at the same time elevated sufficiently to place their points in the lowest portion of the bladder. (Plate LIV., Fig. 5.) When the thickness of the perineum permits it, the left index finger should also be made to depress the posterior angle of the wound, especially in the bladder, and serve as a guide for the forceps; but as, in a large deep adult perineum, this is sometimes impossible, the operator will be compelled to rely upon the know- ledge gained in his previous examinations for the probable position of the calculus. After touching the stone with the points of the forceps, the rings of the latter should be seized between the thumb and fingers of each hand, the blades cautiously expanded, and then by a half turn to the left, made to scoop up or seize the calculus as it is forced into the grasp of the instrument by its own weight, or by the contractions of the bladder. If, however, this should not be the case, the operator may gently expand and close the blades of the instrument, giving them at the same time a gentle lateral EXTRACTION OF THE STONE. 265 and up and down motion, so as to sweep the bladder by their smooth and external surfaces, until the stone is brought within their grasp. When seized, the left forefinger should be slipped along the blades, so as to feel if the short diameter of the stone is parallel with the transverse diameter of the wound, and being satis- fied of this, the calculus, if large, may be extracted by pulling it gently but steadily towards the operator, it being at the same time moved laterally, as well as up and down, in order to favor the dila- tation of the wound. The use of Barton's forceps (Plate LIIL, Fig. 9) will materially facilitate the extraction of the stone, as the fenestra diminish the space occupied by the thickness of the instru- ment; but if the calculus is of the ordinary size, and the incisions sufficiently large, little difficulty will be experienced from the latter source. In many instances, the incision in the prostate has not been sufficiently large, or the inferior angle of the wound, or the opening in the skin is too narrow; and when this is the case, much may be done by persevering and gradual dilatation of the part, or by enlarging the angle of the wound with the bistoury. When the size of the stone forbids all hope of its extraction entire, then it should be crushed by Earle's forceps (Plate LIIL, Fig. 14), or by Heurteloup's lithontriptor, and extracted piecemeal, the fragments being removed by washing out the bladder with barley-water. The Scoop is an instrument that may prove serviceable in cases where the size of the stone forbids the hope of introducing the additional thickness of the forceps, or in cases of numerous cal- culi, or in that of fragments of a calculus. Or, it may be re- sorted to for the removal of such calculous concretions as are occa- sionally found upon parts of the bladder, and which require to be peeled off. Whenever the attempt is made to remove a calculus by the scoop alone, the point of the forefinger of one hand should be placed against the stone to steady it in the hollow of the instrument (Plate LIV., Fig. 6). After removing a calculus by any instrument, the finger should be again introduced into the bladder, and carefully passed around it in order to ascertain whether some particles have not been left. Should any be found, it will be better to wash them out by freely injecting barley-water than to attempt to seize them with forceps, or to remove them with the scoop. The injection will also prove useful by removing clots from the part. If the stone should be encysted, or adherent, the steps to be pur- 266 OPERATIVE SURGERY. sued will depend mainly upon the manner in which it is attached, and on the judgment of the operator. Sometimes the attachment is owing to folds of the bladder being introduced into asperities in the calculus, and these may be often overcome by passing the finger gently round, and hooking out the stone; or, a process from the stone may have entered a dilated ureter, or be placed in an abnor- mal pouch in the bladder. To relieve either of these latter attach- ments, it is usually necessary to exercise judicious traction upon the main portion of the stone; though the process of the mucous mem- brane may require to be ruptured with the finger, or, if it is a simple band, to be divided by the knife, in order to free it; but the necessity for the latter is very rare, and it should never be resorted to until every other means have failed. § 2.