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                     OF


OPERATIVE   SURGERY:
           ALF. A. L. M. VELPEAU,

Professor of Surgical Clinique of the Faculty of Medicine of Paris, Surgeon of the Hospital of La Charitd,
          Member of the Royal Academy of Medicine, of the Institute, &c.


       CAREFULLY REVISED, ENTIRELY REMODELLED, AND AUGMENTED WITH


   A TREATISE ON MINOR SURGERY,

                    ILLUSTRATED BY

       OVER 200 ENGRAVINGS, INCORPORATED WITH THE TEXT:

                   ACCOMPANIED WITH

AN ATLAS  IN QUARTO OF  TWENTY-TWO PLATES.
    REPRESENTING THE PRINCIPAL OPERATIVE PROCESSES, SURGICAL INSTRUMENTS, &.C.


         FIRST AMERICAN, FROM THE LAST PARIS EDITION.


                    TRANSLATED BY

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


                AUGMENTED BY THE ADDITION 07

 SEVERAL HUNDRED  PAGES OF ENTIRELY NEW MATTER,

    COMPRISING ALL THE LATEST IMPROVEMENTS AND DISCOVERIES IN SURGERY,
          IN AMERICA AND EUROPE, UP TO THE PRESENT TIME.


       UNDER THE SUPERVISION OK, AND WITH NOTES AND OBSERVATIONS BY

             VALENTINE MOTT, M.D.

  Professor of the Operations of Surgery with Surgical and Pathological Anatomy, in the University of
       New York; Foreign Associate of the Academie Royale de Medecine of Paris,
                of that of Berlin, Brussels, Athens, &c
                                   .-.en won/-'-. ,

               IN THREE VOLUMES.^ '"V?7/  %


                    VOL.1.   x\„,




                 NEW YORK:

       SAMUEL S.  & WILLIAM WOOD,

                No. 261 PEARL STREET.
                      1847. 
wo




 V, J 
                       PREFACE

                               TO THIS

FIRST  TRANSLATION AND FIRST AMERICAN EDITION

                                  OF


      VELPEAU'S  OPERATIVE  SURGERY,

                                  BY

                   P. S.  TOWNSEND, M.D.
  If I were addressing myself to those who have read and studied the great work
of Professor Velpeau on Operative Surgery, it would be  quite superfluous to dilate
upon its merits.  For its general reception as a classical production, written with a
faultless purity of style, and the unqualified approbation which has been bestowed
upon it by those of the profession in Europe, and in this and other countries, who
can peruse it in the language in which it is written, are a sufficient evidence and
guarantee of the estimation which is attached to it.
  I believe it may be safely asserted that there was no work more wanted, than one
precisely of this description ; for none written upon the plan that the Professor of
Paris has adopted, has, as far as I am acquainted,  ever before been  offered to the
public.  For the most part, general works on surgery,  whether issued from the
English, French, or German press, have the fault of being either too  voluminous
and unsystematized for common use,  as elementary treatises either for students  or
practitioners, or they are too circumscribed and exclusive in their objects, being in
most cases confined to specialities, as, for example, to  certain branches  or depart-
ments only of surgery, to general views on the anatomy  of relations, surgical an-
atomy, surgical pathology, monographs on this or that disease,  &c, all of which,
however, are extremely useful in  their place, and requisite to be completely mas-
tered in detail by all those who wish to arrive at any distinction in their profession.
  There was wanted a work which should embrace all the general axioms, precepts,
and facts of Operative Surgery and of Surgical Anatomy, absolutely essential to an
elementary treatise, and systematized and arranged  upon some  natural and well-
defined principles, which should be in perfect concordance with the known laws and
structure of the human organization.
  Such a work is that of  M. Velpeau, as contrasted with  all others.
  In this work the author has shown how requisite it is  that in  every book on a
vast scientific subject  like that of Operative Surgery, the  whole fabric should be
constructed and sustained upon  some approved philosophical  plan, conformable  to
the received axioms of anatomy, physiology, and pathology, and the different parts or
subdivisions of which  should grow out  of, or be  developed, one  from the other,  so
that  the entire edifice should form a perfect whole in itself; while all the details
should be  in such necessary connection,  harmony, and proportion with each other,
that  as in the  study of the living human organization itself,  each  one should  in
some sort be an exponent or co-relative of all the rest.
  We conceive that M. Velpeau has happily and  fully  attained this desideratum—
and that but very little is wanting to make his work one of such standard value that
no public school or university in medicine, and no individual practitioner or student,
can hereafter possibly dispense with it.
  The peculiar fitness which the author possesses for such an undertaking, is seen
in the sound and well-disciplined mind with which he is gifted by  nature—his ample 
iv
TRANSLATOR'S  PREFACE.
 education—his great professional ability and distinction as a practical  operator and
 teacher of surgery—his practised pen as a man of  extensive literary acquirements,
 together with his habits of untiring industry, patient research,  and lastly, what is
 perhaps fully as important as all the rest,  the  clear judgment, the dignified  impar-
 tiality, amenity of temper, and spirit of thorough philosophical investigation which
 he brings to  every disputed or difficult question, or point, which is presented to  his
 notice.
   The fruits of these rare intellectual and moral endowments, which are perhaps in-
 finitely more desirable, certainly in general far more serviceable in society, than thfl
 irregular sallies and random efforts and effusions of mere isolated genius, are en-
 countered upon every page of his work.  As for example, whatever others may say
 to the contrary,  the exact and full descriptions which he gives in all the first portion
 of this volume in relation to Minor Surgery, or those common and indispensable
 operations, manipulations, dressings, &c, of a  general though not difficult nature,
 which it is nevertheless important to be thoroughly conversant with  as the rudi-
 ments of our art, and the only secure basis of all  correct  knowledge to be attained
 afterwards.   The student cannot place too high a price upon this part of the volume.
 And we particularize these matters because,  though to the practitioner  who has
 passed through this ordeal these minutiae  may at first sight seem prolix or tedious,
 he will, on closely inspecting them, find that they are in fact a perfect and admira-
 bly systematized condensation  (instead of a  diffuse or verbose  amplification) of
 every thing of any utility whatever upon this  subject that has been known in past
 times, or been proposed or invented by the moderns, and that the whole is not only
 absolutely essential to be known by the student, and re-perused and  re-studied by
 the practitioner himself, but has also the rare merit  of being  imparted in the clear
 and agreeable style peculiar to the author; and which of itself gives a charm even
 to a subject naturally, and we may say necessarily, dry and destitute of attraction.
   The professional reader also, whoever he may be, if imbued with the proper zeal
and enthusiasm which should belong to him, will  have reason  to  thank  Professor
Velpeau for the mass of valuable erudition which he has brought to bear, by his un-
conquerable application and assiduity, upon the true history of every operative sur-
gical process, principle, or discovery, which adorn or can  illustrate the annals  of
the science, fortified  as the whole also is by direct and  specific references to every
name, authority, or work, ancient or  modern, upon which  the proofs  of his asser-
tions and citations rest.
  We consider that this vein of rich, and much of it new historical contributions in
surgery, and  which so steadily courses or threads its way through the pages of the
 work, constitutes as  it were the natural  woof upon which the whole superstructure
 is woven, and thus forms to it a substratum of inappreciable value.  Because it not
only  shows what has been done, and what has stood  and still stands the test of time,
and will doubtless continue to be approved of and recognised as of established utility;
but it points out also as dangerous, if not forbidden  paths to future explorers, those
fruitless speculations and experiments that are  to be avoided as not only a destruct-
ive waste of time to the student, but as exposing his mind to be seduced by visionary
pursuits, and  thereby into researches which will be liable to end in the repetition of
similar abortive results.
  Another advantage that we acquire, by having always thus at hand in the course
 of our endeavors, to add some new improvement to surgical science, an exact tran-
 script of what others have done before us, and  of what has failed and what succeed-
 ed, and why and wherefore such have been the results, is this, that we are so much
the better  enabled,  as before observed, to economize our time, to husband our
resources, and to concentrate the  full force of  our investigations upon the point or
 points which  it is desirable to elucidate.
   Professor Velpeau has thus also rendered a grateful service to the whole profes-
 ion, vindicated the silent and unprotected dead, as he has rebuked the ambitious and
reckless  living, by according to each his  appropriate claims and property, and by
 stripping- of their spurious honors all that  class of persons  who, actuated by moral
 principles that sit loosely upon their consciences,  have always, in every age and in
 every clime,  been constantly addicted to the pernicious habit (which to them seems
 to be a source of morbid pleasure) of decorating themselves with the plumes which
 righteously belong to the reputation of others. 
TRANSLATOR'S  PREFACE.
V
  We repeat, that we think M. Velpeau, by assigning  to every distinguished man,
who has ever adorned the annals of surgery, the exact measure of gratitude which
the world  owes to him for his services and discoveries, has done a real and great
good to the profession, and especially to the rising youth who intend to embrace
this pursuit.  For who of them would be inspired with an  ardent zeal and elevated
desire to strike out new routes, and to associate their names with brilliant discoveries
and improvements in operative surgery, whether for personal fame, or for the cause
of humanity and philanthropy ; who, I repeat, would be ambitious to make new tri-
umphs  and farther conquests upon the domain of  our art, if he felt assured  that, in
a few years, the evil spirit of a grasping cupidity and rapacity would, by misrepre-
sentation,  suppression of the truth, false and  fabricated statements, and personal
detraction, defamation, and persecution, combine to rob him of these cherished  pos-
sessions, which he had fondly hoped would reward his  years of laborious study and
of painful  toil!
   What will also strike the reader, and particularly the  student, in this great ele-
mentary work on operative surgery,  as a portion that possesses intrinsic excellence,
are the perspicuous and  condensed  anatomical and  pathological  details  which are
judiciously made to precede  all the different operative  processes practised upon the
various regions of the body.
   What renders  this  present volume  one which will generally  be  considered of
higher interest in many respects than any other part of the work, is the fact  that
it contains nearly all  the  latest  discoveries and processes in  that most important
branch of the  art which has not inaptly been called New Surgery ; since it has
sprung up, or rather, made such astounding advances within the last ten years only,
that it  may almost be said  to date  its very birth and existence within that short
period of  time.   The reader will readily anticipate that we allude to the entire de-
partments of,  1.  Anaplasty, or, as some call it, Autoplasty, or the restoration of
destroyed parts and reparation  of deformities, as of the  nose, lips, neck, &c. ; 2.
Subcutaneous Surgery, or Tenotomy and Myotomy, meaning the  subcutaneous sec-
tion or division cf tendons, muscles,  bridles, aponeuroses, fasciae,  synovial capsules,
articular ligaments, cartilages, bones. &c.;  also, directed for the most part against
deformities proceeding from abnormal muscular contractions, alterations,  and distor-
tions of the limbs, feet, hands, neck, spine, &c, and now already promising to cover,
on its great fundamental principle of occlusion of the external  air from  the  divided
parts, a far greater extent of ground than had ever been anticipated, by being adopted
with even more consideration than the illustrious Hunter attached to it, for the basis.
upon which almost every surgical process should hereafter be conducted.
   We have, in various parts  of the work, it will be seen, expressed our own views
and those  of others freely, in relation to the earnestness with which the division of
parts under the skin, so as to effect as perfect occlusion of the external air as possible,
has been advocated by some distinguished surgeons, whose  reputation is much iden-
tified with subcutaneous surgery.  Some qualifications to such sweeping utilitarian
doctrines  are  undoubtedly desirable as  guards and precautions against allowing
ourselves  to be too much  carried away by the  absorbing impulse, which naturally
presses every one into the service of a cause whose march has been attended with
such uninterrupted and dazzling, but, nevertheless, for  the most part, we  are free to
add, solid, triumphs, as has been that of those two great modern and most important
of all acquisitions to the treasures of our art.   And in this opinion we are sustained
by  the  judgment  of Dr.  Mott.   All this  surgery  in itself,  however,  is  of im-
mense value, and especially  of inconceivable utility by the facility with which the
operations which  it comprises can  in general be-performed, and by  its  special
adaptation  to  the relief of the great masses of the poorer classes, who are  most
frequently the  subjects of these, to them, more particularly distressing  infirmities.
But we repeat that we should guard ourselves against being too much seduced by these
utilitarian popular views, and the eclat which  is elicited  from the world without,
when they see a cripple, by a sudden  plunge of a bloodless tenotome, instantly raised,
as from the dead, upon his feet, the  distorted eye, or twisted  neck, righted  to their
just position, and a becoming  and natural nose in the place  of  one that is lost, made
to adhere and  to perform all  the necessary offices, upon  a face that shortly before
presented  a hideous and  disgusting  aspect.
   But while we express ourselves thus candidly, we would not be thought to take 
Vi                        TRANSLATOR'S  PREFACE.

away in any one iota from the immense benefits which this branch of our new sur-
gery, under proper limitations and in skilful hands, and with persons of sound ana-
tpmical knowledge, has conferred, and  is, as we firmly  believe, destined to confer
upon mankind in every part of the earth.
  We have not found it possible or  practicable, step by step, in the course of the
translation, to incorporate  in its proper place all the new matter which it has been
thought necessary to add,  and some  of which would perhaps have  found a more ap-
propriate location under each particular  head to which it belongs.   The student as
well as the practitioner, however, will find himself compensated in some measure for
the detention which has attended the progress of this volume through the press, by
the valuable communications which, through this accidental delay, it has thus been
in our power to embody in the work. Among these acquisitions, will be recognised
those which have been  transmitted to us from Paris, for this American edition, from
the distinguished author,  M. Velpeau himself; of which  none will be read  with
greater pleasure and instruction than his interesting letter to Dr. Mott;  also some
excellent treatises from his  industrious  pen, published recently, and since his last
edition of this work, viz., that  on the new treatment of erysipelas;  his complete
history of strabismus up to the year 1843, and the account  of the late discussion' on
tenotomy in the  Royal  Academy of Medicine at Paris, 1842, in which  last our es-
timable author, it will  be seen, took, as was to be expected from him, a leading
part; all of which publications have been carefully translated and abridged, in  such
manner as to adapt them more conveniently to the limits of this volume, to which
they belong, without, however, omitting  any thing whatever of value or interest to
surgery contained in those treatises.  The principal reason, however,  why a large
portion of the new matter added has not been found in the body of the text, is that
most of these materials were not made public in Europe  or America until after the
work had nearly passed through the press.
  We have,  therefore, in  addition to what is scattered throughout the pages of the
text, on anaplasty, on tenotomy, myotomy, &c, preferred  to consign the principal
part of what we had to say on these subjects to the form of a brief historic summary in
the Concluding American Appendix, which contains every  thing, as will be seen,
belonging to the branches treated of in this volume, booked up to the last moment.
In that also we have endeavored to do full justice to our own countrymen, for all they
have contributed in  this great department of surgery ; and it is with pride we say,
that they have not been behind-hand in following the example of our trans-Atlantic
brethren of France, Germany, and England.   Two  communications of this nature,
of a very instructive character, have been  inserted in  that Appendix, from Drs.
Watson and A. C. Post, both surgeons of the  New York Hospital.  We have also
in that_Appendix drawn copiously from  the recent valuable works of MM. Serre,
Malgaigne, Pancoast, Mutter, &c.
  Avery useful  table in the beginning of the volume, and showing the names of the
muscles of the human body, as adopted, on the one hand, by the French, and, on the
other, by the English and American surgeons, the differences of which terms (some
French, and mostly Latin) lead to much embarrassing confusion, at this time particu-
larly, when the whole subject of myology is rapidly acquiring enhanced importance,
has been kindly communicated to me by Dr.  William Darling, prosector  in surgery
to Dr. Mott.
  To Dr. Darling I am also much indebted, in the course of the translation, for the
assistance he has rendered me, in giving  a just interpretation to many of the epithets,
exclusively technical, in those parts of the work which touch upon the anatomy of the
various regions.   His accuracy as an anatomist, and his attainments as a scholar,
are a guarantee of the correctness of his  judgment  in those  particulars.
  I have to say  but a few words in respect to the motives which led to this under-
taking, and of the manner in which it has been executed.
  I confess, that the intrinsic value  of the work,  as one especially adapted for the
classes at our medical colleges and universities, had often struck both my friend Dr.
Mott and  myself, in various conversations ; but there was a  feeling  beyond this,
which attached us both to all that concerned the great school of medicine at Paris'
and its noble band of professors.  He had been for years resident there, and knew
intimately most of those contemporaneous surgeons who now occupy the more prorai- 
translator's preface.
vii
nent positions in the profession, and who have added, or are now adding, so much
lustre to surgery.
  I had also, in two different sojourns at Paris and Montpellier, in 1821-22, and at
Paris again in 1827-28, had the happiness to become acquainted with, or to follow
upon the clinical lessons of, some of the most illustrious of these men, as well as of
their  predecessors.  It was  natural that I  should recur back with satisfaction of
hours agreeably, if  not profitably, spent under the instructions of  such men as the
Barons Larrey, Dubois the elder, Percy, and Dupuytren, Cuvier, Lacepede, Delpech,
Richerand, Thenard, Gay-Lussac, Boyer, Roux, Lallemand, Civiale,  Lisfranc, Clo-
quet, Velpeau, &c. &c*  And if, in the preparation of this volume, with the constant
advice and supervision of my long respected and much honored friend and former
preceptor, Dr. Mott, our united efforts shall have succeeded in conveying a just in-
terpretation of the spirit and language of our mutual and estimable friend, M.  Vel-
peau, and in thereby helping, by means of this English dress  in which he now for
the first time appears, to give wider circulation on this  as on  the  other continent,
to the important truths in surgery  his elaborate work  embraces, it will be but a
slight return for the gratification and benefits which  we (speaking  for myself, at
least) have personally derived from his instructive lessons, and those  of the illustri-
ous men with whom he is and has  for so many years been honorably associated, in
the most eminent walks of our profession.
   Of the  translation itself, and its general merits, I will briefly say, that it has  been
revised and re-revised, both  by Dr. Mott and myself, and constantly collated  with
the original text  of M. Velpeau, as the only sure guide to  direct  us.  If labor,
therefore, and  devotion the most  unremitting,  can have imparted  any value or
accuracy to this the purely mechanical  and most fatiguing part of our duty, the work
is entitled to a full share of both.
   As to the absolute correctness and fidelity, therefore,  of this English version of
M. Velpeau's work, we venture, from the pains that have  been bestowed  upon it,
and from some knowledge which we think we possess of both languages, to assert
that we pride ourselves upon this production, as adhering as  closely and rigidly as
possible to the original text of the author, verbum verbo, at the risk of appearing, at
times, to be speaking in an idiom somewhat Gallican.
   We preferred to err on this safer side, rather than to  run  the hazard, in a work
devoted to one of the exact sciences, as we consider operative surgery to be, of
making ourselves obscure, or perverting the true meaning of our author by any
attempted circumlocution or improvement upon his pure and elegant diction.
   Like all other works of human labor, it "doubtless possesses imperfections ; none,
however, we feel assured,  of a grave character, and not one blunder, we almost
venture to assert, in the matter of strict and legitimate grammatical translation.
To which we should add, that the publishers have, in every thing that relates to the
typography and to the engravings, both in  the body of  the work and in the atlas,
quite surpassed our most sanguine  anticipations.
   I have been the more particular  in a work of this extreme value, destined, as we
hope, from its own merits,  to be  adopted  generally in our schools, because the
American press and the standard of American education and character have, of late
years, all been not a little discredited and depreciated,  by the book-making attempts
of certain adventurers in the profession, who, having one object solely in view, that
of pecuniary gain, have given  to the world pretended translations of French, Ger-
man, and other works, on anatomy, surgery, &c, the  inexcusable and gross  blun-
ders contained in which, while they spread error and  confusion to an interminable
extent, indicate the utter incapacity of the individuals  in question to undertake a
task of this description.
   We profess to have been  actuated by a higher feeling and purer motives in this
labor, and we therefore consign it to the public without asking any other favor than
that of a just and unbiased searching  criticism upon its merits as well as demerits.
                                                           P.  S.  Townsend.
  JVero York, Becember, 1844.
  * At the same sitting of the Institute, in my first visit to Paris, could be seen assembled in familiar dis-
course, not only some of the older of the above illustrious savans, but also such as the venerable La
Place, Counts Berthollet and Chaptal, Barons Portal and Desgenettes, Legendre, &c, &c. 
 
             PREFACE

                     TO

THIS  AMERICAN  EDITION.
BY VALENTINE MOTT, M.D.
  The reasons which have induced me, tn connection with my friend, Dr,
Townsend, to undertake the laborious yet agreeable task of placing for the
first time before the profession, a complete and faithful English translation
(with all the required additions) of the last Paris edition (1839) of M.
Velpeau's celebrated work on Operative Surgery, are so fully set forth in
my letter to that eminent surgeon, and so kindly and satisfactorily responded
to and approved of by the author's  valuable reply, that I must, at the risk
of incurring the charge of personal vanity, be permitted  the  privilege of
inserting them both in this place, as embracing nearly all that I would wish
to say in a distinct preface to this edition.
  I would  remark, that the whole of this volume (constituting  over 900
octavo pages, and being  the first of the  three which the translation will
make) has been several  times carefully and thoroughly revised under my
immediate supervision.   The notes  and additions on the subjects  embraced
in it, designed to bring the whole work up to the improvements and discov-
eries in Operative Surgery at the present moment, (1845,) have  been also
carefully prepared by  Dr. Townsend, and meet with my entire sanction
and approval.   They have  been  incorporated with the text, or more fully
given in detail in the concluding appendix.
                                       New York, May 24th, 1843.
My Dear Sir,—
  It is with  much  pleasure that I announce  to you  the intention of the
Messrs. Langleys, publishers of  this city, to bring out at my suggestion.
as speedily as  possible, a  complete and faithful English translation of
the last Paris edition (1839) of your invaluable standard work  in  four
volumes,  octavo,  on  Operative Surgery, together with the folio atlas of
plates  belonging thereto, and the nearly 300  engraved illustrations  that
are incorporated with the body of the work.   I have for several years  past
sensibly felt the want of a standard work on Surgery in the  English  lan-
guage, and which should  be properly systematized and classified, upon
                                  B 
 X                      DOCTOR MOTT's PREFACE.

 the  philosophical  principles  upon which the basis of this greatest depart-
 ment of the  healing art now, thanks to the brilliant march of surgical dis-
 covery within the past thirty years, firmly and triumphantly  reposes.
   It  is true that we  have the elaborate dictionary of my  friend,  Mr. S.
'Cooper, of London, as a most inestimable  archive of surgical knowledge,
 and an indispensable historical  record for  reference.   It is  also true that,
 both  in England and in America, there have been from time to time pub-
 lished, for some few years past, excellent compendiums of a limited charac-
 ter.   But there was siill wanting a great philosophical system and practical
 treatise upon every  branch, more especially of Operative Surgery, and I
 have unhesitatingly recommended your work as the  one  which  comes
 nearest, in my view, to the objects desired, and which, on that account, I
 have constantly referred to as the one most  suitable to be adopted as  a  text-
 book in  the University iti which I am  a professor.  To effect  this  object
 more thoroughly, I have, in association with my friend, Dr. P. S. Townsend,
 of this city, made the necessary arrangements to  prepare with him a
 faithful and  exact version of the same, and to have incorporated  with this
 first  American edition,  all such new surgical  matter of interest  or value
 as may have been contributed to the general fund in Europe as well as in
 America, since the publication of your  last edition  in 1839.   I shall  also
 herein present  a more  minute and authentic detail  than has  ever  yet been
 anywhere published, of all that relates to what I myself may be justly and
 conscientiously entitled  to  claim as my own property,  in the entirely new
 operations and new classes of operations, as well as  new improvements and
 views, such as they have been projected and carried out into successful practice
 and execution by myself, as the  fruits of more than forty years  almost in-
 cessant occupation and  labors in all the different departments of Operative
 and Pathological Surgery.
  I have taken thus the liberty to enter my name as a compagnon de voyage
 with you, upon the great high-road of the science, where  it has been so long
 our cherished pride, fortune, and pleasure  to  travel.    Because I  felt  that
 in associating my labors with those which  have received the approbation
 of your judgment, and which  your genius and  untiring  industry have
 wrought out in your estimable work, as an  enduring  monument to your
 fame, I  might find an  appropriate place and guarantee for  indulging the
 ambition that I, like others, must  naturally have of seeing legitimately trans-
 mitted, through an orthodox and approved  organ,  for the  judgment of an
 impartial posterity, an authentic account at least (if only at best but an
 abrege one) of  my stewardship also in  the great field of surgical  science.
 This, so far as concerns  myself, (and  independent of  perhaps paramount
 considerations,  to give wider diffusion upon this continent to your great and
 useful work,) I felt admonished by the time of life  at which I have arrived,
 to be due as  well to myself and my own reputation,  as to my country and
 profession. 
DOCTOR MOTT's PREFACE.                      xi
  As such, then, my dear sir, I  have ventured thus, while life is  so  short
and  art so long, to ask for myself a niche in the great edifice of  surgical
facts and truths of which you are the constructor and owner.   I  have to
ask of  you the  privilege that I may be allowed within this storehouse, con-
taining so much of the treasures of our science, to make safe deposite and
registration of  the detached  fragments of the scaffolding at least, of that
extended work  of my own on Operative Surgery, which, as you are aware,
I have  for  so long a time meditated, and of which these offerings  must for
the present be received as the pledge.
  For  the fidelity of the translation of Dr. Townsend I feel satisfied, from
carefully collating with him  the part of  the work he has already  finished,
that I may safely stand as his sponsor; as but few, also, from his travel and
residence several  years abroad,  have  had better opportunities than he has
profited of, to  become familiarly and critically conversant with the French
and  other  foreign tongues.  To these, permit  me  to add the additional
pledge  that you will have of  not receiving any disparagement at his hands,
by having him  for your interpreter, from the  fact of his own personal and
extensive experience in the practice of physic and of surgery, and the dis-
tinguished  and well-deserved reputation  he has for many years  enjoyed,
both in Europe, in the West Indies, and  in this his native country, by his
medical works  on various subjects.
  I write you thus opportunely upon the subject, with the hope that it may
be agreeable to you to signify your commendation to this proposed under-
taking, and under the possible contingency that it might be your wish to
suggest some alterations or additions to this American edition of your work.
Whatever  may be  agreeable to you in  these particulars, will be rigidly
conformed to, and your intentions in that  respect, or  whatever contributions
you  may be pleased to favor  us with, will arrive in time for  the first volume,
(the first one-third of your work,) if they reach here when that volume com-
plete is placed  in the hands of the publishers, which it will be on September
1st ensuing.  My correspondents, Messrs. Green & Co., bankers, Place St.
George, Paris, will, with pleasure, give safe and quick conveyance to whatever
you  may place in their hands for me.   The second volume (or second third
of your work)  will, it is  hoped, be ready for the press Jan. 1, 1845, and
the last or  third volume (the last third  of your work) not until May or
June, or perhaps August, 1845,  as you perceive, and can readily  imagine,
it must and  ought  to require time, to put into a perfect English, or rather
Anglo-American dress, with  the addition of two  hundred pages or more of
new  matter, and in the beautiful style of typography, paper,  and plates,
that it is contemplated and intended it shall  be  executed with, a work-of
such magnitude as  your last edition (Paris, 1839) of over 3000 octavo
pages.
  It affords me great satisfaction to have an occasion like this, (that I can-
not but believe, from the substantial good that it offers for both of  us to do, 
xii
DOCTOR MOTT's PREFACE.
should be mutually acceptable to both,) of recalling to mind the years of
unalloyed gratification which I enjoyed in the society of yourself and my
other friends, during my residence in your justly renowned capital.
      '  With every consideration of professional respect and personal
             esteem, I am, my dear sir, your devoted friend,
                                                   V.  MOTT.

  P. S. As anxious inquiries are made here, be pleased to inform me when
you contemplate a new edition of your Anatomie Chirurgicale.

   To M.  VELPEAU,
      Professor, etc., Port*
                         (translation.)

         TO DR. VALENTINE MOTT, NEW YORK.

My very distinguished Friend,
  I have learned,  with  very great pleasure, that  a complete
translation of my work  on operative  surgery is to  appear  at
New York,  under your able  supervision ; in associating your nu-
merous labors with mine, in selecting this translation as a repository
for all  the discoveries and improvements which you have intro-
duced into surgical practice, you will obviously make my work an
important treatise, of unquestionable utility,  for our old  Europe
especially, where your labors, in spite of my efforts, are  still but
imperfectly known.
  If your characteristic modesty induces you to suppose that my
work may serve as a passport to your name, you will permit me to
add, with greater exactness, that my feeble authority will be more
than doubly enhanced by being sustained upon your  high repu-
tation.
  Thus assured of being put in  possession  of all your labors,  of
being enabled to consult them every day and on every occasion, I
myself shall enjoy the pleasure of having it in my power to repro-
duce them in our own tongue, and in a shape perfectly authentic,
both for students and for practitioners.
   Persuaded that I have assembled in my work almost the entire
amount of scientific and practical details, indispensable  for those
who have occasion to consult a didactic treatise on operative sur-
gery, I feel no hesitation in saying, that your proposed publication
will assist in rendering this  branch of human knowledge  popular 
DOCTOR MOTt's PREFACE.
xiii
on both sides of the Atlantic.  It would have been unfortunate, too,
that an experience so extensive as yours, during a practice of forty
years,  and that the reflections of the most celebrated and distin-
guished surgeon of America, should have been nowhere found em-
bodied together in the same work.
  I was already in part acquainted with what you say of Dr. Town-
send : he has a reputation which was not unknown to me.  I have
read many articles from his pen, and I had already formed to my-
self a high opinion of his talent.  I am therefore much gratified
that he has undertaken the task, as  you so well  express it, of in-
vesting me in an  Anglo-American dress.
  As to the  changes, corrections, and additions, which you  speak
of,  and which it  might  be advisable to introduce into the  work
while it is in the press, I have  been  seriously occupied with them,
and it is on this account that I have  not sooner replied to your kind
letter of the 24th  of May last.
  The corrections in relation to certain names of authors, and cer-
tain dates, must  necessarily be numerous in a work of this de-
scription, so numerous, in fact, that I have not the courage to point
them out.  I flatter myself, moreover, with the hope that Dr. Town-
send will rectify the greater portion of them.
  Thus, in the paragraph at page 31, of the  Appendix of the first
volume, M.Fearn should be substituted in the place of M.Morrisson,
while the numbers at the quotations at the foot of the page are for the
most part misplaced as to their figures or in the titles of the journals.
At page 33 of the same Appendix, No. 4, and not No. 5, must be pla-
ced after the name of M. Gagnebe.  Especially is it desirable not to
omit to correct in  volume IV.*  pp. 228 and 229, [French text,] the
phrase relative to M. Parcet y Venuales, which must be  inserted
in place of Purcel; moreover,  that it was in 1807 and not in 1788
that the work of this physician was  published.
  I have thought, moreover, that in  order to  enable  you to  select
from my labors what may appear to you to  be  of  value, I could
not do better than to send you  some  copies of the notice recently
published for my  candidateship to the Institute.  You will see in
this notice what I have published since 1838, and consequently
such as I could not avail myself of for the last edition of my work.
  The Dictionnaire de Medecine, or  Repertoire des Sciences  Medi-
cates,  commonly  known  under the  name  of the Dictionnaire de
Bechet, comprises  the greater part of the articles enumerated near

           * Vol. III. of this translation, not yet published.—V. M. 
xiv
DOCTOR MOTT'S PREFACE.
  the conclusion of my notice, and this  Dictionary may be found, as
  I presume, in the bookstores of New York.
    The Journal entitled,  Les Annales  de la Chirurgie, embraces
  many of my  articles : for example, my treatise on Amputation at
  the lower third of the Leg, on Sulphate  of Iron  in Erysipelas, on a
  New Species of Hernia, on Glossotomy in stammering, on Strabismus*
  &c.  Having preserved some copies' of this last essay, and of my
  memoir on  Shut Cavities, I hasten to transmit  them  to you, and I
  regret that  I have not kept also those of my other articles.
    In the possibility that you do not receive the Bulletin of the Royal
  Academy of Medicine, I send you also  an extract from a long dis-
  cussion on Tenotomy, inserted by M. Vidal  (de  Cassis) in the An-
  nales de Chirurgie.\  You will  also find in the  pacquet a short
  explanation in relation to certain of my labors, the authenticity of
»  which had been called in question by certain charitable and inter-
  ested  persons, while I was a  candidate for  admission into the
  Institute.  I take  the liberty of pointing out to your notice, in this
  sheet, the question relative  to the Ligature upon Veins, either for
  varices or varicocele, and to that also  upon the Torsion of Arteries,
  the article on Erectile Tumors, Immoveable Bandages,%  &c.
    A point which I deem important is that which relates to my new
  processes for Extirpation of Tumors, the Amputation of the Jaws, and
  Exsections.   Persuaded that you must perceive at a glance  all the
  advantages to be derived from the curved incision, substituted for
  the straight, in the extirpation of tumors which may be removed
  without trenching also upon the integuments, I will make no further
  remarks on this subject in addition to  those  which you will  find in
  my notice.
    Have the goodness to recollect only that  I have now made use
  of this incision in a great number of instances, in the extirpation
  of tumors of every description,  situated under the jaw, or in the
  parotid region, above the clavicle, upon the shoulder, and different
  points of the trunk and limbs : also in exsections of all the articula-
  tions, of the bones of the metacarpus and metatarsus, of the  carpus
  and tarsus,  the astragalus, olecranon, acromion, and great trochan-
  ter, and in the long sequestra from necrosis in the body of the limbs,
  &c.  And add to this, if  you are so disposed, that  amputation of
  * See Abrege of the author's treatises on Erysipelas and Strabismus, ia the text of
this volume.—V. M.
  t See Abre'ge' of this brochure in the text of this volume.__V. M.
  t Not received.—V. M. 
DR.  MOTT'S PREFACE.
XV
 the fingers and toes, with the corresponding bones of the metacar-
 pus or metatarsus, without making any incision into the palmar or
 plantar region  of the part, have, by the aid of  Liston's  scissors,
 afforded me results of the most satisfactory nature.
   My process  for amputation of the  lower jaw now consists in
 a curvilinear incision, which enables us to lay bare the whole dis-
 ease without dividing the lips, and leaves  a cicatrix  only in the
 supra-hyoidean region.  Suppose it should be required to remove
 one of the halves of the jaw ?  Having commenced near the chin,
 under the lower lip, the incision is continued under the jaw,  back-
 wards, in form of an arc, which is prolonged as far as  the volume
 of the tumor may require, towards the angle of the jaw  and to near
 the temple in front of the ear, or only merely to the anterior bor-
 der of the mastoid process; dissected from below upwards, the flap,
 circumscribed in this manner, may be raised up on the face as high
 as we wish, and enables us to lay open fully the entire correspond-
 ing half of the jaw.  The bone is then  sawed by means of the
 chain saw of Jeffrey, first in  front, then  behind, after which the
 soft parts that have been preserved fall again by their own weight
 to close up the wound, leavmg altogether intact the circumference
 of the lips.
   You are too much familiarized with the great operations of sur-
 gery, to make it necessary for me to enter  into more  full details
 upon a subject of this nature ; and I have no need of adding what
 should be done when we apply this method to the amputation of
 the chin, or of any other part of the maxillary bone.
   In the upper jaw I require also but one incision, whose curvature
 scarcely exacts as much depth  as for the lower jaw;  carried
 from the commissure  of the lips to above the attachment of the
 ear  and to the temporal region, this  incision, which  avoids the
 canal of Stenon, enables us  to raise upon the forehead the entire
 teguments of the face, and the  whole corresponding half of the
 nose; we then proceed to the section of  the bones in  front  from
 above backwards and then outwards; that is  to  say,  in passing
 the chain saw, 1. Through the nasal passage  to bring it out of the
 mouth, in cutting through the soft parts of the palate, and sawing
 the entire palatine and maxillary vault from behind  forwards;
 2.  In cutting the root  of the nose with Liston's scissors, or, what
is  as well, with  the chain saw passed  from  the inner side of the
orbit into the nasal passage to divide  from  behind forwards the
base of the ascending process of the maxillary bone ;  3. In passing
also from the orbit into the temporal fossa in order to cut the su 
xvi
DR.  MOTr's  PREFACE.
perior angle of the cheek bone, either with the chain saw, or with
Liston's scissors;  4.  Finally, in acting in the same manner on the
zygomatic arch, and  with the same scissors, or, *what is as well, in
sawing this arch with Jeffrey's saw.
  All  these  sections, which are effected without embarrassment,
and with  sufficient rapidity, being finished, it requires only a slight
effort made with the  aid of a lever, applied in some of the cuts of
the saw, to detach the bone, the separation of which is completed
by dividing with the bistoury the soft parts which still hold to it.
A single wound only  remains, which a few stitches of suture soon
convert into a linear  cicatrix.
  When the whole breadth of the lower or  upper jaw  is not
involved in the disease, the operation, which consists only in re-
moving the affected portion of  bone, affords  me  results which are
more and more gratifying.  If it is the dental border, the curved
scissors, carried beyond the insertions of the gums, removes the tu-
mor with  one  cut, without making any wound  in  the face, and
places the patient in  the same position  required  for a person who
is to undergo the operation of having some of his teeth extracted.
If we are operating upon the lower border of the bone, the curved
incision enables us to lay it bare, and to remove  it by a cut of the
saw applied horizontally above it.
  You are at  liberty to make  such use of these details as shall
seem agreeable to you, and you will change or criticise them with
the greatest degree of freedom, and conformably to the estimate
which your excellent judgment may put upon them.
       A thousand thanks and a thousand kind wishes.
  Paris, the ISth of August, 1843.                         VIJLPEAU.

  For the reasons doubtless alluded to by M. Velpeau, that the work which
I had  long since contemplated  on those capital operations and new processes
in surgery, of which I consider myself the legitimate author, has never yet
appeared, he is unacquainted with the fact, that in all my operations for the
removal of the lower jaw, and which go back to the year  1821, (see this case,
with the plate accompanying it, American Journal of the Medical Sciences,
Aug., 1830, p. 553,) I have invariably,  from the first, always made use of
the curvilinear incision, to which he justly attaches so much importance.  His
description of its advantages and superiority over every other mode of reach-
ing  the osseous structures to be exsected by the saw or nippers, is so Clear
and graphic, that I have nothing to  add to it whereby I could impress upon
the  mind of the surgeon its decided  preference over every other mode.
  A very recent case of osteo-sarcoma, for which I have operated within a
few days past, and while these last sheets of  the work  were going through
the  press, opportunely presents itself in illustration of my practice in the
employment of the curvilinear incision.  W. E. B----, a young gentleman 
DR. MOTT'S PREFACE.
xtrii
of New York, aged twenty-five, of  sanguine- temperament,  robust form,
and strictly regular in  his habits, was attacked, last April, with a swelling
in the middle part of the lower jaw of the right side, and, as usual in these
affections, without any pain,  except  occasionally, and then slight only.
About four months since he applied to me, when I found the tumor possessing
a degree of hardness, accompanied, however,  with  a certain  elasticity on
pressure peculiar to those  osteo-sarcomatous growths.   The  face  was
generally enlarged on  that side, the  hardness  extending  down to the os
hyoides, and  so  around beyond the posterior  angle of the jaw.  Upon in-
specting it carefully, the tumor was  found to reach to the cuspidatus tooth
in front, and as far up  on the ascending ramus of the jaw under the parotid
gland as could be felt  from without and within the mouth.  From circum-
stances, I was led also to believe th£t it reached, in fact, near or quite up to
the temporo-maxillary articulation.
  I apprized  him at  my first interview of its nature, and  of the necessity
which  I  believed  there  would be  of a surgical  operation to  remove it.
I, however, stated to him that it would be satisfactory to try what benefit
might possibly be  derived from  local and general treatment.   He accord-
ingly, by my directions, applied several leeches once a week to the tumor,
within the mouth, and used internally the alterative treatment of the hydrio-
date  of potash, and compound sirup of sarsaparilla with decoction of our
indigenous yellow dock root.  I enjoined upon  him, at the same time, a mild
light diet.  This course  was carefully and faithfully persevered in for at
least about four months; but, finding  that the disease sensibly augmented
rather  than diminished, I stated to him that the operation of exsecting the
entire mass was  his only alternative.   This he soon became sensible of him-
self, and fully made up  his mind to submit to.
  On Saturday, at half-past one, P. M., November 23d, 1844, I performed
the operation.  Being satisfied that it would  be necessary to remove the
jaw at the temporo-maxillary articulation,  I tied the primitive carotid in the
middle third of the neck, as the first step, and as I had done in other similar
cases, and as long ago as in the year 1821.  I then commenced an incision
a little  in  front of the  meatus auditorius, over the tumor, and carried it
downward behind the posterior angle of the jaw, traversing the lower front
of the tumor, and thence proceeding upward upon the chin to within  near
three quarters of an inch of the vermilion border of the lower lip, terminating
at a point opposite the second incisor  tooth.  An opening was thus readily
made into the mouth.   The soft parts were detached a short distance upon
the chin, to determine that the bone there was perfectly sound.   The second
incisor tooth was now extracted, and through an opening made close to the
bone within by a sharp-pointed curved  bistoury, a chain-saw was conveyed,
by means of an  eyed probe, from within downward, and thus brought out
below the chin, and the bone immediately sawed through from below upward.
  The^ap of integument was now dissected off the tumor from below up-
ward, until the upper part was exposed and the cheek extensively opened.
The bone was now laid hold of where  it was sawed through, and the  dis-
eased mass carefully disseoted from  the subjacent parts on the side of the
tongue and pharynx, sometimes detaching it from below and sometimes from
above, with a view constantly to keep such  vessels as should be cut acces-
sible to the ligature, instead of cutting in one direction only, which, though
it might make the  operation appear to  be more rapidly executed, would, in
our judgment, be less surgical, because it would be, frequently, cutting in
the dark, and at the risk of dangerous loss of blood.
                                   c 
xviii
DR. MOTT's PREFACE.
   The masseter was now. entirely detached;  and as  it was very much
 thickened and degenerated where attached to the diseased mass, it was neces-
 sary to divide it very high up.   The last external  incision was now made,
 extending  from a little  above the glenoid cavity, over the condyle  and
 through the  parotid gland, directly downward,  to  unite with  the  first in-
 cision.   The parotid gland was now detached  in front from over the  con-
 dyle, carrying with it the upper portion of the masseter, so as  to expose
 the root of the coronoid process, which latter was now followed up, and the
 temporal muscle completely detached from it.   This gave much mobility to
 the diseased mass, which was  .urned over towards the ear.   A few strokes
 of the scalpel now enabled me to open the articulation, and to separate the
 condyloid extremity by cutting as closely as possible to this process anteriorly,
 so as to avoid the internal maxillary artery.  The diseased mass was found
 to have extended  as far up as to the neck of the  condyle.
   In this extensive dissection there were a number of vessels tied.  All the
 arteries cut bled with a continuous stream.  The vessels being all secured,
 the flap was turned down, and a cloth wet  with  warm water applied in the
 wound, so as to invite any bleeding  from  arteries that had not been tied.
   After waiting half an hour,  and refreshing the patient, and doing every
 thing to contribute to his comfort, and promote the warmth of his lower ex-
 tremities by  warm  blankets and a bottle  of warm water, the wound was
 dressed by  a number of interrupted sutures, adhesive plasters, lint, a com-
 press, and a double-headed roller.
  The dressing being completed, the patient was conveyed into a warm bed
 and placed on the sound side.   He  bore  the  operation  with  extraordinary
 fortitude, though it was severe  and necessarily somewhat tedious.   He was
much less exhausted than  many persons are after operations comparatively
trivial.  In a short time he fell into a very tranquil sleep, and passed a very
comfortable  night, without the necessity  of  any anodyne, except  twenty
drops of Magendie's solution of morphine, which had  been given an hour
before the operation was commenced.   A gentle  reaction soon came on, and
at the time of writing this, (Dec. 11th, eighteen days  after the operation,) not
the slightest untoward symptom has appeared,  and all the ligatures have
come away.
  The wounds, up to this time, have been regularly  dressed, and the agglu-
tination of the borders of the incision appears to have been wholly comple-
ted by  the first intention.   Not the least hemorrhage has shown itself since
the wound was first dressed.
  This subject, however, will be again recurred to by me, when we reach
that part of the work which treats of exsections of bones.  In the mean time,
 without arrogating  any particular merit  for the very large additions of new
 matter  which have been made, by Dr. Townsend and myself conjointly, to
 this  edition of  the  author, we  will confine  ourselves to recommending,
 especially to all  who wish to  obtain an  exact and perfect knowledge of
 operative surgery, the subject matter of the text of  M. Velpeau himself, as
 well as the contents of those important and recent treatises embraced in this
 first volume,  which he has had  the  kindness to transmit to us from Paris.
 In the  hope that this American  edition of this admirable work may receive
 the full share of approbation by the profession, which I candidly  believe it
 entitled to over all others, I have but to add, that I cordially recommend it to
 be  adopted as a text-book for surgical  classes, not only in our American
 colleges and universities, but  in all other institutions where the English
 language is spoken.
   Jteu York, December, 1844.                                      V. MOTT, 
MUSCLES  OF  THE  HUMAN  BODY,
ARRANGED ACCORDING TO THETR REGIONS,
WITH THEIR CORRESPONDING NAMES IN  FRENCH AND ENGLISH AUTHORS,
MUSCLES OF THE CRANIUM.
Name in French Authors.
Occipito-frontal,
Auriculaire supe'rieur,
Auriculaire anterieur,
Auriculaire posterieur,
     Name in English Authors.
Occipito-Frontalis.
Superior Auris.
Anterior Auris.
Posterior Auris.
MUSCLES OF THE FACE.
Orbiculaire des Paupieres,
Sourcilier,
Pyramidal du nez,
Orbiculaire des levres,
Transversal,  ou triangulaire du nez,
Elevateur commun de l'aile du nez, et
  de la levre superieure,
Elevateur propre de la levre supeneure,
Canin, ou e"le"vateur de I'angle des levres,
Grand Zygomatique,
Petit Zygomatique,
Abaisseur de l'aile  du nez, ou myrti-
  forme,
Triangulaire, ou abaisseur de Tangle des
  levres,
Carre" du menton, ou abaisseur  de  la
  levre inferieure,
Muscle de la  houppe du menton,
Buccinateur,
Masseter,
Cr6taphyte, ou temporal,
Pterygoldien  interne, ou grand ptcry.
  goldien,
Pterygoldien  externe, ou petit ptery-
  goldien,
Orbicularis Palpebrarum.
Corrugator Supercilii.
Pyramidalis Nasi.
Orbicularis Oris.
Triangularis Nasi.

Levator Labii Superioris Alseque Nasi.
Levator Labii Superioris.
Levator Anguli Oris.
Zygomaticus Major.
Zygomaticus Minor.

Depressor Labii Superioris Alaeque Nasi.

Depressor Anguli Oris.
Quadratus Gense, vel Depressor Labii
  Inferioris.
Levator Menti, vel Levator Labii Infe-
  rioris.
Buccinator.
Masseter.
Temporalis.
Pterygoideus Internus.

Pterygoideus Externus. 
XX
MUSCLES OF THE HUMAN BODY.
                     MUSCLES OF THE ORBIT.

      Name in French Authors.                     Name in English Authors.
L'e'le'vateur de la paupiere superieure,      Levator Palpebral Superioris.
r.  •*    a ■ ,.. «  Ait  *    j  i. -i      S Rectus Oculi  Superior, vel  Attollena
Droit supeneur, ou elevateur de 1 ceil,     <   Oculum
Droit infeneur, ou abaisseur de l'oeil,       Rectus Inferior, vel Depressor Oculi.
Droit interne, ou adducteur de Toed,        Rectus Internus, vel Adductor Oculi.
Droit externe, ou abducteur de l'oeil,        Rectus Externus, vel Abductor Oculi.
Oblique eupeneur de l'oeil, ou grand ob- )   Qbliquus Oculi Superior.

Oblique infeneur, ou petit oblique,         Obliquus Oculi Inferior.


                      MUSCLES OF  THE  EAR.

     Interne du marteau, ou tenseur  du    Internal muscle of the Malleus, or Ten-
      tympan,                            sor Tympani.
     Externe du marteau,                \ External Muscle of the Malleus or Lax-
                                       (   ator Tympani.
     Muscle de Terrier,                    Stapedius.


                     MUSCLES OF THE NECK.

           Peaucier,                     Platysma Myoides.
           Sterno-cle'ido-mastoidien,       Sterno-cleido-mastoideus.
           Omoplat, ou scapulo-hyoidien,  Omo-hyoideus.
           Sterno-hyoidien,               Sterno-hyoideus.
           Sterno-thyroldien,             Sterno-thyroideus.
           Thyro-hyoi'dien,               Thyro-hyoideus.
           Digastrique,                   Digastricus.
           Stylo-hyoidien,                Stylo-hyoideus.
           Mylo-hyoldien,                Mylo-hyoideus.
           Genio-hyoldien,               Genio-hyoideus.
           Hyo-glosse,                    Hyo-gloesus.
           Gemo-glosse,                  Genio-glossus.
           Stylo-glosse,                   Stylo-glossus.
           Lingual,                      Lingualis.


           MUSCLES OF  THE PHARYNX  AND PALATE.

      Constricteur infeneur,              Constrictor Pharyngis Inferior.
      Coastricteur moyen,                Constrictor Pharyngis Medius.
      Constricteur supeneur,             Constrictor Pharyngis Superior
      Stylo-pharyngien,                  Stylo-pharyngeus.
      Peristaphylin externe,              Circumflexus Palati.
      Peristaphylin interne,               Levator Palati Mollis
      Palato-staphylin,                   Levator Uvulse.
      Pharyngo-staphylin, ou palato-pha- ) ~ . ,   ,
         ryngien,                        $ Falato-pharyngeus.

      Glosso-staphylin,                  \ Constrictor Isthmi Faucium, vel Palato-
                                       \   Glossus.

                  DEEP MUSCLES OF THE NECK.

     Long du cou,                        Longus Colli.
     Grand droit anteneur de la tete,       Rectus Capitis Anticus Major
     Petit droit anteneur de la tete,        Rectus Capitis Anticus Minor
     Droit lateral de la t6te,               Rectus Capitis Lateralis.
     Scalene anteneur,                    Scalenus Anticus.
     Scalene posterieur,                   Scalenus Posticus. 
MUSCLES OF THE  HUMAN BODY.
xxi
MUSCLES OF THE BACK.
  Name in French Authors.
Trapeze,
Grand dorsal,
Rhomboi'de,
Angulaire de 1'omoplate,
Petit dentele posteneur supeneur,
Petit dentele posterieur inferieur,
Spl6nius,
Long du dos,
Sacro-lombaire,
Long epineux,
Transversaire du cou,
Petit complexus,
Grand complexus,
Transversaires epineuses,

Interepineux du cou,
Inter-transversaires du cou,
Inter-transvers aires des lombes,
Grand droit posteneur de la tete,
Petit droit posterieur de la t6te,
Oblique inferieur de la tete,
Oblique superieur de la tete,
      Name in English Authors.
Trapezius.
Latissimus Dorsi.
Rhomboideus.
Levator Anguli Scapulae.
Serratus Posticus Superior.
Serratus Posticus Inferior.
Splenius.
Longissimus Dorsi.
Sacro-lumbalis.
Spinalis Dorsi.
Transversalis Colli.
Trachelo-mastoideus.
Complexus.
Semi-spinalis Colli,  Semi-spinalis Dorsi,
  and Multifidus Spina?.
Interspinals Cervicis.
Intertransversales Colli.
Intertransversales Lumborum.
Rectus Capitis Posticus Major.
Rectus Capitis Posticus Minor.
Obliquus Capitis Inferior.
Obliquus Capitis Superior.
MUSCLES OF THE THORAX.
Grand pectoral,
Petit pectoral,
Sous-clavier,
Grand dentele",
Intercostaux externes,
Intercostaux internes,
Surcostaux et souscostaux,
Petit  dentele  anteneur, ou trian-
  gulaire du sternum,
Pectoralis Major.
Pectoralis Minor.
Subclavius.
Senatus Magnus.
Intercostales Extend,
Intercostales Interni.
Levatores Costarum.
Triangularis Sterni.
MUSCLES OF THE SHOULDER.
Deltolde,
Sus.epineux,*
Sous.epineux,
Petit rond,
Grand rond,
Sous-scapulaire,
Deltoideus.
Supra-spinatus.
Infra-spinatus.
Teres Minor.
Teres Major.
Subscapularis.
MUSCLES OF THE ARM.
Coraco-brachial,
Biceps humeral,
Brachial anterieur,
Triceps  brachial,
Coraco-brachialis.
Biceps Flexor Cubiti.
Brachials Internus.
Triceps Extensor Cubiti.
MUSCLES OF THE FORE-ARM.
Rond Proaateur,
Radial anterieur ou grand palmaire,
Petit palmaire,
Pronator Radii Teres.
Flexor Carpi Radialis.
Palmaris Longus. 
XX11
MUSCLES OF THE HUMAN  BODY.
  Name in French Authors.
Cubital anterieur,
Fiechisseur superficiel ou sublime,
Fiechisseur profond,
Long fiechisseur du pouce,
Carre pronateur,
Long supinateur,
Premier, ou long radial externe,
Second, ou court radial externe,
Extenseur commun des doigts,
Extenseur propre du petit doigt,
Cubital posterieur,
Ancone,
Court supinateur,
Long abducteur du pouce,
Court extenseur du pouce,
Long extenseur du  pouce,
Extenseur propre de 1'index,
      Name in English Authors.
Flexor Carpi Ulnaris.
Flexor Digitorum Sublimis.
Flexor Digitorum Profundus.
Flexor Longus Pollicis Manus.
Pronator Radii Quadratus.
Supinator Radii Longus.
Extensor Carpi Radialis Longior.
Extensor Carpi Radialis Brevior.
Extensor Digitorum Communis.
Extensor Proprius Minimi Digiti.
Extensor Carpi Ulnaris.
Anconeus.
Supinator Radii Brevis.
Extensor ossis Metacarpi Pollicis.
Extensor Primi Internodii Pollicis.
Extensor Secundi Internodii Pollicis.
Extensor Proprius Indicis, vel Indicator.
MUSCLES OF THE HAND.
Court abducteur du pouce, ou scaphoido-
 ' phalangien,
Opposant du pouce, ou trapezo-meta-
  carpien,
Court fiechisseur du pouce, ou trapezo-
  phalangien,
Adducteur du pouce, ou metacarpo-pha-
  langien,
Palmaire Cutane, ou peaucier de la main,
Opposant du petit doigt, ou unci-meta-
  carpien,
Court fiechisseur du petit doigt, ou pisi-
  phalangien,
Adducteur du petit doigt, ou  pisi-pha-
  langien,
Lombricaux,
Interosseux dorsaux,
Interosseux palmaires,
Abductor Pollicis Manus.

Opponens Pollicis.

Flexor Brevis Pollicis.

Adductor Pollicis.
Palmaris Brevis.
Abductor Minimi Digiti, vel Opponens
  Minimi Digiti.
Flexor Brevis Minimi Digiti.

Adductor Minimi Digiti.
Lumbricales. •
Dorsal Interossei.
Palmar Interossei.
MUSCLES OF THE ABDOMEN.
us Abdominis Externus.
Grand oblique, ou oblique  externe  de
  Tabdomen,
Petit oblique, ou oblique interne de Tab- ).-.,..     .,,   .  .
  domen,                             } Obliquus Abdominis Internus.
I Obliqu
Cremastre,
Transverse de Tabdomen,
Grand droit de l'abdomen,
Pyramidal,
Diaphragme,
Carre des lombes,
Grand Psoas,
Petit Psoas,
Iliaque,
Cremaster.
Transversalis Abdominis.
Rectus Abdominis,
Pyramidalis.
Diaphragma.
Quadratus Lumborum.
Psoas Magnus.
Psoas Parvus.
Iliacus Internus.
MUSCLES OF THE PERINjEUM.
Sphincter,
Transverse du perinee,
Ischio-coccygien,
Releveur de Tanus,
Sphincter Ani.
Transversus Perinei.
Coccygeus.
Levator Ani. 
MUSCLES OF  THE HUMAN  BODY.
xxiii
Name in French Authors.
Name in English Authors.
               PECULIAR TO MAN.
Ischio-caverneux,           Erector Penis.
Bulbo-caverneux,            Accelerator Urinro.
Pubio-urethral,              Sling Muscle of Wilson.
Ischio-bulbaire,             Transversus Perinei.

              PECULIAR  TO  WOMAN.
Ischio-caverneux,           Erector Clitoridis.
Constricteur du vagin,       Constrictor Vaginas.


      MUSCLES OF  THE HAUNCH.
Grand fessier,
Moyen fessier,
Petit fessier,
Pyramidal,
Jumeau superieur,
Obturateur interne,
Jumeau inferieur,
Obturateur externe,
Carre de la cuisse,
Glutffius Maximus.
Glutaeus Medius.
Glutaeus Minimus.
Pyriformis.
Gemellus Superior.
Obturator Internus.
Gemellus Inferior.
Obturator Externus.
Quadratus Femoris.
MUSCLES  OF THE FORE AND LATERAL PARTS OF THE THIGH.
Muscle du fascia lata,
Couturier,
Droit anterieur,
Vaste externe,
Vaste interne,
Crurale,
Droit interne,
Pectine,
Deuxieme adducteur superficiel,
Petit adducteur profond,
Grand adducteur profond,
Tensor Vagina? Femoris.
Sartorius.
Rectus Femoris.
Vastus Externus.
Vastus Internus.
Cruralis.
Gracilis.
Pectineus.
Adductor Longus.
Adductor Brevis.
Adductor Magnus.
MUSCLES OF THE POSTERIOR PART  OF THE THIGH.
Biceps femoral,
Demi-tendineux,
Demi-membraneux,
Biceps Flexor Cruris.
Semitendinosus.
Semimembranosus.
'  MUSCLES  OF THE LEG  AND  DORSUM OF THE FOOT.
Jambier, ou tibial anterieur,
Long extenseur commun des orteils,
Extenseur propre du gros orteil,
Peronier anterieur,
Pedieux,
Long peronier lateral,
Court peronier lateral,
Jumeau externe,
Jumeau interne,
Soieaire,
Plantaire Grele,
Poplite,
Jambier ou tibial posterieur,
Long fiechisseur commun des orteils,
Long fiechisseur du gros orteil,
Tibialis Anticus.
Extensor Longus Digitorum Pedis.
Extensor Proprius Pollicis Pedis.
Peroneus Tertius.
Extensor Brevis Digitorum Pedis.
Peroneus Longus.
Peroneus Brevis.
Gastrocnemius Externus.
Gastrocnemius Internus.
Soleus.
Plantaris.
Popliteus.
Tibialis Posticus.
Flexor Longus Digitorum Pedis.
Flexor Longus Pollicis Pedis. 
xxiv
MUSCLES OF THE  HUMAN  BODY.
MUSCLES OF THE SOLE OF THE  FOOT.
      Name in French Authors.
Abducteur oblique du gros orteil,
Court fiechisseur commun des orteils,
Abducteur du petit orteil,
Accessoire du  long fiechisseur commun
  des orteils,
Lombricaux,
Abducteur transverse du gros orteil,
Court fiechisseur du gros orteil,
Court adducteur du gros orteil,
Court fiechisseur du petit orteil,
Interosseux plantaires,
Interosseux dorsales,
      Name in English Authors.
Abductor Pollicis Pedis.
Flexor Brevis Digitorum Pedis.
Abductor Minimi Digiti Pedis.
Musculus Accessorius, vel Massa Car
  nea Jacobi Sylvii.
Lumbricales.
Transversus Pedis.
Flexor Brevis Pollicis Pedis.
Adductor Pollicis Pedis.
Flexor Brevis Minimi Digiti.
Plantar InterosseL
Dorsal Interossei. 
TABLE   OF   CONTENTS
THE  FIRST  VOLUME.
Prkfa.cs to the Translation of this Ameri-
   can Edition, by P. S. Townsend, M. D.,
Preface to this edition, by Valentine Mott,
   M. D., containing a letter of Dr. Mott to
   M. Velpeau, and M. Velpeau's reply, • •
Table of French and Latin names of all the
   muscles of the human body; by Wm.
   Darling, M. D.,.......................
Preface of the Author to the First Edition,
   «     «     "    "   Second  "
Supplemental Appendix, by M. Velpeau,
Definition and Division,--..............
Page.
  xix
xxxv
xxxix
 xliii
    1
TITLE FIRST.—OPERATIONS IN
        GENERAL,.......................   2



CHAPTER FIRST.—Classification,........  ib.


CHAPTER SECOND. —Nature of Opera-
        tions,.............................   4

Articlk I.—Systematized Operations, and such
        as are without rules,...............  ib.
Art. H.—Operations on the Dead Body........   5
Art. HI.—Methods,........•..............••   6


CHAPTER THIRD.—The Care required in
        Operations,......................   7

Art. I.—Indications,........................  ib.
Art. H.—Various Precautions,...............   9
   6 I.—Hygienic Precautions................  ib.
   S H.—Moral Precautions,.................  11
   § HI.—State of the System,...............  13
CHAPTER FOURTH.—The Conditions that
        are accessory to Operations,-•••  16

Art. I.—Before the Operation,...............  ib.
   G I.—The locale,.......................••  ib.
   S II.—Assistants,........................  17
   § III.—The Instruments and Dressing,. ■..•  ib.
Art. n.—During the Operation,«.............  18
   $ I.—Position of the Patient, Assistants, and
        Surgeon,..........................  ib.
   § H.—To arrest the course of the blood in
        the Diseased Part,.................  20
   $ HI.—To prevent Pain,..................  22
   $ IV.—Accidents,....-.,..............■••  24
      A. Hemorrhage, •»•..............•—  25
      B, Nervous Accidents, •••.............  26
      C. Entrance of Air into the Veins,.....  30
   $ V.—Sang-froid of theSurgeon,..........  40
                    D
                                     Page.
Art. III.—After Operations,.................  42
   § I.—To arrest Hemorrhage,...........■ • •  ib.
   § II—The Dressings,.....................  52
   § HI.—Union of the Wound,.............  54
      A. Indirect Union, or by Second Inten-
         tion, .....•........................  ib.
      B. Immediate Reunion, or  by First In-
         tention,...........................  55
      C. Relative estimate of Dressings by the
         First and Second Intention,.........  58
      D. Conclusions on the Relative Value of
         the two kinds of Reunion,..........  59
      E. Secondary Immediate Uniop,.......  61


CHAPTER FIFTH.—Consequences op Oper-
         ations, ....................•......  62

Art. I.—Natural Consequences,...............  ib.
   § I.—Regimen for those operated upon,.• • •  63
   § H—Separation of the Ligatures,........  65
Art. II.—Accidents,...........•.............  ib.
   § I.—Spasms,............................  ib.
   § n.—Hemorrhage,......................  ih.
   § IH.—Various Inflammations,............  67

Erysipelas.—NEW AND SUCCESSFUL
         TREATMENT OF ERYSIPELAS,
         BY SULPHATE OF IRON,.......  67
      1. Nature and march of Erysipelas, •.. •  ib.
      2. Treatment of Erysipelas,............  68
      3. Special local application,............  69
      Mode of application of the Sulphate of
         Iron...............................  71

   $ IV.—Purulent Infection,................  75
TITLE SECOND.—MINOR SURGERY,  88
Part  First.—ART OF DRESSING,., — .  89

CHAPTER FIRST.—Instruments required
         for Dressing.....................  90

Article I.—Forceps,........................  ib.
   $ I.—Dressing Forceps,...................  ib.
   § II.—Artery or Dissecting Forceps,.......  91
Art. n.—Scissors,...........................  92
Art. m.—Razor, ...........................  93
Art. IV.—Spatulas,.........................  ib.
Art. V.—Porte-Crayon,......................  94
Art. VI.—Probes,...........•.......,.......  ib.
   $ I.—Ordinary Probes,...................  ib.
   § H.—The Chest Sound,..........  95 
xxvi
TABLE  OF  CONTENTS.
      »™,                                Pa*e-
 Art. VTI.—Catheters or Sounds, .............  95
     4 I.—Female Catheter,...................  96
     § U.—Male Catheter......................  ib.
 Art. Vin.—Director,........................  97
 Art. LX—Porte-Meche,......................  98
 Art. X.—Needles and Thread,...............  99
 j


 CHAPTER SECOND.—Lint,................  100

 Art. I.—Pledgets and Layers, (Plumasseaux and
          Gateaux,).........................  101
     6 I.—Plumasseaux.......................  ib.
     5 II.—Gateaux,..........................  102
 Art. n— Different Rolls of Lint,.............  ib.
     6 I.—Boulettes, or Small Balls,...........  ib.
     0 II.—Rolls, properly so called,...........  103
,     6 III.—Dossils, or Bourdonnets,...........  ib.
     5 IV.—Pelotes,..........................  ib.
     § V.—Plugs, or Tampons,................  104
 Art. IH.—Meches and Tentes,...............  ib.
     $ I.—Tentes,............................  ib.
     $ II.—Meches,......'.....................  105
 Art. IV.—Scraped Lint,.....................  ib.
 Art. V.—English Lint,......................  106
 Art. VI.—Filasse............................  ib.
 Art. Vn.—Cat-Tails........................  107
 Art. VIII.—Cotton,..........................  ib.
 Art. IX.—Substitutes for Lint,...............  110


 CHAPTER THIRD.—Linen,.................  Ill

 Art. I.—Dry or Wet Linen,..................  112
 Art. II.—Perforated and Fringed Linen,......  ib.
 Art. HI.—Linen spread with Ointment,.......  113


 CHAPTER FOURTH.—Compresses,........  114

 Art. I.—Form of Compresses,................  ib.
 Art. H.—Divided Compresses,...............  ib.
 Art. IH.—Folded Compresses,...............  115


 CHAPTER FIFTH.—Bands,.................  116

 Art. I.—Linen Bandages,....................  117
 Art. H.—Bandages of Cambric Muslin, or Cal-
          ico................................ 118
 Art. HI.—Woollen Bandages,................  ib.
 Art. IV.—Caoutchouc Bandages,  ............  ib.
 Art. V.—Thread-Riband Bandages,.......... 120
 Art. VI.—Roller Bandages,.................. 12]
 Art. Vn.—Wet Bandages,................... 122
 Art. VIII.—Glutinous Bandages.............  ib.
       Dr. Van Buren on Glutinous, Starch, and
          Dextrine Bandages,................ 123


 CHAPTER SIXTH.—Adhesive Plaster.....127

 Art. I.—Plasters of Vigo or Diapalme.........  ib.
 Art. H.—Adhesive Plaster,..................  ib.


 CHAPTER SEVENTH.—Various Articles,. 129

 Art. I.—Fanons,............................  ib.
 Art. H.—Cushions, ......................... 130
 Art. IH.—Splints,  .......................... 132
 Art. IV^-Trough-Boxes,.................... 133
 Art. V.—Hand-Board and Foot-Board.........  ib.
 Art. VL—Tapes,............................ 134
 A*T. VLI.—Surgical Beds,....................  ib.
 Art. VHI.—Hoops,.......................... 136
CHAPTER EIGHTH.—Bandages,...........  137

Art. I.—General Bandages,..................  >*>•
    4 I.—Containing Bandage,................  J38
    4 II.—Compressing Bandage,.............  139
    $ HI.—Circular Bandage,.................  ib-
    $ IV.—Roller Bandage,...................  140
      Rules which should govern in the appli-
         cation of Bandages in general,......  ib.
    6 V.—Tail Bandages,....................  146
    & VI.—T Bandages.......................  148
    § VH—Square and Triangular Bandages, .  149
Art. n.—Special  Bandages, or such  as are
         adapted  to those regions  of the body
         in which they are required,  ........  153
    S I.—Bandages for the Cranium,..........  ib.
    $ H.—Bandages for the Face,.............  156
      A. Bandages for the Eyes,.............  ib.
      B. Bandages for the Nose,.............  158
      C. Bandages for the Lips and Chin,....  159
      D. The Mask,........................  160
      E. Bandages for the Region of the Ear,  ib.
    $ HI.—Bandages for the Neck,............  163
      A. Uniting  and Dividing Bandage,.....  ib.
      B. Redressers of the Head,............  164
    $ IV.—Bandages for the Thorax,..........  165
    § V.—Bandages for the Abdomen,........  169
    5 VI.—Bandages for the Genital Organs, ..  171
    § VII.—Bandages for the Scrotum,........  173
    § VIII.—Bandages for the Diseases of the
         Anus and Perineum,  ..............  176
    § IX.—Bandages for the Upper Part of the
         Limbs,....................'........  177
    § X.—Bandages for the Hand.............  180
    § XI.—Bandages for the Lower Extremities,  182
    $ XII.—Bandages for Fractures...........  ib.
      A. Fractures of the Hand, ............  183
      B. Fractures of the Fore-Arm,.........  ib.
      C. Fractures of the Humerus,.........  184
      D. Fractures and Luxations of the Clavi-
         cle, ...............................  185
      E. Fractures of the Ribs and Sternum,.  187
      F. Fractures of the Lower Extremity,. •  ib.
CHAPTER NINTH.—Provisional Dressing
         for Fractures,.................. 191

Art. I.—Bandages for the Head,.............. ib.
Art. II.—Bandages for the Face.............. 192
Art. ni.—Sling for the Lower Jaw,.......... ib.
Art. IV.—Bandages for the Neck,............ 193
Art. V.—Bandages for the Axilla,............ 194
Art. VI.—Bandages for the Thorax and Abdo-
         men,.............................. 195
Art. VII.—Bandages for the Pelvis........... 196
Art. VHI.—Bandages for Amputations,....... ib.
Art. IX.—Scarfs............................. 198
Art. X.—Uniting Bandages,.................. 199
Art. XL—Bandages for Fractures,............ ib.
CHAPTER TENTH.—Hernia Bandages, .
200
CHAPTER ELEVENTH.-Various kinds of
         Dressings,........................ 202

Art. I.—Dressing with Cerate,............... ib.
Art. H.—Dressings with Pomades,........... 203
Art. III.—Dressings with Plasters............ 205
    5 I.—Adhesive Strips,...................   206
    5 II— English Court Plaster,...........'!.'.' 207
    $ IH.—Strips of Adhesive Plaster employed
         as a Topical or Compressing Band-
         a8e................................ ib.
ART; rV—Dressings with Cataplasms......... oil
    5 J--Cataplasms applied bare,........     010

       ~1inenPlM,M between two Ple«» 'of

    $DX-Remarks"onlhe*UMofCatapiaVm.; 2£ 
TABLE  OF CONTENTS.
xxvii
Art.

Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
Art.
                                  Page.
V.—Dressings saturated with various Li-
    quids...................•.......... 215
VI.—Irrigations,........................ 216
VII.—Application of Hot Air,........... 219
VHI.—Application of Liniments,........  ib.
IX.—Employment of Embrocations,..... 220
X.—Fomentations,.....................  ib.
XL—Lotions,..........................  ib.
XII.—Gargles,......................... 221
XIII.—Collutories,.....................  ib.
XIV.—Fumigations,....................  ib.
XV.—Injections,....................... 222
XVI.—Enemata........................ 224
XVn.—Douches,....................... 227
XVHL—Baths,........................ 228
XIX.—Precautions required in Dressing,.. 229
I.—Action of the Air,...................  ib.
H.—Treatment of the Wound at the First
    Dressing........................... 230
HI.—Removal of the First Dressing,..... 231
IV.—Hours for Dressing,................ 232
V.—Dressings at Long Intervals,........ 233
 TITLE THIRD.—ELEMENTARY OP-
          ERATIONS, ...................... 235



 CHAPTER FIRST.—Bleeding, or Sanguine-
          ous Emissions,........•...........  ib.

 Art. 1...................................... 236
    $ I.—Bleeding at the Arm,................  ib.
    § H.—Bleeding in the Neck............... 254
    § in.—Bleeding in the Foot,.............. 258
    § IV.—State of the Blood drawn from  the
          Veins,............................. 261
    § V.—Bleeding in certain particular regions
          of the Body,....................... 262
 Art. II.—Arteriotomy....................... 263
 Art. m.—Local Bleeding,................... 264
    $ I.—Leeches,...........................  ib.
       A. The kind to be preferred............  ib.
       B. Application,....................... 265
       C. To stop the bleeding from Leeches,.. 267
       D. Preservation of the Leeches,........ 268
       E. Regions of the body where Leeches
          may be applied,.................... 269
       F. Leeches internally,................ 270
    $ H.—Bird-peck Punctures,  and Scarifica-
          tions,..............................  ib.
       A. The Bird-peck Puncture,...........  ib.
       B. Scarifications,..................... 271
    $ III.—Cupping-Glasses,.................. 273
       A. Dry Cupping,......................  ib.
       B. Scarified Cuppings,................. 274
       C. Air-Pump Cupping-Glasses,........ 275
       D. Cupping-Glass of M. Toirac,........  ib.


CHAPTER SECOND. — Cutaneous Irrita-
          tions.............................. 277

Art. I.—Frictions,..........................  ib.
Art. II.—Massage,..........................  ib.
Art. III.—Rubefaction,...................... 278
Art. IV.—Vesication,....................... 279
    5 I.—Temporary Blisters,................. 281
    $ U.—Permanent Blisters,................ 282
Art. V.—Drains,........................... 284
    $ I.—Issues,............................. 285
    ft II.—Setons,............................ 288
    & 111.—Accidents from Drains,............ 292
    § IV —Suppression of Drains,............. 293
CHAPTER THLRD.—Cauterization,........ 294

Art. I.—Potential Cauteries,.................  ib.
    $ I.—Nitrate of Silver, or Lapis Infernalis,..  ib.
    § U.—Nitrate of Mercury................. 295
    § IH.—Other Caustics,................... 297
Art. II.—Actual Cauteries,......•........... 299
    $ I.—Moxa,..................•...........  ib.
    § U.—Metallic Cauteries.................. 302


CHAPTER FOURTH.—Vaccination,........ 305

Art. I.—Operation...........................  ib.
Art. II.—Progress of the Vaccine,............ 307
Art. HI.—Anomalies of the Vaccine,......... 308
Art. IV.—Preservation and  Transmission  of
         the Vaccine,....................... 309


CHAPTER FIFTH. — Perforation of  The
         Ear,.............................. 313


CHAPTER SIXTH. —Operations that are
         performed on the Teeth,........ 315

Art. I.—Incision of the Gum to favor the egress
         of the Teeth,......................  ib.
Art. n— Straightening of the Teeth,......... 316
Art. III.—Cleaning the Teeth,............... 317
Art. IV—Filing the Teeth................... 319
Art. V.—Filling the Teeth................... 320
Art. VI.—Cauterization of the Teeth,........ 321
Art. VII.—Of Extraction of the Teeth, and the
         Instruments that are used in this Op-
         eration, ........................... 322
    § I.—The Key of Garengeot,..............  ib.
    § II.—The Straight Tooth Forceps,........ 324
    S III.—The Curved Davier,...............  ib.
    § IV.—The Elevator, or Carp's Tongue,... 325
    $> V.—Dog's Foot,........................  ib.
Art. VIII.—The Straight and Curved Cutting-
         Pincers, ........................... 326
Art. IX.—General Remarks..................  ib.
TITLE  FOURTH. —GENERAL,  OR
         COMMON OPERATIONS,........ 327



Part First.—SIMPLE, OR ELEMENTA-
             RY OPERATIONS............  ib.

CHAPTER FIRST.—Divisions...............  ib.

Section First.—Cutting Instruments,........  ib.

Art. I.—Manner of holding the Bistoury,..... 328
    § I.—First Position.  The Bistonry held as
         a knife, the edge downward,........  ib.
    § H.—Second Position. The Bistoury held
         as a knife, with the edge upward,...  ib.
    § IH.—Third Position.  The Bistoury held
         as a pen, the edge  downward, the
         point forward,.....................  ib.
    § rV.—Fourth Position. The Bistoury held
         like a writing-pen,  with the point
         backward,......................... 329
    $ V.—Fifth Position.  The Bistoury held as
         a pen, the edge upward,............  ib.
    § VI.—Sixth Position.  The Bistoury held
         as a drill bow,.....................  ib.
Art. H.—Manner of holding the Scissors,..... 330 
xxviii
TABLE  OF CONTENTS.
                                        Page.
Section Second.—Incisions,................. 330

Art. I.—Simple Incisions,..........•........ 331
Art. H.—Compound Incisions,............... 335
Art. III.—Incisions applicable to Deposites,... 338
    § L—Opening of Abscesses from within out-
         ward, ............................. 339
    $ H.—Opening of Abscesses  from without
         inward,........................... 340
    § HT.—Opening of Abscesses by Complex
         Incisions,.......................... 342
Art. rV.—Incisions applicable to the Dissection
         of Tumors and Cysts,.............. 343
    § I.—Form of the Incision................sib.
    $ H.—Dissection of Flaps,................ 344

Section Third.—Puncture*.................. 346

Art. I.—Acupuncture........................  ib.
Art. H.—Exploring Punctures,............... 347
Art. UI.—Puncture with the Trochar,........ 348


CHAPTER SECOND.—Reunion,............ 349

Art. I.—Sutures,............................  ib.
    fl I.—Interrupted Suture,................. 351
    § II.—The Loop Suture,.................. 354
    § in.—Continuous Whip, or Glover's Su-
         ture, ..............................  ib.
    § IV.—Zig-zag, or Basting Suture,........ 355
    § V.—Twisted Suture,................... 356
    § VI.—Ouilled Suture,................... 357
    § VU.—General Remarks on Sutures,..... 358
Part Second.—COMPLEX  OPERA-
         TIONS, ......................... 359
Section First.—Operations  which are
         performed for Diseases of the
         Cuticular Surface of the Integ-
         dments,.......................... ib.

Art. I.—Operations required for Warts, Corns,
         and Diseases of the Nail,........... ib.
    $1.—Warts,............................ 359
    § II.—Corns upon the Feet,............... 361
    § HI.—Callosities,....................... 362
    § IV.—Diseases of the Nail,.............. 363
      A. Runround,........................ ib.
      B. Nail imbedded in the Flesh,.......... ib.
         I. Destruction of the Nail,.......... 364
           a. Destruction of the imbedded part
                   of the Nail,.............. ib.
           6. Tearing out the Nail,.......... 365
           c. Destruction of the Nail by Caus-
                   tics, .................... 367
           d.  Appreciation,  ................ 368
         U. Destruction of the Fungosities on-
                   ly,...................... 369
         m. Re-adjustment and  Reduction of
                   the Nail,................ 370
         TV. General Remarks,.............. 372
    6 V.—Exostosis, with Sub-Ungual Fungosi-
         ties of the Toes.................... 375
Section  Second. —Operations  which
         MAY BR  REQUIRED  FOR  DEFORMI-
         TIES,  • ••.......................... 377

CHAPTER FIRST.—Morbid Cicatrices,—  ib.

Art. I.—Anatomy of Cicatrices,..............  ib.
Art. n.—Treatment,........................ 378
    & I.—Excision,  .............•............  ib.
    | II.—Incision,.......................... 379
    $ UI.—Extirpation........................ 380
                                         Page.
CHAPTER SECOND.—Sur-Cutaneous  Bri-
         DLES,.............................

Art. I.—Anatomy of Sub-Cutaneous Bridles, • •  lb.
Art. II.—Treatment,...........••••••.......  &®
    § I.—Section of the Abnormal Bridle,.....   lb.
    § H—Extirpation of the Bridle,........•■ ■  Jo*
Art. Ill—Operations according to the Region
         in which the Bridle is situated,.....  Joo
    $ I.—The Hand..........................   "»■
    § II.—Fore-Arm..........................  *":
    $III.-Arm,.............................  *"
    & IV.—Toes,.............................  *»
    ft V.—Legs,..............................  •*■**
    6 VI— Thighs,..........................   in-
    \ VII.—Abdomen and Genital Organs,---  395
    $VIII —Trunk..........................  W6
CHAPTER THIRD.—Deformities from Al-
         terations of  the  Tendons,  or
         Muscles,.........................  399

Section First.—Accidental Divisions,.....  ib.