—ACCIDENTS CONNECTED WITH LITHOTOMY. An accident that occasionally complicates the operation of litho- tomy, even in careful hands, is hemorrhage, though, under ordinary circumstances, it is not sufficiently severe to demand active treat- ment. A wound of the rectum may happen, but it can generally only be regarded as evidence of the incompetency of the operator. Hemorrhage may arise from several points connected with the incisions in lithotomy: 1st, it may come from the perineal arteries; 2d, from the vesical plexus of veins; and, 3d, from the internal pudic; the latter being, however, much less frequently wounded than an inexperienced surgeon might suppose, as it lies too near the ascend- ing ramus of the ischium to be in the way of any ordinary incision. When, however, the hemorrhage from any point is sufficient to de- mand treatment, it may be arrested either by the application of the ligature, or by pressure. I. LIGATURE IN HEMORRHAGE. The ligature of the smaller perineal arteries does not differ in any respect from the ligature of other vessels, the open vessel being seized with a tenaculum, and then tied with the silk ligature. But if by any accident the main trunk of the internal pudic artery be divided, the hemorrhage will be more troublesome, though it may ACCIDENTS CONNECTED WITH LITHOTOMY. 267 be promptly controlled simply by compressing the artery with the finger against the ramus of the ischium until a ligature can be thrown around it. To accomplish the latter, few instruments will be found more serviceable than that resorted to by Dr. Physick under similar circumstances, and hence named Physick's forceps and needle (Plate III., Fig. 5). The needle being passed beneath the trunk of the artery, the ligature is carried around the vessel, and made to compress 'it by inclosing a portion of the flesh near the vessel.1 II. PLUGGING IN HEMORRHAGE. From the varicose condition of the vesical plexus, especially in old men, a general hemorrhage or oozing is sometimes seen from the wound, without its being possible for the surgeon to detect any point suitable for a ligature. Under these circumstances, compres- sion is the only alternative, and may be readily accomplished by passing a large catheter into the bladder through the wound, and then packing the latter full of lint or charpie, the escape of the urine through the catheter preventing distension of the wound in the neck of the bladder, whilst the lint at its sides favors the forma- tion of the clots which tend to close the vessels. After the lapse of three days, or when there is evidence of suppuration in the wound, this lint should be carefully withdrawn, lest it interfere with the cicatrization. III. WOUND OF THE RECTUM. From want of attention to the entire evacuation of the bowel before the operation, or from the great dilatation of the prominent pouch or enlargement generally noted near the middle of the gut, or from the surgeon wandering from the staff in the prosecution of his incisions, the rectum has been perforated on its anterior surface, and the after-treatment of the case complicated with the production of a rectal fistula. Although such a fistula is a source of annoyance, adds an unnecessary risk to the chances of the patient, and is, I 1 Dorsey's Surgery, vol. ii. p. 190. 268 OPERATIVE SURGERY. PLATE LVI. • INSTRUMENTS EMPLOYED IN THE OPERATIONS OF LITHOTOMY AND LITHOTRIPSY. Fig. 1. The sound employed in detecting the presence of a stone in the bladder of the male. 1. Its smooth handle. 2. A curve of a medium size. Schiveley's pattern. Fig. 2. Staff employed in operating for lithotomy on the female. Schiveley's pattern. Figs. 3, 4, 5, 6. Staves of different sizes and curves, so as to be adapted to the urethra of different patients in the ordinary lateral operation for lithotomy. The handles should be broad and well serrated, so as to fur- nish a firm hold, and prevent the groove slipping or turning from the position in which it is wished to be held during the perineal incisions. Schiveley's pattern. Fig. Y. Jacobson's instrument for crushing a calculus in the bladder. 1. The articulated loop which holds and crushes the stone when it is caught in the grasp of the instrument. 2. The screw which closes and expands the loop. Schiveley's pattern. Fig. 8. Heurteloup's Lithontriptor. 1. The female blade. 2. The male blade. 3. The vice in which the screw works in crushing the stone. 4. The screw. Schiveley's pattern. Fig. 9. A Litholabe for extracting fragments of a calculus or pebbles from the neck of the bladder. Schiveley's pattern. Fig. 10. Leroy d'Etiolles's articulated scoop for the removal of frag- ments which lodge in the urethra. Schiveley's pattern. Plate lr. Fi£ 1 "*" I Km i 1!1L ~^^iHJ;:!|j;| Fig. 9 ■f^-fa JDl XT ^^^ AFTER-TREATMENT IN PERINEAL LITHOTOMY. 269 think, positive proof of the want of skill in the operator, its evils, in most instances, have been over-estimated, as it is usually readily amenable to treatment. In the simple case of a small puncture of the gut, which is detected at the time or soon after the operation, the best mode of obviating it is to evacuate the contents of the bowel, give a large anodyne enema to keep the parts at perfect rest, and then, by means of the catheter passed into the bladder through the wound, prevent urinary infiltration of the surround- ing structures. In more extended injuries, the entire division of the sphincter ani muscle, as in rectal fistula, together with the free use of anodynes, by allowing the gut to collapse, will favor the union of the incision. But even where a recto-vesical fistula has resulted, cauterization and perfect rest have often sufficed to heal it. In two instances, I have seen this accident occur in the operations of careless surgeons, who were evidently desirous rather of operating quickly than carefully, and, in both, little or no treat- ment was requisite, the patients recovering without being aware of the occurrence. SECTION VIII. AFTER-TREATMENT IN PERINEAL LITHOTOMY. The importance of a judicious after-treatment in every operation' has been perhaps sufficiently insisted on in the previous pages, yet the knowledge of a case in which an inexperienced operator, after succeeding in extracting a calculus by lithotomy, felt compelled to seek directions respecting the proper steps of the after-treatment, induces me to give to it in this operation such extra attention as my limits will permit, and to refer those desirous of further details, both on this and other points connected with stone, to the excellent volume recently published by a distinguished surgeon of the west.1 1 See A Treatise on the Diseases, &c. of the Urinary Organs, by Samuel D. Gross, M. D., Louisville, a work of great value, and indicative of the extended experience of this accomplished surgeon. 270 OPERATIVE SURGERY. § 1.—PUTTING TO BED. After the completion of the operation, including the arrest of hemorrhage, the first point to decide upon will be the dressing. In most instances, nothing is required except rest, as the wound is intended to heal by granulation. According to some surgeons, cer- tain advantages are to be obtained from tying the patient's knees together, and keeping him upon his left side, so as to favor the union of the edges of the wound and the escape of the urine without infiltration of the surrounding parts. Others, again, place a large catheter in the bladder by passing it through the wound, fastening it in position by a strip of adhesive plaster, which is attached to the perineum, so that the catheter, by leading the urine off to a saucer, may keep the patient dry. But the use of this catheter is liable to the serious objection of preventing union of the neck of the bladder by the first intention, as was the fortunate result in two of the operations of Dr. Physick;1 and when it is retained in this way more than a few days, it is very apt to lead to the establishment of perineal fistula. For many years, and espe- cially in the practice of the late Dr. Eandolph, of Philadelphia, I have been accustomed to see patients removed directly from the operating table to the bed without any dressing, the bed being kept dry by the strict attention of the nurse, and the removal of the clothes placed beneath the wound as soon as they were wet. I would, therefore, urge the advantages of preparing the bed and patient as follows: Place a piece of oil-cloth upon a good elastic hair mattress at a point corresponding with the patient's hips; place over this the ordinary sheet; and place upon this, transversely, the end of another sheet folded in four lengthwise, so that as soon as one part is wet by the urine it may be drawn away and a dry part substituted. The position of the patient, " upon the left side, with the knees drawn up," has long been a standing rule, and so reli- giously observed by some that I have seen the great trochanter and crest of the ileum almost ready to come through the skin from the continued pressure, the patient being compelled to use large doses of opiates in order to obtain sleep. In cases which I have had occasion to treat, I have never paid much attention to the position 1 Dorsey's Surgery, vol. ii. p. 191. CONSTITUTIONAL TREATMENT AFTER LITHOTOMY. 