Art. I.—Tendons in general,.................  400
    $ I.—Pathological Anatomy,
    § II.—Treatment,
                                   ........  ib.
                                   ........  401
      A. Position, .'.........................  405
      B. Suture,  ...........................  ib.
Art. H.— Tendons in particular,.............  407
    S I.—Tendons of the Fingers,.............  ib.
    § II.—Tendons of the Hand,..............  412
    6 III.—Tendons of the Elbow,............  413
    § IV.—Tendons of the Foot,..............  416
      A. Tendons of the Tarsus and Metatar-
         sus, ...............................  ib.
      B. Tendo-Achillis,....................  418
    § V.—Tendons of  the  Femoro-Tibial  Re-
         gion, ..............................  422
    $ VI.—Tendons and Muscles of the Thigh, 426
Art. III.—Deformities by the Retraction of the
         Tendons, or Muscles,...............  ib.
    § I.—Treatment,.........................  ib.
      A. Topical............................  ib.
      B. Tenotomy,.".......................  ib.
         I. Tenotomy in General,............  428
           a. Tenotomy in cases of Wounds,, ib.
           b. Tenotomy, properly  so called, ■ • 429
           c. Appreciation of the Methods,... 431
           d. Pathological Anatomy,.........  434
         II. Tenotomy in Particular,.........  438
           a. Hand,........................ ib.
           b. Elbow, and Bend of the Arm,.. 440
           c. Tendons or  Muscles of the Ax-
                  illa...................... 442
           d. Tendons of the Toes,.......... ib.
           e. Tendons of the Foot,........... 443
             1st. Plantar Surface  of the Foot,  444
             2d. Section of the Tendo-Aehil-
                   lis,...................... 445
             3d. Talipes, or  Club-Foot  For-
                   ward,  or Talus,.......... 449
             4th. Club-Foot Inward, or Varus, 450
               A. Section of the  Tibialis An-
                   ticus,.................... 451
               B. Section of the Tibialis Pos-
                   ticus,....................  ib.
                  Tendons of the Great Toe,. 452
             5th. Section of the Peroneus Lon-
                   gus and  Brevis  in Club-
                   Foot Outward, or Valgus,,  ib.

             General Remarks on  Club-
                   Foot,................... 454

            /. Tendons of the Leg,........... 462
           g. Tendons of the Head—Torticol-
                   lis, or Wry-Neck,........ 465
            h. Section of some other Muscles of
                   the Neck, in  cases of De-
                   viation of the Head,......473 
TABLE  OF CONTENTS.
xxix
                                        Page.
CHAPTER FOURTH—Deformities in con-
         sequence of Alteration of the
         Deep-seated Ligaments, or Apo-
         neuroses, ........................ 474


CHAPTER FIFTH.—Deformities from Al-
         teration in the Skeleton,....... 478

Art. I.—Anchylosis,........................  ib-
    $ I.—Fracturing the Anchylosis...........  ib.
    § U.—Excision of Bone,.................. 479
    § HI.—Supplementary Articulations....... 483
       A. The Upper Extremities,............ 484
       B. The Lower Extremity,............. 485
Art. n.—Deformities  from  Deviation  in the
          Body of the Bones,............•..... 486
     S I.—Breaking of the Callus,..............  ib.
     $ U.—Excision of the Angular Callus,..... 488
 Art. HI.—Appendix,........................ 489
       Late Discussion on Tenotomy in general,
          and particularly on Tenotomy of the
          Flexors of the Fingers, at the Acade-
         my Royal of Medicine, Paris,........ 490
       New Operations in Tenotomy and My-
         otomy, ............................ 511
       General Remarks on Myotomy and Ana-
         plasty in America,  including Dr.
         Schmidt's Division of the Masseter, 517


 Strabismus,............................ 523

 Art. I.—History,............................ 524
 Art. U.—Anatomy,......................... 528
       Theory of Vision, and Action of the Mus-
         cles of the Eye; by the late Profes-
         sor David Hosack, of New York, • • • •  ib.
     § I.—Muscles of the Orbit,................ 534
     l H.—Globe of the Eye,.................. 535
     $ni.—Nerves,..........................  ib.
     IIV.—Vessels,................,......... 536
     § V.—Aponeuroses,......................  ib.
 Art. ID.—Operative Methods,................ 539
 Art. IV.—Comparative value of the Operative
          Processes,......................... 547
 Art. V.—Treatment,........................ 550
 Art. VI.—Consequences of the Operation,.... 551
 Art. Vn.—Inconveniences of the Operation,.. 556
 Art. VHI.—State of the Parts after the Opera-
          tion, .............................. 559
Art. IX.—Counter Indications,............... 560
 Art. X.—Advantages of the Operation,....... 565
Art XI.—Amelioration of Vision............. 573
Art Xn.—Section of the Muscles of the Eye,
         to remedy other diseases,.......... 576
Art. XHI.—New varieties of the Operation, .. 580
       Strabismus in Great Britain, and on the
         Continent of Europe,............... 581
       Strabismus in America,................ 584
Section Third.—ANAPLASTY, OR AU-
         TOPLASTY,......................
PART FIRST— Anaplasty in General,-
ib.
CHAPTER FffiST.—Anaplasty by Restitu-
         tion,..............................  589

Art. I.—Restitution of Organs partially divi-
         ded................................  ib.
Art. H.—Restitution of Organs completely sep-   >
         arated,............................  ib.
    61.—The Nose...........................  ib.
    $ H.—The Fingers.......................  595
                                        Page.
CHAPTER SECOND.—Anaplasty by Hete-
         rogeneous Transplantation,..... 599

Art. I.—Transplantation of Analogous Parts,. ib.
Art. U.—Transplantation of Parts that are dif-
         ferent,  ............................ 601


CHAPTER THIRD.—Anaplasty by  Trans-
         position........................... 602

Art. I.—Anaplasty  by remote Flaps, or the
         Italian Method..................... 603
    S I.—The Italian Process,................ ib.
    § II.—Process of Graefe,.................. 604
Art. U.—Anaplasty by Flaps from Neighboring
         Parts,............................. 605
Art. m.—Anaplasty by Separation of the Tis-
         sues, .............................. 606
    § I. Process of Franco.................... ib.
    5 II. Anaplasty  by Internal Incisions  or
         Scorings, or the Process of Celsus,. • • 608
    $ HI. Anaplasty by External  Incisions  or
         Scorings, or the Process of Thevenin, ib
    § IV.—Anaplasty by Simple Lateral Inci-
         sions—Process of Dieffenbach, ...... ib
    $ V.—Anaplasty by Transportation of a Cu-
         taneous Bridge,.................... 609
    § VI.—Anaplasty by raising an Arcade  of
         the Integuments,................... ib.
    § VII.—Anaplasty in the manner of a Draw-
         er, ................................ ib.
    § VIII.—Anaplasty by Invagination,...... 610



PART SECOND.—Anaplasty in Particu-
         lar, .............................. ib


CHAPTER FIRST.—Anaplasty of the Cra-
         nium.............................. ib.

CHAPTER SECOND.—Otoplasty, (Anaplas-
         ty of the Ear,) ..................... 611


CHAPTER THIRD.—Rhinoplasty, (Anaplas-
         ty of the Nose,) .................... 613

Art. 1...................................... 614
Art. II.—Operative Processes,............... 615
    § 1.—Rhinoplasty by Transplantation,..... ib.
    § II.—Rhinoplasty by Transposition,...... 616
       A. The Italian Method,............... ib.
         I. Process of Tagliacozzi,........... ib.
         n. Process of Graefe,.............. ib.
         IH. Appreciation,.................. 617
         IV. By means of a  Cutaneous Flap
               from the Breech,............. 618
         V. By Transplantation of a Nose, • • • ib.
       B. The Indian Method,................ 618
       C. The French Method,............... 622
       D. Relative Value of the different Meth-
         ods,............................... 623
       Operation for a new Columna, by Mr.
         Liston,............................ 625
       Rhinoplasty in America,............... 626


CHAPTER FOURTH.—Blepharoplasty, (An-
         aplasty of the Eyelids,)............ 627

Art. I.—History and Indications.............. ib.
Art. II.—Operative Methods,................ 629
    $ I.—Process of M. Fricke, or the Indian
         Method,........................... ib-
    « II.—The Author's Method,............. 630
    § IH.—Blepharoplasty  by Sloping of the
         Flap,  ............................. ib.
    5 IV.—Process of M. Jones............... 631
Art. IH.—Appreciation,..................... 632
       Blepharoplasty in America............. ib. 
XXX                          TABLE  OF CONTENTS.
                                       Page.
CHAPTER FIFTH.—Keratoplasty, or Ma-
         king of a New Cornea,  ......... 633


CHAPTER SIXTH—Anaplasty of the La-
         chrymal  Sac,..................... 634


CHAPTER  SEVENTH. —Cheiloplasty, or
         Anaplasty of the Lips,........... 635
Art. I.—The French Method,................  ib.
Art. H.—Indian Method,..................... 640
Art. III.—Cheiloplasty by a Hem of the Mu-
         cous Membrane,................... 641


CHAPTER EIGHTH—Genoplasty, or Ana-
         plasty of the  Cheek,............ 644

Art. I.—The Indian Method,................ 645
Art. H—The French Method................ 646
      Cheiloplastic  Operation by Dr. Mott,.... 648
CHAPTER  NINTH. —Staphyloplasty,  or
         Anaplasty of the Uvula and Ve-
         lum Palati,...................... 650


CHAPTER TENTH.—Palatoplasty, or An-
         aplasty of the Vault of the Pal-
         ate, .............................. 651
      Mutter's Process of Anaplasty for Cica-
         trices from Burns,.................. 652


CHAPTER  ELEVENTH. —Bronchoplasty,
         or Anaplasty of the Larynx and
         of the Trachea,................. 654

Art. I.—Anatomy,..........................  ib.
Art. II.—Indications,........................ 655
Art. III.—Operative Process,................ 657
    § I.—Process of  the Author,..............  ib.
    § II.—Ancient Processes,................. 661


CHAPTER TWELFTH.—Anaplasty of the
         Thorax,.......................... 662


CHAPTER  THIRTEENTH.—Anaplasty of
         Stercoral Fistulas, and Artifi-
         cial Anus,........................ 664


CHAPTER  FOURTEENTH.—Anaplasty of
         the Scrotum  and Penis,......... 666
CHAPTER  FIFTEENTH. —Uretroplasty,
         or Anaplasty of the Urethra, . 667
CHAPTER SIXTEENTH.—Vaginal Anaplas-
         ty, or Elytroplasty,............ 669
CHAPTER SEVENTEENTH.—Anaplasty of
         the Perineum,................... 674
CONCLUDING AMERICAN AP-
         PENDIX,...................... 675


Acupuncture,................................  ib.
Electro, or Galvano-Puncture,............... 676
                                       Paffc
Hemostatic Means............................ "76


SUB-CUTANEOUS SECTIONS IN TENOT-
         OMY AND MYOTOMY,.......... 678

Strabismus,................................  ib.
  Proposed Excision of a Portion of Elongated
         or Paralyzed Rectus, [by P. S. T.,] ... 679
Division of the Tendc-Achillis................  ib.
Division of the Muscles of the Face,.......... 680
Pancoast on Talipes, or Club-foot,............. 681


ANAPLASTY, ............................. 684

Pancoast's Processes of Rhinoplasty,..........  ib.
Pancoast on Cheiloplasty,....................  694
Pancoast's Process of Posthioplasty, or Ana-
         plasty of the Prepuce,..............  696
Pancoast's Process of Chalinoplasty, or  the
         Making of a New Frenum Preputii, .  ib.
Mutter's  Anaplastic Operations  for the
         Reparation of Deformities  from
         Burns,............................  697
Guerin  on Optical Strabismus.............  701
Treatment of Erysipelas by Nitrate  of Silver,.. 703
Blepharoplasty for Navus Maternus,..........   ib.
Dr. Mott's Process  for the Cure of Nm-
         vi,................................   ib.
The Red-Hot Iron for Phlebitis,..............  704

Early Operations for Geno-Cheiloplasty,
         or Anaplasty of the Cheek and Lips,
         by Dr. Mott,.....................  706
  Case I.—By Displacement,.................   ib.
  Case II.—By Displacement and Flaps,.......  707

Metopoplasty—Anaplasty of the Forehead. By
         Dr. Jno. Watson,..................  711
Anaplastic Operations and Sub-Cutaneous
         Sections.  By Dr. Alfred C. Post,..  714
Tiemann's Improved Eye Speculum,...........  723
General Review of the Progress of
         Sub-Cutaneous Sections and An
         aplastic Surgery, since the Last
         Edition of Velpeau..............  724


THE SUB-CUTANEOUS SECTION,........  725

Strabismus,................................  725
  Myotomy of the Levator Palpebrae..........  757

Torticollis, and Proposed Division of the Sple-
         nitis Capitis........................  759

Dorsal  or Rachidian Myotomy,  {Myotomie
         Rackidienne,) for Lateral  Curvature
         of the Spine,.......................  7gn
  M. Jules Guerin's views thereon,...........   ib
  Professor Robert Hunter's Process,..........  767
  M. Malgaigne's Objections to Dorsal Mvoto-
         W................................  768
M. Guerin's Table of Diseases, to which Sub-
         Cutaneous  Sections   and  Punctures
         may be or have been  applied........  774
M. Doubovitski's Case, as related by himself,... Tit
Diagnosis and Treatment of Contraction of the
         Fingers of both Hands, from Con-
         traction of the Fascia Palmaris.  Bv
         Caesar Hawkins, of London........f 777
Section of the Flexor Longus Pollicis..........  77a 
TABLE OF  CONTENTS.
xxxi
                                         Page.
Division or Muscles, Tendons, etc. of the
         Lower Extremity,............... 779


Sub- Cutaneous Kelotomy,.....................  ib-
  Division of Muscles of the Thigh for Con-
         tracted Hip, ....................... 781
  Ditto in ununited Fractures of the Patella, • •  ib.
  Rupture of the Tendon of the  Triceps Femo-
         ris,................................  ib-
  Fracture-Box for Rupture of the Tendon of
         the Triceps Femoris, and of the Lig-
         amentum Patellar,.................. 782
  Division of the Ham-Strings,................  ib.
  Division of the Flexor Muscles of the Leg, • • 783


 Club-Foot,................................... 784

  Section of the Tendo-Achillis  in recent com-
          pound Fractures and  Dislocations of
          the Leg, Ankle, &c.................  ib.
  Section of the Tendo-Achillis in Fractures of
          the Malleoli,....................... 785
  Ditto in certain luxations of the Ankle-joint,. 786
  Division of the Tendon of the Flexor Longus
          Digitorum Pedis,...................  ib.

 Sub-Cutaneous Incision of Joints,.............  ib.

 Sub-Cutaneous Section in  Congenital Luxations,
          by M. Guerin...................... 788

 Ditto for Psoas Abscess, Buboes, Tumors, ire.,. 790

 Division for Bursal Tumor j, Cysts, ire, by M.
          Velpeau........................... 791

 M. Guerin s great Operation,................. 792

 Proposed Division of the Hyo-glossus and Stylo-
          glossus Muscles for Stammering, by
          M. Velpeau,....................... 793
 Contraction of the Limbs in Inflammatory Soft-
          ening of the Brain,................. 794
 Diseases for which Prof.  Robt. Hunter suggests
          the Sub-Cutaneous Operation,...... 795



 ANAPLASTIC OPERATIONS,.............. 796

 Blepharoplasty,..............................  ib.
 New Suggestions for Rhinoplasty,............. 798
 Cheiloplasty in Cancerous Lips................  ib.
 Early Geno-Ckeiloplastic Operation, by M. Lis-
          franc..............................  799
 Anaplasty applied to the Operation for Compound
          Hare-Lip, by M. Malgaigne,........  800
  Dr. Mott's Remarks on ditto,..............  ib.
 Anaplasty for Ranula,........................  801
 Anaplasty for the Cure of Cicatrices from Burns,
          as first performed by Mr. Carden, —  ib.
 Uretroplasty,................................   ib.
 Episcoplasty,................................  805
 Penoplasty, by Dr. Mettauer, of Virginia,.......  ib.
                                          Page.
Artificial Joints.—Exsection of  the Ar-
         ticulations—Elbow and  Knee, • • 806
  Operation  of Exsecting the Elbow Joint in
         Anchylosis, as first perfected by Mr.
         Syme, ............................ 807
  Exsection of the Elbow Joint, by Dr. Gurdon
         Buck, of New York,...............  808
  Exsection  of the Entire Knee Joint, by Dr.
         Gurdon Buck, of New York,........ 80S

Anaplasty as applied to the Deformities of
         the Face, by Professor Serre, of
         Montpellier,....................... 810

Facial Anaplasty...............f.........  815

Cheiloplasty,.................................  819
  Dr. Mott's Views as to Cancerous Degenera-
         tion of the  Mucous Buccal  Lining of
         the Lips,.......................... 821
  Anaplasty of the Commissure of the Lips, • • 825
  Restorations of the Upper Lip,.............. 827
  Restoration of an Entire Mouth,............ 828
Rhinoplasty,  ................................ 830
Gynoplasty,..................................  ib.
Anaplasty in Immobility of the Lower  Jaw, •••• 831
  Dr. Mott's Process,.........................  ib.

M. Malgaigne's Last Edition  (1843) of his
         Manual of Operative  Surgery, • 833

  The Sub-Cutaneous Incision,.  ............   id.
  Caustics and Cauteries,..................... 834
  The Sub-Cutaneous Principle for the Cure of
         Goitre, ..........................  ib.
  Compression of  the Arteries  and  Veins for
          Hemorrhage,...................... 836
  Cauterization with the Hot Iron,............ 837
  Ligatures..................................  ib.
  Torsion,...................................  ib.
  Application of Adhesive Plasters,........... 838
  Leeches and Leeching,.....................  ib.
  New and Prompt Mode of arresting Bleeding
          from Leech-Bites,.................. 84)
  Venesection over the Brachial Artery,.......  ib.
  Electro-Puncture for the Cure of Goit-e, •■•■  ifc
  M. Amussat's Process to prevent  the re-adhe-
          sion of Inodular Cicatrices,.........  ib
  Division of the Masseter,...........,........  ib.
  Division of most of the Muscles of  the Coxo-
          Femoral Articulation, by M. Guerin,.  ib.
  Division of the Tendo-Achillis............. 841
  Morbid Cicatrices,.......................... 842
  M. Goyrand's Process of Extracting Foreign
          Bodies from the Joints..............  ib.
  Artificial Joints,........................... 844
  Tarsoraphy................................  ib.

Myotomy for Strabismus,............-4... 845
  Section of the Superior Oblique,............ 846
  Section of the Inferior Oblique,............. 847
  M. Bonnet's Process........................  ib.
M. Malgaigne's Process for Cheiloplasty,...... 848
Uretroplasty,................................ 850 
I
ERRATA.
For Art. IV. p. 104, Art. V. p. 105, and so on down to Art. X. p. 110, inclusive, read
        Art. III. IV. V. VI. VII. VIII. and IX.

For TITLE  II. p. 235, read  TITLE  III.

For CHAPTER VI. p. 305,  read CHAPTER IV.

For TITLE  III.  p. 327, read TITLE IV.

For §  IV. p. 375,  read $ V.                                               •

For " Alterations of the Ligaments," &c., heading of Chapter IV. p. 474, read "Alter-
        ations of the Deep-Seated Ligaments," &c.

For Section II. p. 573, read Article XI. 
xxxiii
           WORKS  OF M.  VELPEAU,

                          [IN FRENCH,]

REFERRED TO BY HIM IN THIS WORK ON OPERATIVE SURGERY
Complete Treatise on the Art of Midwifery, or Theoretic and Prac-
    tical Tocology, etc.
Embryology, or Human Ovology.
Convulsions in Women during Pregnancy and Labor, and after Par-
    turition.
A Small Treatise on the Diseases of the Breast.
On the Operation of. Trephining in Wounds of the Head.
A Complete Treatise on the  Surgical, General, and Topographic An-
    atomy of the Human Body.
Manual of General and Topographic Surgical Anatomy.
Description of a Remarkable Case of Cancerous Disease.
Researches on the Spontaneous Cessation of Traumatic Hemorrhages.
Contusion in all the Organs.
Laryngeal Fistulas and Bronchoplasty.
Amputation of the Leg at the Articulation of the Knee.
Mercurial Frictions in Peritonitis.
Memoir on the Membrana Decidua, (Caduque.)
On Artificial Anus, (Contre Nature.)
On the Treatment of Burns.
On Diseases of the Lymphatic System.
On Luxations of the Shoulder.
Letters on the Introduction of Air into  the Veins.
E 
 
XXXV
          PREFACE
                  TO

THE  FIRST  EDITION.
  In publishing the first edition of this treatise, in 1832, my object was to satisfy a
want generally felt.  That which M. Roux promised in 1813, has noj; been effected.
The work of M.  Sabatier had already become old.  A crowd of neglected opera-
tions, scarcely known in the time of this author, and which to-day engage the atten-
tion of the  learned world, had not  yet found a place in classical  works.  Rhino-
plasty, cheiloplasty, blepharoplasty, otoplasty, bronchoplasty, staphyloraphy, torsion,
puncture of the arteries, lithontrity, cauterization of the urethra, amputation of the
uterus, extirpation of the ovary, and of the anus, and many exsections, were of this
number; and we may say that a review of operative surgery entire, had really be-
come indispensable.
  The course of instruction which I have undertaken since 1823, made me recognise,
at the very outset, the species of void of which I speak, and  would have induced
me at an early occasion  to have attempted to remedy it, had  I not been fearful of
undertaking a task beyond the measure of my strength.   I limited myself  at first
to the idea of a simple manual; but  the researches into which I naturally found my-
self drawn on  this occasion, soon convinced  me that, to be truly useful, not only a
manual, but a complete treatise was necessary.  Many chapters were already com-
pleted with this  view, when  the journals  announced, in 1825, a work of the same
kind which would immediately appear, but which has  not yet been  published.  I
thought it  proper to arrest my course and wait.   Other motives encouraged me to
this delay.   Sustained  only upon the demonstrations of the amphitheatre, my as-
sertions  would have been but of feeble value.  The processes essayed upon the
dead body cannot be definitively adopted but  after having been submitted to the test
of the Hospitals.  My position at this epoch, would not then have given me the
right to appeal, with a sufficient degree of confidence, to my personal  experience.
   Four years  of practice at the Hospital of Perfectionnement, the service of the
Hospital of St. Antoine, with which I have been intrusted for nearly two years,
and the wards  of which I have had the direction at La Pitie, procured me at length
the opportunity of applying frequently to the living body, the processes which I had
so often repeated on the dead subject.  To set out from that point, I thought it
might be permitted me to express an opinion on the propriety, absolute or relative,
of the different methods which should be examined in a treatise like the present.
   Writing in  the sole  interest of truth, I accepted thus the labors of  all, without
distinction of country, school, or persons, reserving to myself the right to discuss 
xxxvi               preface to  the first  edition.
their merits with independence, and  of stating, without prejudice,  what, in my
opinion, they might offer of useful or defective.  Our epoch presents, under this
point of view, difficulties which can only be appreciated fully by him who should un-
dertake to make an impartial history of it.  While men are living, they are rarelv
just towards one another.
  The improvements for which we are indebted to the greater number of practitioners
who share the domain of science, being unpublished by their authors and  unknown
but by  tradition, it was indispensable to make a conscientious examination of them,
and to  seek out with care their true sources.  No work having been composed in
this spirit, and  the history of surgery of the  nineteenth century being a task yet
unattempted, I have been under the necessity of consulting an infinity of periodical
collections, particular memoirs, and monographs of every description.
  A work of great application, where every thing is to be in some sort mathemati-
cal, treating of  dates,  of inventions, and of processes which  have given birth to so
many discussions, and to controversies so multiplied, the subject and each one of the
objects of which have been presented  in so many different forms, and so differently
interpreted, exacted in this respect an attention, a care, and  a  labor,  wjiich few
persons would suspect, and an amount of researches of which it is, in reality, diffi-
cult to  form an idea, except by one who has himself undertaken it.
  In short, in order to be sure of omitting nothing essential, I frequently addressed
myself to the persons themselves, to those especially whose researches  were un-
published, or have been written by a third  party.   It was thus, in order to know
what Dupuytren had  done on certain operations, I believed it my duty to  make in-
quiry of M. Marx, his special pupil.   I  have in this  manner learned, through M.
Moulinie, that the success attributed  to the refrigerant method in the treatment of
aneurisms, was  far from being  well established; that all, or almost all of it, was
due to other means concurrently employed, for  which no allowance was made in
the detail of the observations.
  As to what relates to the epochs that are past, I have done all in my power to go
back to those sources.  When I have not been enabled to do so, either  from the
scarcity of works or owing to the language in which they are written, I have  relied
for my authority upon Sprengel, confirmed  by that of Le Clerc,  Freind, Dujardin,
and Peyrilhe.
  Having scarcely anywhere given the title or passages of  the works that I have
drawn  from, I might have dispensed also with giving the name of the authors.   One
may thus neglect all historical research, and have no need of contradicting, person-
ally, any one, whoever he may be ;  but nothing appears to me more contrary to the
true interests of science.  Seeing thus no name  in the text they read, students, un-
just without knowing it, constantly impute to the author whom they have in their
hands, ideas which often date many ages back, or that twenty others have already
originated.   Hence comes that credulity so adroitly experimented upon in all times,
and now more so than ever, by the  inventors of new  methods ; hence so many of
those academic mystifications, and that currency which the fabricators of discoveries
obtain  among numerous practitioners, who, in this respect, are scarcely less difficult
to be imposed upon than pupils.  In  collecting upon each  subject  upon which I
treat, the principal names that belong  to it, I in  the first place acquitted myself of
a strict sense of justice;  and have also thought  that  my assertions gained by this
means a support and an authority which it would have been wrong to have deprived
them of.  In a  word, I find  also here the advantage of showing to the reader that 
preface  to  the  first  edition.
xxxvii
the object with which he is occupied is or is not new, or that such and such persona
have already spoken of it.  To persons who would reproach me that I have thereby
rendered it impossible for them to verify the  exactitude of my citations, I would
reply, that in reproducing the opinion of others, I have in general given it as I un-
derstand it, without pretending  in any manner rto render them responsible for my
interpretations.  Addressing myself, as I do, to pupils, I have desired, in pointing
out things, to lead them to suppose that there is a history of them, and thus to give
them, in advance, some taste for scientific literature.
   No one has ever called in question the importance of anatomy in the practice of
operations.   Nevertheless, as it was not possible to introduce but a small number
of its details in a treatise on operative surgery, I have thought it advisable to look
to those only that are indispensable, and to choose  the form which is best adapted
to their abridged exposition.
   Sabatier, who was capable of  giving the state of the science with so much clear-
ness, has, nevertheless, from his want of descriptive details, the  defect of not satis
fying any but those who are already acquainted with it, or who are  content  with
studying it in their closet, and of being, therefore, insufficient for those who operate
in amphitheatres.  Seeing this rock, I  have endeavored to shun it, without losing
sight of the opposite inconvenience, knowing  how fatiguing  by their aridity, and
how irksome by their multiplicity, are those long and interminable manual directions
that are found in some publications of our time.
   As for the rest, in order to satisfy all  on this point, I have, under the title of oper-
ative process, given, as often as the  extent of the subject has permitted me to do so,
the details purely mechanical and practical that are absolutely required for the per-
formance of the operation, whether on the living body or on the dead subject.  The
history, the examination, the discussion, the appreciation of the methods, the acci-
dents, the  consequences, the indications, forming  the subject of so many distinct
titles, will  always be easy to consult separately by those who  would not desire tc
read the article entire.  I have not applied these divisions, however, except to the
operations  somewhat complicated, and have not thought it necessary to adopt them
in those  which may be conveniently described  in a few pages.   Not having made
up my mind to treat exclusively of operative processes, nor wishing, on the other
hand, to make a book on surgical pathology, I have confined myself on this point to
the discussion of the indications, setting aside, except in cases of special necessity,
whatever relates to  the nature, to the  development, symptoms, and general treat-
ment of the diseases.  The comparison of the  methods, and the results that  they
have furnished, formed another point too much neglected up to the present time,
and one too unquestionable in its utility, not to require from me every attention pos-
sible.
   If I have often adverted to processes long since forgotten, or justly proscribed ;
if I have, also, not omitted a crowd of recent inventions, which may not have any
value in themselves, and that science can derive no advantage  from ; it is because,
on the one  hand, there is no method, however extravagant we may suppose it to be,
which does not  run some risk of being reproduced at some future time by some new
inventor, and that, on the  other hand, it is indispensable  to enlighten  students, not
only on what they ought to adopt, but also on what they  ought to reject, when the
subject is the cotemporary history of assertions and of opinions that they are every
day accustomed to hear unjustly praised or censured.  Although I  may have done
all this, in order to follow out, under this double  relation, the march of mind, and to 
xxxviii
preface  to the first edition.
represent with exactitude and impartiality the actual state of the science ; and that
I have neglected nothing which might enable me to procure correct information on
its most modern improvements, I nevertheless apprehend that I may have forgotten
some  things that are useful, and I make no  pretension of having described every
thing.  As to the rest, I shall receive with gratitude the advice which the judg-
ment of learned men may be pleased to furnish me with.
  The engravings annexed to the descriptions are not  as numerous as the nature
of the subject would seem to render necessary ; but the  price of the book is already
so much enhanced by them, that I have not  thought it  proper to  extend them fur-
ther.   All  have been taken from nature with the greatest care.   Though for  the
most part considerably reduced, the objects will be found represented with neatness
and precision.  I have chosen, as much as possible,  new points of view, and those
which permit us to seize at a glance the ensemble of the operation.
  Their only object being to replace tedious written details, I have looked less to
their finish than to  the accuracy and clearness of the  design.  The  execution of
them was, moreover, confided to one of our most distinguished artists, M. A. Cha-
zal, Professor of Iconography at the Museum of Natural History, who, as is well
known, possesses great skill in this particular branch.   Such instruments as I have
not been able to find in the collections of the  faculty, have almost  all been procured
for me by M. Charriere, the most extensive and skilful manufacturer in this branch
at Paris.
    Paris, 1833. 
            PREFACE
                    TO

THE  SECOND   EDITION.
  A more extended practice, the service of a large hospital, and the requirements of
teaching, have made it a more and more imperious duty for me to submit to the cru-
cible of experience, almost the whole round of surgical operations.  Led by these
means to compare the various resources of surgery with each other, I have thought
it proper to consign to the present edition of this work the conclusions to which  I
have arrived from  the researches which  I have made, and never to  shrink from
giving a positive appreciation and judgment, when the questions have  appeared to
me susceptible of it.
  In this respect I have had to divest myself more than ever of opinions deduced
from the dissections of the amphitheatre. Habituated, like my cotemporaries,to judge
of the importance  of operations by the processes on  the dead body, I had  at first
attached too much value to a great number of methods and precepts of which I now
recognise the  insignificance  or puerility.  In imitation of surgeons  who,  taking
for serious the approbation of some young students,  have believed that they could
remodel operative surgery by directing the incision of tissues at  so many lines or
inches from such or such a groove, under an angle of such or such a degree, follow-
ing out, as they say, the  rules of geometry,  I had  abandoned myself also  to  the
innocent pleasure of extolling the superiority of methods that were altogether inap-
plicable, or utterly  useless.  I now know, that on living man it is less  important to
act  quickly than to act properly; less important to establish regular  wounds,  and
geometrical incisions, than to follow the line indicated  by the diseased tissues ; less
important to give  to the divisions a ready approximation, than to place them in
conditions which offer the greatest possible security.
  Believing that I have  the  right, at the present time, to modify and to change
what has been erroneously said or done by others, I have not hesitated, as formerly,
to declare what I have found best, or least objectionable, in the processes which I
have tested or projected.  After having pointed out and described the different pro-
cesses, I have taken upon myself to  propose a choice  among them to  students  and
to surgeons, and to designate those which appeared to me to merit the preference, by
whatever title it may be.  Considering that the dressings, bandages, and the small
operations which are generally known under the title of minor surgery, exercise
the greatest influence on the subsequent success  of operations,  and are not, in fact,
sufficiently studied, neither by students nor  by the  mass of practitioners, I have
believed it my duty to treat of them at length in  this edition. 
xl
preface  to the  second edition.
   The books that science  possessed already on this subject, it is true, are numer
 ous and sufficiently complete ; but as they form treatises apart, few persons attach
 any value to them, and they thus attain but imperfectly the object in view.
   Having perceived that long descriptions were not equal in value to a few figures,
 I  have thought that designs on wood would here be of true service.   In place of
 forming an atlas of them, or separate tables, I have believed that this was a suita-
 ble occasion to intercalate thern with the text, in  the manner of the ancients, and
 as has been the practice for some years past in England and America.
   Wishing  thus to embrace all operative surgery, I  have thought it necessary to
 add numerous chapters to  my first work.  An entire new class of operations has
 been created in our days, that of operations relative to deformities.  I have conse-
 crated a long article to it.  The section of cicatrices, bridles, tendons, and retract-
 ed muscles,  thus  demanded  a place in a systematic  treatise.   Neither could I
 neglect the operations relative to  the maladies of the nail, and those of the epider-
 mis  and teeth.  The operations which concern kinepock, the application of cup-
 ping-glasses, moxas, leeches, the  cautery, bleeding, etc., could  not, for  the same
 reasons, be passed over  in silence.  The restorations of organs have led me to
 establish the  great class of anaplasties; so that, in adding also what relates to ab-
 scesses, fractures, and the generalities of operative surgery, I have out of the whole
 composed the first volume and the  half of the second, of all of which there is no
 trace in the first edition.
   As special  operations, which I likewise  had to treat anew, or on a more  enlarg-
 ed plan, I mention those which comprise the numerous series of  tumors, and those
 of exsections.  Other diseases, the openings in the perinaeum, vesico-vaginal fistu-
las, and polypi  in the urethra, are likewise made the  subject of articles almost en-
tirely new; so that the entire book is in reality completely recast, and increased to
double  its size.
   The  reasons that I had given for not indicating the sources from which I have
derived materials, have not appeared satisfactory to most of those who  have occu-
pied themselves with my work.  Yielding to a wish that has often been expressed
by them, I have on this occasion followed the opposite course.  Nevertheless, this
new plan has encroached so much on the space destined to the  text, that  I have
found it necessary to modify it a little in the two last volumes;  I have abstained,
for example, from subjects which I have treated of elsewhere, whether  in the Dic-
tionary of Medicine, in my Tocology, or my Anatomy, or in the particular memoirs
whose titles are seen at the head of this work.   Under this point of  view I ought
to  recall, as in 1832, the fact that my intention never has been to give a history of
 surgery; and that, if I often cite the labors of others, it is solely out of a spirit of
 equity, to enable those who read me to be capable of  understanding what  has been
done by the ancients as well as by the moderns, and also by myself, in order that,
after having  read  me, both the student and the practitioner may know what  are
 the true merits of the question under consideration.
   Not always having it  in my power to verify the facts announced by  certain au-
thors, I have, therefore, not made myself the guarantee of their declarations, but
 have made them incur all the responsibility.  My quotations, then, have no other
 end  than to awaken the attention of the reader, and  to apprize him, that whether
 right or wrong, such a fact has been mentioned  or such an opinion advanced.   I
 had perceived, indeed, that writers from whom I borrowed in this manner materials
 of a certain  description, were often inexact.   I may on this subject refer to  the 
preface  to the  second edition.
xli
researches of Jaeger on Exsections.  The suspicions of inaccuracy which I had in
regard to this writer have been since fully confirmed in the Thesis of M. Vulfrand
Gerdy.
  Convinced that in order to be useful to students and to  other readers, in a classi-
cal work, it is necessary to make an examination and review as complete as possi-
ble of the riches that science possesses; and persuaded that the name of a man, or
the locality of a place, does not change the nature of facts  faithfully narrated, I have
addressed myself to every one, in order to obtain precise information.  Not  being
able to bring myself to believe that whatever is interesting in surgery is exclusively
confined to Paris, I have received with satisfaction what  many practitioners of the
departments have had the kindness to communicate to me.   It is thus that I have
obtained materials from  Messieurs Castara, surgeon of the Hospital of Luneville ;
Chaumet and Moulinie, surgeons of the Hospital of Bordeaux ; Caffort of Narbonne,
Buret of Caen, Haime and Tonnele of Tours, Philippe of Reims, Stoltz  of Stras-
bourg, Lallemand and Serre of Montpellier, Pichausel of Cleirac, Fristo of Sierck,
Jacquier of Evry, Robert of Chaumont, Lefevre of Joinville, Loreau of Valenciennes,
de Mazieres of Bergues, Jozzet of Vannes, L'Herminier et Rufz of Guadaloupe,
and from many others.   At Paris even, to be more exact, I have thought it right
to apply to M. Roux for the exsections that he has practised ; to M. Le Roy d'Eti-
olles, M.  Laugier, M. Robert, M. Sedillot, etc., for certain processes of their inven-
tion, and  to M. Toirac for what concerns the teeth.
  I have obtained like communications from many foreign practitioners.  In Italy,
M. Fabrizi has communicated to me the operations that he practises on the ear.
I have received from Germany, from MM. Sprengler and  Adelmann, suggestions
and observations of great value in relation to the exsections practised at Wursbourg.
M. Rorhbye has given me all that there is important in  Denmark.  I am indebted
for some information of  the same kind to M. Baroni, and M. Peyrogoff for Russia,
and to MM.  Hysern and S. de Toca for Spain.  M. Kerst  of Utrecht has furnish-
ed me valuable facts relative  to Holland.  An extended note has been communi-
cated to me from M. Warren, on what this surgeon has done at Boston.  MM.
Rodgers, Gibson, Paul Eve, and Norris, have also communicated to me some facts.
But  the most detailed illustrations that I have  obtained relating to America, are
due to Mons. V. Mott.
  Communications and notes  without number have, moreover, been furnished to me
by M. Champion of Bar-le-duc.   This  surgeon, as remarkable for the qualities of
his heart as for his prodigious learning, has, by his own efforts, procured for me an
infinity of facts  relative to  anaplasty,  tumors,  exsections,  and deformities.  The
reader will then recollect, in reading this work, that many facts and opinions of
which I cite  the author, without pointing  out any work from which I have  taken
them, have come to me by direct communication.  I have been enabled in this way
to embody a crowd of materials unpublished or  little known, that they may speak
for their country, and for surgeons of high ability, or worthy of being placed  in a
high rank in the dominion of science.   It has also resulted from this, that in place
of laws and  precepts dogmatically prescribed, I have willingly confined myself  to
an accumulation of facts on a given point, when those facts themselves have ap-
peared to speak with clearness.
  Works on operative surgery have, moreover, been published in different'places
and by different authors, since the publication of mine.  Without speaking of nu-
merous articles inserted by  M. Berard in his dictionary of twenty-five volumes, of
                                        F 
xlii
preface to the second  edition.
the treatises of M.  Liston, of M. Syme, of M. Gibson, and of some German works
I will make mention of the excellent Manual of Operative Surgery, by M. Mal-
gaigne, the Essays of M. Dieffenbach, of M. Korneziewski, of M. Mayor, and of
M. PI. Po   '.  An extended work, which treats however more of surgical patholo-
gy than of operative surgery, has been published by M. Begin.   At Paris, also, we
have seen the commencement of a treatise of the same  kind, a treatise which, con-
ceived upon a larger plan, seems to promise better to place us in possession of the
actual'treasures of surgery, than that of the  professor of Strasbourg.   It is a work
whose completion we look forward to with impatience ; I speak of the work of M.
A. Vidal, (Traite de Pathologie Externe et de Medecine Operatoire, Paris, 1839,
t. i. et ii., in 8°.)   If the conclusion corresponds with what I have  already seen,
the new manual of which M. Sedillot has just given us  the first part, will constitute
in that  respect a work of real utility. The  operative processes borrowed by the
author from military surgery, will make an excellent practical surgical compendium.
I sincerely regret that  the seventh edition of the Dictionary of Surgery of M. S.
Cooper did  not reach me till the month of February, 1839.   This work, which
posts up the actual state of surgery in Europe, and which the author has considera-
bly augmented, would have furnished me some important materials.
  Nevertheless, having analyzed with care  whatever of note has been said among
ourselves, and having interrogated on all sides for correct information, I believe I
have made a recapitulation sufficiently exact of  what exists to-day in the science
of the operative surgeon.   Perhaps, in consideration of so much effort,  and of my
own proper experience, I shall be  pardoned for having indulged the hope of im-
parting an aspect less mechanical, and an impulse more  medical, to operative sur-
gery than my  predecessors had  done, while  I have endeavored to enlarge and to
systematize the field, and  the basis of the processes which have from time imme-
morial formed its legitimate domain. 
xliii
APPENDIX.
  Having commenced the publication of this work two years since,
I am now obliged to insert some facts which it was impossible for
me to mention at the  time in their proper place.  These facts are
of two orders, or form two series.  Some have been communicated
to me directly; the others already constitute a part of the domain
of science.

               Article I.—Facts Communicated.