271 of the patient after the first twenty-four hours, as the lymph effused ,upon the edges of the wound during this period was generally suf- ficient to prevent smarting from the urine passing over it, whilst as soon as any amount of urine collected in the bladder, the patient invariably turned himself to one side, in order to favor its evacua- tion. It is, therefore, with much satisfaction that I find this prac- tice sanctioned by the excellent authority of Dr. Gross, of Louisville, and the direction given to permit the patient to take, cautiously, any easy position, experience having taught him that " it matters little what posture the patient assumes after he has been put to bed."1 § 2.—TREATMENT OF THE WOUND. The urine escaping from the wound by the lowest angle occasion- ally induces some little cutaneous irritation, which, if it become an annoyance, should be obviated by anointing the part with mild cerate. After two or four days, the lips of the wound usually become tumid, and present signs of inflammation. In most instances, this is only indicative of the efforts of nature to close the perineum, and should not, therefore, be interfered with unless excessive, when warm, moist cloths, frequently changed, will suffice for its removal. If calculous matter forms around or in the wound, it should be washed away with a stream of water from a syringe, or loosened by the action of a weak solution of hydrochloric acid. The bowels also should be kept at perfect rest by anodyne enemata until the fourth day after the operation, when the adminis- tration of a mild laxative, as castor oil or citrate of magnesia, will be serviceable. If, on the escape of urine through the penis, the perineal wound does not heal, a catheter may be placed in the urethra, and the union of the wound facilitated by the use of caustic or by means of pressure. § 3.—CONSTITUTIONAL TREATMENT. As a general rule, the constitutional treatment, after the opera- tion for lithotomy, should be antiphlogistic, though strict attention 1 Opus cilal., p. 465. 272 OPERATIVE SURGERY. should also be given to the previous habits of the patient. If the patient is an old man, good diet or even stimulants will often be demanded, and tardy healing of the wound will often be removed by such an increase of diet. But among the most important of the steps connected with the constitutional after-treatment of lithotomy is the removal, if pos- sible, of the calculous diathesis, as it is not sufficient for the cure of the patient that the surgeon should have removed the stone, unless he effects a change in the character of the urine. It is, therefore advisable, in every case, to test the urine both before and after the operation by litmus paper, the microscope, or similar means, until its peculiar characters are known, and then to obviate the unhealthy action of the kidneys by acids, alkalies, diet, or other appropriate means of treatment. SECTION IX. GENERAL ESTIMATE OF THE VALUE OF THE DIFFERENT METHODS OF OPERATING FOR LITHOTOMY. After what has been said under the preceding sections of the spe- cial advantages of the different modes of operating, there is but little that is new to offer in a general estimate of the whole of them; and yet such a summary is not without its value. Apart from the pecu- liar predilection of certain surgeons for instruments of their own invention (which really afford nothing that can materially aid a good anatomist in the performance of lithotomy), there is, however, little that is settled on this point, and, in examining the advantages de- rivable from the lateral, bilateral, or supra-pubic plans of operating, it is difficult to obtain anything like an accurate result when so much of the success of either must necessarily be due to the skill and judgment of the operator. Statistics of the Lateral Operation.—The statistics of litho- tomy, though presenting the results of a large number of cases, do not offer a perfectly reliable result, because in many instances nothing is said of the peculiarities of the case, the age of the patient, or other incidents which must exert a very important influence upon an opinion. Yet, as such statistics have a certain value, and are at present the only data upon which an inexperienced surgeon could STATISTICS OF LITHOTOMY. 