                              §1-

  In the note of M. V. Mott, which gives a summary of what I have
communicated from him in the text, I see that this skilful professor
has practised the ligature of the arteria innominata once, of the com-
mon iliac once, of the external  iliac six times, of the internal iliac
once, of the femoral artery forty-nine times, of the right subclavian
within the  scaleni muscles, once,  of the right and left subclavian
without the scaleni muscles, three  [now four] times, of the primitive
carotid, nineteen times, [now twenty,] and of the external carotid,
twice.   He has amputated [for osteosarcoma] the lower jaw nine
times, two  of which operations were at  the temporo-maxillary ar-
ticulation, and the upper jaw fourteen [sixteen] times. He has twice
practised tracheotomy in the case  of croup, [and a number of times
for  the removal of foreign bodies,] four [nine] times the section of
the sterno-mastoid muscle to relieve  torticollis, once the extirpa-
tion of a thyroid  gland  which  weighed five  pounds two ounces,
once [several times] the  ligature of the thyroid arteries, with the
view of causing atrophy of a goitre, once the exsection of the clavi-
cle, several times the operation for empyema, once gastrotomy, one
hundred  and six times the operation for hydrocele with injection
of sulphate of zinc, twice the exsection of the rectum, twice [sev-
eral times]  the extraction of loose bodies in the articulation of the
knee-joint,  many times the excision of false articulations, and once
amputation at the hip-joint, and  at the shoulder and  the wrist,
[four times operated successfully for false articulations of the thigh
by the seton, several times successfully on the tibia and other bones
by the  same mode, once successfully the restoration of  an  imper-
forate  vagina  to  all its functions, in thirteen  cases effected  the
perfect restoration of the functions of the lower jaw after years of 
xliv
new  elements  of  operative surgery.
permanent immobility, and once performed exsection of a portion
of the nose and upper jaw for a large fibrous tumor.]   M. Mott
adds: "Our amputations at  New York are rarely followed by
death; I cannot recall to mind, at present, but four cases of ampu-
tation which have thus  terminated.  I have amputated two  legs
and a thigh for gangrena senilis, without waiting for  the disease
to be arrested.  The amputation of the thigh, and one of the two
amputations of the legs, were followed with success.  Union by
the first intention more frequently occurs at New  York than in
France.   I have  remarked  that in  America, the  inflammation
which follows operations is altogether of a healthy character, whilst
at Paris there is more  irritability than true inflammation.  We
must ascribe this difference to our climate, and to the  constitution
of our countrymen.  If  our operations are followed  by more  con-
siderable inflammation,  and by a more intense fever, our inflam-
matory diseases are also more acute than those that are observed
in France."  It is well  to remark, that in their communications,
MM. Warren,  Gibson, Paul Eve, and some physicians of Philadel-
phia, hold precisely the same language as M. Mott on this head.

                             §11.

   M. Gibson, author of  a Treatise on  Surgery, which has reached
its fifth edition, and Professor  in the University of Pennsylvania, at
Philadelphia, thus expresses himself:  "During a period of thirty
years practice  in the United States, I have performed the operation
for strangulated hernia fifty or sixty  times, without losing  more
than seven patients.  I  have more than fifty times  practised the
lateral operation for lithotomy, and have lost but six cases.
  " The greater number of the amputations that I have performed
for diseases of the articulations, wounds from firearms, and com-
plicated fractures, have been followed by complete success. I have
especially succeeded when the operation has been done in season.
In some cases I have succeeded in prolonging the life of the patient
from ten to fifteen years, and  in one case to twenty-five years.
The  operations for cancerous  breasts have  not prevented the reap-
pearance of the disease  at the end of  some months,  in the greater
number of the  cases.  I have always failed in cases of cancer, when
it was at the same time accompanied  with affection  of the glands
of the groin and arm-pit, and of those  of the neck when the mala-
dy had its seat in the lower jaw.
   " The ligature of the subclavian and  iliac arteries has rarely suc-
ceeded with me, whilst that of the carotid, the brachial, and of the
femoral in cases of aneurism  of the popliteal artery, has generally
been followed with the cure of  the patient.  I ought to say, how-
ever, that aneurisms are not  frequent in America;  at New York
a city almost entirely inhabited by strangers, this affection is rarely
observed but  among individuals born in England.  I have rarely
had recourse  to the trephine in the case of fractures of the crani-
um, with lesion of the brain  and its membranes.  I have in such 
appendix.
xlv
 cases had  reason to congratulate myself upon the success of the
 antiphlogistic treatment.   At Philadelphia, with the exception of
 six weeks  of intense heats during the summer, and six weeks of in-
 tense cold  during winter,  the temperature is constantly agreeable.
 This circumstance  is sufficient to explain why the  results of our
 practice are more  satisfactory than in Europe, and in the great
 cities  like Paris and London, and than  in more remote latitudes,
 where the  extremes of temperature are prolonged to a much greater
 length of time.  I cannot  believe, for example, that the two Cesa-
 rean operations in which I saved the mother and  infant, would
 have succeeded as  well at Paris as at Philadelphia.  All these op-
 erations have been performed after the usual modes."
   [Professor Gibson appears to  be under a misapprehension, both
 in respect  to the character of the climate of the United States, and
 its influence upon curative surgical processes, and also in  respect
 to the nature of our population at New  York, as well as the non-
 frequency  of aneurisms, and their limitation to persons from  Eng-
 land.
   1. Of the Effects of our Climate on Surgical Operations.—So far
 from the climate of the United States being in the least degree en-
 titled to the appellation of a mild, or equable, or moderate temper-
, ature and  character, with only six weeks of extreme summer heats,
 and as many of intense cold  in winter, it is proverbially  known,
 all over the world, that all the northern portion of the United States
 for many degrees of latitude, and  especially its  seaboard, is char-
 acterized by the most extraordinary and sudden vicissitudes of heat
 and cold, and of every other meteorological phenomenon.  It was
 remarked by Volney, that an American never becomes acclimated
 to his own country; and  this  is not surprising, when we consider
 our  protracted  and most  inclement winter of four  to six  months
 duration, of an  almost polar severity, our long, wet, cold, and un-
 wholesome spring  of two to  three months, and our violent heats
 often for months, during July, August, and September, in the mid-
 dle  portions of  the  day exceeding  by many degrees  what  is  ever
 known even in the tropics.   [See my work on the Topography,
 Weather, and Diseases of  the Bahama Islands,  1823-4-5; also, my
 work on the  Yellow Fever at Havana, 1830.]
   So far from our climate being, as Professor Gibson infers, a mild
 one, the range of Fahrenheit's thermometer during the year is fre-
 quently, on this northern  part of our seaboard, from 110° to 120°;
 and  even  in  the same day, in  midsummer, the mercury has been
 known  to descend  rapidly over 40° in  24 hours!  In this  respect
 the climate of Europe has, on the contrary, a great superiority, as
 the thermometer there, as at Paris and  London, seldom varies in
 any  part of the  year over 10 to 15 degrees in 24 hours, which I
 know from personal observations in those cities.
   Again, the experience of Dr. Mott, whose observations, both in
 this  country, and in Europe, Asia, and Africa, have been directed
 to this  subject, and have given him great advantages, is directly to
 the point, that it is precisely during  those extreme and arid sum- 
xlvi
NEW ELEMENTS OF OPERATIVE SURGERY.
mer heats, which Prof. Gibson makes an unfavorable exception,
and when the thermometer is ranging in the neighborhood of 100°
Fahr., that surgical operations always do better than at any other
time.   It is, we believe, proverbially known to all our practitioners,
that it  is then that such operations are most generally succeeded,
says  Dr. M., by that most desirable of all results after operations,
a rapid and healthy adhesive inflammation, without violent consti-
tutional reactions and protracted wasting suppurations.   And it is
to this  to which Dr. M. has reference in his preceding note to Prof.
Velpeau, in  speaking of the  healthy and entonic character of the
fever which succeeds to surgical  operations, as compared to that
which is seen  in European hospitals.   But it must  be understood,
says  Dr. M.,  that the  contrary unfavorable results in  European
hospitals, and  the atonic febrile excitement of irritation, and  the
prostration and exhaustion of vital power, are produced, not by any
circumstances connected with the climate of Europe, but by the
character and class of persons who  are  the  subjects of hospital
treatment in those countries.  They are, with but few exceptions,
such as belong to the poorer classes, who have long endured every
privation as to food  and  other comforts, and whose constitutions
are "for  the most part worn out and impoverished, and, therefore,
incapable of sustaining the  shock of severe surgical operations.
Whereas, in our own country, where every individual of our popu-
lation,  it may be said, whether poor or rich, and in all our public
establishments, and charities, and hospitals, even in  our prisons,
lives in  comparative luxuriousness, such privations  as are seen
among  the peasantry and mechanics  of other and  older countries
are utterly unknown.
  The favorable influence of our intense summer heats in promoting
union by the first intention, was strikingly confirmed to  Dr. Mott
by what he observed also in Egypt, during his visit to that country.
The somewhat similar climate of the valley of the Nile to our own
during the summer, and its often long-continued and parching heats,
have nevertheless, he observed, a most  remarkable and  salutary
effect in accelerating the cure of all surgical operations by adhesive
inflammation—a result favored, also, by the spare sinewy make
and dry fibrous temperament of the Arab, resulting from the char-
acter of their climate, their food, and their active habits.  The same
beneficial results which an elevated and dry temperature produces
upon the processes of  adhesive inflammation, seem to be derived
also, says Dr. M., from the tonic power of intense cold during  our
protracted winters.
  Thus, therefore, our climate, and its  action on surgical processes,
are, toto corto, at  variance with the supposition of any advantages'
deducible from an erroneous conception of its mild temperature.
  2. In regard to the subject of aneurisms, Professor Gibson errone-
ously asserts that they are not common in the United States  and
that at New York our population is almost exclusively foreign', and
that aneurisms are almost exclusively confined to them, and par-
ticularly to  the  English.   The experience of  Dr. Mott  is directly 
APPENDIX.
xlvii
at variance with that of Professor Gibson.  In the first place, says
Dr. Mott, not less than six  sevenths  of the whole population of
New York is of native-born citizens, and the whole amount of all
our population so far exceeds that of Philadelphia, that a compari-
son cannot justly be made between those cities as to the class of
diseases prevalent in either.   In the next place, there is no greater
frequency of aneurisms or other surgical cases at New York than
are naturally derivable from the fact, that as the great emporium
of commerce, our city presents a far greater proportion  of hard-
working laborious population, directly connected with commercial
pursuits, than her excess of  inhabitants over the population of any
other city would seem  to denote.  Aneurisms, therefore, and espe-
cially every kind of casualty, or injury, or accident purely surgical,
are natural  casualties among a vast  industrial people engaged in
those arts and mechanical labors, whether on shipboard or on land,
that pertain to  a highly commercial and enterprising mart and em-
porium so considerable  as  our own.   Few  surgeons, perhaps, of
the present day, or of the past century, have treated so many cases
of aneurism as  Dr. Mott, and his experience goes directly  to estab-
lish the fact, that of all that number, and of all  that he has seen in
this city in a practice of near forty years, the great majority, if not
all, were our own countrymen.   He does not recall a solitary case
of a foreigner, and nearly all belonged to that class who had been
habituated, as might naturally be supposed, to  severe mechanical
labor.   Nor could  such  cases, notwithstanding the  fact  that our
city, out of  350,000 souls, (including the cities and towns imme-
diately adjacent  to  it,) contains, besides some 15,000 negroes, a
population of perhaps some  50,000 to  60,000 foreigners, be confined
to natives of England, for at least 30,000 of our foreign population
are Irish; and of the rest,  the total  of Scotch, Germans, French,
Spanish, Italians, Swedes, &c,  exceed by double the number those
from England.—T.]

                             §111.

  Spain, that we think so poor in a surgical  point of view, is less
so,  perhaps, in  reality than in appearance.  MM. Argumosa, S. de
Toca, Hysern, all three professors in the school  of Madrid, are dis-
tinguished there as anatomists and  as surgeons.  M. Hysern him-
self has communicated to me an infinite number of facts.  In Feb-
ruary, 1829, he  performed, at the general hospital at Barcelona, the
partial amputation of both feet at the tarso-metatarsal articulations,
on  a child of ten years, in a  case of gangrene from cold, which had
extended  to near one  half  the metatarsus.  This gangrene was
already limited by a regular inflammation.  The success was com-
plete.
  [It is not, perhaps, extraordinary, that M. Hysern, living in the
semi-tropical atmosphere of Madrid, should advert to a disease like
that of gangrene from cold, which must necessarily be a rare occur-
rence in so mild a climate as that part of Spain.   Dr. Mott remarks 
Xlviii         NEW  ELEMENTS OF OPERATIVE SURGERY.

with great justness, that there is, perhaps, no seaport or other city
in the world, where  practitioners have such ample and frequent
opportunities of studying this disease, as at New York.  The long-
continued severity of our winters, and the extremely tempestuous
and dangerous character of our coast in that season, and our prox-
imity, at the same time, to hot latitudes, and the immense extent of
our commerce with such latitudes,  whether with the West Indies,
South America, Africa, or the  Asiatic  tropics and China, render
this affection one of the commonest occurrence every winter among
the crews of vessels arriving from such countries  upon our coast,
who being prevented, by violent  storms and  contrary winds, from
entering  our ports, are thus imminently exposed to every variety
of frost-bitten limbs.   It is  particularly noted, that the crews of
what are  called wet ships, or such as during this perilous  coast-
navigation frequently ship seas, generally escape, as their feet are
almost constantly immersed in water on deck, and  therefore in a
temperature above the freezing point.   This casualty of inflamma-
tion of the extremities ending in gangrene, and resulting from ex-
posure to cold, is, as we have said, of such frequent occurrence, that
its  treatment is exceedingly well understood in, all our hospitals,
those being  the places where nearly all this class of patients are
received.  Dr. Mott coincides with the general observation of prac-
titioners in saying, that not only the phalanges of the toes and fin-
gers, but all  the metacarpal and  metatarsal bones, and the entire
foot, and  frequently both feet or  both legs or awns, are, after the
limitation of the gangrene is well defined, amputated under  such
circumstances, and almost invariably with perfect  success.   For it
must be remembered, that this species of gangrenous inflammation
is of the mildest and least malignant kind, generally occurring in
young and healthy seafaring subjects;  that it is disconnected, for
the most part, with any constitutional taint; and  is purely a local
affection.  In addition to  the observations of Dr. Mott, I may re-
mark, that I noticed it frequently while I was Physician to the Sea-
men's Retreat, Staten Island, (New  York.) and that it occurs to me
here, as not  irrelevant, to refer specially to a case of  a sailor in
the prime of life, in whom, by the malpractice of the official person
under whose care he had previously fallen, there  was established,
by the prolonged and unmedical  application of poultices, a perma-
nent or chronic gangrene of some months, in all the  phalanges of the
toes.  These bones successively rotted out under the system of
poulticing, and when he was brought to the Retreat, his feet pre-
sented the  case of two stumps with red flabby granulations, and
the anterior extremities of the metatarsal bones protruding out be-
yond the flesh to the distance of an inch or more, and having the
 appearance of black burnt  brands, or ends of beams in the  frame-     f
 work of a building half consumed by fire. These necrosed neglect-
 ed projections were clipped off by a pair of common strong nippers,
 close to the sound flesh, and until the fresh bleeding surface of the
 healthy portion of the bones was reached.  The effervescing cata-
 plasm of bark, yeast, charcoal, and alcohol, was applied for a few 
APPENDIX.                       Xlix
days, followed by adhesive straps, bringing the flesh well and firmly
in every part over  the ends of the bones, which, with tonic treat-
ment internally, rapidly completed the cure.   Emollient poulticing
is undoubtedly proper in the onset of the disease, (which resembles
that of a severe blister,) to allay the acute and often agonizing pain
of the  inflammation, and to  promote the sloughing of the  parts
which follows; but nothing is more  injudicious than to  continue
this practice beyond the time when the line of demarcation of the
gangrene is clearly established.—T.]
  A. " Towards  the month of September, of the same year, says
M. Hysern, I practised, for the first time, blepharoplasty on a girl
of twenty years, to restore a loss of substance of the external half
of the two eyelids of the left eye.  I employed a method which is
mine, and  which I have called temporo-facial.   The success was
complete.
  " In July, 1833, I practised  anew  the  temporo-facial  blepharo-
plasty, to restore the totality of the inferior eyelid which I previous-
ly extirpated at  the same sitting, in consequence of a naevus ma-
ternus which had invaded that and the conjunctiva  of the ball, up
to the lower half of the base of the cornea.  The result was  suf-
ficiently satisfactory;  the new lid perfectly shut the eye with  the
upper, which had its movements free.
  B.  "In August,  1833, I performed  rhinoplasty  by the Indian
method, on a man forty-eight years of age, from whom I  had extir-
pated a cancerous  tumor that affected the nose, the  nasal notch of
the left superior maxillary, and almost the entire pyramidal bone
of "that side, extending below to the upper third of the upper lip.
The operation succeeded.  The enormous wound of the face was
reduced to a  crucial cicatrix of an inch and a half in length in its
transverse branch, less than an inch in its vertical, of two to three
lines in breadth throughout almost its whole extent, and of four to
six lines in the centre, that is to say, at the crossing of the branches.
  "In September, 1837,1 practised another rhinoplasty by the Italian
method, that  is to say, in place of taking the patch at hazard on
the limb, I procured it from the place where there are more nerves
and cutaneous vessels; that is, from the anterior and external part
of the arm, near the bend of the elbow, and over the course of the
branches of the  radial nerve and the profunda.  The patch was
adherent in more  than three quarters  of its  periphery.  Fifteen
days after, I cut off the base of it;  but in spite of  every possible
precaution, gangrene commenced, except on one inch of its upper
part, which kept in place and preserved its vitality.
  " In the month of October following, I practised another rhino-
plasty by the Indian method, and with success.  To hold  the new
nose, I employed advantageously a framework of cork, divided verti-
cally into three parts, in the manner of the forms that hatters use.
  C. " In March, 1835,1 performed, on a girl of five years, the ex-
tirpation of a lupus {loupe) of the size of a pullet's egg, having its
seat in the middle of the upper part of the forehead, on the hairy
icalp.  This lupus had eroded the bones, and was adherent to the
                              6 
NEW ELEMENTS OF OPERATIVE SURGERY.
membrane of the superior longitudinal sinus, so that M. S. de Toca,
who assisted me, and myself, as well as some other persons, had a
perfect view of the influence of  the  respiratory movements  upon
the circulation of the blood  in this sinus, which was raised up every
time that the infant cried or made an expiration, and sunk and re-
ceded, on the contrary, at each inspiration.  Notwithstanding  the
close and extended  adhesion of the tumor, I did not cut  the sinus,
and the success of the operation was complete.
  D. " In May, 1835,  1 made a complete extirpation of the  left
parotid, in a cancerous state and adhering intimately to the sterno-
cleido-mastoid muscle.  It  was necessary to tie the external  caro-
tid  very near its origin.  The immediate success of the  operation
was complete, but the cancer returned some time  after.
  E.  "In August, 1835, I performed the exsection of the  left supe-
rior maxillary bone  on'a girl of eleven years,  by removing the  an-
terior and external  wall of the sinus, and  all the alveolar border,
for  a sarcomatous polypus of this sinus.  I extirpated the polypus
by means of the handle of a scalpel;  I scraped all  the osseous parts
which were  visible, and finally applied to  them the actual caute-
ry.   The  operation  was perfectly successful, and  the polypus  did
not reappear.  This tumor  was as large as half of the fist, threw
the nose very much to the opposite side, forcibly raised up the eye,
and depressed the palatine  arch.
  " In February, 1835, I exsected  the left half of the lower jaw at
the articulation, with extirpation of the parotid and submaxillary
glands.  I was obliged to tie the external jugular vein, as well as
the primitive carotid artery; the  operation was  successfully exe-
cuted, but the patient died  two hours after in  a state of stupor. I
was not permitted to open the body.

                        F.  Cheiloplasty.
  "In July, 1833,  I performed, on  a man aged fifty years, the  ex-
tirpation of a cancerous ulcer which  occupied two thirds of  the
right side of the lower lip, the sixth part of the upper lip, and  ex-
tended itself to an inch beyond, into the lower portion of the cheek,
embracing the greater part of the chin, and involving more than
two inches of the external  table of the lower jaw.  After the  ex-
tirpation of the soft parts, I removed with a gouge  the affected part
of the external table of the bone.   I afterwards undertook the res-
toration of the soft parts, in  adapting to them the  skin of the supe-
rior and lateral region of the neck, with the  subjacent  portion of
the platysma myoides, according to my autoplastic method.*  The

  * This method differs from the others in four principal points :
  First. The patches describe always an arc of a circle, but never the semicircle, as in
the  Indian autoplasty;
  Second. I preserve carefully in the patches the subjacent cutaneous muscles;
  Third. I cut and I apply those patches in such a manner that  the new muscles may
take a direction analogous to those that I cut away;
  Fourth. In fine, I apply sutures to a great number of points, for example, from liue to
line; I remove half of them twenty-four hours afterwards, the rest at the  end of forty-
eight hours; and then substitute for the suture adhesive plasters. 
APPENDIX.
li
patient got well without a relapse, and the restoration produced
the effect that we anticipated from it, leaving scarcely any deform-
ity.
  "In September, 1837,1 extirpated another cancer from  the left
side of the lower lip, cheek, and submaxillary gland.   I practised
for this case, also, cheilo-genoplasty by the same method ;  this au-
toplasty succeeded, but two months after, the  cancer, which had
already reappeared once, returned again, and I therefore declined
another operation.
   G. "In June, 1834, I operated on D. J. Bonavida, aged fifty-four
years, attacked eleven  years before with a severe neuralgia on the
right side of the face,  and  for which other surgeons had in vain
performed the section  of the inferior dental  nerve, the extirpation
of some lines of this nerve, its cauterization in the foramen  men-
tale, and the section  of  the  facial nerve; I effected  the  extirpa-
tion of the nerve in the whole length of the dental groove of the
lower jaw.  To effect this,  I  raised almost  the whole external
table of the bone,  in isolating it by four cuts of the saw, aided by
the gouge and  mallet.  I afterwards took hold of the nerve with
the dissecting forceps,  and  extirpated it completely, after which I
cauterized the superior extremity of it with red-hot iron.  Having
remarked that the pains affected not only the dental trunk, but also
the most superficial parts of  the lower  half of the cheek, and the
corresponding half of the lower lip, and of the chin down to the base
of the jaw, where were distributed the filaments of the nerve for-
merly extirpated by Professor Argumosa, I took away also all these
soft parts, and I finished  the operation by autoplasty, according  to
my method, by means  of the skin of the neck  and of the platysma
myoides.
   " There was at  first considerable relief, and the patient felt no
other than slight  pains produced by atmospheric changes.  This
state lasted for nearly six  months; the pains  returned then with
the same intensity as before, but in the direction of the infra-orbital
plexus, the buccal nerves, the lingual, and, as it seemed to me, of
the portion of the  inferior dental trunk which remained behind the
jaw.
   " The patient immediately demanded  another  operation.   I re-
sisted for some time, seeing the return of the disease ; but at length,
perceiving no other means of relief, I  yielded.  I undertook and
effected the extirpation of  the infra-orbital plexus and the buccal
nerve, from the internal face of the masseter muscle to an inch and
a half in front, then that of the inferior dental and lingual nerves,
at three to four lines below the  foramen ovale  of the sphenoid
bone; so that I took away  more than an inch of the dental nerve,
and twenty lines of the lingual.
   " Having commenced by incising freely, and almost horizontally,
the cheek, from the commissure of the  lips  to a little  beyond the
anterior border of the masseter muscle, and without interfering
with that, I dissected  out the buccal and the inferior dental and
lingual nerves, between the pterygoid muscle and the ramus of the 
Hi
NEW  ELEMENTS  OF OPERATIVE SURGERY.
jaw ; then I took hold of them with the blunt hooks, (erignes mous
ses.)  I assured myself, and more than twenty persons present, most
of them distinguished surgeons,  also satisfied themselves, that it
was truly the nerves described that I held in the erignes.   I then
passed a blunt-pointed  very narrow bistoury to their upper part,
and turned  the edge of it against the nerves.  In drawing, at  the
same time, the erignes with the other hand, I was enabled to make
their upper section, avoiding thus the internal  maxillary artery and
every other vessel;  I avoided, also, the internal lateral ligament of
the lower jaw, and I finished by cutting the  nerves  at  the lower
part with the scissors.
  " M. Obrador, then professor in the Royal School  of Medicine at
Madrid;  M. S. de Toca, one of our most distinguished  operators;
M. Arnero,  and  M. Quintanar,  skilful physicians and surgeons,
aided me in this operation.  The nervous pains ceased immediate-
ly.  When  they reappeared, after  some  months,  they were  ex-
tremely slight: never did they become as strong and insupportable
as before.
  H.  "I have made eight artificial pupils: 1st. Two in September,
1833, one of them with  success ; 2d. Two others in August, 1835.
without any success; 3d. Two in July, 1836, with success;  4th.
One in August, 1837, with success for complete obliteration of the
pupil; 5th.  One in  September, 1837, for leucoma complicated with
cataract.  In this case I performed  the operation for the cataract
by extraction, and the artificial pupil, at the same time, by a pro-
cess of my own, and which is a modification of that of Wenzel for
iridectomy.   The operation was fully successful.
  I.  " In July, 1835, I effected, at the Surgical Clinique of the school
of Madrid, the complete extirpation of a degenerate  goitre, of the
size of the head of an adult, and with two lobes distinctly separated.
1 commenced by tying the four thyroid arteries as  well as the  cor-
responding  veins, which were enormously developed, and finished
by the extirpation of the diseased gland.  The extirpation succeed-
ed ; but the patient died a month and a half after from a hectic fever,
owing to a deposite of matter upon the chest.
   J. " In May, 1834, I extirpated  an erectile  tumor from the scro-
tum, of the size of two fists, with perfect success.
   K. "I was the first at Madrid, in November, 1833,  to perform
lithontrity for a stone of extreme hardness, of the size of  a large
 hen's  egg.   Iused the method  of M. Civiale.  The success  was
 complete, and there has been no relapse.
   L. "In April, 1838, I performed  the exsection of an  abnormal
 articulation at the lower  third of the left arm of a soldier, aged
 twenty-eight years, who had been wounded by a musket-ball a
 year and a half before.  In December, 1837,1 made the exsection
 of the inferior half of the  fifth metacarpal bone of the right hand,
 for an osteo-sarcoma.  I saved the muscles and the tendons.   The
 success  was complete, and by means of a double ring  the finger
 preserved its movements.
 k  M. "In September, 1832,  I extirpated  a degenerate lipoma on 
APPENDIX.
liii
the right thigh of a soldier aged thirty-four.  This  lipoma, which
weighed fifteen pounds, extended from the popliteal  space along
the internal and posterior part of the thigh, separating and flatten-
ing the semi-tendinosus and semi-membranosus muscles, the  graci-
lis, sartorius, adductor, and pectineus, upon the crural artery in its
whole extent, and had penetrated, by two productions in form of
cones, into the interior of the abdomen under  the crural  canal.
The operation was laborious ;  the immediate result appeared satis-
factory ; but absorption of pus supervened, and the patient died the
eighth day."

                             §IV.

   Besides what I have had it in my power to say on the subject in
the detail of special operations, I see in the note of  M. Jacquier,
the case, 1st. Of a  naevus on the  eyebrow, in  an infant  of  six
months, cured by a caustic composed of sulphate of zinc, sulphate
of copper, and honey; 2d. Of a fatty tumor of the sclerotica, cured
by excision and cauterization; 3d. Of a soft brownish vegetation
upon the oculo-palpebral groove, extirpated with success on a man
of sixty years; 4th. Of an extraction of an invaginated necrosis
of the  clavicle, in a young  girl; 5th. Of an  amputation  of  the
arm near the axilla, by the spontaneous separation of the  injured
parts.

                  Article II.—Facts  Omitted.

                              §1-

   In addition  to what I have said of the introduction of air into the
veins, I have here  to subjoin a few words.   M. Mayor,  (Acad.
Roy ale  de Medecine, 28 May,  1839,) who professes to  have noticed
this accident, has given two new examples of it, which appear far
from conclusive.  In fine, we see in an extended labor of M. Busse,
(Gaz. Medicale, 1839, p. 261,) that the subject has  been examined
in Prussia under the point of view in which I treat it in the present
work.

                              §11.

   Numerous cases of section of the tendons, or of the muscles, ought
to be added to those which  I have mentioned.  In the case of a
patient  in whom the semi-tendinosus muscle was contracted like a
cord for seven months, the cure was effected by M. Lutens, jeune,
(Gaz. Med., 1838, p. 149,) by means of tenotomy.   Since  then,  I
myself  have four times performed the section of the tendo-Achillis
for club-foot  backward,  (pes-equinus,) and in   all  the four cases
with prompt  success; once  the  section  of the tibialis posticus,
twice the section  of the tibialis anticus; once  the section of  the
extensor longus pollicis pedis ; once the section of  the extensor of 
liv
new  elements of operative surgery.
the little toe;  once the  section of the  plantar aponeurosis; twice
the section of the biceps flexor cruris ; oner the section of the semi-
membranosus;  and twice the section of the semi-tendinosus, graci-
lis, and sartorius.  These examples have  demonstrated to me more
and more the safety of tenotomy.
  The history of this operation as applied to the treatment of club-
foot, (pied-bot,) comprises, moreover, two periods.   In the first, they
confined themselves to the experiment of dividing the tendo-Achillis;
hi the second, the operation was extended to all the tendons of the
muscles of the leg and foot.   It is to M. J. Guerin that we owe this
generalization.   Having established that the club-foot, and the dif-
ferent forms that it may assume, are but the result of the primitive
muscular retraction, differently distributed in the muscles of the
leg and of the foot, this physician, whose  researches were not well
known to me when the first volume of this work was printed, has
been naturally conducted to lay down as a principle, the successive
or simultaneous division of the tendons  of those muscles which hold
each variety of the club-foot under their subjection.  Here is the
way in which he has embodied this precept in a memoir  recently
published, (Gaz. Med., 1839, pp. 205, 321, and 337,) but the conclu-
sions in which had  been addressed to  the Academy in the month
of July, 1838, and the first applications  of which go back to the
epoch of the concours of the Academy  of Sciences, 1836.
  " The surgical treatment of club-foot," says he, " ought to compre-
hend the section of  the tendons of muscles whose retraction deter-
mines the special forms of each variety  of this deformity: for the
elevation of the heel, the section of the tendo-Achillis ; for the in-
version  of the  foot [i. e., when turned]  upon its outer edge, the
tibialis anticus ; for the eversion of the foot [i. e., when turned] up-
on  its inner edge, the peroneus tertius, and all  or part of the ex-
tensors of the toes;  for the flexion of the foot on the leg, the tibialis
anticus and the peroneus tertius, and sometimes the extensors of the
toes ; for the forced adduction of the foot, the tibialis posticus; for
its abduction, the peroneus longus et brevis ; for the curvature of
the foot following its internal  border, the adductor of the great toe ;
for the  permanent  extension or flexion of the toes, the section of
the corresponding muscles; and  finally, the  simultaneous section
of the tendons of those muscles, according to  the concurrence of
their contraction in the different combinations of form  that the
club-foot presents."  This doctrine, which the author had explain-
ed to me verbally about a year past, has been applied by him in
the treatment of more than a hundred  cases of club-foot, since the
month of January,  1836, the  epoch at  which he made the section
of the tendo-Achillis, of the  flexor proprius  pollicis  pedis, and of
a portion of the plantar aponeurosis, for a case of club-foot back-
ward, in a young girl of the Hospital of  Orphans, submitted to the
examination of the judges of the  concours of the Academy of Sci-
ences. 
APPENDIX.
lv
                            § III.

  The suture of the extensor tendons of the index-finger has com-
pletely succeeded with M. Valentin, (Journal des Conn. Med.-Chir.,
1839, p. 107.) A section of the tendons of the extensor carpi radialis
longior et brevior muscles, treated with the suture by the same sur-
geon, terminated well, (Ibid., p. 108.)  A girl  aged eleven years,
who had the forearm flexed by a band, the consequence of a burn,
has been cured by means of excision, and permanent well-conduct-
ed means of extension, by M. A. Thierry, (Jodin, L'Experience, t.
iii., p. 268.)  In consequence of a wound by firearms, which caused
a complicated fracture, a patient was left with  an angular leg.
M. A. Key (Gaz. Med., 1839, p. 366) sawed out the callosity, ad-
justed the limb,  and cured the wounded man.

                      § IV.—Anaplasty.

  Employing the Indian mode  of rhinoplasty, M. Serre, (Comptc-
rendu de  la Clin, de Montp., 1838, p. 16,) in 1838, obtained complete
success from it.  By incising in  the direction of the lateral commis-
sures, after having cut out a cancer by a V-shaped incision so as to
have two triangles to  unite on the median line, M. Bonnet (Bullet.
de Therap., t. xvi., p. 217) is of opinion that he has employed a new
process, though it is nearly the same that I have myself many times
used, and which I have spoken of further on.  Cheiloplasty seems
to have equally  succeeded with M. Payan, (Revue Med.,  1839, t. i.)
An enormous  fungus haematodes, growing  from  the septum, and
which occupied  the upper lip, was extirpated  with success by M.
Serre, (Compte-rendu,  1838, p. 18,) who, by means of cheiloplasty,
reduced  to nothing  the deformity caused by the first operation.   I
have twice performed, in  1839, blepharoplasty with partial success,
by insertion of a V-shaped portion of integument.

                        § V.—Arteries

  A  remarkable  case of a dissecting aneurism of the thoracic aorta
has been published by M. Pennock, (Gaz. Med., 1839, p. 39,) and
M. Goddard (Ibid., p. 40)  has related another which is scarcely less
so.   Besides those which  I have related, M. S. Cooper (Surg. Diet.,
1838, p. 160) ascribes  cases of ligature of the internal iliac artery
to a Russian surgeon, and to M. Thomas and M. Hudson, and states
that two  of the patients were cured; but are these facts authentic ?
That of M. Hudson, for example, is it not the same as the fact pub-
lished by M. Pomeroy White,  of Hudson ?  The ligature  of the
hypogastric artery practised with success, according to  the same
author, (S. Cooper, oper. cit., p. ix.,) by M. White, relates proba-
bly to the same  fact.   I  find, also, in M. Cooper, that M. Busche
tied the common iliac  artery in an infant aged  two months, which
died  at the end of some weeks. 
lvi
NEW ELEMENTS OF OPERATIVE SURGERY.
  The point of a scythe wounding the right nates, produces a hem-
orrhage, followed by a pulsating tumor that M. Riberi (Gaz. Med.,
1838, p. 796) considers  to  have been  a varicose  aneurism ;  but
every thing shows that this case was one of aneurism proper.  The
particulars of the case of the ligature of the right carotid and sub-
clavian  arteries, by M. Morisson, (Lf Experience,  t.  iii., p. 302,) are
now published.  The  subclavian artery has been  once tied with
success by M. Gibson, (Journal des Conn. Med.-Chir., t. xii., p. 2S7.)
  A fact, having some analogy to the  case I  have mentioned, of
ligature of the external iliac, from a recent wound,  presented itself
in the practice of M. Mouret, (Gaz. Med., 1839,  p. 298.)  A  man
receives, under the  groin, a cut from a knife wrhich opens the fe-
moral artery.  A ligature, after the method of Scarpa, is  applied be-
tween the  profunda femoris artery and the wound.  Imprudent
movements  cause a hemorrhage on the twenty-seventh day.   M.
Mouret passes then a single ligature around the external iliac, and
effects the cure of the patient.
  The patient  in whom M. PI.  Portal (Ibid.,  p. 297) tied the ex-
ternal iliac artery, in consequence of the excision  of a bubo wound-
ing the vessels, died at the end of some days.  A  ligature upon the
external iliac, by M. Petrunti, for an inguinal aneurism,  was, on the
other hand, followed by success.
  Cases of ligature upon the subclavian artery have been publish-
ed by M. Syme, (Edinb. Med. and Surg. Journ., vol. exxxvii., p. 338,)
who was obliged afterwards, in one case, to amputate at the shoul-
der-joint.  M.  Woodroffe informs me that he has met  with entire
success in this operation.  In a case related by M. Neret, (Archiv.
de Med., Juin, 1838; L'Experience,  t. iii.,  p. 106,) an aneurism of
the left  subclavian artery extended  into the chest  and  penetrated
the lung.   A ligature upon the subclavian,  for a wound in the
axilla, caused gangrene of the limb, rendered necessary  amputation
at the shoulder, and was followed by death, in a patient of M. Has-
pel, (Gaz. des Hopit., 1839, p. 186.)
  Embarrassed by the swelling of the limb, in a case of gangrene
succeeding to  a wound of the brachial artery, M. Petrunti (Gaz.
Med., 1839, p.  186) tied the vessel by passing a riband through the
arm, with a seton-needle, and secured it by a knot  on the skin and
a graduated compress.  The success was complete, and the author
says that his preceptor succeeded in the same manner with a sol-
dier.  A military surgeon, M. Haspel, (Gaz. des Hopit., 1839, pp.
190,191,) has seen, also, wounds of the  palmar arch, of  the dorsalis
pedis, &c, cured without the necessity of ligature.
   A patient in whom M. Lallemand (Archiv. Gen. de  Med., 1838,
t. iii., p. 370) had tied the femoral artery, for a varicose aneurism,
was attacked on the sixth day by a hemorrhage, which rendered
necessary a ligature upon the external iliac, but did not prevent
the death of the patient from the renewal of the hemorrhage.  Hav-
ing tied the external iliac, and perceiving  gangrene established in
the leg, M. Syme (Edinb. Med.  and Surg. Journ., vol. exxxvii. p.
372) had recourse  to a ligature upon the common  iliac, and  after- 
APPENDIX.
lvii
wards amputated the thigh at the hip-joint, but the  patient died
soon after.  Having passed a ligature around the external iliac for
an enormous varicose aneurism in the fold of the groin, M. Moris-
son (Gaz. Med. de Paris, 1838, p. 682) found violent pains produced
in the leg on that side, which  resulted  in  death  at the end of two
days.  A case of diffused traumatic aneurism of the femoral artery
was cured by M. Castara, by means of compression in the fold of
the groi'n.
  A popliteal aneurism opened and suppurated, in a case in which
M. PI. Portal (Gaz. Med., 1839, p. 298)  had tied the femoral artery
by the method of Anel, and in which case  there was a gangrene to
considerable extent at the heel. I have myself tied the femoral artery
with success, for an erectile tumor upon the condyles of the femur.

                             § VI.

   Adopting my process for the treatment of varices, M. Liston says
he has succeeded  in removing the pins at  the  end of forty-eight
hours.  I am the more  astonished with this result, because expe-
rience has taught  me that ten to fifteen or eighteen days  were
really necessary effectually to obliterate the vein thus strangulated.
Varices have been treated  successfully by M. Melvin, (Encyclogr.
des Sc. Med., 1839, p. 275,) by means of the pins and  the twisted su-
ture.   Apprehending that the strangulation, whether  by my mode
or that of M. Davat, might not be sufficient to obliterate the veins,
M.  Bonnet (These,  No.  5-, Paris4  1830) combines cauterization by
potash to the treatment of varices by pins.  The process of M.
Gagnebe, (Archiv. Gen. de Med., Mai, 1839, p. 30,) which I explain-
ed in 1832, and which consists in passing a thread around the vein
under the teguments, by a simple puncture of the  skin,  has, it is
said,  succeeded  in  the  hands of M. Ricord, (Gaz.  des Hopit., 12
Juin,  1839.)

                             § VII.

  A curious  case of lithontrity has been  published by M. Taron,
(Ibid., 1839, p. 266.)  A man aged thirty years, introduced a shoe-
tie into the bladder; lithic concretions gathered  upon this foreign
body, which  three  or four applications of lithontrity sufficed to
break up and extract.  By further information we learn  that this
patient died, in consequence of the operation, (Journal de Scalpel,
No. 1, Juin, 1839.)   I myself, in June, 1839, cured a young man of
eighteen  years, in a single sitting, at lithontrity, of a calculus of
eight lines.

                            § VIII.

  Examples of amputation in  cases of spreading gangrene, have
been published to a certain extent since the printing of the article
which  I have  assigned  to this subject.  M.  Segond  (Gaz. Med.,
                              H 
Iviii
NEW  ELEMENTS  OF OPERATIVE SURGERY.
1837, p. 523) having  thus  amputated the arm, lost his patient on
the twenty-second  day, owing, says  the author, to his having ab-
stained from taking any sort of aliment after the operation.   Three
patients, on  the contrary, in whom amputation was  performed on
both legs  at the same time by M.  Luke, (Ibid., 1839, p. 104,) for
gangrene of the feet, the consequence of typhus fever, recovered.
  In a fracture near the  knee, one  of the  fragments compressing
the popliteal vessels caused sphacelus of the leg.   M. Smith, (Gtiz.
Med., 1839, p. 43,)  who amputated the  thigh  before  the arrest of
the gangrene, cured his patient.  In the case of M. P. Eve,  (Lane.
Franc.,  t. xii., p. 540,) the gangrene had reached the  thigh,  and
amputation was performed in a line with the trochanters.   The
cure was effected in  six weeks.  M. Morisson, (Ibid.; Med. Chir.
Rev., Oct., 1838,) in amputating the thigh to arrest a gangrene of
the leg, caused by a wound from firearms, was not less successful.

                            § IX.

  Desiring to amputate the  arm in the manner of M.  Onsenort, and
to exsect the acromion, M. Voisin (Gaz. Med., 1839, p.  92) thinks,
erroneously, that  he is projecting a new  method.  A  patient in
whom M. Liston (Encyclogr., 1839,  p. 233) had exsected the head
of the right humerus  for a caries, appears to have been well  cured.
It is stated that an amputation practised upon the humero-cubital
articulation, by M. Blandin, (Gaz. des Hopit., 1839, p.  173,)  has
succeeded well.  Out of eight amputations, one of the  thigh,  two
of the legs, one of  the arm, two of the forearm, one of  the middle
finger, and one of the first metatarsal bone, in the practice of M.
Moulinie, (Bermond, Compte-rendu, etc., p. 45-55, 1838,)  three have
been followed by death.  Pains, with convulsive movements, which
existed for eight years  in  the stump of an amputated thigh, were
removed without any return by acupuncture, under the direction
of M. Longhi, (Gaz. Med., 1839, p. 123.)  M. Blandin, (Ibid., p. 79)
has a second time extirpated, with success, the first bone  of the
metacarpus.  Of two new cases of amputation at the hip-joint, by
M. Syme,  (communicated  by M. Hardie,  pupil of the  schools of
Edinburgh,) one has  perfectly succeeded.   Having amputated the
thigh by circular incision  near the  trochanters, for osteo-sarcoma
in a boy aged  fifteen years, M. Brainard (Encyclogr. des Sc. Med.,
1839, t.  iii., p.  35) afterwards extirpated the head of the femur, in
consequence of the diseased state of the bone.  The young man
died on the forty-eighth day, two  days after  passing a ligature on
the femoral artery  for repeated hemorrhages.   A vast tumor occu-
pied the iliac fossa.

                             §X.

   Numerous cases of exsection of the jaw, have still to be added to
the table that I have given.   The exsection of the upper jaw has
been performed with success by M. Syme.   I have myself taken 
APPENDIX.
lix
away the whole of this bone for an encephaloid tumor, in a patient
who left the hospital cured, and whose case has been given by M.
Jeanselme, (Gaz. des Med. Prat., 1839.)   M. Capelleti, (Annales
Univ. de Mid. d'Omodei, vol. lxxxvi., p.  39,) who  has published a
long memoir on this subject, relates that the exsection of two thirds
of the lower jaw was completely successful in the case of a woman
who was pregnant.  Not less successful were the  cases of the two
patients operated upon by M. Syme, (Edinb. Med. and Surg. Journ.,
vol. exxxvii., p. 382.)  I also twice removed, at the Hopital  de la
Charite, in 1839, the right half of the lower jaw  in two women,
who both recovered.  Operated upon after my method by M. San-
son, for a cancer which occupied the left side of the lower jaw, the
patient of whom M. Tigne (Bulletin de la Soc. Anatom., 1838-39, p.
302) speaks, appears to have done exceedingly well.  I have  ex-
sected, in one case, the posterior extremity of the  two last meta-
carpal bones, with  the unciform  bone; in another, the  cuneiform
bone alone ; and in  a young man, the phalangeal  extremity of the
third metacarpal.   One of the  patients died ; the others remained
a long time in the hospital.

                      § XI.—Lithotomy.

  M. H. Thomas,  (L'Experience, t. iii., p. 301,) an  English surgeon,
following M. Philippe, of Reims,  has performed  the  operation of
lithotomy with success, upon a pregnant woman.  Having,  in a
case of my own, a stone of three ounces weight to remove from the
bladder of a woman, I concluded  to adopt the vesico-vaginal me-
thod.  This appears to have been the first time this operation was
performed at Paris.  Operating upon an adult by the high opera-
tion, the  18th of June, 1815,1 succeeded, says M. Champion, in ex-
tracting  two stones, one of the form of the little finger,  and some-
what larger in size, and which had entered by one of its extremi-
ties  into  the left  ureter; the other weighing thirteen and a half
ounces.  The volume of this stone obliged me  to detach the peri-
toneum above the superior portion of the bladder,  in order to carry
my incision in the latter to more than three inches in extent.  The
stone was so strongly embraced that it was impossible to introduce
the forceps, even when they were  unjointed, in order to seize and to
hold it, which  compelled me, says the author, to  employ a curved
lever, with which I  had provided myself, and which  I  cautiously
insinuated beneath in  order to raise it  gently, that  I might disen-
gage it from its bed, while I supported it  with the hand that was
free.  The internal coat of the bladder was lined throughout with
a false membrane, strewed with coarse sand, resembling a thick
wet spider's web covered with  gravel.  At the end of some days,
this false membrane, wrhich I had intended to  attack by solvents,
detached  itself by fragments, which made their way to the wound
in the hypogastrium, and thus  enabled  me to extract them.   The
patient recovered perfectly.
  The difficulties that I .encountered in this case, says  M. Cham- 
lx
NEW  ELEMENTS OF OPERATIVE  SURGERY.
pion,  were necessarily numerous, for they were  the  consequence
of the long-protracted retention of the calculus, and  the size this
body had  acquired.  I know that in one case, Deguise, the father,
could not seize the stone after the incision by the high operation,
and that he was obliged to force it upward by aid of a forceps, or
a curette introduced  by the cut through the perinaeum.  More re-
cently, one of the distinguished surgeons of the capital, assisted by
one of his brethren not  less skilful,  was much embarrassed in a
similar  case, by reason of the narrowness of the  vesical cavity, a
circumstance which determined them to  perform  the  recto-vesical
incision, by which the stone, in fact, was extracted.  The case of
M. Leonardon much resembles the preceding.  The stone extracted
by M. Champion has been deposited  in the cabinet of the Faculty,
and the curved lever invented by Levret,  (Encyclopedic Methodique,
partie chir., t. ii., p. 236,  col. 1, du texte, p. 106, col. 2 de l'expl. des
planches,  par Allan,  pi. xxxix., figs.  8, 9, 10.) to  raise large-sized
polypi in the vagina, and to serve as a guide to the ligature-carrier,
(porle-anse,) is the instrument that he made use of.

                            § XII.

  An instance of success obtained by the  suture, in a case of vesico-
vaginal fistula of the fundus (bas fond) of the bladder,  and where
the fistula was large, transverse, and of four months standing, has
been published by M.  Coley, (Ibid.)

                            § XIII.

  Desiring also to simplify staphyloraphy, M. Sotteau (Annales de
la Soc. de Med. de Gand., t. iv., p. 333) has invented a forceps which
carries and brings back the needle through each side of the divi-
sion, and  which  is really very ingeniously constructed.  Since I
made mention of them, this sort of  suture forceps, which are ap-
plicable alike to vesico-vaginal fistulas, recto-vesical, &c,  have
been still more improved by MM. Bourgougnon, Foraytier, and Des-
pieris.

                            §XIV.

  A simple puncture, made in the direction of a vagina, which had
been rendered completely imperforate by inflammations and eschars,
was followed by peritonitis and death  in a woman operated upon
by M. Liston, (Gazette des  Hbpitaux, 1839, p. 183.)

                       § XV.—Tumors.

   A tumor of the weight of two  pounds, situated under the jaw,
and extirpated  with  success by M.  Rufz, (Archives Gen. de Med.
Avril, 1839, p. 479,) was, according to all appearance, a lymphatic
glandular tumor. The tumor of the breast extirpated  by M. Eti- 
APPENDIX.
lxi
enne, (Gaz. Med., 1839, p. 123,) of the character of elephantiasis,
was probably only an hypertrophy of the mamma, as in the cases
that 1 have described.  Believing that he had removed a tumor of
the character of elephantiasis, of  the  size of a child's  head,  and
which occupied the  labium majus of the right side, in a woman
aged thirty-two years, M. Michon (Bulletin de la Soc. Anatom., Mai,
1839, p. 69) found in reality that it was nothing more than a fibro-
lobulated tumor.  Was hot the tumor of two pounds weight, taken
from the fore  part of the knee by M. PI. Portal, (Clin. Chir., p. 277,)
under the title of lipoma, an hematoma ?   A woman, aged sixty-six
years, had on her knee a true lipoma of  eight pounds weight, and
which the  same surgeon (Ibid., p. 274)  took away with success.
M. Lawrence, (Gaz. des Hopit.,  1839, p. 125,  126,) who appears to
have noticed  a great number of synovial cysts about the knee, has
seen death ensue in two patients operated upon by him.   M. Rey-
bard (Anus Artificiels, p. 193) was not, until after fourteen or fifteen
sittings, enabled to remove an enormous exostosis of the cranium
in a woman,  whom, however, he succeeded in curing.   M. Philips
(Lettre Chir.  a M. Diefifenbach, etc., 1839) says he has obtained sat-
isfactory results from anaplasty,  after the removal of cancerous
tumors.

                            §  XVI.

   An enormous swelling of the tongue, caused by the bite of a vi-
per, induced  M. Weger (Encyclogr. des  Sc. Med., 1839, p. 261) to
practise tracheotomy, which perfectly  succeeded.  A tumor of the
tongue, strangulated by the method of  MM. Cloquet or Mirault,
was completely destroyed by M. Arnold, (Ibid., t. iii., p. 16.)

                           § XVII.

   A large  erectile tumor on the ..temple of an infant, treated by
needles by M. Maclachlan, (Gaz.  Med.,  1839, p. 362,) appears to
have entirely disappeared.  An erectile tumor, which occupied the
labium majus of the left side of a woman aged twenty-nine years,
was extirpated with success by M. PI. Portal, {Clin. Chir., etc., p.
142.)  After having extirpated one of these tumors on the fore part
of the thigh,  the same practitioner (Ibid., p. 141) was  obliged to
cauterize the  wound many times, with the butter of antimony, the
nitrate of mercury, and the nitrate of silver.  An  erectile tumor
which surrounded the anus, was cured by means of numerous liga-
tures, by M.  B. Philips, (Lond. Med. Gaz., Fev., 1839; ^Irc^. Gen.
de Med., Juin, 1839, p. 239.)  In order to cure a pulsating tumor,
of the size of  a nut, situated on the external part of the  dorsum of
the tarsus, and caused by a punctured wound from a nail, M. Fleury
(Archiv. Gen.  de Med., Mai, 1839, p. 87)  was  obliged to  cauterize
the base of it with red-hot  iron some time after he  had freely in-
cised it. 
1a.11           NEW  ELEMENTS OF OPERATIVE SURGERY.
                           § XVIII.

  A new case of hydrocephalus cured  by compression, in a female
infant aged twenty-seven months, has been communicated to me by
M. Lowenhardt, (Journal des Conn. Med.-Chir., t. xii., p. 257 ;  Ency-
clogr. des Sciences  Med.,  1839, p.  177.)  A hydrocephalic child,
treated by puncture, in the practice of M. Tetlow, (Gaz. des Hopit.,
1839, p. 185,) was much relieved, but died on the tenth day of an
acute bronchitis.

                            § XIX.

  M. Heyfelder,  (Archiv. Gen. de Med., Mai, 1839, p. 59,) following
my method of operating for empyema ; first, in a child aged seven
years, at the end of two and a half months of the disease; second,
in an infant aged six years, at the end of three months and a half;
third, on a soldier aged twenty-one years, at the end of some weeks;
fourth, on a boy aged six years; fifth, on a child aged seven years,
obtained success in each, except that the wound in his third patient
remained fistulous.   A  like result  was obtained by M. Brugnon
(Ibid., p. 80) in May, 1837.  F. Wetzel, (Heidelb., ami. 1838, t. iv\,
cap. 4 ; Arch. Gen. de Med., Juin, 1839, p. 229,) aged nineteen years,
operated upon for empyema  the 21st of June, 1834, and several
times afterwards, was  still living  in 1838, with a fistula in the
thorax.

                             §XX.

  A case of intestinal  hernia, strangulated  through the ruptured
mesentery,  has been published by M. Ranking, (Encyclogr. des Sc.
Med., 1839, t. iii., p. 15; Gaz. Med., 1839,  p. 103.)   The kelotome
and the sonde-bistoure, as proposed  by M. Peraire (Bulletin de VAcad.
Royale de Med., t. iii., p. 606) for the operation of strangulated her-
nia, are evidently useless.  If the son of a distinguished practitioner
of Rouen, M. Flaubert,  (De  la Hemic Etranglee, etc., Paris,  1839,)
thinks  that he can  maintain that the  operation for strangulated
hernia succeeds better when the peritoneum is inflamed, than when
it is sound; it is  because he has not given attention to the state of
this membrane at the moment of  the operation in the hospitals of
Paris.

                       §  XXL— Urethra.

  Adopting the cauterization from before backward, after the plan
of Wiseman,  M. Barre (Cauterisation Antero-poster., etc., de VUretre,
Rouen, 1839) makes use of a very convenient instrument, which I
have thought it right to delineate in the atlas. 
APPENDIX.
lxiii
                           § XXII.

  The incision of strictures in the rectum has been followed by great
advantages in the hands of M. Stafford, (Gaz. Med., 1839, p. 363.)

                           § XXIII.

  An ascites of three weeks, treated at first by squills, calomel, &c,
was cured in a short time by acupuncture, (Campbell, Gaz. Med.,
1839, p. 105.)  I have observed two favorable cases from this treat-
ment: MM. Bricheteau and  Barthelemy have also cited similar
cases.
                           § XXIV.

  Supporting his declaration by a number of observations, M. M.
Smith (Gaz. Med., 1839, p. 41) pretends that the trephine should be
employed to prevent necrosis and caries in ostitis, as also for curing
those diseases when they are once established.

                    § XXV.—Emphysema.

  A man blowing his nose too violently after an operation for fistula
lachrymalis by  the canula, that M. Blandin (Gaz. des Hop., 1839,
p. 174) had performed upon him, was suddenly seized with a strong-
ly-marked emphysema of the eyelids. 
/
V 
NEW  ELEMENTS
                         OF


OPERATIVE    SURGERY.
              DEFINITION AND  DIVISION.

   In medical science the word operation may be defined a mechani-
cal action, directed by the hand, and designed as a remedy upon
one who is infirm or sick.  It embraces thus the same idea as that
of surgery;  but usage has resulted in giving to it  a  value, if not
different, at least very much restricted.  To-day, surgery means in
fact surgical pathology, and all diseases are  included in  its  domain
in which a topical application forms the leading feature of the
treatment, whilst operative surgery (la  medecine operatoire)  is  con-
fined to the study of the  therapeutic means which require the in-
tervention of the hand, whether by itself or armed with instruments.
One is a true science, which is scarcely distinguished from  medical
pathology, properly so called ;  the other approximates more to the
arts.  The first cannot be cultivated with advantage but by those
who are endowed with a great aptitude  for labors of  the mind;
the hand, on the contrary, is the instrument, and the indispensable
and characteristic agent  of the second.  As for the rest, it is im-
possible to establish between them an exactly defined limit.  Thus
also do we  see them constantly   trenching upon one  another  in
the works that have been devoted to each.
  If it is permitted to operative surgery to include within its  pro-
vince the  rules relative to the employment of cataplasms, plasters,
ointments, leeches, cupping, acupuncture, blisters, moxas, cauteriza-
tion, the seton, and  bleeding, we cannot see by what title  the re-
duction of fractures and of luxations, and the study of bandages
and dressing, should be excluded from it.
  Catheterism in general, the extraction of a foreign body, whether
in the ear or between  the eyelids,  and the section of the fraenum
of the tongue, require  neither more address nor knowledge than ve-
nesection or the opening of an abscess.  The manner then of cir-
cumscribing the field of operative  surgery is an affair purely con-
ventional, which every one has a right to interpret according to his
own mind or particular views.  For myself, I shall treat of opera-
tive surgery under  four principal  heads: the first section will be
                              1 
2
NEW ELEMENTS OF OPERATIVE SURGERY.
devoted to operations in general; the  second will  include every
thing relating to minor surgery; in the  third I shall occupy myself
with the ordinary operations; and special operations will be de-
tailed in the fourth.
                     ORDER FIRST.

                 OPERATIONS  IN  GENERAL.

  There are an infinity of rules which are not peculiar to any opera-
tion in particular, from the fact that they are  applicable to all.
The  examination of the  classifications, methods, indications, and
counter-indications, and of what it is necessary to do before, during,
and after an operation, all justify this assertion.
                         CHAPTER I.

                     CLASSIFICATION.

  There has always been felt an  urgent necessity of distributing
operations into a certain number of divisions.   The ancient division,
mentioned by Celsus, which would refer them all to dieresis or synthe-
sis, to exeresis or prothesis, and which reigned for so many ages in all
the schools of Europe, cannot now be retained.   In the eight classes
substituted for them by Ferrein, he is still more unfortunate.   The
union, the separation of tissues  accidentally united, the dilatations
and the re-establishment of natural passages, the closure or oblitera-
tion of channels that have become useless, the extraction of certain
liquids, the removal and the extraction of foreign bodies, the  reduc-
tions, of which he makes so many different kinds, form, in fact, the
most unnatural distribution that could  be imagined.  Diarthrosis,
or the process of remedying deformities, added, at the time of Dionis,
to the four primitive orders ; dilatation and  compression, to which
M. Roux accords a separate place ; while prothesis, rejected also by
Ferrein, does not appear to be worthy of any, would answrer but
very imperfectly to complete the arrangement.   The exploration of
the bladder, of the Eustachian  tube, and the  lachrymal passages,
the injection of those different parts, and the pure and simple torsion,
for example, of  the vessels, would have no rank, though in them-
selves they may frequently constitute important operations.
   The  efforts of Lassus and of Rossi,  to  avoid the  difficulties
pointed out by the preceding authors, have had no success ; and the
plan at last adopted by Sabatier has so many disadvantages, and is 
CLASSIFICATION.
3
so inconvenient, that hereafter no one will ever think of reviving it.
In fact, with what incongruity it strikes us, when, for the  eye, for
example, we see fistula  of the cornea, hypopeon, hydrophthalmy, sta-
phyloma,  scinhus, procidentia iridis, foreign  bodies, cataract, and
artificial pupil, scattered about in the midst of three volumes, and
into so many distinct classes.   It results  from this, that  it is next
to impossible  to know in what part of the work to search for the
article we wish, unless we run over beforehand an interminable
index. For example, to open the anterior chamber of the eye, we
should be obliged to consult in turn the second, third, and fourth vol-
umes, according as it may relate to the extraction of pus, a foreign
body, or the crystalline lens.  In this  point of view the essay of Del-
pech  is still more unfortunate.   Nor, in fine,  is the  method devel-
oped  by M. Richerand, though one of the most  advantageous for
study, and conceived in an  intellectual spirit, totally free from the
objections which may so justly be made  against that of Sabatier.
From whence  it results, that the topographic arrangement that had
already been  proposed  by J. Fabricius, and from which Boyer did
not think proper to deviate, notwithstanding the criticisms, more or
less just, that were made upon it at different epochs, is still the best,
and the only one, perhaps, which can, up to the present time, be of
any help to the reader in a treatise on operative surgery.
  It is the only system which embraces the general ideas in use by
all the world.   By its aid there is no one who may not know immedi-
ately  where to find trephining,  cataract,  empyema, lithotomy, &c. ;
whilst in  imitating  Sabatier or Delpech, we  should  have to ask
whether such  operations belong rather to wounds and foreign bo-
dies, or to fractures and effusions, &c, and afterwards to find in
what order of those different chapters they are to be classed in re-
gard  to one another.  The nature and the causes of disease are too
little  known, or too changeable, to serve as the  foundation for the
classification of operations.  In proceeding exclusively by the ar-
rangements of functions, or by the organic system, we take our de-
parture, it is true, from fixed points, but we are obliged to associate
together subjects the most dissimilar, (salivary  fistulas, abdominal
hernias, polypi of the rectum, &c.,) or to  separate others,  (foreign
bodies in the trachea and the oesophagus, tracheotomy, oesophagoto-
my, &c.,) which have the greatest analogy to each other.
  We may here glance at the operations under two general points
of view: first, as independent subjects, and class them according to
their  greater or less  analog)'' or difference ; secondly, as therapeutic
resources, and submit them to the same divisions as the affections
they belong to.  In practice, the first of these methods is not appli-
cable  but to the very smallest number of  operations; for example,
to trephining,  amputation, ligature of arteries, and suture.  The
incisions, extractions, and special operations cannot in truth be ad-
justed with it.   The second would be yet  more difficult to general-
ize ; for if cataract,  fistula lachrymalis, hare-lip, &c, may  serve as
heads of  chapters in a work of operative  surgery, it is not so with
complicated fractures, caries of the joints, gangrene, and  wounds 
4
NEW  ELEMENTS  OF OPERATIVE SURGERY.
from fire-arms.  Perceiving, by the difficulties against which all
others have vainly struggled up to the present time, that it would
be impossible for me to  create a  classification well systematized
and regulated, I have believed it to be my duty to decide in favor
of the plan the least  fatiguing for  the pupil.  This plan approaches
more an anatomical arrangement  than any other.  It is the only
one, with some few modifications,  that is allowed to be followed in
the amphitheatres, and is the one  of which M.  Dubois (Traite des
Etudes Med., Paris, 1837, p. 600) has endeavored  to point out the
advantages.  Founded upon the same principle as that of my treat-
ise on surgical anatomy, it permits me to place in the first class all
the general operations, and to reserve for  the second all the special
operations.  It has afterwards appeared to me, that for the special
operations, the best plan was to run over  the whole trunk, from the
head to  the pelvis, taking sometimes the operation itself, sometimes
the diseases, and sometimes the organ, or  the parts which belong to
it, for my  guide and  chapter.  Having had no other intention in
adopting this method than to  render  a knowledge of the  subjects
more easy, and to aid  as much as possible the memory of the reader,
I  attach no further importance to it, and consign it without a mur-
mur to the criticism of those who are capable of judging of it.
                        CHAPTER  II.

                   NATURE OF OPERATIONS.

Article I.—Systematized Operations, and such as are  without any
           rules—(Operations Reglees et non Reglees.)

  Among operations, there are  those  of which  all the steps are
known in advance, and others in which no rule can enable us  to
foresee the difficulties.
  The first, generally  designated  under the title  of Operations
Reglees, are fortunately numerous and important.   It is to these
that we assign amputations, the operation of aneurism by the
method of Anel, cataract, hare-lip, lithotomy, &c.  The second com-
prehend tumors, whether cancerous or of other descriptions, which
develop themselves upon the cranium, face, neck, axilla, and in the
abdomen, and which we  are obliged to extirpate.  There  exists
a third class of operations which hold in some sort the middle place
between the two preceding ; such  are those which have reference
to cancers of the breast, sarcocele. fistula in ano, hernias, and even
exsections and the operation for aneurism  by the ancient method.
We know effectively what are the  coverings to divide in an opera-
tion of strangulated bubonocele, but we are more frequently igno-
rant of what is the  true  pathological condition  of  the parts to  be 
NATURE OF OPERATIONS.
5
reduced.  Thus operations are arranged naturally into three series:
1.  In  the  one, the instrument acts on parts altogether sound, or
scarcely disturbed by the disease ; 2. In the second it bears upon
points whose principal anatomical relations have been changed, or
its object is the eradication of a tumor, whose limits, if not its very
nature and seat also, it is at first  almost impossible to determine;
3.  In the third, in fine, we apply it to diseases whose limits it is
easy to establish, and which are surrounded by organs well known,
but which are too numerous in variety to permit the rules for ope-
rating in one case to be exactly proper for the  others

            Article II.—Operations on the  Dead Body.

  The convenience of the division, essentially practical, of which I
have just spoken, is especially confirmed by the processes that  are
performed on the dead body.  There it is  possible, in fact, to imi-
tate the removal of limbs, the ligatures  of arteries, in a word, all
the operations which apply to the organs in their normal state, that
is, all the systematized operations.  Nothing like this can be had
for sarcomas of the face, and of the maxillary sinus, for amputation
of the upper jaw, of the parotid, of the thyroid, for a cyst of  the
ovary or the interior of the abdomen, and, in  fact, for  all the  ex-
temporaneous operations.
  There is no pupil who does not know that the ideas that we  get
in the  amphitheatre  of ligatures upon  polypi, of excision of  the
neck of the  uterus, and of the operation for fistulas in perineo  or
in ano, and especially for hernias, are extremely imperfect, and  but
feeble aids when we come to operate upon the living patient. We
should therefore  be grossly deceived if we  believed ourselves per-
fectly instructed in all operations, because we had repeated them
a great number of  times on subjects for dissection.  No one, how-
ever, can be a skilful surgeon without having been for a long time
thoroughly versed in those exercises.  ^They give precision, confi-
dence, address, and a manual adroitness that the most minute ana-
tomical knowledge can never supply.  But this is not all, even for
the operations of the first kind.  While  the  eye  is more flabby,
more  soft, and less transparent on* the  dead  body, nothing there
gives us that idea of mobility, that tendency of the vitreous humor
to escape, and of the eyelids to contract, and of the tears incessant-
ly to flow, which are seen in life.   When we amputate a  limb, the
tissues, being more firm and  better extended, are, it  is true, more
easy to cut than  after death; but in this  last case we have no mus-
cular retraction, no blood which incommodes or disquiets us, and no
explorations to make, to know  if certain  hemorrhages proceed
rather from  veins  than arteries.  However superficial an artery
may be, we cannot  lay it bare  without  dividing some  vascular
branches, whose contents sufficiently mask the parts to render  the
power of distinguishing them more or less  embarrassing ;  while in
the dead body nothing analogous to this is met with.  The pulsa-
tion of the vessels, which, at the first glance, would seem to be a com- 
6             NEW ELEMENTS OF OPERATIVE SURGERY.

pensation, is, however, so  little manifest, and so indistinct at the
bottom of wounds, that we cannot in reality derive but a very fee-
ble advantage from it.  In tracheotomy and cesophagotomy, is it
possible to represent even the smallest number of the embarrass-
ments which arise from the venous plexuses, anastomoses, and the
numerous arteries of the neck ? In passing to the other two classes,
we must note also the difficulties that are  inherent in  them  from
these general  differences.   We do  not  operate for fistula lachry-
malis, unless the angle of  the eye is glued together, ulcerated, or
more or less altered.  It is the same, most usually, with the nasal
fossae when we wish to extract polypi from them. The movements of
the throat, the  desire to vomit, the mucus or the blood, and the state
of agony into  which the patient falls at every moment while we
are operating  for  a hypertrophy of the tonsils, or a bifurcation of
the velum of the palate, are not found on the dead body.  The
states of caries and necrosis which render the exsection of a joint
indispensable,  constantly and profoundly alter the surrounding soft
parts.  From whence it follows, that there is no possible compari-
son between what we are  then forced to do, and the trials that we
make on the dead body.  In those different cases we know, never-
theless, what is the number and the situation  of the coverings and
of the organs that we are  to divide, or where the  part is that we
wish to take away or perforate ; but let me suppose that a morbid
mass, of a  certain volume, develops itself in the perineum, of
what use to the surgeon will be his exercises on the cadaver ? But
what I say of the perineum, is applicable to the groin, to the axilla,
the neck, the abdomen, and  all other points of the body.   Though
this kind of exercise, therefore, is not  to be neglected, we  must
guard ourselves from according to it too much importance.
   The experiments on living animals,  wrhich, under this point of
view, are of infinitely greater value, have not, nevertheless, all its
advantages.  First, the forms being  rarely similar, we obtain, in
general,  but fallacious results, if we would make rigorous deduc-
tions from one to the other.   Moreover, it is necessary to study an
operation with the mind at  rest, and with all necessary care, and
to practise it on the dead  body, and not. on a being endued with
life ; so that there are two kinds of means that come to the aid of
each other,  without our having it in our  power to substitute the one
for the other.
   Operative Surgery, then, is definitively founded—1. On anatomy;
2. On operations on the dead body ; 3. On living dissections ;  4. On
pathological anatomy; 5.  On the constant practice of operating on
the living subject.


                     Article III.—Metlwds.

   As there  are but few operations that cannot be performed in dif-
ferent ways, we must seek out in season for a proper word to ex-
press the ensemble of the steps, of which each one of them is com-
posed.   The terms methods,processes, and modes, have been applied 
THE CARE REQUIRED IN OPERATIONS.
7
  to this use.  These  three words, which are nearly  synonymous,
  have for a long time  been employed almost  indiscriminately, and
  they are so still on a great many occasions.   It has, however, been
  attempted, following the example of M. Roux, to give to each of
  them a distinct value, and a special signification. The term method,
  for example, has a much more extensive signification than the. two
  others.  It  is thus that we say method, and not process, or mode,
  when we speak of extraction or depression of cataract;  whilst in
  the operation for stone, with the concealed lithotome, (lithotome
  cache,) we make use  of the word process, and not that of method,
  to point out the modification of the operation by Boyer.  The liga-
  ture upon polypi is a method.  The ligature, after the ideas of such
  or such an author, is only a process.  In short, we generally under-
  stand by method something  fundamental, sufficiently broad to be
  divided and modified in many ways; while the word process is
  more restricted, and is scarcely used but in designating a diminu-
  tive  of some method.  The  operations of aneurism, amputation,
  hydrocele, and lithotomy, are all excellent  examples to point out
  the justness of these distinctions.   To place a ligature  on the
  artery without touching the tumor, is called a method ; to place it
  higher or lower, takes the name of a process.  To open the sac  is
  a method; the manner of opening or that of placing the ligature is
  a process.   To sum  up the whole, method embraces the entire
  thing, while process is applied to each one of its modes of applica-
  tion.   It is far from happening, however, that, in  ordinary language,
  we do not constantly deviate from these conventions purely arbitrary,
  or that we do not often use, even in works that are the most carefully
  written, the words process and mode of operation, in place  of the
* word method, and vice  versa.  Fistula lachrymalis, among  other
  things, proves this sufficiently.  In  fact, we almost indifferently
  say the method and process of Dupuytren, Desault, and Boyer.  Hy-
  drocele, hernia, and  lithotomy, are  subject to  the same remark.
  The process and the method of cauterization and of injection ; the
  method and the process of dilatation, and dividing strictures ; and
  the process and the method of Frere Come, are in daily use.  This,
  at best, is a question entirely of a secondary character, and of no
  moment.  It is permitted to every one, in such a discussion, to ad-
  here to such usages if he pleases, or to reject them, and place no
  value upon them.
                       CHAPTER  III.

            THE CARE REQUIRED IN OPERATIONS.

                   Article I.—Indications.

  The first object which should engage the solicitude of the sur-
geon, before performing an operation, is to ascertain the indications. 
8
NEW ELEMENTS OF OPERATIVE SURGERY.
It is on such  occasions that the most extended and precise medical
knowledge becomes a matter of indispensable necessity.  After hav-
ing  established that the cure is more difficult or even impossible in
any other manner, it is then necessary that he should recognise the
utility of it;  that he should acquire the conviction that the patient
incurs less of danger in submitting to it than in  remaining under
the action of  the disease that  has rendered the operation necessary.
It is not that  we are permitted to perform operations  only, as Du-
puytren (Sabatier, Med. Op£r., Paris, 1824, t. i.,  p. 13-16) lays it
down—1.  When these are the only means indicated; 2. When we
have vainly essayed all other means; 3. When they form the last
resource;   4.  When we  are  sure of being enabled  to complete
them ; and, 5. When there is to result from it an entire and perma-
nent cure ; but, likewise, when compared with other  therapeutic
resources, and with the inconveniences of the disease, they present
both more advantages and  fewer dangers.   1. We operate, and
with propriety, upon a great number of tumors which it would not be
possible for us to cure, but with difficulty, by the aid of "caustics or
certain ointments ;  2. It is useless to try all the other remedies be-
fore operating for fistula lachrymalis, hydrocele, cancers, &c.; 3. In
phymosis,  cataract, hare-lip, and abscesses, the operation ought to
be the first rather than the  last resort; 4. We proceed to  the ex-
amination  of a  strangulated hernia, of a foreign body, and of a
wounded artery, without being sure of succeeding or of completing
the operation ; 5. The puncture of the abdomen, of the  bladder, and
the thorax, and the extraction of polypi from the nose, are practised
every day, without being followed in general  by any other result
than a temporary relief.
   A diagnosis, therefore, elucidated by a thorough knowledge of #
pathological  anatomy, a prognosis  founded  upon what the most
sound judgment can ascertain of the progress or probable issue of
the derangements of the organism, and as exact an appreciation as
possible of the  power or of the value of the ordinary therapeutic
agents, will alone enable the  surgeon to  resolve this first problem,
which, in one of its aspects, does not seem to me to have hitherto
been considered in a proper point of view.
   I shall now speak in relation to the choice that is to be  made
between the  operation properly so called, and the  other medica-
ments that might be substituted for it.  Thus, because the lachry-
mal tumor, hitherto considered of  a nature  which  confined  it
within the limits of operative  surgery, yields sometimes to regimen
and the antiphlogistic method, and because certain tumors of the
breast are discussed by means of compression, we should be alto-
gether wrong, in my opinion, to conclude from this, as some have
lately done, that the application of this treatment  ought always  to
precede and be made trial of, with the view of dispensing with the
aid of the cutting instrument.  In fact, the question is not to know
if cancer or any tumor whatever may be made to  disappear under
the action of  such or such  a medicament, or by the intervention of
a serious operation; but to know which of the two offers in the last 
THE CARE REQUIRED IN  OPERATIONS.
9
resort the most advantages to the animal  economy.  I agree that
the application of leeches, frequently repeated, and that emollient
cataplasms and abstinence cure a certain  number of tumors, and
even lachrymal fistulas;  but should  we therefore infer that this
treatment, the  success of which is far from being  constant, and
which may be prolonged many months, deserves to be substituted
in the place of a metallic tube in the nasal canal, if it is true that
this application, which is made in a second of time, would cure in
two days a disease of ten years' standing, and succeed  in  a great
majority of  cases ?   Allow that leeches and diet may sometimes
prevail over masses that have the appearance of sunhus or cancer,
I do not deny it; but if these tumors were moveable and favora-
bly placed, who would venture to maintain that the bistoury would
not remove them still more effectually, certainly with more rapidi-
ty, at the same time  producing a less severe shock upon the sys-
tem, and causing in reality a much less amount of suffering ?  But
what I say of lachrymal fistula and  of cancer  is applicable to a
crowd of other maladies, and  is the  basis of an  observation that
the surgeon should never lose sight of.  If it is cruel to subject to
the operation of the actual cautery those whom we might treat  by
more gentle means, it would be still less conformable to the inter-
ests of humanity to  compromise  the future health of the  patient,
under the vain pretext of  exempting him  from  a little suffering.
The slightest puncture, it  is true, opens a  gate to death; but this
axiom, which is applicable to the bite of leeches,  to bleeding, cup-
ping, blisters, cauteries, setons, moxas, and  the capital  operations,
does not and ought not to  prevent us  from resorting to  abstraction
of blood, to revulsives, or  to drains ;  and there is no internal medi-
cation, if it possess some activity, to  which we may not apply the
same  remark.

               Article II.—Various Precautions.

                  § I.—Hygienic  Precautions.

  The choice of the season is certainly not a matter of indifference
for the performance of operations.   Other things being equal, if the
spring and autumn suit better than the  winter or midsummer, it is
not only because their temperature is more mild, but also because
the system is then in a better condition  to resist general morbid re-
actions.   So also we should not perform, except  in temperate sea-
sons, lithotomy, the removal of large  tumors, or  any  other opera-
tions which produce a severe shock upon the system.
  But we  must not accord too much importance to this  precaution,
since we know that there is no season capable of rendering impos-
sible the success of an operation, whatever it may be, and that the
question of time cannot be any other than a mere matter of greater
or less convenience.  At the hospital  where I operate for cataract,
stone in the bladder, fistula lachrymalis, tumors of the breast, both
in winter and summer, I have not  observed that  success or failure
depended upon one season more than  another.  No doubt  the ap-
                               2 
10
NEW ELEMENTS OF OPERATIVE SURGERY.
pearance of an epidemic is a substantial reason for greater caution,
and that we must at the same time look to the morbific constitu-
tions that exist at the moment.  We cannot, however, apply this
rule  but to operations  where urgency may be questionable.  A
strangulated  hernia, a  wound of an artery  or  of the  intestines,
croup,  or foreign bodies in the oesophagus,  would not admit of
delay.
  Pelletan  and Dupuytren were in the  habit  of keeping  patients
in the hospital some time before operating upon them, in order, they
said, to acclimate them.  MM. Viricel and Champion do not con-
form to this rule, unless it has been impossible for them to operate
immediately.   On this subject I find it  difficult to lay down rules.
We cannot deny that  the  atmosphere,  regimen, exercise, and the
concomitant circumstances, constitute an entirely new life to most
persons who,  for the first time, enter a  hospital, and  that to most
people from the country especially, this  sudden transition  may be
a formidable  cause of disease.
  A man having an artificial anus comes from a remote province,
and wishes to be operated upon immediately.   I object.  The third
day he is seized with a gangrenous erysipelas, and on the fifth day
dies.  The  operation for a fistula lachrymalis, which I was asked to
perform on a mason from the country, was  deferred for some days.
A peritonitis  supervened,  and  proved  fatal in  forty-eight  hours.
Another countryman wished me immediately  to extirpate  a can-
cerous eye, in order that he might quickly return to his labors.  He
was seized  with an erysipelas, which proved fatal to him in a few
days.   The day was fixed for taking away  a  polypus from the
uterus in a peasant girl, who was in other respects in  good health.
All the symptoms of a violent peritonitis showed themselves the
same morning, and death took place on the third day.  An  opera-
tion would not have prevented these  patients from dying: and
who does  not see that if, yielding to their entreaties, 1  had per-
formed it, it would have been made to assume the responsibility of
all these fatal results !
  What I have said of hospitals I might also apply to private houses,
when speaking of patients  who are strangers to the city, and who
visit it for the sole purpose of being operated upon.
  It is certain, on the other hand, that in operating immediately, we
relieve the  patient of one cause of ennui, of anguish, and of moral
suffering, which also are sources of danger.  On this subject there
is nothing absolute.  For trifling operations, or for those of a mode-
rate degree of severity, for cataract, fistula lachrymalis, hare-lip, sta-
phyloraphy, and excision of the tonsils, for example, and for those ope-
rations intended to relieve acute  pains in some severe maladies, de-
lay, as it appears to me, would be improper. For the great operations,
the extirpation of tumors of considerable size, lithotomy, and opera-
tions for aneurism, if life is not actually compromised, it is on the con-
trary prudent, as I conceive, to wait some days, and not  to be in  a
hurry.
   The  age also is  a condition which must be taken into account. 
THE CARE REQUIRED IN OPERATIONS.
11
With infants we need not be in haste to operate for lachrymal tu-
mors, small erectile tumors, hydrocele, the removal of enlarged
tonsils, &c, because the growth of the individual often causes these
diseases to disappear.  We desist often from the operation  for hy-
drocele, cataract, artificial pupil, and a great number of other ope-
rations in old people, because at that period they offer less chances
of success, and that in the decline of life, even under the most fa-
vorable circumstances, they lose a great many of their advantages.
I shall, however, be  obliged to recur to many of these  questions
when speaking of particular operations.
   In selecting the morning rather than the  afternoon, the operator
has the advantage of finding his patient less fatigued, and himself
better enabled to watch with care the wants of the patient imme-
diately after the operation.  In other respects,  there is nothing im-
perative in this matter; and the  most plausible argument  for this
preference is, that in general  the forenoon  is most convenient for
every body.   As to urgent operations, we perform them as soon as
we can, without taking into consideration  the season or hour of
the day ;  on which account authors have been induced to establish
two  periods, a time of election and a time of necessity.

                    §  II.—Moral Precautions.