273 form even an approach to an estimate of the risks to which a pa- tient is exposed by the operation, they are presented as obtained from the sources mentioned, with the addition of the opinion of Dr. Cross that about one out of every five of those cut in lithotomy die after the operation.1 Dudley, of Kentucky2 . Pennsylvania Hospital, Philadelphia2 Gardner, of Kentucky3 Davis, of Ohio3 Eve, of Georgia3 . Bush, of Kentucky3 Gibson, of Philadelphia1 Mettauer, of Virginia4 Jno. C. Warren, of Boston4 Marsh, of Albany4 Smith, of Bristol, England, reports for Great Britain Mortality in Great Britain after the operation, 22J per cent. Mortality in United States, 6| per cent. Showing that the operation of lithotomy has been nearly four times as successful in the United States as in Great Britain. Statistics of the Bi-lateral Operation.—After examining the various tables, and separating these from the cases specially mentioned as operated on by the bi-lateral section, the following result has been obtained:— Paul F. Eve, of Georgia5 Spencer, of Virginia5 Mussey, of Cincinnati6 Hotel Dieu7 Dupuytren1 Warren, of Boston1 . ASES. DEATHS 207 6 83 10 15 1 72 6 2 1 5 0 50 6 73 2 30 2 7 0 544 34 354 79 CASES. DEATHS. 25 4 specified. 16 2 18 0 " 26 0 70 6 3 0 " 149 Or, a mortality of about 5| per cent. 1 Gross on Urinary Diseases, p. 470. 2 Trans. Am. Med. Assoc, vol. iv. p. 273, 1851. 3 Ibid., p. 274. 4 Trans. Am. Med. Assoc, vol. i. p. 161. 5 Ibid., vol. iv. p. 274, 1851, and again in a report, April, 1852. 6 Ibid., vol. ii. p. 22G, 1849. 7 Velpeau, Op. Surg., by Mott, vol. iii. p. 918. VOL. II.—18 271 OPERATIVE SURGERY. In the twenty-five cases operated on by Dr. Eve, two were females, and in no case did he know either of a fistula in perineo, or of a stone having ensued upon the operation. . Statistics of Supra-Pubic Lithotomy.—A brief account of the cases operated on shows that this operation has obtained a suffi- ciently large success to justify its repetition where other means are not permissible. Out of twenty-five cases which I have collected from various sources, twenty-one have been cured and four died, thus presenting a mortality of about sixteen per cent. Great allowance must, however, be made for the results, as shown in all these tables. In several instances, the deaths have not been specified; in others, the surgeon has relied upon his recollection, and supposed that he has operated on about fifty cases with a mode- rate number of deaths, and in the statistics furnished under the head of the lateral operation, it is not always certain that the lateral method was the one employed. I have, however, examined the statements closely, and endeavored to obtain a correct result, and my conclusion is that the only point that can be depended on in the above tables is that out of 715 cases, 541 were cut by the lateral, 149 cases by the bi-lateral, and 25 cases by the hypogastric opera- tion, thus showing a decided preference among surgeons in favor of the lateral operation. CHAPTER III. LITHOTRIPSY, OR CRUSHING OF STONE IN THE BLADDER. The removal of a calculus from the bladder by the introduction of crushing instruments capable of reducing its particles to such a size as could pass out by the urethra, is an operation of great anti- quity, having been spoken of by Ammonius about 110 B.C.,1 though it .appears to have been lost sight of, until again brought forward, through the efforts of Civiale, of Paris, about 1822. Like most other novel operations, the progress of lithotripsy was at first re- tarded by the great number of instruments supposed to be neces- sary for its performance. Enlightened by the experience of the 1 Smith's Diet. Greek and Roman Antiquities, art. Chirurgie. PRELIMINARY TREATMENT NECESSARY IN LITHOTRIPSY. 275 distinguished European surgeons who seconded Civiale's efforts, and simplified the method very considerably, the operation has now been brought to such perfection that any surgeon can accomplish it, if a sufficiently dexterous manipulator; gentleness, a delicate sense of touch, and a light'hand, aided by a good crushing instru- ment, being the points most essential to its performance at the pre- sent period. In the United States the operation of Lithotripsy has been prac- tised to a considerable extent, in the employment of Heurteloup's instrument as well as with that of Jacobson. The first operation was, performed by Dr. L. Depeyre, of New York, in 1830; the second *by Dr. Alban G. Smith, then of Ken- tucky, in 1831; and soon afterwards by Drs. Randolph of Phila- delphia, Spencer of Virginia, Uttery of Rhode Island, Gibson of Philadelphia, Nathan R. Smith of Baltimore, as well as by many others. To the late Dr. Jacob Randolph, of Philadelphia, the Ame- rican profession are, however, chiefly indebted for the early and progressive cultivation of lithotripsy