   Moral precautions, so far as operations are concerned, vary, land
must vary, according to the individuals.   The first rule is to inspire
an unlimited confidence in the patient; and we all know that con-
fidence is acquired in a thousand different ways.  The second is, to
convince the patient that the operation  is the  best possible  means
of arresting the progress of his sufferings, and we should take care
to undeceive him if he exaggerates  the dangers of it.  In short, we
must do every thing, without exceeding the limits of truth, to induce
the person to be  operated upon, not only to desire, but to demand
the operation, and to look forward to the moment of its performance,
if not with pleasure, at least with resignation.   In this respect we
have two sorts of people to deal with.   Some, of extreme pusilla-
nimity, are so alarmed at the idea of the slightest cut of the bistoury,
that we are compelled to deceive them  upon  the duration and the
acuteness of the pains they must undergo, as well  as the dangers
they are about to be exposed  to. Others, and who are  rarely met
with except in public establishments, imagining that they must be
operated  upon whether or no, and even without any notice being
given to them, never speak to the surgeon but with an air of in-
quietude, and remain in a continual state of apprehension until we
disabuse them of their error.   Upon this subject it has been asked,
if it was well to announce to the patient the day and hour of the
operation. To this we may reply yes and no.   As a general rule,
operations with the day and hour fixed, as was formerly the practice
in public establishments, and which Pouteau compares to a species
of auto-da-fe, are  bad.  I have also taken care completely to eradi-
cate this  practice from La Charite, where there  were still some 
12
NEW ELEMENTS OP OPERATIVF. SURGERY.
traces of it when I first entered upon my duties in  this hospital
But we are  not  to infer from  this that we ought to  conceal  from
every patient what we are going  to do  to him up to the last mo-
ment.   If there  are  some that we ought to prepare without  their
knowledge, and take them, so to speak, unawares, there are a great
number of others who should be gradually familiarized with the
idea of  the  operation,  and be not only made to understand and
reason upon the  details of it, but informed beforehand  of the time
fixed upon.
  Practice shows us, moreover, two other kinds of persons whom it
is necessary to look to in a moral point of view.  Among these we
may arrange such as, having no fear of the dangers that they run,
and making a boast of their courage, submit themselves with per-
fect indifference  to the  knife of the operator, and take  pride in re-
ceiving the cuts  of the knife without making any complaint.   ,
  The second class of whom I would speak, comprises persons that
are naturally timid  or very susceptible, but who,  after having
hesitated a long  time, become convinced that  an operation is abso-
lutely necessary, and then concentrate all their courage with  such
force that they refrain  from uttering a single cry, suppress even a
reasonable manifestation of suffering,  and stifle the slightest mur-
mur of complaint.
  The fear  of Pope  Innocent  was so  great, says St.  Augustine,
(Cite de Dieu,) when they  announced to him that it was necessary
for him  to be operated  upon a second time for fistula in ano, that
the physicians, the day after, found only a firm and solid cicatrix
in the place of the sinuses and of the small openings which were
seen the evening before.  A hemorrhage which yielded to nothing,
was suddenly arrested when F. Collot had told the patient that he
was in danger, and that it was necessary for him to put his affairs
in order.  (Operat. de la Taille, p. 141.)   M. A. Petit, on the con-
trary, has often  caused hemorrhages to be arrested  by dispelling
fears with which the patients were overwhelmed.   (Med. du Caeur.)
An artificial stoicism is no more favorable to the success of oper-
ations than an extreme  pusillanimity, as  is familiarly known to all
well-informed surgeons.
  It is consequently sometimes as useful  to calm  and repress the
extravagant courage of some patients,  as it is  to quiet the fear and
timidity of others.  To  the former it is necessary to point out the
grave nature of  what they are disposed to treat so lightly, and to
show them the necessity of not making up their minds with so little
reflection.  To the others we must explain that assumed bravery
can never take  the place  of true  courage; that it is as dangerous
to suppress their sufferings as it is improper to exaggerate°them,
or to utter them when there is no reason for doing so ; that in acting
thus they do violence to nature, whose intention is, that the distress
of each suffering organ should be expressed  freely  and without
constraint.  Nothing, moreover, is a more unfavorable augury than
these forced exhibitions of courage, and these  affected dfsplays of
calmness or  of resignation.  It seems  that the vital power is ex-
/ 
THE CARE REQUIRED IN OPERATIONS.
13
hausted in thus retracting upon itself, and that it is afterwards in-
capable of resisting the onset which has been made upon it.  The
fact is, that operations performed under such circumstances have
generally a less favorable issue  than others, and are of a  nature
not to be relied upon.
  Ought we to operate upon a patient against his will ? is a ques-
tion that I have often heard asked.   For myself, I answer, no, if the
person is an adult and of sound mind; but, yes, on the contrary, if
we have to deal with a child or  an idiot.   Though all the family
should desire  it, the  surgeon would, in my opinion, be culpable in
operating by  force upon a  patient who enjoyed his civil  rights.
Our duty is to explain to patients what  is most suitable for their
complaints, and to enlighten them  upon the dangers to which they
are exposed in not submitting to the proper remedies; but they, and
they alone, have  the right to do  or not  to do  what  we  advise.
Children and   idiots   are exceptions, because,  not having their
will free, and dreading only the pain, they do not know how to pro-
tect themselves from the dangers of the future;  but we must not
in such cases attempt any thing without the consent of relatives.
  We are, however, sometimes permitted  to operate upon  certain
patients, not absolutely in spite of themselves, but without their
knowledge, and by surprise.   Prompt and easy operations of little
importance are of this kind, especially with pusillanimous and very
timid persons ; such are simple incisions, the opening of abscesses,
the excision of small pedunculated warts, the removal of a nail
which  is partly detached, some operations for hydrocele, &c.
  If  an operation can be performed in  many  different ways, I
would  advise the surgeon to apprize the patient or his family of it.
We operate thus  for cataract by extraction or depression;  we re-
move a stone from  the  bladder by lithotomy or  lithontrity; we
amputate the leg near the ankle or near the knee.   It is possible
that the patient may have a preference for one of these methods to
the exclusion of the rest.  If his choice is not the best, his physi-
cian will endeavor to convince him of his error; but if, after  having
used every means of persuasion, he finds him  resolute, he may, if
there is no serious objection, accede to his wishes.

                § III.—The State  of the System.

  Not  to operate unless we are sure of removing all the  disease,
and that there does not exist in the  system an affection more serious
than that for which the operation is performed, is a law which has
a great number of exceptions.
  I have proved by a great number of examples, that even in cases
where  it is impossible to take them entirely away, th^ extirpation
of lymphatic  tumors  should  nevertheless be  attempted.  The
amputation of a limb is sometimes  indicated, though there may be
other parts of the osseous system  or other articulations affected, as,
for example,  in scrofulous  patients.   A  consumptive  patient,  a
paralytic, a patient affected with aneurism of  the heart, or a can- 
14
NEW ELEMENTS OF OPERATIVE SURGERY.
cerous lesion, ought, notwithstanding, to undergo amputation imme-
diately in the event of a serious injury to the limb.  These diseases
also should not prevent us from performing the operation for stran-
gulated hernia, aneurism, or tracheotomy.  It is nevertheless true,
that we ought then to apprize the family or the friends of the pa-
tient of the object we have in view in  undertaking the operation,
and that in sueh patients we ought not to take the bistoury in hand
except in cases of urgent necessity.  In fine, it is better to wait for
death than to run before him.
  The operation  often is the only remedy we have ; but the patient
is in so serious a state, and the malady so far advanced, that there
is scarcely any thing to be hoped for from it.  Then what must be
done 1   If we do not  operate, death is certain ; but after how long
a time ?  If we  operate, one patient in ten, twenty, or thirty, will
be saved ; but the rest will  sink under it a month or a year later.
If it is just to say with Celsus, Melius anceps remedium quam nullum,
it is also just to say, better to let the patient die than to kill him.  In
supposing then that the operation may be  very dangerous in itself,
and that, in the  circumstances  in which we are placed,  it offers
only one chance  of success in ten, it would in my opinion be com-
promising surgery to subject the patient to it.  The extirpation of
the womb, when  not out of  its  place, of the thyroid body, degen-
erated throughout its substance, and of the entire lower jaw, &c,
are cases of this kind.  If the chances for success, on the  contrary,
are more numerous, and if, in  spite  of the dangers, the operation
is one of easy execution, we  ought not to hesitate, and it becomes
a case of conscientious duty from which the surgeon ought  not to
shrink.  Such are certain cases of strangulated hernia, where,
whether from extensive peritonitis or from the probabilities of
gangrene, the  success of the operation, so to speak, is  rendered
impossible.
  One circumstance,  important to be  considered, though the classic
authors who have preceded me have scarcely paid any attention to
it, is that which  concerns the serious consequences which are actu-
ally complicated with the disease which we wish to remove.   I will
suppose, for example, that a tumor, or a bone to be excised, or a finger
to be amputated, may be surrounded by an acute diffused inflamma-
tion, whether erysipelatous or phlegmonous, the limits of which are not
yet in any manner definable, and which has not ceased to keep up an
evident general  reaction.  Following that old axiom, sublata causa,
tollitur effectus, it would seem that in such a case we ought to operate
as soon as possible.  This, however, would be an error ; observation
proves that in such cases operations succeed badly, that they aggra-
vate the inflammation, and  do  not save the patients from  death.
With the exception of some particulars, the inflammation is here like
that of gangrene, and before  operating we must wait until it is posi-
tively located and definitively circumscribed. I would not, however
wish  that, from  excess of timidity, we should be deterred from per-
forming any operation upon persons who are troubled with certain gen-
eral complaints: diarrhoea, for example, a febrile movement whether 
THE CARE REQUIRED IN OPERATIONS.
15
permanent or intermittent, loss  of  appetite, loss of  sleep, night
sweats, &c, are not a sufficient reason to postpone lithotomy or the
amputation of limbs.
  In short, I postpone the  operation, if the  general  disturbance is
connected with an acute inflammation, developed in the neighbor-
hood of the part to be removed, rather than in the primitive  disease
itself; I hasten, on the contrary, if the general symptoms are under
the influence of the evil we wash to remove.  If, in  destroying the
diseased part, we may hope to eradicate the germ,  we must  then
operate ; but if, when the operation  is terminated, the germ should
remain in the system, it is better to temporize.  Such is the law
which I would venture to lay down.
   The examination of the precautions relative to the lesions which
may be complicated with the principal malady, would be superflu-
ous.  We do not undertake the performance of a serious operation
which may be postponed in a pregnant woman, or a nurse, or while
the patient is under the influence of a formidable  disease, unless it
may be the best means of putting an end to the functional disturb-
ances of the whole economy.   Moreover, these disturbances should
have been resisted by the surgeon in proportion as they presented
themselves, before, as well as after having made up his mind to op-
erate.  The manner of recognising  and of treating them being ne-
cessarily detailed in works of pathology, it would be  abusing the
patience of the reader to repeat them in a work on operative surgery.
   The preparations, then,  of which  wre are permitted to speak, are
those which the state of a patient, otherwise in good  health, may
require.   On this point authors are  far from being agreed.  There
are some who scarcely  prescribe  a single day of diet, while a
greater number  only operate  after using  tisans, purgatives,  re-
vulsives, bleedings, or a regimen of great severity, and precautions
the most minute,  in fact, during one or more weeks.  So that it is
difficult to lay down a general rule  as to which is right or which
wrong.
   Almost all the  preparations, whether hygienic  or medicinal, to
which patients were formerly subjected before being operated upon,
have been abandoned by the moderns.  These preparatory steps are
nothing, in fact, says Pouteau, but a protracted meditation upon  the
malady.  (QHuvr. Posth., t. iii., p. 113.)   And M. Champion, (Cor-
respond. Privee, 1837,) on the strength of the success which  attends
operations of immediate urgency in the army, submits none of his
patients to these preparatives.  Nevertheless, there are some  of
them that deserve to be  retained, when the nature of the  lesions
allows of delay.
   It is in treating upon each operation in particular, that it  will be
proper to touch upon this question.  I will confine  myself  for the
moment to remarking, that every operation, sufficiently important
to exact, immediately after it, a rigid diet during a certain number
of days, in order to diminish the  general reaction, and to effect a
temporary change in the habits  of  the patient, require? that we
should precede it by a gradual diminution of the aliments, and that 
16
NEW ELEMENTS OF OPERATIVE SURGERY.
nothing more should be given  the  day before than some soup or
light broth.  The use of some light and refreshing diluent, one or
more bleedings, whether by phlebotomy or by leeches, if the patient
is robust, or but little enfeebled, a purgative, or  at least enemata,
or laxative drinks, in order that the transition may not be too  sud-
den, and that there may not remain any germ of morbid derange-
ments in the system other than  those which may be produced by
the  consequences of the operation itself, are also necessary to be
attended to.
  All the preceding considerations ought equally to  be understood
of local preparations.  The only one which it is necessary to recall
here, is  that the part which is  about to sustain the action of the in-
struments, or of bandages or other portions of the dressings,  must
be carefully shaved and washed.
                        CHAPTER IV.

    THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.

  Operations, once  decided upon, exact three orders of auxiliary
means, according as these become necessary before, during, or after
the operation.

               Article  I.—Before the Operation.

  Before taking the instrument in hand, we must look well to the
locale, the assistants, and the dressings.

                       § I.—The Locale.

  In hospitals it is generally to the amphitheatre that the patient
is taken, in order that his companions in misfortune may not hear
his cries, or see the mutilation he is about to undergo.  This locality,
expressly intended for  this purpose, has  no  other inconvenience,
though it be otherwise commodiously arranged, than that it is more
difficult to warm than an ordinary chamber.  It  is the only place
which can give those present an opportunity of appreciating  all
that the operator is  doing.  Strictly speaking, it is fitted only for a
small number  of operations.   That of-hydrocele,  lithontrity, her-
nia, cataract, fistula lachrymalis, and trephining, may and should
be frequently performed in  the ward where  the patient is.  It is
scarcely for any other than lithotomy, amputations, and the dissec-
tion of certain tumors,that the amphitheatre is really indispensable.
In private practice,  we choose  the room which is the largest and
the best ventilated,  and gives the most light, in place of the sick-
room itself, when that does not appear suitable.  Here the number
of persoBS present ought to be as small as possible ; seeing that
those who are of no service almost always do harm, either by their 
        THE CONDITIONS THAT ARE  ACCESSORY TO  OPERATIONS.      17

indiscreet or inconsiderate remarks, or by the  impressions that are
depicted in their countenances; the vitiation  which they cause in
the air of the apartment, or the inconvenience they give to the pa-
tient or the  operator.  The interests of the pupils, and of science, are
in hospitals paramount to these  considerations;  but  here every
thing being public, the patients know beforehand what they are to
expect, and resign themselves to it without complaint.

                       § II.—Assistants.

  The  subject of  Assistants  merits  also  the greatest attention.
Their number cannot be  fixed,  some being absolutely necessary,
others merely useful.  Private practice  admits only of the first;
while in public establishments we employ all whose services can
afford the least advantage. In the country we are often from neces-
sity for the most part deprived of them.  Some of them may not
have yet passed through any medical studies; to such we confide
duties that exact only physical strength, coolness, and a  little ad-
dress or intelligence.  It is important, also, that all  have  their du-
ties well defined, and that each one know beforehand,what he has
to do.   The surgeon takes  care to arrange  the parts according to
the skill, sagacity, stature, or strength of the persons who are to
be employed, and to select his aids, as far as possible, among pupils
who have been in the habit of assisting him  in practice, who can
divine his thoughts by the slightest sign, and who have at heart the
success of  all his operations and labors.

      § III.—The Instruments and Dressing—(i. e.  I Appareil.)

  The instruments  and dressing  form another department whose
importance is  not to be forgotten.  The objects which compose it
are naturally divided  into three  orders.  Some of them, like the
garrot,  tourniquet,  pelote, compressing  bandages, &c,  have for
their  object the prevention of certain accidents during the opera-
tion ; the second comprise every thing necessary to the manipulations
of the operator himself; the last belong to the dressings.  Thus we
must  be provided :  1. With one or more  flexible tapers, commonly
called rats-de-cave, rather than lighted candles, in case the natural
light is not sufficient; 2. A chafing-dish full of live  coals and cau-
teries ;  3. A little wine, vinegar, Cologne water, and brandy, in so
many separate glasses; 4. Hot and cold water, basins and sponges;
5. The means of temporarily arresting the current of blood  in the
part which is about to be operated upon ; 6. Compresses, lint, ban-
dages, and folds of linen (alezes) to dress  the patient or  protect
certain organs.
  The second series comprehends the different instruments that we
may require, such as bistouries, knives, needles, scissors, saws, liga-
tures, tenaculums, forceps, &c, which are arranged on a platform
or on  a table, in the order in which they are to be successively
employed.  The strips of  adhesive plaster,  the  pledgets of lint,
                               3 
18
NEW ELEMENTS OF OPERATIVE SURGERY.
(plumasseaux) compresses, bandages, and other portions of the dress-
ings, are then arranged on another table, so as to be presented in
their turn without confusion.   As these details will be again re-
ferred to in a great number of operations, amputations and aneu-
risms among others, where their utility will be best appreciated, I
do not think it necessary to dilate upon the subject here.
  The position of the patient, of the surgeon, and  the  assistants,
being necessarily governed by the nature of the operation, the part
affected, and the preferences  of the operator, cannot be advanta-
geously pointed out except under each particular head.   The same
may be said of the means of arresting  the  flow of blood, whether
provisional or definitive, and also of those which are proposed for
moderating the pain.
  These remarks apply also to the attention that we must  give to
syncope, convulsions, spasms, and all other matters that relate, to
the immediate consequences  of the operation.  As we shall be
obliged to pass in review these last chapters, as well as dressing,
the question of union by the  first  intention or not, and the prin-
cipal accidents to which the great  operations are  exposed, when
we come to treat of minor  surgery  and  elementary operations,
of amputation of limbs and  of aneurism,  it would,  in truth, be
a useless repetition to occupy the reader with those matters at
present.
  Neither will I stop to discuss the sense  or propriety of the old
adage, Cito, tutd, et jucunde, which was formerly proclaimed in the
schools.  This saying is of Asclepiades and not of Celsus, as some
are pleased to repeat it.  Hippocrates and Galen said: Celeriter,
jucunde, prompte, et eleganter,  which no longer has  any value.  To
say that an  operation  ought  to be performed  with promptitude,
steadiness, and some address,  is a triviality which has no need of
being repeated in our  days.   The  important, part of it is, not to
sacrifice one of these advantages to the others;  to keep constantly
in view, for example, that promptitude is not  precipitation, nor
always quickness ; and that m surgery it is safety which ought to
be paramount to all.  I shall  not therefore treat of these different
subjects but in a very general way.


                 Art. II.—During the Operation.

       § I.—Position of the Patient,  Assistants, and Surgeon.

   As a  general  rule, it is  better to operate upon patients lying
down than  sitting up; the former of these positions is the only one
which  suits for almost all operations  that are  performed on the
neck,  chest, abdomen,  genito-urinary organs, and  the inferior ex-
tremities ; the second, perhaps, is more convenient for the opera-
tor, in operations to be performed on the face, the cranium, and
certain  parts of the neck, the chest, and superior extremities; but
it is not really more advantageous  to the patient, except the oper-
 ation is of short duration and  of little severity.  In truth, there arc 
       THE CONDITIONS  THAT ARE ACCESSORY TO OPERATIONS.      19

scarcely any other than the operations in the interior of the mouth
or of the nose, which render the sitting posture absolutely prefera-
ble, and that  because of the blood, which otherwise would have a
tendency to be carried  towards the pharynx rather than to the ex-
terior.  In a sitting posture, the patient grows feeble much sooner,
is more difficult to hold, and is more exposed to swooning, (lypothy-
mies,) and to syncope; while  lying down he  has no need of any
muscular effort, and seems better able to support the pain; nothing
then prevents us from  allowing  him to repose from time to time ;
no embarrassment is experienced in giving him  such a degree of
inclination rather than another, and of being  prepared on the spot
for whatever accidents may happen.
  As for the rest, when we desire to operate upon a patient in the
sitting posture, it is sometimes a matter of indifference whether he
be placed on  the edge of a bed, table, or any other object; for ex-
ample, for puncturing a hydrocele, the introduction of the bougie,
or of a porte-caustique into the urethra, &c.;  in some cases a stool
is better, from the liberty it permits to move the patient  round ;  it
is, however, a chair or an easy chair that is most  commonly used ;
an  arm chair  for persons very  feeble or intractable, and an ordi-
nary chair for those whose position we may wish  to vary.
  I need not add, that the assistants must  incline  the head of the
patient sometimes to  one side,  sometimes to another; that they
must retain it in the most perfect immobility, by supporting it with
napkins and with pillows; that it will be  proper  for  them to turn
the back, face, or side of the patient towards the back of the chair,
according as the disease has its seat in the right or left, in front  or
behind.
  If the patient is to be placed in a recumbent posture, we may
often dispense with changing him from his bed. The  operation for
cataract, tracheotomy, catheterism, hydrocele, fistula in ano, and
lithontrity, are of this description.   Patients that are very  weak,
operations in which the  least  shock  might aggravate the  conse-
quences, such as strangulated  hernia, the  trephine, and aneurisms,
often demand the same precaution.  On the contrary, for all opera-
tions accompanied Math a  considerable discharge of blood, and
whose  success cannot be endangered by slight starts or movements
of the patient, it is better to operate on  a separate bed.   There is
in hospitals, for this purpose, a table, whose two ends may be  raised
or depressed at pleasure, and which is supported on a pivot,  which
permits the whole to be turned in any direction.  This table, which
is about thirty inches high, and which would be still more perfect
if it were possible to vary its entire elevation or depression, accord-
ing to circumstances, is to be furnished with a mattress, also with
a sheet and with folds of linen.  Out of the public establishments,
they use  a solid  cot,  furnished  with mattress, cushions, pillows,
sheets, and napkins;  in the absence of a solid cot, the mattress  is
placed on a table, or drawers, or on some planks fixed firmly on chairs
or arm-chairs; the important part  of it is,  that the bed shall be
firm, solid, straight, without bed-posts, or raised edges; that it shall 
20
NEW  ELEMENTS OF OPERATIVE SURGERY.
be of a convenient height, and so arranged as to allow of passing
all around it.
  Upon the bed we give to the patient a variable position, neces-
sarily in relation with the exigencies of the operation about to be
performed upon him.  Lying on his back,  belly, or on one of his
sides, sometimes lengthened out almost horizontally, now bent up
almost double, sometimes  seated with either  the  head or lower
limbs elevated, he ought to be held and supported  by a sufficient
number of assistants.
  In former times, surgeons made use of cords, straps, and machines
to control the movements of the  patient during  operations ; now
we have  recourse to nothing analogous, except in  some cases of
operations for stone.  Such contrivances  have  been renounced;
first, because they are useless, and that intelligent  assistants may
almost always be substituted for them ; secondly,  because they had
become an object of terror  for many  patients.   It  does  not, how-
ever, result from this, as Dupuytren seems to wish us to infer, that
assistants are never obliged to use force or violence during opera-
tions.  In saying, " It is almost unheard of that  any patient ever
manifested a desire to have an operation suspended, or made seri-
ous attempts to interfere with its  completion," this practitioner evi-
dently deceives himself.  For we every day  see  individuals pray-
ing in mercy that we would stop, that  we  would  finish, thus im-
ploring and menacing us, and who would not fail to escape if they
were not firmly secured.  The  assistants ought  not, however, to
forget that their strength is uncalled for, while the patient makes
only slight movements ; and that they ought  not to  restrict, stop, or
prevent any but those which might interfere with the manipulations
of the surgeon.
  The position of the operator, and of the assistants about the  bed,
during the operation, can have no general rule :  provided it is the
most commodious for all concerned, and the least fatiguing to the
surgeon,  we have all that can be said ;  it is in treating of opera-
tions in particular, that we  may  be allowed to speak definitively
on this point.

   § II.—To arrest the course of the Blood in the Diseased Part.

  It is scarcely ever required at the present  day to recur to a pre-
cautionary ligature upon the arteries to suspend the  circulation in
the part  upon which we are to operate ; direct pressure is almost
always sufficient, but this is not equally practicable on all the ves-
sels.  While it  is difficult on the subclavian arteries, fatiguing on
the  abdominal aorta and the iliac arteries,  it  is impossible on all
the  arteries of the  splanchnic cavities: it is only upon the limbs,
neck, and head, that it is generally easy and certain; it is effected
by meanu of the fingers of  an assistant, by a pelote, the garrot, the
tourniquet, or some other compressor.
   A.  Circular Compression.—To obtain compression, the circular
mode was for a long time  in use.  It was  the means adopted by 
        THE CONDITIONS THAT' ARE ACCESSORY TO OPERATIONS.      21

Avicenna, and by the Greeks, and which Pare also continued to
practise.  Some, however, among the ancients, employed tempora-
ry haemostatic expedients of a more efficacious kind;  it appears,
in fact, that ArchigeneS encircled the whole thickness  of the limb
with a ligature, which he thus applied directly upon the artery.
  B. Garrot.—The  circular bandage was  gradually perfected in
the hands of the French surgeons.   They commenced by separating
it from the course of the vessels, by the aid of a  square compress
of linen of greater  or  less  thickness. In  1674 Morel  changed it
into a true garrot.   This garrot, successively modified by Nuck,
Verduc, and  La Vauguyon, is still in use  at present.  To prevent
the skin from being pinched, to diminish as much as possible com-
pression on the  points of the limb that do not correspond to the
artery, there  is previously placed on  this last a compress of many
thicknesses.  A piece of pasteboard, horn, or  leather, slightly con-
cave, is moreover applied on the point opposite, in order to support
the small stick (batonnet) of the garrot.
  C. The Tourniquet, invented by J. L. Petit, towards the begin-
ning of the last century, and of which different modifications have
been proposed in England and Germany, has rendered the employ-
ment of the garrot  much more rare than formerly.  The  instru-
ment of Petit, in  fact, is so arranged, that it acts with a certain
force only on the course of the vessels that we wish to compress.
Once applied, it may afterwards be left to itself;  while the garrot
has need of being watched  or supported by an assistant to the end
of the  operation.  When we have  at our disposal only a small
number of assistants, or wrhen these are not sufficiently instructed,
as in the country and in the army, for example, or when unlooked-
for circumstances render indispensable some great operation, the
garrot, being an  instrument that we can make on the spot and any-
where, forms a valuable resource.  The tourniquet of Petit would
be still more advantageous if we could procure it; but in every
other case, it is on the hand of the assistant that we must rely.
  D. Bridle, (bride.)—An easy and sufficiently safe mode of com-
pressing an artery, when we have at our disposal intelligent assist-
ants, consists in  placing on a rolled band (globe de bahdes) or any
other solid pelote previously adjusted upon the track of the vessels,
the middle portion of a bandage, whose two extremities are brought
together on the opposite side,  in the same way as  with  the garrot.
The two middle fingers, passed under the knot of the bandage  thus
arranged, while the thumb and other fingers rest on the two halves of
the bandage, as on the sides of a bridle, give the assistant the power
of augmenting, diminishing,  or varying the  compression of the arte-
ry, without the least fatigue, and without incommoding the neigh-
boring parts.
  E. The naked hand, however, is most frequently quite sufficient;
in this  case we apply the pulp of the four fingers  on  the artery,
while the thumb takes a point of support on the other  side.  We
may also effect the  compression with the thumb itself.  In that
case it  is well to place the last phalanx of the thumb crosswise on 
22            NEW ELEMENTS  OF  OPERATIVE SURGERY.
 the  course of the vessel; fixing  then the  thumb or fingers of the
 other hand perpendicularly upon  this, we may, in acting sometimes
 with the first thumb, sometimes with the second, compress for a
 very long time without being fatigued.  The  same rule is applica-
 ble to the fingers.
   F. When the  artery lies very deep, we  make  use of a sort of
 bureau seal, padded, in form of a  pelote.  With this instrument we
 cause less pain, and do not interfere Mrith the retraction of the mus-
 cles, or the movements of the operator.
   G. In certain cases a still more secure method may become in-
 dispensable.   We lay bare the artery at a certain distance from
 the place where the operation is to be performed, and apply a liga-
 ture to  it.
   Whatever may be the method that we prefer, it  is nevertheless
 indispensable to confide this part of the operation  to an  assistant
 that can be relied upon, and one of acknowledged  coolness.  It is
 evident, also, that this assistant must be possessed of certain phy-
 sical strength, be of tall stature, and have  great composure ; that
 he ought to be'thoroughly acquainted Mrith the  anatomical relations
 of the artery to be compressed, and should understand all the steps
 of the operation.
  The  great operations thus require the compression of the artery
 between the  heart and the seat  of the disease.  Also, it is laia
 down as a rule, that they are not to be undertaken until we are  as-
 sured beforehand of the course of the  blood above the part.  This
 rule, however, has many exceptions.  Every time, for example, that
the operation does not of itself require the opening of large arte-
ries,  as in the operation of aneurism by the modern methods, and
the extirpation of most tumors, we may dispense with this precau-
tion. We disregard it, also, when the section of the principal vessel
is not to take place until towards the end of the  operation, as may
be the case, we will suppose,  in amputation at the  shoulder-joint;
so that the law of which I  have just spoken has full  application
only to amputations in the body of the limb, and in the operation
of aneurism by opening the sac.

                   § III. To Prevent Pain.

  It has long been a subject of research to discover a method  of
performing operations without causing suffering to the  patient.
Theodore, and many after him, recommended placing under  the
nose a sponge  impregnated with opium, with water of night-shade,
henbane, and lettuce,  in order to induce the patient to  sleep, to be
 awakened afterwards by applying in the same manner a sponge
wet with vinegar, or introducing into his nostrils or ears the juice
 " the fennel or of rue.
   [If any efficacy could be derived  from  such applications, or if
 the  plan still sometimes advocated  of blunting the sensibilities
 of the  nervous system by morphine were  not of doubtful utility,
 from its impeding afterwards a full and healthy  reaction, then the 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      23

anodyne effects of opium  might be introduced into the  system in
the manner which is now believed to be the  most gentle  and
innocuous,—we  mean that practised by the Chinese of inhaling
the fumes of opium into the lungs, which, according to  the recent
experience  of some British surgeons at. Hong-kong, during the
expedition just  closed, appeared to  them to be  eminently the
best mode of administering this medicament.  Some  more recent
marvellous accounts of putting the patient in a  profound state of
sleep, or trance,  by what is called Mesmerization or animal mag-
netism, and then amputating or performing other  severe  operations
without the subject indicating the slightest  twinge of a muscular
fibre, or the faintest  expression of complaint, need confirmation.
And were there  truth in Mesmerism, it could even, by the  confession
of those who produce it, be  but of very partial application.   And
we have still to  recur to the objection of narcotics of every kind
that diminish nervous  excitability, and thus throw the  system, as it
were, off its guard, and therefore render it less capable of rallying
after the operation, when  all its energies are demanded.  Thus it
is that small-pox, before vaccination was introduced, was observed
to be always more fatal when  taken in the natural way, where, as
Sir  Gilbert  Blane has remarked, the virus was  unconsciously im-
bibed into the system,  than where communicated artificially by in-
oculation, when  the will  and consciousness, being prepared for the
shock,  resist, as it were, its full effect on the  constitution.  The re-
mark of M. Velpeau (supra) on the bad effect of foolhardiness in
patients on the operating table, is in unison with  these views.—T.]
  Others limited themselves, from the time of Guy de  Chauliac, as
Sassard (Journal de Physique, 1781) and others have done since, to
the prescription  of opium.  For a long  time it was  thought we
could succeed better by applying a strap tied tight above the place
where  the parts were to be  divided.   M.  Liegard  has shown
(Melanges de Med. et de Chir.,  p. 350, Caen, 1837, in 8vo) that this
practice, so much extolled by Juvet, is not to be despised in some
cases.  It  is preferable, in my opinion, to the compression of the ner-
vous trunks towards the root of the limb, as advised by J. Moore,
(Ancien Journal  de Med.,  t. lxv., p. 306) and B. Bell,  (Cours de
Chir., t. vi., p. 61.)  Recurring back to the usage of the ancients,
M. Hirckman has recently maintained that  we  may perform  the
most extensive operations without causing pain, if we  make the
patient respire a certain quantity of stupifying gas.  [See our pre-
ceding note.—T.]
  Nor has magnetism been forgotten.   All the journals have rung
with the account of an extirpation of the breast without the  pa-
tient being conscious of it.  It is also known that a woman  who
was in a magnetic sleep underwent, without awaking, the extrac-
tion of a molar tooth.   But every thing leads to  the belief that in
such cases the operators must have been  deceived  by  the insensi-
bility or the chicanery  of the patients, or by some confederate.
  The Earl of Mansfield caused an arm to be amputated under a
blast of trumpets.  La Peyronie, whose leg was to be amputated, 
24            NEW  ELEMENTS  OF OPERATIVE SURGERY.
 himself arranged on his bed the apparatus and instruments that
 were necessary.   A peasant even amputated his own limb with a
 coarse saw, according to Scharschmidt.   M. Champion speaks of
 two women and of some men, who exhibited the same  calm and
 the same resignation.    1 have  amputated the thigh of three  pa-
 tients, who did not utter the slightest cry during the operation.
 A robust man, otherwise very susceptible, chatted tranquilly with
 the assistants  while I was removing from him a large-sized sarco-
 cele, without his manifesting the least sign of pain.
   To avoid pain in operations, is a chimera that we can no longer
 pursue in our time.   A cutting  instrument and pain in operative
 surgery,  are two words  which are never presented  separately to
 the mind of the patient, but in an association which he must of
 necessity admit.  The efforts of the surgeon ought then to be con-
 fined  to  the  point  of  rendering the pain of operations as little
 acute as possible,  without diminishing the certainty of the prin-
 cipal  result.   The pretension of some writers, who  believe they
 attain this  end in not using the bistoury until they have dipped it
 in oil, does  not appear to me to have any foundation.  The oil, in
 attaching itself to the porosities of the wound, would, in fact, have
the inconvenience  of obstructing the circulation of the fluids, the
exudation of  the  plastic matters,  and the  agglutination of the
bleeding  surfaces.  Cerate, succeeding to washing, would be much
better if any fatty substance whatever could  be of utility.   We
 cannot deny, that the instrument dipped into hot water, as M. Rich-
erand advises, or  brought in some  other  way to the temperature
of the body, or even above it, as M. Guillot wishes, gives less pain
to the patient. But in the result the  difference is not sufficiently
important;  the precaution M^ould be too troublesome  to introduce
into general practice.  It is not to such accessories, but to the hand
of the operator and the qualities of the bistoury, that we must look
to obtain the desired result.  Let the hand be light and steady, and
the bistoury smooth and well sharpened, and give with  the first
stroke the whole length and depth that the incision should have, if
you can do so without danger ; then act with promptitude and with-
out hesitation, and  give to the wound rather a little more than less
 extent, without uselessly  prolonging it, and you will have no  other
 pains to encounter than  those which are inherent in the operation,
 and which nothing can separate from  it.  Longer details on this
 subject would  be entirely superfluous.


                       § IV.—Accidents.

   The principal accidents which may take place during an opera-
 tion are hemorrhage, convulsions, syncopes, and the entrance of air
 into the veins. 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.       25

                       A.  Hemorrhage.

  The issue of blood from  the divided vessels during operations
becomes an accident only when it has not been foreseen, or when
it is more abundant and more difficult to check than we expected.
In feeble subjects it is of a nature to give immediate cause for real
danger.   Sometimes it is owing to the tourniquet, the  garrot, or
the  fingers of the assistant having  been displaced.  Sometimes,
also, it arises from our wounding vessels that  we  had hoped to
avoid, from its having been impossible to retain the  patient in the
position that M'e had given  him.  The  blood in such  cases comes
either from the  veins or the arteries,  and oozes out or forms a jet.
  I.  Venous hemorrhage in these cases presents two aspects, accord-
ing as the vessel is cut through, or only upon the side.   In  this last,
we  stop the blood by the application  of the finger, a ball of lint, or
small masses of sponge or agaric upon the wound, or by surround-
ing with a  thread the circumference of the wound, whose lips have
been previously seized by the forceps.
  If the blood runs from the gaping  extremity of a vein, it is  al- ■
most always owing to  the  central circulation being more or  less
impeded.   The accident is owing then sometimes to the circular
strangulation of the part, sometimes solely to the mere compression
of the large vascular trunks above the wound, which last compres-
sion, acting on the veins, hinders the  blood from proceeding on its
course to the heart, and forces it to flow backwards  and out of the
vein.  At other times the  obstruction is owing to the patient vio-
lently contracting the muscles of the chest, and to his impeding as
much as is in his power his natural respiration. The  remedy for this
kind of hemorrhage, which is more frequent after than during  an
operation, is to  remove all pressure on the course of the veins, and
to induce the patient to respire freely, and not to restrict, but even
to multiply his inspirations.
  II. Though the hemorrhage may in reality be arterial, even when
the  blood oozes out, it is unnecessary to occupy ourselves with it,
unless the patient is very much weakened.  In this  case we arrest
the  bloody exudation by means of pieces of agaric  or sponge,  and
then hasten on to  finish the operation.  If the blood escapes in
jets, we effect compression by the fingers, by torsion, or by the lig-
ature.
  Before considering direct compression or the ligature, it is neces-
sary to see  that the haemostatic  means have not been disturbed.
If the tourniquet, the garrot, the pelote, or the hand of the assistant
have been previously applied on the principal trunk of the artery,
the hemorrhage is evidently caused by these having been displaced,
and the first thing to do is to replace them in a proper manner.   In
the event that this precaution is not sufficient, or cannot be adopt-
ed, from the operation being of a nature that does not admit of these
means, we  must then recur to one of the modes already pointed
out.
  a. Application of the fingers.—In  having recourse immediately to
                                4 
26
NEW  ELEMENTS OF  OPERATIVE SURGERY.
the ligature or to torsion, the surgeon is obliged to suspend the
operation at every cut he  makes with the bistoury.   If, on the con-
trary, he can avail himself of intelligent assistants, he may continue
on without hinderance to the end, in directing them to place the pulp
of the finger on each artery he opens.  Unfortunately, the fingers
employed in this way sometimes interfere considerably with the ma-
nipulations of the operator ; and there are so many of these required
in certain operations, that  we  cannot have recourse to this expe-
dient.  In proceeding thus, we arrest, it is true, the hemorrhage on
the spot;  but we  crowd the blood more  or less into the vascular
branches in the tissues, and  render their  separation  afterwards
very difficult.  Nevertheless, it is a kind of resource which I prefer,
when there is but  a  small number of arteries to close, and when
the whole operation is not to be of long continuance.  In the other
cases, I prefer torsion or the ligature.
  b. Torsion.—To twist the arteries in proportion as we cut them
in operations, is neither difficult nor an affair that  requires much
time ; but in treating of torsion, we must take into consideration all
the good or evil that  has been attributed to it, and of that we shall
speak further on.
  c. The Ligature, at last, is that which  offers the  most security
and  advantages, unless it  be in respect to wounds, of which it is
our intention to  undertake the complete  and immediate union.
Those  surgeons who, like  J. L. Petit and some moderns, wish that
the small arteries should be closed by the fingers of an assistant in
proportion as they are opened, have principally in view the com-
pletion of the operation as quickly as possible, and of thus effec-
tually putting an  end to the hemorrhage.   Those M'ho prefer tying
the arteries in  proportion as they present themselves, know well
that they render  the operation  longer, because at each  moment it
is necessary to stop for each new ligature, and that sometimes we are
obliged to use a great number of  them ; but they add, that we are
thus sure of letting no important artery escape ; that  we are better
protected from  consecutive hemorrhages;  and that we have no
difficulty in finding the wounded  vessel:  in fact, that the amount
of the pain is not  thereby  increased, and  that the whole operation
is thus made more regular and complete.   It is, in  fact, what in
reality exists; and if we apprehend that we shall not afterwards find
the vessels whose hemorrhage we  dread, or that we shall be obliged
to open a great number of them, or if we have no particular motive
for proceeding with great rapidity in our manipulating movements,
this method is without contradiction the  most advantageous to
the patient, and that which offers the greatest security  to the sur-
geon.

                     B. Nervous Accidents.

   I. Certain patients, during operations, experience  swoonings or
syncopes, which alarm all the assistants, and may also disquiet the
surgeon.  These  accidents happen sometimes from exaggerated 
       THE CONDITIONS THAT ARE ACCESSORY  TO  OPERATIONS.      27

fears.  We prevent them in this case by the aid of reasoning and
of moral means, in order to inspire the patient with courage, by
demonstrating to him, as well as we can, that  he is deceived, and
that he is exposed to no  danger.  If the pain is the cause of it, as
happens with persons who are  nervous or very susceptible, espe-
cially with inhabitants of the south, we have  no other means of
remedying it, but by operating as rapidly as possible, and with in-
struments that are perfectly keen.   It is on such patients that the
employment of narcotics, the benumbing the parts by means of com-
pression, the immersion of the bistoury in hot water, and even mag-
netic influences, may offer  some benefit.  (Vide a note above on
magnetism, &c.—T.)
   Faintings and swoonings, from hemorrhage, are to be apprehended
in patients already enfeebled, and in those in  whom every loss of
blood, however inconsiderable, produces this result.  In these cases
the preventive means are found in the previous and perfect com-
pression of the arteries,  and in the employment of the fingers or of
the ligature, as has already just been said.
   Though the accidents of  which we speak are such as rarely dis-
turb us seriously, they nevertheless  require  to be remedied as soon
as possible.   The  first thing to  do in such a  case is to give free
and easy access  to the air about the patient, to open the windows,
and remove from about the bed all the assistants that are not in-
dispensable.  If the operation  is far  advanced, we terminate it
rapidly;  and then give  to the patient a position perfectly horizon-
tal, and even more  or  less lowering the head.  This  position of
itself alone is capable of preventing the syncopes, and causing them
quickly to disappear, by returning the blood upon the brain.   More-
over, we shake him, and push him about the chest, and slap him on
the face, the  temples, or the neck, but, better still, throw cold water
upon his face. Cologne water, brandy, ammonia, and vinegar, placed
under the nose, or applied by friction on the temples, forehead, and
region of the heart, ought to be combined with the foregoing means,
whether as preventive or curative remedies.   As to the rest, every
person is too familiar with  the remedies for  fainting and swooning
to make it necessary for me to say any thing  more on the subject.
If, nevertheless, the syncope should  resist and continue for too long
a time, and that the operation should also be necessarily protracted,
it would be  advisable  to  lay  the  bistoury aside and return to it
afterwards, rather than  to persist, especially if  the operation should
of itself be one of a dangerous nature.
   II. Convulsions.—The convulsions which  happen in the course
of some operations, are generally ascribable to the same causes as
the  syncope; so  also do we employ the same means to  prevent
and overcome them.  Convulsions, however, being, more than syn-
cope under the influence of pain and of fear, demand also more fre-
quently the  suspension  of the operation.   If, then, it concerns an
operation that must be long, and which is at the same time of a
grave character, and that the convulsions have interfered with our
progress from the very beginning, it is far  better not to continue, 
28
NEW  ELEMENTS OF OPERATIVE  SURGERY.
but to  replace the patient on the bed, and wait until his feelings
and his courage are in a better condition.
  III. Operations  at two times, (Operations en  deux temps.)—Those
operations that we desist from to resume at another time, have re-
ceived the name of Operations en  deux temps; and should  be di-
vided, in  this point of view, into those of necessity and those of
choice.
  The first are not performed at two different times by the surgeon
but from necessity, and in consequence  of particular  accidents;
others  are completed on two different occasions, because particular
reasons, known beforehand to the  operator, give the preference to
this method.  It  is thus that  some surgeons still  act with  respect
to the double hare-lip; as  others formerly  did in lithotomy by
the perineum, and as a certain number of moderns now propose
for the hypogastric incision  for that operation.   As for myself, I
never determine upon operating at two different times, unless it is
impossible  for me to do otherwise  without real danger to  the pa-
tient.  As a method of choice, this kind of operation appears to me
to be essentially pernicious.
  [Dr. Mott remarks, that  he totally disapproves of, and does not
recognise, any rule in surgery, by which  an operation, which is a
unit, or an  entire, and a whole in itself, should be directed to be
performed at two different times ; or in other words by halves.   He
himself, in his very extensive  and varied practice, has never done
it, in any one instance.  If reference be had in the above expres-
sion, en deux temps, to certain complex operations, or complications
in which parts are involved that require distinct operations in them-
selves, then there  are  certainly cases,  and even these are  rare, in
which  an intermission of a day or more may intervene between
the execution of one portion of the duty of the surgeon, or one of
the preliminary steps he is obliged to take, and the final processes
which  are to complete the  M^ork before him.  Thus, in the  case of
a child of three  months old,  with complicated  hare-lip, where
there is a bony  hook, or proboscis, of an inch or more in  length,
that grows from, or rather is a  prolongation of, the septum narium,
(as it often happens, also, from  one side of the fissure of the jaw,)
such may be the extent of the hemorrhage after the preliminary
removal  of that  excrescence, which may, in  most cases, be most
effectually and conveniently accomplished by a blunt-pointed  scis-
sors, of strong and short thick branches, that  the hot iron or other
means become necessary  to arrest it, and a delay  of a  day or
two is demanded, to give the infant time to recover itself  for the
completion of the operation upon the hare-lip itself, whether that be
single or double.   Though  it is to be remarked, en passant, that there
is no operation  in surgery, apparently, so formidable, (and which
may so frequently be made so, in reality, by want of delicate and
adroit manipulation in the operator, as this of hare-lip in infants,
in all its forms,) that cures with such rapidity, and so perfectly, by
first intention, or that evinces  such irresistible recuperative ener-
gies in the system.  In two  cases only of the numerous hare-lips 
        THE CONDITIONS THAT ARE  ACCESSORY TO OPERATIONS.      29

operated upon by Dr. Mott, and one of them was of the nature of
the one just described, was it found necessary to wait the interval
of several days after the removal of the proboscis, before the opera-
tion for the hare-lip proper, which was of a most complicated char-
acter and of the double variety, was undertaken.  Another case in
which such double duty was  required, was one in which, for the
first time, Dr. Mott tied  the carotid artery, many years  since, for
the removal of a large osteo-sarcoma of the lower jaw.  As it was
the first occasion  upon which he was  to operate in  that class of
important jaw operations, as projected and established by him, and
the first time, also, in  which he had ever had occasion to tie the
carotid in an operation of that kind, he naturally felt disposed to
adopt every possible  precaution.  He, therefore,  reflected  with
himself whether in such cases it would not be  sometimes advisa-
ble, both for the purpose of cutting off hemorrhage and consecutive
inflammation, to tie the primitive carotid before proceeding to the
removal of the tumor.  And we believe the credit of first making
this suggestion is due  to Dr. M.  Accordingly, the patient being a
young lady,  who, but for this most unpleasant  deformity, was
extremely comely, (as the restoration of the natural form and con-
tour of her face after the  cure fully testified,) the carotid was on
the first day tied with facility without  the slightest untoward symp-
tom following.  On the  succeeding day, finding her  in a state so
exceedingly comfortable and favorable, and in such good spirits and
strength, he determined  at once  upon  the removal of the osteo-
sarcoma, and was astonished to find, that throughout the  extensive
incision and the section of the side of the jaw containing the tumor,
arid which was  made in two places, to wit, near the  symphisis of
the chin, and then at the bifurcation of  the processes  of the lower
jaw near the angle, there Mras, so to speak, scarcely a table-spoon-
ful of blood from the  vessels, and the  cure afterwards was directly
and speedily effected by the first intention.  The advantage of re-
moving the jaw so soon after tying the carotid  lay in this: that hem-
orrhage was, in a measure, totally cut off, and the consecutive con-
stitutional inflammatory reaction, both for the operation on the caro-
tid and that for the osteo-sarcoma, were both anticipated, as it were,
by the direct adhesive inflammation  in the  parts themselves, all
those important results being imputable to the fact that there had
not been  time in  the interval of the  twenty-four hours  for anas-
tomosing arterial connections to be established.   Dr. Mott was only
induced to defer the operation for the osteo-sarcoma, because of the
anxious state  of the  mind of  the patient, after he had tied the
carotid, she knowing,  as Dr. M. told her, that the removal of the
jaw was a new  and  untried operation.   These  are the  only two
instances in which Dr. Mott has  ever  performed upon a patient
operations which, by any latitude  of construction, could be deemed
to accord with the phrase  en deux temps, or two stages ;  and as a
general rule, except in the event of double operations being required,
as in the cases above  mentioned, he totally disapproves of and pro-
scribes the practice in all cases to  which it may be  supposed to be 
30
NEW ELEMENTS OF OPERATIVE SURGERY.
applicable, that is, the practice of commencing with an operation,
and then, from apprehensions (generally not well grounded) of dan-
gerous consequences, leaving off in the very inception or middle of
them, and afterwards, recommencing and completing them at the
expiration of an interval of some  days.  Yet there may be, as he
thinks, some rare exceptions, as in great exhaustion from hemor-
rhage, to these remarks;  as, for example, in some large and ex-
tremely vascular tumors of the scalp.—T.]

              C. Entrance of  Air  into the  Veins.

  The introduction or development of air in the  vessels of man or
animals during life, recognised during the last two centuries by a
certain  number of pathologists, whose observations are  referred to
by Morgagni, had, almost  for the last twenty years, been  entirely
forgotten.  It M'as even necessary for an unfortunate event to occur
in the practice of a celebrated surgeon, to draw attention to this
grave subject, and to persuade persons to believe that air entering
into the veins could cause death during an operation.
  We knew by the experience of Bichat, as well as by the physi-
ologists of the seventeenth  and the eighteenth centuries, that animals
could be  killed by introducing atmospheric air into  the heart.
After having multiplied and varied his experiments  almost to in-
finity, Nysten, in 1809, concluded that air injected into the veins, in
a certain quantity,  caused  death, but he  maintained, also, as Lan-
grish  had already done, in 1746, that this is caused by its arresting
the movements of the heart, and not by destroying the functions of
the brain, as Bichat had believed.
  More recently, the experiments of Barry, which I  myself wit-
nessed, and especially those of M. Pqiseuille, which I also attended,
showed, as did those of M. Magendie, not only that the air, when
forced artificially  into the heart,  speedily caused death, but also
that this gas may spontaneously  introduce  itself into veins that
have  been previously opened.   We must, however, add, that the
observations of M. Poiseuille  scarcely admit the possibility of this
phenomenon but in veins subject to the venous pulsation, or in Mrhich
is observed an actual reflux of blood during life, that is, in those
large veins which extend for some inches beyond the apex of the
chest.  Beyond that, in fact, the expansion either of  the  heart or
the thorax appears  to have no influence on the column of blood.
Atmospheric pressure, by  immediately flattening  the calibre of the
vessel between the opening of  the vein and  the  apex of the chest,
seems to  present an insurmountable obstacle to the admission of
air in the direction of the heart.
   It remained to ascertain why the  blood  may thus flow back to a
 certain distance, and not to some inches beyond.  M. Berard the
 elder undertook this inquiry.   Anatomical  examination  and  an
 attentive dissection  of the parts demonstrated to him, as I also
 have often been enabled myself to confirm, that  the internal jugu-
 lar, subclavian, and axillary veins are naturally united to the bones 
       THE  CONDITIONS  THAT ARE ACCESSORY TO OPERATIONS.      31

or to the muscles of the neighborhood, by fibrous plates or bridles, so
solid, that when those veins are opened they remain gaping after the
manner of inert canals : from whence it follows, that up to two or
three inches above the sternum, that is to say, to near the larynx,
the internal  jugular vein is not flattened under atmospheric pres-
sure when the blood ceases to fill it, and that it is the same Mrith the
subclavian  vein throughout its  whole  length, and also  with the
upper half of the axillary.
  By recent experiments, we have seen that dogs of different sizes,
horses, and  mules, that have received air  into the veins, either  by
injection or inflation, almost always die  at the end of from five
to forty or fifty minutes, when there had  been introduced  a con-
siderable quantity of this gas  into the heart.  To effect this, how-
ever, it was necessary for the opening in the vessel  to be  from
two to six lines in diameter, to be kept gaping open, and also to be
made in the  regions indicated by MM. Poiseuille  and Berard.  We
have also seen that the introduction of air  was announced by a dull
sound, generally perceptible, sometimes nearly inappreciable, being
in the horse  a sort of gurgle, (glougou,) and not a  hissing (sifflement)
or whizzing, (renifiement,) as some persons have said.   Agitation,
convulsive movements, and epileptic-like  attacks, soon announced
the danger and formed the common  preludes of death.   The autop-
sy of the dead body disclosed the distension of the right auricle and
ventricle of the heart, the presence in the cavities of this organ of a
red blood mingled Math a great quantity of air, and perfectly frothy,
that is," a sanguineous froth," (mousse sanguine,) as already observed
by Magendie.  In some cases the same state of things was seen in
the left cavities of the heart, and also air was detected even in the
vessels of the brain.   As to the rest, the opening of the jugular
veins on  the side  of the face, or of the axillary vein in its lower
portion, and, a fortiori, the brachial veins, were not followed by any
accident.
   In fine, these experiments, demanded by the Academy of Medi-
cine, in 1837, and  made in presence of a commission, of which I
formed one,  by M. Amussat on one side, and M. Barthelemy on the
other,  show, as the ancients did, that air can, by the opening of
a vein, be introduced spontaneously into the heart, and destroy the
animal;  provided this  aperture  shall have  at least two lines  of
diameter, that it shall exist near the apex of the chest, and that it
shall allow  to enter  from ten to forty cubic centimetres of air into
the circulatory system of the wounded individual.  Let us now see
to what point the observations made upon the human species are
analogous to the facts derived from animals.
   Surgical practice had long since afforded instances of almost im-
mediate death in the course of certain operations ; but these  acci-
dents had been attributed sometimes to  hemorrhage, sometimes to
the exhaustion of the patient by excess of pain, sometimes to fright,
and sometimes to syncope.  For my own  part, I  know that many
patients have succumbed in a few minutes, while removing  from
them a degenerate thyroid gland, a tumor at the bottom  of the ax- 
32           NEW ELEMENTS OF OPERATIVE SURGERY.
 ilia, or in the simple operation of tracheotomy ; and that no other
 explanation has been sought after than those I have just given.
 Not satisfied with these reasons, and  availing themselves of the
 experiments of  physiologists on animals, modern  surgeons have
 called to their aid the entrance  of air into the veins to account for
 cases of unexpected death happening in the course of an operation.
 The facts of this kind that have come to my knowledge are  about
 forty in number.   I have given the  analysis  of them in a special
 paper.  (Lettre sur VIntroduction de VAir, etc., Paris, 1838 ; et Gaz.
 Med. de Paris, Mars, 1838.)
  We may divide them  into four groups; one  for facts of trivial
 importance, the second for  those where death  has not ensued, a
 third for cases followed by death but without an autopsy, and  the
 fourth for those wTith autopsy.
  1. Rejected Cases.  I arrange among trivial  facts such as rest
 only on hearsay evidence.   They  are five  in  number.  Such  are
 those of MM. Graefe, Cooper,  Lodge, Stevens, (Cornack,  Inaug.
 Dissert., etc., Edinb., 1837,)  and Duportail.   Every  thing indicates,
 in truth, that these cases had no  existence, or that they have arisen
 only from some erroneous statement.
  2. Cases  not followed by death.  Sixteen of the observations that
have come  to my knowledge, showing that  the  patients have been
at first restored, seem at least to prove that they did not die from
the  effects of the first accidents.   These cases are those  of Sim-
monds, 1; MM. Mott, 1 ; Clemot, 2;  Barlow, 1; Warren, 1; Roux,
 1; Mirault, 1 ; Rigaud, 1 ; Delaporte, 1 ; Dubourg, 1 ; Malgaigne,
 1; Begin, 1 ;  Toulmouche,  1 ; Arnussat, 1; and one of my own;
total, 16.
  These observations differ much in importance. Those of M. Ri-
gaud, of M. Malgaigne, and of M.  Mott, show only a wound of
the  external jugular vein.   Those  of MM.  Amussat and Toul-
mouche  relate only  to the mammary  veins.    In the case of M.
Barlow,  and in some  of those of  M. Clemot, it seems  that  the
wound had nothing to do with the  veins, neither with the axillary
nor the  internal jugular.
  There remain, then, only those of Simmonds, (Med. Facts and
 Obs., vol. viii., p. 23,) MM. Roux,  Warren, Begin, Delaporte, Du-
 bourg, Mirault, and my own, with one of those of M. Clemot, which
 permit us to allow the fact  to be possible, according to the region
 and the  part of the veins wounded.
  3. Cases  followed by death, without autopsy.  The  cases  followed
 by death, but M'hich have not been accompanied by a post-mortem
 examination, are six in number, and are authenticated by the names
 of MM. Warren, 1; Clemot, 1 ;  Barlow, 1 ;  Goulard, 1 ; Klein, 1;
 and Maugeis, 1 ; total, 6.
  In these six cases, we  perceive that  the wound  was on a vein
 not well ascertained in the case of M. Clemot, probably on the in-
 ternal jugular in that of M. Barlow, the thyroid plexus in that of
 Klein, and  a sub-scapulary branch in that of M. Warren.   M. Du-
 plat says positively that it was the  axillary  in  the  case which he 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.       33

attributes to M. Goulard.  The median vein in the fold of the arm
was the only one opened in the case of M.  Maugeis.  This simple
enumeration shows the uncertainty which must remain in the mind
with such facts before us.
  4.  Cases followed by death, and in which there was an autopsy.  In
this last group I find seven observations.   They are those of M. Pie-
dagnel,  1 ; of Dupuytren,  1 ; of  Delpech, 1 ;  of MM. Castara,  1 ;
Ulrich, 1 ; Roux, 1 ; and Putegnat, 1; total, 7.  That of M. Pute-
gnat, being given without any detail and  on the authority of a
third person, ought, I think, to be laid aside.   M. Piedagnel says
that it was the external jugular  vein which was wounded in a pa-
tient of Beauchene.  This practitioner has  also told me  that in the
case of Dupuytren,  the tumor  occupied the  posterior  and  right
lateral region of the  neck.   It is not possible, therefore, that  it was
either the internal  jugular or subclavian which was wounded.  In
the case of M. Roux and  that of Delpech, the operation was the
amputation at the  shoulder-joint, and veins  other than the axillary
vein,  had  alone been wounded when the accidents took  place.
M. Saucerotte says, that in the  patient of  M. Castara it was, like
that of M. Warren, a subscapulary vein which had  been opened,
and that to the extent of at least a line.   The case of M. Ulrich is
then the only one which accords with the region where, after our
experiments upon animals, the introduction of air into the veins
may occur and prove dangerous.
  If  now we take  a survey of the whole question, we are in some
measure forced to admit the following conclusion: Either the ex-
periments which have hitherto been made on living animals are  in-
complete and delusive, or  the  cases  of introduction of air into
the veins of man are not conclusive. In viewing  it with the  great-
est impartiality, I  see, in  fact, 1. That from  direct experiments, a
large quantity of air is necessary to destroy a dog : that this gas is
not introduced spontaneously into the heart, but by means of suffi-
ciently large  openings  into the jugular, subclavian, or axillary
vein; that the right cavities of the heart are then always distend-
ed, by a matter of a  red color, and  frothy, and evidently made  up
of the intimate mixture of the air with the blood.   2.  On the other
hand, the facts collected in reference to  man,  show that many of
them relate to the  veins of the breast or shoulder, the external jug-
ular, or  the  veins  of the face.  In  the others, the opening  of the
vein was small, and there  could  not enter but a small quantity of
air.  In fine, autopsy does  not disclose in any of them, what direct
experiment has permitted us to establish.
  It is not my province to refute,  in this place, the language of those
who,  without  doubt,  through inadvertence,  have always  either
in the course of our experiments, or during the debate in  the
academy, which resulted from them, travelled out of the limits of
the subject under discussion, and who have  always reasoned, as if
myself and many  others had  ever denied the possibility and the
dangers of the entrance of  air into the veins.   Without seeking
for the  motives which could have induced some of our brethren
                               5 
34
NEW  ELEMENTS OF OPERATIVE SURGERY.
 constantly to fall into this pernicious habit, it is sufficient for me to
 refer to the account of the discussions in the academy, to shoMr the
 falsity of such reasoning.  (Bulletin de VAcademie Roy ale de Mede-
 cine, Paris, 1837 et 1838, torn. i. et ii.)
  May it not be said, then, that all the observations collected upon
 the human species, have in them something strange and altogether
 unusual ?   If it is true that patients may die of syncope, of hemor-
 rhage, of  fright, and of exhaustion during the performance of cer-
 tain severe operations,  then  is  it  also true,  that  life  may be
 extinguished with another  order  of symptoms than those  that
 have been related.  If we take away  from the catalogue  which
 I have given,  the cases of  Klein,  of MM. Duportail,  Lodge,
 Cooper, Dubourg, and Maugeis, which are utterly of no importance,
 or which are satisfactorily explained  without the intervention of
 air  into the veins, it will prove difficult to withhold  the same  ex-
 planation  for the  others.  In  supposing, that in the cases  related
 by MM. Rigaud, Clemot, Begin, Malgaigne, and in that of mine,
 the  jet of a small artery against some of the  organic tissues, or
 the  introduction of air into some of the sinuous culs de sac, may
 have assumed a resemblance to the hissing, gurgling, or bubbling
 (bouillonnement) mentioned by the  narrators, it is almost impos-
 sible not to  concede  something more in the facts of MM. Piedag-
 nel, Dupuytren, Castara,  Delpech,  Ulrich, Barlow, Warren,  and
Goulard.
  In this  state  of uncertainty, may it not be asked, if, at the  mo-
 ment of operating upon a man, the veins, being kept pervious (cana-
lisees) by the nature even of the tumor, or by the tractions exerted
upon it, might not have been temporarily put in the state in which
we  find that those of the apex of the  chest naturally are in living
animals ?  By means of this interpretation, however, we could not
include in the group of facts that are very probable, any but those of
MM. Goulard, Piedagnel, Dupuytren, Castara, Delpech, Warren, and
Mirault.   It appears evident to me that nothing had  effected  this
change in  the cases of MM. Rigaud, Amussat, Toulmouche, Mott,
and Malgaigne.
  Could we not also call to our aid the previous debility of the pa-
tients ?  Every thing  shows, although  our direct experiments  still
present some doubts on this point, that the loss of a great quantity
 of blood must render the admission of air into the veins more dan-
 gerous. But in analyzing the facts, we see that, apart from those
 of M.  de Piedagnel,  of M. Roux and of Klein, all  the patients
 were still strong; that most of them, moreover, enjoyed perfect
 health, and that they had scarcely lost over a few ounces of blood
 at the  moment when the accidents happened.
  If we do not wish  to abandon this comparison, there remains
 only one other resource : it is to admit, that whether under a physi-
 cal, or a physiological, or pathological point of view, the conditions
 upon which air enters the veins present  marked differences in the
 human species  and in animals. We may look upon these differ-
 ences as possible, when we consider that air in the veins destroys 
       THE CONDITIONS  THAT ARE ACCESSORY TO OPERATIONS.      35

the horse more quickly than the dog ;  that under the  influence of
this gas, death is more  rapid when  we hold the animal in one
position rather than in- another ; that by means of the air blown in
by the mouth we kill sometimes with the velocity  of lightning,
whilst, with a syringe, a long interval of time is required to produce
the same result.
  1 will, nevertheless, admit, that none of these reasonings are con-
clusive, and that there is nothing in them which places the  accu-
racy of what has been  said  in favor of the introduction  of  air
into the veins of man,  beyond dispute. t
  To express frankly my opinion, I consider the introduction of air
into  the veins of  men to  have been probable in the patients of Sim-
monds, MM. Begin, Malgaigne, Mirault, Warren. Barlow, Delaporte,
one of those of M. Clemot, the first case that M. Roux speaks of, and
my own.  Nothing proves that the accident took place in the cases
of MM. Toulmouche, Mott, the second and third  of M. Clemot, and
those of MM. Rigaud, Dubourg, Maugeis, and Amussat.  It was, in
my opinion, extremely probable in the case of Delpech, and  in that of
M. Ulrich, and I think it almost certain in the cases of Dupuytren,
and of MM. Castara and Goulard.    v
  Thus, without denying the possibility of this phenomenon, when
the veins form canals  that open in the chest, I am of opinion that
new experiments are indispensable to resolve  this question defini-
tively.  If the fact is true  of  man, we must seek another physical
explanation than that which has been given by MM. Poiseuille and
Berard ; for there have certainly been seen elsewhere than in  the
neck and axilla, phenomena similar to those which seem to denote
the introduction of air into the veins.
   Treatment.—In all scientific discussions, there is a rock that we
should do all in our power  to avoid, viz.: that of adopting an opin-
ion too hastily, and of coming to a conclusion too positively, in spite
of the absence of proofs, either for or against; without protecting
ourselves alMrays, at any sacrifice, in doubtful questions, with  the
saving clause, / know nothing of it, which is so often the substance
of our knowledge or of our  answers.   Because the facts hitherto ad-
duced in favor of the introduction of  air into the veins are incom-
plete,  we should  be  wrong, for example, to conclude from  liience
that the accident itself has never existed.  As for myself, I repeat,
that this kind of accident appears to me to have been many times
met  with; only I feel that  until there are proofs more conclusive,
fhis opinion cannot be  any  thing but a personal belief, and that sci-
ence possesses nothing at the  present  day which can change this
belief  into a fixed and general conviction.
   With this idea, I have thought it due to consider, as so many others
have done, the means that we may use to meet the dangers attribu-
ted to the introduction of air into the veins. Our intentions should be
confined here to two kinds of remedies, viz., preventive and curative.11
   Preventive means.—An important difficulty will for a long time
 render doubtful the efficacy of the attempts that it might be possi-
 ble to  make to prevent the admission of air into the veins of a person 
36
NEW  ELEMENTS OF OPERATIVE  SURGERY.
during operations.  This difficulty is, that no  one can tell before-
hand, M'hether, on the supposition of opening such or such a vein,
the phenomena will or will not take place..  I have, myself, more
than fifty times extirpated submaxillary, parotid,  axillary, supra-
clavicular, or supra-sternal tumors, which have  placed me under
the necessity of approaching very near the large veins of those
regions, and  often even of opening them.   It is  nevertheless true,
M'hen I say, that the case of which I have given  an  extract, and
that of the young boy, are the only ones which have for a moment
alarmed me under the impression  that air was introduced into the
veins.  I will add, that, while serving as  assistant to M. Roux, I
have seen this surgeon open freely the upper part of the subclavian
vein in one case, the superior portion of the axillary in another,
and the inferior portion of the internal jugular in a third, without
any thing resulting therefrom that could be referred  to the intro-
duction of air.  When we reflect upon the number of amputations
that have been made at the shoulder-joint, the frequency of opera-
tions that have been performed in the axilla for cancerous or lym-
phatic tumors, and  the numerous cases  of ligatures upon the arte-
ries in the  supra-clavicular and  earotid  regions, without being
followed  by any result similar to  that Mrhich air produces when
carried into the heart, we are forced  to admit that  the accident in
question cannot, at  least, take  place but seldom.   How then can
we become certain, if it has not taken place in any  given oper-
ation, that  we are  to impute this exemption to  the  precautions
employed, rather than to the natural resistance of the organs.
  We thus see clearly, that in order  to  solve this question of pre-
ventive means, as for all the others, it will be necessary  to have fur-
ther and repeated experiments.  Let us, however, examine those
which appear to have hitherto claimed attention.
  The compression of the thorax, during the entire continuance of
the operation, does not appear to me proper, neither theoretically
nor from  the experiments already made.  If the compression were
sufficiently powerful in  the human species wholly to prevent the
elevation of the ribs, the patient would obviously experience from
it great inconvenience, if it did not in fact become insupportable.
Besidf s, the chest would not the less enlarge  itself in its vertical
diameter by the depression of the diaphragm.   Moreover, it is not
yet demonstrated  that the dilatation of the heart has  any part in
the inhalation of the air.
  Reasoning  upon  the^ supposition that  inspiration  alone could
draw the air  into the heart, M. Poiseuille thought it M'ould suffice,
to prevent this accident, if we charged the  patient  carefully to
avoid any thing like a full inspiration.  But experience has long
shown  surgeons, that during  serious operations, the chest of the
patient is generally kept contracted in a spasmodic manner; that
respiration is retarded and made by small movements, and that we
are rather obliged to urge the patient to make full inspirations than
to prohibit him from doing so, provided we guard against the
venous circulation being thereby too much obstructed. 
       THE  CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      37

  Compression of the veins between the heart and the wound.—When
the idea of the introduction of air into the heart of man presented
itself to practitioners, the first femedy which naturally offered was
evidently the compression which I have  named above, so natural
and certain does this means  seem to be.  Thus M. Larrey had
already remarked, in speaking of taking blood at the  neck, that we
must compress the vein below the puncture, and until the dressing
is finished, if we would prevent the entrance of air into the heart.
Dupuytren is careful to point out the same precaution while relat-
ing his case.  We find a similar recommendation in the memoir of
M.  Barlow.   M. Putegnat also gives it in his thesis.  I perceive at
p. 266 of the Treatise  upon Tumors, by M. Warren,  that the sur-
geon who operates in the neighborhood of the jugular, subclavian,
axillary, or  iliac veins, or even of the' saphena when it is dilated,
should reserve  to the last the separation of the peduncle of the
tumor upon that side, in order to be better enabled to compress the
veins before opening them.   This author  adds, that, if the thing is
possible, we should  compress the veins between the incisions and
the heart.   I have  believed it myself right to adopt this advice
and to practise it in some cases of extirpation of parotid and submax-
illary tumors.  But it must be admitted that this remedy is but of
little value.   If, with the first observers, we could admit the possi-
bility of the inhalation of the  air at a very considerable distance
from the heart, it would deserve to be taken into serious considera-
tion.  Nothing would  be more easy than to put it  into practice
with the internal saphena, or the femoral, or iliac veins,  the veins
of the arm and face, and the external jugular;  but if it is true that
the introduction of air  into  any of these regions is impossible, com-
pression, as a preventive means, becomes for that reason altogether
useless.  On the other hand, who does not see that for the supra-
clavicular region, the upper part of the axilla, and the supra-hyoi-
dean region, where its  aid might be invoked, it is quite impractica-
ble ?  Concealed  by the clavicle or sternum, and separated from
the ribs by the lower attachment of the  scaleni muscles, the sub-
clavian vein is so placed that nothing can obliterate  the cavity of
it by pressing through the skin.  It is the same with the internal
jugular vein beloM' the larynx.  We must also add, that  the com-
pression of this vein, in operations  near the parotid region, favors
the  engorgement of the face, and  increases the volume of all the
veins that we are in danger of wounding.
  After these various reasons, then, we are compelled to admit that
the  compression of the venous trunks between the  wound and the
heart is, in fact, a resource of but little importance,  and rarely
practicable.
  It  results  from  this  examination  that, in -practice, we cannot
count on the efficacy of any of the preventive means of which we
have hitherto spoken; that we  must make still  further researches ;
and that, under this point of view, the only resources within the
reach of the surgeon resolve themselves into these :  First, To do
every thing during an  operation to avoid wounding the internal 
38
NEW ELEMENTS OF OPERATIVE SURGERY.
jugular and subclavian veins: and, secondly, In the event of  his
being forced to penetrate to the neighborhood of these vessels, he
must not separate the peduncle of the tumor without having first
seized  it, on the side of the heart, with two fingers, or included it in
a strong ligature : third, To avoid, as  much as possible, extending,
pulling, or moving the parts, raising the arm, or throwing back the
shoulder, or the neck, when the bistoury approaches the large ves-
sels at the apex of the thorax.
  Curative Means.—If therapeutics possesses no means which can
absolutely prevent the air from entering into an open vein, it is no
less  humiliating  to  confess that it is still more powerless in the
means of expelling this gas from the heart.  I very much doubt if
placing the patient on the right side, as M. Forget recommends, can
be of any great efficacy.
  The alternate raising and depressing of the thorax, (compression
saccadee,) by the aid of which, Nysten thought to expel the air from
the auricle through  the Mround of the vein, is evidently useless, at
least in the human subject.   Even in dogs, we cannot thus make
the air contained in the right ventricle  ascend ; and the auricle
will yield only a  small portion of it.   Who does not perceive that,
in the human species, the thorax, infinitely less compressible than
in dogs, will not admit of being sufficiently flattened to react effica-
ciously on  the heart.
  The means  which first suggests itself, that is to say, the closing
of the  venous wound,  a means practised in   a great number of
instances, presents, perhaps, as many dangers on one side, as ad-
vantages on the other.  If it puts a stop  to the introduction of  air
into the wounded vessel, it has the evil, also, of preventing the
egress of that which the contractions of the heart tend to force out;
so that it cannot  succeed, unless, at the moment of  its application,
the gas is not in sufficient quantity to cause death.   Inhalation by
the mouth, through  the  opening of the vein, will scarcely ever be
practicable ; the  plainest  reflection, also, suffices to show that it
could not succeed.   Artificial respiration, whether effected by tra-
cheotomy, or by  introducing  a tube through the natural  air-pas-
sages,  as  attempted by M. Warren, could not, as it appears to me,
have any object.   The introduction of a saline  liquid by some other
vein, as is also recommended by that physician, could not but add
to the  danger that  the patient is already exposed to.
  There remains, then, suction with a tube or a syringe, conveyed
even into  the heart; but this resource, originating  in experiments
upon animals, ought to be, in my opinion, severely proscribed on the
human subject.  It  is obviously clear, that the wounds of the in-
ternal jugular only  would admit of its application.   Who does not
also see that, in order to introduce the tube, it would be  necessary
to put the vessel precisely in the conditions which would most favor
the  introduction of the air ?   In short, who has not felt that, during
a serious operation, it is necessary first to  ask if the accidents which
take place, in reality depend upon this phenomenon; to seek, after-
 wards, for the opening of the  vein; to demand of the assistants the 
        THE CONDITIONS THAT ARE  ACCESSORY TO OPERATIONS.      39

tube arranged for this purpose; to introduce this tube, and to ap-
ply to it the syringe or the mouth; and that all this would neces-
sarily exact more time than is required for the patient to expire, if
what has been said of the entrance of air into the heart during the
course of certain operations on man is realy true?
  We  are  then  reduced,  in this  matter, to  the means generally
resorted to  for syncope, unless bleeding, as formerly recommended
and still eulogized by MM. Boulay, Le Blanc, &c, may, in reality
have some  efficacy; to place the finger upon the wound, and imme-
diately  suspend  the  operation, when  the alleged characteristic
sound has been heard  ; to keep the patient in a horizontal position;
to stimulate him with the vapor of ammonia, alcohol,and vinegar;
to use frictions on the body, and to throw water in the face;  such
are, at present, the only measures that reason and experience per-
mit  us to  make  use of, with safety.  A pupil of the  hospitals  of
Paris,  M. Mercier, has made experiments which would tend to
prove, that the compression of the abdominal aorta is a means of
great efficacy ; that in forcing the blood to mount towards the brain,
it brings back to life animals that appear to be on the point of ex-
piring ;  and that it is, in short, an infallible remedy; but I have not
yet had an  opportunity of testing the value of this method.
  [Entrance of Air into the Veins.—In the case of Dr. Mott, above
alluded to,  he was then convinced, and ever  has been since more
and more confirmed in the belief, that the  symptoms in that case
were entirely ascribable  to the admission or suction of air  from
without into the incised facial vein.   And he also would embrace
this occasion to add, that  reflection upon the  subject, and upon the
facts that have been so clearly given by M. Amussat in his Report
to the  Paris Academy of Medicine,  1839,  and by  other  practi-
tioners M'ho have witnessed this phenomenon, and also that the de-
tails of another  remarkable case  to which he has himself been  an
eye-witness, satisfies him fully in his own mind of the entire possi-
bility of this alarming event during operations.  The case of which
Dr. Mott would  now speak, was that of a  French lady at New
York, from the southern states, of middle age and tolerable health,
in whom an enlargement of the thyroid body assumed, strange to
say, the complete character of a malignant bleeding fungus hcema-
iodes of the worst description.  Dr. M., not being able to bring
himself to  the propriety of attempting to remove so formidable a
mass of disease of that nature in so unfavorable a subject, declined
the operation, M'hich, however, was undertaken by another surgeon.
  The operator had proceeded but very little distance in his incis-
ions, when  it was discovered  that the  calibres of the venous and
arterial plexuses, particularly those of the former, were, as  so gen-
erally happens, enlarged to a prodigious extent, and that therefore
the hemorrhage M'ould, as it began to evince, be most profuse.  At
this critical moment of suspense, a wheezing or whizzing noise was
suddenly heard by all present, (some  twelve to twenty  persons,)
resembling  in sound that of air  quickly rushing into a tube by suction,
*nd so unusual and unaccountable as to cause the late deceased 
40            NEW ELEMENTS OF OPERATIVE SURGERY.

eminent professor Dr. David Hosack, who was present, to involun-
tarily  exclaim,  "What's  the matter?   Have you  cut  into  the
trachea ?"  This of course had not been reached or disturbed, and
the remark had  scarcely been uttered when the patient instantly
expired.  Take this one pathognomonic symptom alone of the ac-
cident, we mean the peculiar and readily recognisable and charac-
teristic sound as of suction of bubbling air (as if, for example, from
frothy blood) suddenly rushing into the  aperture of a tube, or, as
Dr. M. expresses it in the case he has published, into an aperture
in the exhausted  receiver of an air-pump ; and it is quite sufficient,
with the rapid fatal sinking  and almost instantaneous loss of life
which but too often succeeds, to show that there can be no analogy
whatever found  between the manifestations that take place in this
phenomenon and those that are ordinarily observed during the faint-
ings, swoonings,  and prostration that are caused sometimes by pro-
fuse hemorrhage during operations,  and that are thus  as frequently
also the immediate  precursors of death.  We might dwell also on
another peculiar symptom which does 'not always exhibit itself, it is
true, when air has been imbibed  in  the vessels, but which, when it
does, is equally removed in its character from what occurs in death
from exhaustion  caused by hemorrhage.'  This symptom is, as Dr.
M. has shown in the case of his own,  described in his letter to M.
Amussat, (see Report  to the  Paris  Academy of Medicine, already
cited,  and M. Guerin's Gazette Medicale of Paris,) that of convul-
sions of a  most violent and peculiar nature, where the patient threw
himself on the floor, and  twisted and contorted his body and limbs
with spasms of  the most  frightful  description, resembling  rather
the agonizing sufferings  of one  laboring under hydrophobia, and
indicating certainly the most poignant distress, such as might arise
from sudden  strangulation or smothering, giving rise to the most
energetic  exhibitions  of muscular  poMrer.   A very  different  and
opposite state, it must be confessed, from that of extreme exhaus-
tion, prostration, syncope, and swooning from profuse hemorrhage
or concussion upon the nervous system, but imbodying results which
might rationally be explained by analogy, from the supposition that
the introduced air had, as it is proved  to do in the experiments on
living animals, penetrated into the right auricle and ventricle of the
heart, and thereby directly interrupted the vital  functions of  that
organ.—T.]

                § V.—Sang-froid of the Surgeon.

  When every thing  is in  order during operations, the  surgeon
rarely troubles himself, but many practitioners are disconcerted and
lose their self-possession at  the  slightest untoward accident.   M.
Champion has instanced to me a very distinguished operator, whose
sang-froid is admirable when nothing particular occurs in the course
of the operations he performs, but who  is embarrassed with  sur-
prising facility in presence of every unusual obstacle.  He aban-
doned one day, for dead, a female patient from whom he removed 
       THE CONDITIONS  THAT ARE ACCESSORY TO OPERATIONS.     41

a tumor on the fore part of the neck, because she fell into a syn-
cope, from which M. Champion soon revived her by placing her on
the bed and throwing a glass of cool water in her face.   I myself
know of one who operates Math a remarkable composure, but who
quickly becomes discouraged when he sees any thing of a disquiet-
ing nature that he did not anticipate.   I  have seen'this physician,
who  is one that bears a celebrated name, and is justly esteemed,
faint at the sight of a simple operation for empyema performed by
one of his colleagues, and at the extirpation of a tumor from the neck
in which he himself assisted.  These are moral peculiarities that
are very unfortunate, seeing that if it  is important that the surgeon
should reflect a long time, and analyze and weigh  every circum-
stance before  commencing an operation, it is also  necessary that,
when he is once armed with the  instrument, he should be discon-
certed at nothing; entirely absorbed  in the Mrork that he  has com-
menced, he should have calculated all its chances and all its diffi-
culties, whether natural or  contingent, and  be ready to change
them, avoid, or remedy them, and  foresee  their consequences.  It is
under these circumstances  that the qualities of the mind denomi-
nated composure  and cool self-possession are indispensable, and
merit the title of surgical intrepidity.
  When these qualities  are MTanting, it is of great importance, as
it  is, in fact, in almost all the cases  where the operation involves
some serious responsibility, that the surgeon should be surrounded
by skilful colleagues and assistants. Young practitioners, especially,
have need of assembling about them compeers of reputation when
they decide upon performing some important operation.  They thus
procure for  themselves more  confidence and security, and  place
themselves under  protection  from every harm if any unforeseen
event should happen.   There is instanced on this subject an exam-
ple which the great masters  themselves should sometimes call to
memory: Marechal wished to open an abscess of the liver in the
minister Leblanc ; but  it was Morand, who was then only a pupil,
who  prevented him from plunging the bistoury on the side of the
abscess.  Some time after, the minister presented Marechal to his
family as the one who had saved his life.  The surgeon replied, as
he pointed out Morand, " It is to this young man that you owe it,
for but for him I should have killed you !"   (Leblanc, Precis de Chi-
rurgie, t. i., p.  535.)
  In possession of self-composure,  and of  every kind of knoMdedge,
anatomical, physiological, and surgical, with which an erudite man
may adorn his mind, the surgeon has the  right to undertake an in-
finity of operations, which  another should never attempt;  those,
especially, which are performed in  regions where the compression of
the principal artery cannot be effected between the heart and the
seat of the disease.
  The operations required for diseases of the infra-hyoid and supra-
clavicular regions, and  for those of the chest, abdomen, and peri-
neum, are, almost all of them, of this nature ; as to the others, we
may readily conceive that the  agitation  of the operator, and his
                          6 
42
NEW ELEMENTS OF OPERATIVE SURGERY.
want of self-possession, would not prevent the assistants from arrest-
ing hemorrhage, and placing the patient out of the reach of all real
danger.