in this country, his name being extensively known in connection with his labors on this subject. Few surgeons in the United States have repeated the operation more frequently than he did upon patients of all ages, and few have been more distinguished in this department of surgery either for the beauty of their manipulation, or for the success which attended their operations. In every case he was remarkable for the care he exercised in the preparation of his patients, as well as for the brevity of " the sittings." Without entering into the general history of the progress of the operation, or spending time in the description of the multifarious instruments heretofore devised and emplo}Ted, this account will be limited to the operation as performed with the "lithontripteur," or "stone-crusher," of Heurteloup, this being the instrument now most frequently resorted to. § 1.—PRELIMINARY TREATMENT NECESSARY IN LITHOTRIPSY. As the principal danger in the operation of lithotripsy arises from the production of inflammation, it is of the utmost import- ance that every means be employed to prevent it. The preliminary treatment will therefore often be the chief source of success, and it 276 OPERATIVE SURGERY. PLATE LVII. OPERATIONS FOR THE REMOVAL OF STONE FROM THE BLADDER. Fig. 1. Hypogastric Operation for Lithotomy. An incision having been made in the linea alba and the bladder opened, the left forefinger of the surgeon is seen holding up the superior angle of the wound. Whilst an assistant separates the left side by a blunt-hook, the right hand of the surgeon elevates the calculus from the bas*-fond of the bladder by means of the scoop. 1. Left hand of the surgeon. 2. His right hand elevating the Stone. After Bourgery and Jacob. Fig. 2. The scoop which thus supports the stone and prevents its again falling into the bladder being now held by an assistant, the surgeon seizes it in the forceps with both hands, and ig seen in the act of extracting it. 1, 1. Hands of the surgeon. 2. Assistant holding the stone near the WOUnd, SO that the forceps Can readily Seize it. After Bourgery and Jacob. Fig. 3. A view of the Operation of Lithotripsy. A section of the parts around the pelvis shows the position of the patient, and the manner in which the stone is seized and held by the lithontriptor of Heurteloup. After Bourgery and Jacob. Fig. 4. Another view of the same operation, showing the position of the fragments in the bladder and the mode of seizing them, after the stone has been crushed tWO or three times. After Bourgery and Jacob- Fig. 5. Extraction of a fragment of a calculus from the prostatic por- tion of the urethra by means of the articulated scoop of Leroy d'HtiolIes. The instrument is introduced as a straight sound, gradually passed be- hind the fragment, and then its end made to turn up at a right angle with its stem by means of a screw concealed in its shaft. 1. Handle of the instrument. 2. Its articulated point. 3. Fragment as held by it. 4. Prostate gland. After Bourgery and Jacob. Fig . 5. Fi£.3 Fig. 4 OPERATION OF LITHOTRIPSY. 277 should be pursued according to the following plan: After giving attention to the condition of each organ, especial efforts should be made to remove the irritability of the bladder by the free use of the warm hip bath, by anodyne enemata, and especially by the use of alkalies, as they, by depositing on and equalizing the surface of a rough stone, often counteract one great source of irritation. When these constitutional remedies have induced a less irritable condition, a local preparatory treatment should be commenced, especially the frequent introduction of bougies, so as to dilate the urethra gradually, and accustom the parts to the passage of an in- strument. By perseverance in the daily use of a bougie for about eight days (allowing it to remain in the bladder for a half hour or hour, according to the irritation it causes, care being always taken to remove it if the patient complains much of pain), and gradually augmenting its size, the urethra, may be prepared to receive the largest lithontriptic instrument not only without pain, but without much irritation. The preparation of a narrow bed or table of a convenient height, some tepid water, a little oil, and a good instrument, complete the preliminary measures. The selection of the lithontriptor is a matter of the greatest con- sequence, and, unless it is of the finest temper and finish, it should never be used. I have been accustomed to test these qualities by crushing a moderate-sized tamarind stone in the instrument before attempting to break a calculus. The danger from an imperfect in- strument is, however, not in its breaking, so much as in its bending or spreading at the point, so as to prevent its retraction. In two instances, in the hands of the late Dr. Geo. McClellan, of Philadel- phia, the male blade of Heurteloup's instrument was broken short off in the bladder, and yet subsequently voided with the urine and sand; but when from want of temper the female blade is expanded, or either blade is twisted or bent, the withdrawal of the instrument may become impossible without a serious laceration of the neck of the bladder and urethra. § 2.—OPERATION OF LITHOTRIPSY. Having in former years aided in carrying out the plan of treatment directed by Dr. J. Randolph, of Philadelphia, who was eminently accomplished as an operator in this department of surgery, I have 278 OPERATIVE SURGERY. selected his method as that which may be advantageously followed; not that it presents anything peculiar, but because it is sanctioned by the experience of one of the earliest and most frequent operators in the United States. Operation of Dr. Randolph, of Philadelphia.—The patient, after a careful preliminary treatment, being placed upon his back on a narrow table, covered with blankets, and with a pillow under the hips, bring the latter to the end of the table, elevate the head and shoulders slightly by pillows, and support the feet on chairs so that the knees may be wide apart. If the urine has now been retained, the lithontriptor may be immediately passed into the bladder in the same manner as the catheter, and with quite as much ease by a practised hand.; but if the urine has escaped, a silver catheter should be first passed and tepid water injected into the bladder until it is partially distended, when* the lithontriptor being gently introduced, its blades may be cautiously expanded and carried from before back- wards, or from right to left, or from behind forwards, or from left to right, according to the position of the stone, the manipulation of a few seconds usually enabling the operator to catch it (Plate LVIL, Fig. 3), though sometimes it apparently falls into the grasp of the instrument as soon as the latter is expanded in the bladder, and before the instrument is carried to any extent laterally. After seizing the stone, and moving it a little in the bladder so as to be sure that no portion of the mucous coat is included in the grasp of the instrument, close the blades by turning the screw with the hand, and thus break the stone, after which another part may be seized and broken. If the patient does not complain, it may now be seized a third time (Plate LVIL, Fig. 4), after which, the instru- ment should be gently tapped and moved about in order to free it of the fragments, when the blades should be perfectly closed and the instrument withdrawn from the urethra. The "sitting" may sometimes last only about five minutes, but seldom over twenty, even when it causes the patient no pain. After-Treatment.—The patient, if comfortable, should now be kept on a light diet; but if in pain, use a hip-bath, and take an enema of sixty drops of laudanum, or a dose of Dover's powder, when if, after the lapse of from three to five days, no constitutional or local irritation forbids it, the operation may be repeated. After crushing a stone, it sometimes happens that a fragment in being voided, lodges and becomes fixed in the urethra, and this is OPERATION OF LITHOTRIPSY. 279 usually the most troublesome part of the after-treatment. If seated near the neck of the bladder, the better plan is to push it back into the bladder by means of a sound; but when it is near the fossa navicularis, it may become necessary to dilate the orifice of the urethra, and remove it, if possible, with fine forceps. Should it, however, be further back, an effort may be made to draw it out by means of Leroy's scoop (Plate LVL, Fig. 10); or, if fast in the spongy portion of the urethra, by cutting down and extracting it through the opening. (Plate LI., Fig. 5.) Remarks.—In operating for lithotripsy, much will depend on the manual skill of the operator, as well as on his accurate knowledge of the anatomy of the structure operated on. In order to obtain the first, the young surgeon will find it very useful to practice upon stones introduced into the bladder of a subject, or to place them in a moderately soft buckskin bag, lay the latter upon a pillow, and then with closed eyes endeavor to catch the stone without inclosing also a portion of the buckskin. But, although the operation of litho- tripsy may thus be made to appear an apparently simple one, it is only so when practice has rendered the operator dexterous. In the hands of Civiale and Randolph, I have seen a patient continue in conversation with a smile upon his face during the whole sitting, whilst other operators have given rise to the most intense suffering, by their heavy, clumsy, and thick-fisted manipulations. Since the introduction of anaesthetic agents, it has been thought that all pain from the operation could be avoided, and yet the dangers not in- creased, and such, I think, is truly the case, because, when the blad- der is freely distended by the water previously injected, and the surgeon is a practised operator, the use of the anaesthetic will not only prevent any suffering, but facilitate the operation by preventing straining. To such a surgeon the sense of touch, and that mental perception which enables him to see with his fingers exactly where the point of the instrument is in the bladder, will prevent any injury to the coats of the latter. But, under other circumstances, and in the hands of those who can only imagine what they are doing, the use of anaesthetics will be attended by much danger, as the cries of the patient will be the only proof that can be offered of the coats of the bladder being injured; in other words, anaesthetics will facilitate the operation of lithotripsy, in most instances, though it may also lead to most serious accidents. In the primary operations of young surgeons, it will certainly be safer for them to omit it. 280 OPERATIVE SURGERY. § 3.—CASES ADAPTED TO THE OPERATION OF LITHOTRIPSY. The merits of lithotripsy and its advantages over the operation of lithotomy, is a question that has engaged considerable attention at different periods since the early efforts of Civiale, and been dis- cussed with a fervor that has shown the strength of individual predi- lection rather than the real merits of the question. It is sufficient evidence of the prejudice that has sometimes been exhibited in the expression of opinions on this subject, to know that very few sur- geons, who prided themselves on their dexterity as lithotomists, have ever practised or advocated lithotripsy; whilst some of those who excelled in lithotripsy, as warmly designated lithotomy "as a barbarous operation," &c. Such a result being very frequently the consequence of the en- thusiasm, and reaction, observed in all new movements, it may suffice rny present purpose merely to allude to it, as a caution to the young reader against allowing himself to be influenced by the authority of any name, no matter how high it may stand in surgical repute, and induce him to pursue the more judicious and eclectic system of selecting for his patient either lithotomy or litho- tripsy, in accordance with the following general ideas:— 1st. Very soft and phosphatic stones are the best for lithotripsy. 2d, Hard and rough calculi the best for lithotomy, because, even if crushed, the fragments will prove a source of irritation both to the bladder and urethra. 3d. A sound condition of the urethra and bladder, as well as a good constitution, is essential to the success of lithotripsy. 4th. Lithotomy will do better than lithotripsy in emaciated, nervous, and dyspeptic patients, though these of course are not promising cases for any operation. 5th. Lithotripsy is applicable especially to the young and middle a°*ed—the diseases of the prostate and the condition of the bladder consequent on it, forbidding the operation, as a general rule, in old age. 6th. Lithotomy, if judiciously performed, will afford a better chance of success than lithotripsy, in cases attended by symptoms of vesical catarrh, &c. But in every case of lithotripsy, let it be remembered that the preliminary and after-treatment are quite as important in the result LITHOLIBY. 281 as the operation itself. Rigors and fever, retention of urine, and cystitis, are among the results of lithotripsy in many instances, and a high degree of skill is necessary to protect the patient from the effects of this condition of the system. Both the preliminary and after-treatment are so essential to the success of the operation that it is difficult to decide between them, but if there is a difference I should assign the greater value to the preliminary treatment. To operate for lithotripsy without the most careful preparation of the patient's general health, is certainly indicative either of the igno- rance or indifference of the operator, as to the result of the opera- tion. § 4.—LITHOLIBY. Litholiby (m0oj, stone, 0u,3