                  Art. III.—After Operations.

  Having finished with the use of the instruments, there remain,
for  the  completion of the operation, many important things to be
done.


                  §. I.—To arrest Hemorrhage.
  The loss of blood being that which gives the most alarm, and
which may, in fact, the most speedily compromise the life of the pa-
tient, deserves to be considered first; nevertheless, there are an in-
finity of operations, which may, in this respect, be neglected without
real danger.  Arteries of small calibre, those of the fingers, great toe,
scrotum, margin of the anus, neck of the womb,  face, superior part
of the cranium, those of the skin, and of the  subcutaneous tissue in
general, would rarely give place to serious hemorrhage in patients
not previously enfeebled, if we could summon sufficient boldness not
to apply the ligature to them ;  in other respects, as there is no incon-
venience in obliterating them when it is easy to seize them, it would
be  imprudent not to close them immediately ; it  is only when  they
have ceased  to bleed,  and in cases  where  all the  surface  of the
wound  may be covered, and more or less completely compressed
by small balls of lint, that I Mrould advise abstaining from the ordi-
nary haemostatic means.
  A.  Various  Topical Applications.—We  hear no more to-day of
cauterizing the wound of an operation with hot iron, boiling oil,
or  melted  lead, as was done in the  time of  Paul  of Egina, and
Abu-1'Kasem ;  nor of stuffing it with tow, and enveloping plasters
saturated with white of eggs, bole Armeniac, or other astringents
pointed out by  Guy de Chauliac (Grande Chirurgie) and almost all
the surgeons  of the middle ages ; nor of having recourse to arsenic,
vitriol, and alum, (Borel, dans Bonnet, t. iv., p. 89,)  still recommended
by  Lavauguyon and Le Dran;  nor, in fine, of  employing sponge,
or  the  agaric from oaks, as  Brossard and Morand proposed, long
time after Encelius, (Bonnet, Collect., etc., t. iv. p. 364,) towards the
middle of the last century.   Some, however, still extol the remedies
that are included in this enumeration.  M. Binelli says, that Math a
water of his invention it is easy to arrest every kind of hemorrhage;
and some  experiments on animals seem, in fact, to give support to
his assertion.  M. Bonafoux  (Revue  Med.,  1831, t.  i., p.  49,  324)
composes with charcoal, gum, and colophane, a  powder which, ac-
cording to him, possesses  the same properties.    In fact,  MM.
Talrich and  Grand (Bulletin de Therap., t. i., p.  137)  have discov-
ered a  liquid whose efficacy has been placed beyond doubt  by  a
great many experiments on dogs, sheep, horses, &c. ; but the appli-
cation of these new means, which, in my opinion, are little to be 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      43

relied upon, not having  succeeded in man, it becomes unnecessary
that I should say any thing further of them.
  B. The ligature is properly preferred to them.  Pare is the au-
thor who revived and rendered new this important modification.   If
Galen, Avicenna, Tagault, and some others had already mentioned
it, it must be conceded that it was of no advantage to their succes-
sors.  Fabricius of Hildanus, Wiseman, and Dionis, who soon adopt-
ed it, did not neglect to bring it' into general use.   For more than a
century past, there are but some few exceptions in which we do not
use it, or substitute  other means for it.   We begin with the princi-
pal artery, seeing that it is that which it is most easy to find, that it
is the one more important to be tied, and that afterwards the other
branches are more easy to be discovered, because they then carry a
greater quantity of  blood.  We seize it with the forceps, called the
artery or dissection forceps, embracing it throughout all its thick-
ness, and taking care at the  same time not to include the nerve  or
vein.   Some persons, however, have advised to seize and tie at the
same  time the artery and the vein together.   Their object was  to
avoid by that means the hemorrhages which the large veins may give
rise to.  The moderns have rejected this practice, first, because it is
useless, and also because it is  dangerous : useless, since the retro-
grade circulation of the  veins does not allow the  blood to escape by
their mouths into the thick part of the stump, or because, if this acci-
dent happens, it is not necessary to recur to the ligature to remedy
it;  dangerous, because, as it is  said, in tying a large vein, we run the
risk of .producing inflammation. Others add, that it is proper to sepa-
rate the artery carefully from the surrounding tissues.  Experience
enables me to say  that these  are rules  of but  little importance.
Whether we seize the artery alone, or deprived or  not of its surround-
ing tissues, or embrace the whole of it, or insert one of the branches
of the instrument in its tube, while the other occupies the interior of
the neighboring vein, or that the ligature encloses the entire artery
only, or the artery and the vein, the operation will  nevertheless have
nearly the same chances of success or failure.  The difficulties and
the dangers do not lie there ;  and what  has been said on this matter
is in no degree borne out by practice.  As to a simultaneous liga-
ture on the nerves, all recommend that it should be avoided.
  In the place of the forceps, Bromfield  and most  of the English sur-
geons make use  of  a  pointed instrument, in form of a prolonged
arc, to which they give the name of tenaculum; but this tenaculum,
though it renders the application of the ligature  more certain and
easy, is less convenient than the forceps for seizing the artery with-
out tearing it; it is  on this account, without  doubt, that it is but
rarely employed in France. The English themselves have recently
made  such modifications of it,  that it resembles now our hook for-
ceps, (pinces a  crochet.)  Be that as it may, having once seized the
artery, the operator  endeavors  to bring it out to the  surface of the
wound; an assistant passes a ligature beneath, in order to unite its
two extremities above, and to form a circle, which he pushes Jbeyond
the point of the forceps, which is  then inclined horizontally.  We 
44
NEW  ELEMENTS OF OPERATIVE SURGERY.
tighten this ligature by embracing its extremities with the last fin-
gers of the two hands, and by drawing upwards, while with the
thumbs, or the  index  fingers, we force the knot as deeply as pos-
sible into the bottom of the wound.  Some persons prefer drawing
on the ligature so  as to carry the extremities of it backward be-
yond  the plane of the artery that we wish to tie.   If it is in the
bottom of a cavity where the vessel is found, it suffices, in order to
obtain the  same result, that we support the  ligature  outside the
knot with  the index fingers, which thus represent a sort of pulley.
But it is evident in this matter, that every one must adopt the course
which appears to him the most convenient and the most safe.  The
principal artery being tied, we  carefully search for the others,  to
secure them successively in  the  same manner ;  only that it is use-
less then to isolate them as carefully from the small veins and other
tissues which surround them : that is to say, if the direct ligature is
almost indispensable  for  the  large  arteries, it is not as important
for the smaller ones.  Here  the  tenaculum, grasping the  vessel as
a hook would  do, brings  it  out  more easily, and enables us with
greater facility  to surround it with the ligature.  If the  artery is
deep or too difficult to separate, we have recourse to the  interme-
diate ligature ; that is, M'e include in the thread the entire organic
mass  from whence the blood seems to come.  In those cases we
are sometimes obliged to use a curved needle in order to  pass the
ligature around  the vessels.
  The threads that are used  are single for vessels of  the second or
third  order ; a double or triple  ligature is preferred  for the large
trunks.  However, in England, where fine ligatures have been gen-
erally adopted in the treatment of aneurisms, they make no further
use of double or triple  threads even  for other operations.  With-
out being indispensable, the French method is, however, rather the
most safe.
  The principal artery is sometimes so hard, incrusted with phos-
phate of lime or diseased, that, in applying a ligature upon it, it
breaks like glass;  in this case we may introduce into its interior a
small cone of linen, of cork, gum-elastic, or any other substance,
or place between it and the ligature, and of sufficient breadth to sur-
round it, a  small cylinder analogous to that which is  known under *
the name of the rouleau of Scarpa.
  Sometimes the blood escapes from the interior of a bone, either
by simple transudation or by the trunk of its nourishing artery.   A
small graduated compress applied on the spot where the blood es-
capes, while we are proceeding  in  the  search for  other vessels,
generally suffices ; or sometimes  it will be necessary to have re-
course to cauterization, or to insert in the  medullary  canal a piece
of wax, plugs of lint, or of agaric.
  There is  a crowd of  arterial branches noticed during an opera-
tion, that soon after cannot  be found, but which sometimes  give
rise, a little while later, to a sufficiently abundant flow of blood.
On this subject an explanation has been given, which to  me appears
any thing but satisfactory.  I  do not see that the momentary absence 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      45

of the hemorrhage ought to be imputed to the spasm of the divided ar-
teries, nor to their retraction, nor perhaps to the instantaneous effect
that the action of the atmosphere  exercises upon  them.  If they
seem to reopen themselves at the end of some hours, it is evidently
because the concentration of the organic  actions produced by the
operation finishes by giving place to an eccentric movement more
or less energetic, which brings back  the fluid from  the interior  to
the  exterior.  The mode followed at first by Parish  in America, by
Klein in Germany, by many surgeons in England, and in France by
Dupuytren, a mode which consists in not dressing the  wound until
after the expiration of some  hours, does not consequently appear to
me  to be justified by reason, and I think myself  authorized to cen-
sure it as a general  method.  Except in some rare cases, it is al-
ways possible to guard effectually against hemorrhage immediately
after the operation.   The wound remaining open, undoubtedly gives
a better opportunity for placing new ligatures if they become neces-
sary ; but who  does  not know at the present time  that we render
the  ligature useless  upon an  infinity of small arteries, by uniting
immediately the greater part  of the solutions of continuity.  Be-
sides, the patient, seeing that he is not dressed, becomes  restless, and
dares not trust himself to  sleep.  In fact, it is  a practice which,
though good in some cases, ought not to become  general.
  Since immediate union after operations has been proposed and
followed by a great number of operators, it has  been suggested  to
leave in the wound as few foreign bodies as possible.   They thus
began by cutting off  one of the ends of each  ligature very near the
artery.   Veitch, who considers himself the inventor of  this modifi-
cation, strongly insisted, in  1806, on the advantages thereby pro-
cured.  He was in  the habit of employing very fine  ligatures of
silk, in order to be enabled to cut their two extremities, and to leave
their knot around the  artery.  Doctors Wilson and Hennen fol-
lowed  this practice  for a long time  before M. Lawrence had given
any account of it.   MM. Collier, S.  Cooper, and Delpech, who have
also tried it successfully, declare that these ligatures often give rise
to abscesses, and that it is better to leave their extremities out.  It
would appear further, that they were in the habit, in different coun-
tries of Europe, from the year 1780, of cutting the two portions of
the  ligature very near the knot.  As silk and thread do not appear
susceptible of absorption, and act always like foreign bodies, an at-
tempt was made to use ligatures of another kind.  Ruysch had al-
ready proposed for aneurisms  wide  strips  of leather.   Beclard re-
vived the use of them in France.   In America M. Physic tried liga-
tures of deerskin, and M. Jameson, (Journal des Progres des Sc. Medi-
cates, t. vi., p. 117; t. vii., p. 126; t. ix., p. 150,) who has employed them
for a long time, speaks much in their favor. Others have had recourse
to the gut of the silk-worm, to  catgut, &c.  But experience has not
yet  decided upon the  real and precise value of these different sub-
stances.  [Dr. Mott  has tried forms of animal  ligatures, catgut,
buckskin, raw-hide, &c, in the treatment of aneurism, and, from his
3xperience, it is preferable to leave one  end out, as abscesses will 
46
NEW  ELEMENTS OF OPERATIVE SURGERY.
otherMase form in the wound.—T.]   At Paris they generally use
ligatures of thread, single  or double, according to  the size of the
artery.  When they are applied, and before proceeding to the dress-
ing, we cut one of the ends off near the vessel, in order to diminish
the bulk they Mould make in the midst of the tissues.  The other ex-
tremity rests without, to serve to draMr out the knot M'hich it forms
deep Mdthin, when that shall be detached from the artery.  As a
general method, it is  the best in practice.
  C. Compression.—Kock. (Bulletin des Sc.  Med., t. xiii., p. 361,)
surgeon of the hospital of Munich, affirms, that for more than twen-
ty years he has not in any case  had recourse to ligatures after am-
putations.   He confines  himself  to pressure upon the principal
artery  of the limb, by means of  graduated compresses, and a roller
bandage  extended from  the  trunk to near the wound, which  he
unites  immediately.  Numerous facts, he  says, support this prac-
tice, and  prove that the arteries have no need of being tied to pre-
vent them from carrying blood to the surface of the stump.  A
serious question  appears  to me  to lie at the bottom of these asser-
tions.   The annals of science contain  facts without number which
prove that the division  of the largest  arteries  may not be folloMred
by any flow of blood.  Every one knows that lacerated wounds,
amputations  folloMing gangrene, and  wounds  by fire-arms, have
often,  in this respect,  astonished  operators.   S. Wood had his
shoulder  torn off by the wheel of a mill, and got well without any
artery  having been tied.   De la Motte, Carmichael, Dorsey, and
M. Mussey, each one, relate a similar fact.   A child of nine years,
mentioned by Benomont,  had the leg torn off, and recovered in the
same  manner.   The thigh violently  separated  from the  hip, in
another case, was in like  manner not folloM^ed by  any flow of
blood.  Amputations of the thigh, related by Tcheps, Scharchmidt,
Theden, Thomson, MM. Taxil, S. Cooper, Beauchene, Segond, and
Labesse, were attended with the  same phenomenon.  MM. Arbe,
Lizars, Mudie, Smith, and Flandin, have all stated the same of many
amputations of legs, arms, forearms, &c, as I have elsewhere shown.
(Journal  Hebdomadaire, 1830, 1831.)   Similar  facts have also been
mentioned by M.  Briot,  (Soc. Med. d'Emulat., t. viii., p.  273,) by
Chabert,  (Malgaigne,  This.  No.  55,  Paris, 1831,)  by M.  Roux,
(Voyage  a Lond., etc., 1815, p. 53,)  &c.  We thus explain the ideas
of Theuillier, (Thes. de Haller, extr., t. iii.,) who, in place of ligatures,
prefers that, after operations, we  should confine  our  treatment to
diet, bleeding, and relaxants, a  practice since  revived here  (Roux,
 Voyage a Londres, etc.) by a surgeon of the provinces.  Although
the dangers of Kock's practice had been shoMoi by the evidence of
M. Graefe, at Berlin, and even by M. Kock, his son, (Journal des
Progres, t. xii., p.  248,) I have, nevertheless, thought it my duty to
make  some  experiments myself,  of which  the following are  the
principal results.
   D.  Bruising.—The bruising  mentioned by  M. Briot (Soc. Med.
d'Emulat., t. viii., p. 273) scarcely answers but for the small arteries;
if people who make  use of it, after having cut or torn off the cord 
       THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      47

from new-born infants, if the animals M'ho do the same succeed
thus in preventing hemorrhage, it is because, as a general rule, the
circulation naturally ceases of itself in  the umbilical vessels after
birth.   Nevertheless,  having employed it successfuly on the epi-
gastric arteries, the tibials, and the arteries of the fore-arm, I can
imagine that  Le Dran may have  found it  to answer 'after  the di-
vision of the testicular cord of man.
  E. Plugging the Artery, (Fermeture.)—A cone  of  alum  or sul-
phate of iron, four to six lines long, inserted into the crural  artery,
and even into  the carotid of a dog or cat, becomes  firmly fixed
there, and suffices in  general to stop the effusion of blood;  except
that from the kind of eschar which results from it, rendering the im-
mediate union impossible, we run the risk of seeing the hemorrhage
reappear  M'hen the foreign body falls out;  it is proper to add, that
its  introduction  is not always easy except in the larger arteries.
Wax  produces the same effects, except that, being more slippery,
and without any chemical action on the vessels, it becomes neces-
sary to insert it deeper.  Nevertheless, if,  when it is introduced,
the operator endeavors to push it from above down with a forceps
or Math the fingers, across the walls of the vascular tube, which
he holds firmly grasped, there results from this a sort of swollen
knob  which  the blood cannot easily remove.  The  small probe
(stylet)  which   Chastanet  (Gouraud,   Principales  Operat.,  etc.,
Tours, 1815)  appears to have used with the same  intention a long
time ago, though  less safe, often  effects a permanent obliteration
of the artery.  The point of a wax bougie  is infinitely better, pro-
vided it is not allowed to penetrate over an inch in depth.  Catgut,
deerskin,  or  chamois  leather, scarcely acting as foreign  bodies,
have  yet greater advantages, inasmuch as they do not prevent
our closing the wound immediately.  These different means are at
the best but  a species of plugs, whose manner of acting  is too sim-
ple to require long explanations.
   M. Miquel d'Amboise (Journal des Connaiss. Med., t. iii., p. 3, 70,
75, 102, 131) had  made, at the jclose of the year 1828, observations
similar to those of mine.   I  have proved,  he remarks, by thirteen
experiments, that  in introducing into the arteries of a dog a  foreign
body, especially the string of an instrument, there is soon  perma-
nently developed there a morbid condition, Munich renders them
incapable of receiving the blood, though they may not be mechani-
cally obliterated.
   F. Reversing, (Renversement.)—Wlien it is  not too difficult to
isolate the artery, so as to reverse it upon itself, as Theden (Pro-
gress de la Chir., etc., p. 78) says he did on the intercostal, and Le
Dran (Operat., etc., p. 193) on the M'hole cord after  castration, we
 almost have it in our power effectually to arrest the flow of blood.
 For that  purpose  it is sufficient, as I have often done, to fold back
 the end of the  vessel, double it, and then force it a little into the
 tissues, or immediately shut the outer wound, in order to maintain
 it  in the position  that we have given it.  But as it is possible that
 without this  reversing all those arteries would have equally ceased 
48
NEW ELEMENTS OF OPERATIVE  SURGERY.
to bleed, prudence demands that we should wait before drawing any
conclusion from it.  In passing, afterwards, the inverted end across
the trunk of the artery itself, as M. Stelling proposed and did at Paris,
in 1835,  (Gaz. Med., 1835, p. 367,) we should make of this operation
of reversing one that was difficult, dangerous, and very unsafe.
  G.  The Perpendicular Compression, which J. L. Petit, (OSuvres
Posthumes, t. iii., p.  152,) in the last century, wished to see prevail,
has not been adopted.   Inserting plugs of linen, agaric, sponge, or
lint, and maintaining them, as this author directs, by the aid of a ma-
chine, on the arteries at the bottom of the wound, could only have
the effect to aggravate the consequences of the operation, Mdthout
the certainty of preventing hemorrhage ; and in respect to the dis-
tinguished personage of whom  he speaks, it would have been bet-
ter to have searched for the principal arterial trunk of the limb
above the solution of continuity, than to have done what he did.
  H.  Torsion.—A subject which naturally arises out of the fore-
going experiments is that of torsion, as a substitute for the ligature
after operations.  I  was  led to  this discovery in  1826,* in making
experiments  on dogs of the various  known haemostatic means.  I
had not,  however, yet attempted it on the  human subject, neither
had I  sufficiently varied my experiments  on animals to permit me
to speak  of it to others than to the pupils who followed my lessons
in operative surgery at the close of the year 1827.  But on the 13th
of November, 1828, after having amputated the fore-arm of a girl
named Rohan, in presence of  MM. Al. Dubois and Malteste, I
twisted the radial and  ulnar  arteries, reversed the  anterior inter-
osseal, and immediately closed  the wound; no hemorrhage  super-
vened, and the cure was effected in twenty-three days.   On the 4th
of December following I did the same  thing, and with the same
success, after amputating the  first metatarsal bone in a strong and
vigorous  adult.  Nevertheless, it was not  until the 21st September,
1829,  that I  performed the first amputation of the thigh without
ligatures. I  had  only to twist  the femoral artery and  two small
muscular branches.   There occurred no  hemorrhage.   The  young
girl, who Mas nineteen years of age, did well  till the fourth day,
but died on the twelfth.   The autopsy of the dead body showed nu-
merous purulent and tuberculous abscesses (foyers) in her  lungs.
The ilio-femoral articulation was in  a complete state of suppura-
tion.  Some  days later, on the  26th  of the same month, I did the
same, after an amputation of the arm in a young man aged twenty-
three  years.   The brachial artery, the anastomotica magna, and two
branches of the external communicating artery, were twisted Mdth-
out difficulty ; but many other branches  caused me more trouble.
Perceiving, at the end of a quarter of an hour, that in spite  of the
tourniquet the blood continued to flow, I took off the dressing. None
of the twisted arteries bled. The hemorrhage was from the bruised
(frois.sv.es) branches, and from three others that I had not at first per-
ceived.   1 tied them all, and the bleeding did not return.  The pa-

  * Those who have since appropriated to themselves this discovery, did not SDeak of it
till in 1U29.                                               * 
       THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      49

tient died  on the sixth  day, and  the  necropsy disclosed  no other
lesion than extensive disease of the scapulo-humeral articulation.
Neither the arterial nor  venous vessels snowed any trace of inflam-
mation, and  the ends of the arteries were firmly closed, and alike
lost in the midst of the other tissues, in both of these cases.
  Be that as it may, I had from that time the conviction that torsion
may succeed as well upon the arteries of men as on those of dogs,
and that, in truth, we might sometimes use it in  lieu of a ligature.
It remained to show if it was better, or ought to  be preferred to it.
The experiments  now known, without enabling us to decide  this
question definitively, are sufficiently numerous, however, to allow
us to make an easy examination of it.
  Operative Processes.—Like every thing that depends on the hand
of man, the manner of twisting the arteries necessarily varies more
or less, according to the ideas or notions of each.
  I.  M. Thierry, wishing to do it parallel with the axis of the vessel,
is satisfied with  seizing the divided tube  by its extremity with a
valet a patin, of which the branches are more or less flattened, ac-
cording as the calibre of the artery itself to be  twisted is more or
less considerable, and he afterwards turns it from four to eight and
ten times  on itself, without grasping the base of it.
  II. In Germany many other modifications,have already been  pro-
posed.   M. Kluge, for example, warmly extols an instrument of his
invention, with which the torsion is effected by  loosening a spring
which causes the forceps to turn on itself.
  III. As  for myself, I most frequently employ a grooved forceps of
any description, or even an ordinary ligature  forceps.  After hav-
ing seized the vessel crosswise by its  extremity,  I separate it from
the surrounding tissues, and immediately grasp it near its root at
the bottom of the wound, with another forceps intended to hold it,
or with the  thumb  and fore-finger of the left  hand, whilst with
the first I turn it on  its axis from three to eight times, and not only
three times for the large arteries, as they have incorrectly made me
say.
  IV. M. Amussat recommends  that after  the artery  has been
grasped with a forceps  with rounded  branches,  it should be pulled
out several  lines beyond the bleeding surface;  that  after having
cautiously separated it  from the veins, and from the nervous fila-
ments and all the tissues  that  surround it, we  should force back
the blood that it contains, and grasp  the vessel  near its  root with
another forceps, whilst  the first, by means of gentle movements,
tears its  internal and  middle  coats; that we  should then, with
the last-named forceps,  twist the end  of the vessel  from  six to ten
times with a rapid motion, at the same time that the fixed forceps
holds it  firm, without  pressing too much upon the sides of the
 wound;  and that the separation of the internal  coats having been
 effected, we are to push them  back through the cellular coat in a
 direction  towards the  heart, as I have shown  under the  article
 Aneurism.
   In place of pushing back the coats  and leaving the twist of the
                              7 
50            NEW ELEMENTS OF OPERATIVE SURGERY

artery at  the bottom of the wound, we may continue the torsion
of it until it is completely detached, and leave only a simple shred
in the middle of the division.  Nevertheless, " we are obliged to
admit," says M.  Vilardebo,  (These, No. 158, Paris,  1831,) from
whom I cite these details, " that such manipulations are more easy
when  the fingers  limit the torsion than when we make use  of
two instruments.   The  second forceps is of use only to break  up
the artery and  push back the coats.   After this, we seize the end
of the vessel with the thumb and fore-finger of the left  hand,  on
a line with the tunics that  have been pushed up, and we give the
first  series of turns with the  forceps,  which we then  bring the
fingers nearer to, in order to continue the torsion during another
instant; the  artery is then seized again still  nearer to the instru-
ment, twisting it all the time, and so on successively.  The. opera-
tion is terminated by twisting, after the  manner  of a corkscrew,
the spiral thus formed, and by crowding it  into the depths of the
tissues."
  Two things, as it seems  to me, ought to be distinguished in this
matter : first, the isolation ; second, the torsion of the vessel.  The
first, which is applicable to the ligature as well  as to torsion, is in-
comparably the most  difficult and delicate.   If the large arteries
surrounded with healthy tissues, and themselves elastic  and unalter-
ed, and all those that repose in the muscular or cellular tissues, may
easily be divested of their coverings, elongated, and drawn  out to the
distance of several lines, it is far from being always the case with
those that run into the substance of certain tendons and large nerves,
or that adhere by their circumference or their outer side to the fatty
tissues that envelop them, that  are fragile,  scarcely  distinguish-
able, or crushed upon the least pressure, or which we  are in dread
of having escape from  us as soon as we have grasped them.  If it
were absolutely necessary, we might, nevertheless, in most of these
cases, effect our object through force of time, address, and precau-
tions ;  but to what purpose ?  It is an error a hundred  times de-
monstrated, to believe that there is danger in including some
lamellae of cellular tissue, or some fleshy fibrils, in  the ligature
along  with the artery.   The  nervous filaments, even  the small
veins strangulated in this manner, involve in reality no other  in-
conveniences than that of causing momentarily a little more pain.
One must be a stranger to  the  routine of practice in the large hos-
pitals, to impute to the defective isolation of arteries, the accidents
which too frequently follow  operations.   It is then for torsion only
that these preliminary attentions are indispensable.  From Mdience
it follows, as M'e may at once admit, that, so far as regards its prac-
ticability, the ligature will always have the advantage.
   As for the rest, when the favorable  conditions above mentioned
exist, and we have given all necessary attention to the operation,
the twisted arteries are as solidly closed as if they had been tied.
Inflammation, suppuration, external or internal, of the vascular and
nervous tissues, do not appear  to me more to be apprehended after
torsion than from ligatures.  That the first should cause them more 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      51

than the second, must have been owing to its having been performed
with one forceps only, and without taking the precaution of limiting
its extent inwards, as, for example, in the process of M. Thierry.
Nothing at least proves, in the facts published at Berlin, Hamburg,
and  Paris, nor in all those that belong to myself, that these fears
are well founded.  The  reproach which  has been cast upon it of
leaving the remnant of an artery that may act as a foreign body in
the wound, does not appear to me to have  any force.  In the two
patients amputated upon by me at the hospital of St. Antoine, in
1829, and who died, the vascular cone, still recognisable, was so
mixed up with  the surrounding tissues,  that it could  not have
created any inquietude in reference to the future, and I have  not
learned that other practitioners have positively established any inju-
rious effects from it.  Thus the only indisputable objection in tor-
sion is in not always offering as much security as the ligature, of
not being applicable to  all cases,  of  requiring much practice in
order that  it may be  well done, and of rendering the  operation
longer and more fatiguing;  on the other hand, in permitting  no-
thing to be left  of a foreign nature in the stump, it presents  the
advantage of producing less irritation to the wounded surface, and
of favoring the  cure without suppuration.   In this respect, how-
ever, the anticipations of practitioners will be rarely realized.   The
patients operated upon by M. Amussat did not recover faster, with
the exception of one only, an infant, Mrho was well, I believe, at the
end of from twelve to fifteen days, than if  they had been treated by
the ligature.  Neither was complete  union by the first intention
obtained in certain cases of amputation by MM. Fricke, (Rev. Med.,
1831, t. iv., p.  62,) at the hospital of Hamburg, Ansiaux at the hos-
pital of Liege, Dieffenbach and Rust at the hospital of Berlin, (Bull.
des Sc. Med., t. xxii., p. 445,) Guerin at Paris, Bedor (Schrader, Thes.,
Berlin, 1830) and Fourcade (Lancette Franc., t. v., p. 56) at the hos-
pital of Troyes, Lallemand and Delpech at Montpellier, and M. Key
at Guy's hospital, (Journ. Hebd.  Univ., t. vi., p. 400.)   That being
the case, torsion should not, in fact, be deemed of any importance
except in certain operations which are performed solely on soft
parts.  In fact, ligatures properly applied may generally be removed
from the sixth to the twelfth day ; and a crowd of facts prove that,
after their separation, eight to fifteen days, and sometimes less, suf-
fice to complete  the reunion; but  we do not  find that a wound
which comprises muscles, bones, aponeuroses, &c, can be perfectly
cicatrized and solidly agglutinated in less than from tM'elve to
twenty days.   To resume: I consider that after operations it is not
advisable to twist arteries that are difficult to isolate ;  that it  is
better  to tie those that torsion  could  not be practised upon, but
with every desirable degree of  security, and that we must not
admit this haemostatic means in such cases, but as a method liable
to exceptions.
   I.  Conclusion.—The haemostatic means  ought, moreover, to  be
varied after operations according to circumstances.   The ligature
is preferable wherever the blood escapes by  jet from  a rather 
52            NEW ELEMENTS OF OPERATIVE SURGERY.

large artery, which can be easily secured.  In the breast, scrotum,
and omentum, however, and in every part where the arteries are
long, flexible, and surrounded with  loose tissues, torsion offers real
advantages.  Bruising, and reversing, and pluggings (les bouchons)
are of infinitely less value.  If the blood oozes out from small arte-
ries, as  after extirpation of tumors of the neck, breast, and axilla,
and we are  not desirous of effecting immediate reunion, compres-
sion  by small balls  of lint (boulettes de  charpie) is an excellent
means which I cannot too much recommend.   [On the same princi-
ple act  the  admirable styptic pressed  sponge, punk,  cobweb, fur
of hats, &c.—T.]   Compression on the course of the vessels through
the teguments, as Kock applies  it, would be practicable on  the
limbs or head, if it should not be possible to tie or twist the divided
artery.  At  the bottom of certain moveable cavities, such  as  the
pharynx, mouth, and anus, the hot iron  frequently should have  the
preference.  Liquids, medicaments,  and styptics ought not to be
used but upon wounds already inflamed, or for consecutive hemor-
rhages, and when it is not proper to act mechanically on the wound
itself.  We must add, in  conclusion, that cool air, and cloths satu-
rated with cold water, are after a great number of operations suf-
ficient to arrest the hemorrhage in the space of an hour or two, if
there have been no other than small arteries divided.


                     §.  II. The Dressings.
  After the  haemostatic means have been employed, we attend to
the cleansing and dressing of the  wound.
  A. We clean two things in operations,—the wound and its neigh-
borhood, or  all the regions which have been soiled by the blood.
The M^ound should be cleaned at first, and while Mre are engaged in
securing the vessels.  Here our manipulations should be more or less
minute,  according  to two circumstances—according to the haemo-
static means employed, and the kind of dressing that we wish to
use.   If we use only small balls of lint, either naked or on fine linen,
it is of little importance that all the anfractuosities  of the wound
are or are not perfectly freed of clots of blood.   It is much the same
where torsion has  been used, or where  the two ends of each liga-
ture are to be cut off near the knot.  When each ligature remains
with one of its ends entire, thorough abstersion from the wound of
all the blood that may have contracted adhesions with it is no  lon-
ger a matter of absolute necessity, if we are going to dress the
parts flat, (a plat.)  In every case, on the contrary, where it is desira-
ble to effect the  approximation of the edges  of the  M^ound imme-
diately, it is important to free it as completely as possible of every
kind of foreign body.  To clean it, we use sponge and tepid water
rather than  wet cloths.  In pressing the sponge, we first wash it
freely with water, then  cleanse  and detach all the portions of
adherent fibrine, by brisk but gentle rubbing.  That done, we wash
all the  other parts, and  then wipe them and  dry them with soft
linen.   We return  then to the wound, to sponge  up the exudation 
THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.       53
 from it by a last wipe of the sponge, and proceed then to the dis-
 tribution of the ligatures.


                 B. Disposition of the Ligatures.

   When  the  hemorrhage  has  rendered it  necessary to employ
 ligatures, and  the  ends  of these ligatures have been retained, it
 is convenient to fold them  outside, and to fasten them on the skin,
 at some distance  from the wound.  Many modes of doing  this
 have been proposed.  Most surgeons are in the practice of gath-
 ering  all the  ligatures into one group, which they place near the
 most depending angle of the  wound.  But, by this method, some
 of the ligatures are  obliged to occupy the whole extent  of the
 wound before  they reach  the surface,  and there remains  at the
 bottom of the  wound a species  of roller or network, which neces-
 sarily increases the irritation and suppuration, and by that means,
 in fact, interferes  with the agglutination.  Others, and  I for one,
 have for a long time followed this practice:  conduct each  thread
 separately in a straight line towards the point nearest to the sur-
 face.  In this manner the ligatures represent rays as short as pos-
 sible, which do not hinder the surfaces from placing  themselves in
 contact, and becoming adherent to each other.  This last method
 is incomparably the best when it is practicable to undertake  imme-
 diate reunion, wdthout leaving cavities under  the borders  of  the
 wound.  In  the contrary case, as after amputations of the leg, for
 example, there  is but little  inconvenience in  following the ancient
 practice, since then it is next to impossible to avoid the suppuration
 of the parts which  are covered by the teguments, and brought to-
 gether by the suture, or straps, or in any other way.
  These threads, folded outside,  were formerly covered there by a
small compress known under the name of the ligature compress. It
was then necessary for an assistant to hold his finger upon this com-
press, until the  first portions of the dressing were applied around
the wounded region, at least for amputations.   Now we prefer, and
I scarcely ever deviate from this  course,  a plaster of gum diachylon,
from one to two inches long, or the end of an adhesive strap, (ban-
delette,) in fact, which is applied over the extremity of each thread,
or each group of ligatures.  If there should still remain any bloody
exudation, or should it be renewed, it must be removed for the last
time, and we then proceed to the dressing.  The dressing after ope-
rations is  a  point of the greatest importance.   Perhaps it has as
much to do with the success of many important operations, as the
mode by which  the  operation itself has been performed.   Also, it
has been conceded from all time, that the dressing should be treated
of apart, and form a special subject, in works of surgery.  I refer
then, for all that relates to its details, to  that portion of this work
which treats of minor surgery, not intending at present to speak
ot it  but in its connection with the great operations. 
54
NEW  ELEMENTS OF OPERATIVE SURGERY.
                   § III.—Union of the Wound.

   There are two modes of treating wounds after operations.  Some-
 times we approach the lips as exactly as possible, and  endeavor to
 keep them in the most perfect contact; sometimes, on the contrary,
 they are kept  apart  by placing  between them foreign bodies and
 different kinds of dressing. In the first case, we endeavor to obtain
 what is called the immediate union, or that  by first intention; in the
 second, we promote suppuration, and the cure or cicatrization is only
 obtained indirectly, (mediatement,) or by second intention; I will add
 to these, immediate secondary union.

      A.  Indirect (mediate) Union, or that by Second Intention.
   As late as the termination of the last century, indirect union (la
 reunion mediate) is, to a certain  extent, the only one of which sur-
 geons have made  mention;  but this is far  from saying that it has
 always been performed after the same rules.
   The ancients  had the practice  of filling the wound with com-
 presses, or sponges, dipped in vinegar, and of treating it? in fact, like
 all other solutions  of continuity in which they wished to promote
 suppuration.  Those who, like Archigenes, Heliodorus, and Paul of
 Egina, had recourse to cauterization to arrest the hemorrhage, made
 use at first of garlic and salt, with the view to make the eschar fall
 off, then  cataplasms  of honey, flour, or  eggs, or simply emollient
 substances.   The  Arabs  have  particularly extolled  astringents,
 styptics, and Armenian bole;  they also frequently employed the
 balsam  of sulphur.  Fabricius of Hildanus thought he could  sim-
 plify this dressing  in amputations by contriving a woollen purse,
 with which he enveloped the stump after having padded it with dif-
 ferent substances.  Wiseman preferred a beef's bladder to the purse
 of *abncms.  He employed also the dry suture* to approximate a
 little the lips of the wound.  Sharp wished nothing- more than the hot
 iron ; but to hinder the  soft parts from retracting, he  had recourse,
 like Pigray, to two ligatures applied crosswise.  It is thus we come
 to the mode of dressing generally folded towards the close of the
 last century.  At present it is done in the following manner.   The
ligatures being  arranged as we have above  said, we  place  a fine
piece of linen, covered  with  cerate, and perforated by holes, over
 the whole extent  of the wounded surface, whose edges are brought
 more or less forward, so as to form, by means of these, a large cav-
 ity.  Coarse lint fills this space ;  some smooth pledgets are placed
 over it;  long compresses, conveniently arranged, are then made to
 embrace the whole extent of  this region; then,  with a bandage of
 sufficient length and width, the dressing is completed
  In the place  of applying fine  linen immediately Jo the wound,
some surgeons fill it with sponge, agaric, or lint, as was done in the

  * La Suture seche—z. phrase of the schools for adhesive „/„<,*   ~>   I
 farther on-Art. Suture.  The phrase took its oribZt ^l^ff
strips together.—T.                        g lrom sewin& the edges of the 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.        55

last century ;  except that they border the circumference of it with
a liseret, or small bandage of linen, slashed (decoupee) on  its outer
edge, and spread with cerate.   The perforated compress appears
to me to be preferable.  As it is easy to turn it over upon the edges
of the wound, we have no fear of seeing the lint or other  material
of the dressing contract adhesions with the  cellular  granulations,
and the living parts that have been divided ; by means of this, in
fact, the second  dressing can be performed without pain  and with
the greatest ease, as soon as we judge proper.
  The  Maltese cross, in such general use formerly, has given place
to the long compresses, which are more convenient, and better ap-
plied to the form of the different parts.   We must take care  not to
push back these compresses with too much force  against the root
of the limb in amputations, for in doing so we should be certain to
crowd back the muscles and teguments whose retraction we are so
desirous of moderating.   It is for the purpose of avoiding this re-
traction, and to diminish as much as possible the protrusion of the
bone which results from it, that Wiseman, and especially Louis, have
recommended the application of the containing (contentif) bandage
from above downwards, and not from below upwards.  I cannot too
strongly recommend on this subject the following method: We first
pass the bandage once or twice around the trunk, then we bring it
to the root or upper part of the limb, conducting it by turns mode-
rately tight to a level with the extremity of  the bone, and proceed
afterwards to the rest of the dressing, as has been just described.
Another bandage, or the remains of the first, serve  to fasten  the
compresses by a second layer of turns, and to hold the whole firmly
together.  In this manner the muscles find difficulty in retracting.
The skin is pushed forward, and we moreover prevent, in a  great
degree, the swelling of the stump, and the erysipelatous or  phleg-
monous inflammations of which it may become  the seat, and even
the phlebitis, which it is so important for us to arrest, the moment it
begins  to be manifested.


        B. Immediate Union, or that by the First Intention.
  The explicit direction to bring together the edges of the wound,
and to close it immediately after amputations, does not appear to
go back before the time of Alanson, or at farthest  to Gersdorf.
Adopted by Hey, and soon after by almost all the surgeons of Great
Britain, it was not received among us but with a certain repugnance,
except  by Percy, who had frequent occasions of testing its advan-
tages in the midst of camps.   Pelletan,  M. Larrey,  &c, at first
stoutly  opposed it; but Dubois, Boyer, Dupuytren, Delpech, MM.
Richerand and Roux, and almost all the distinguished operators of
Paris and  of other  cities of France, nevertheless, adopted it in a
majority of cases.   It appears, however, that  Dupuytren had not as
much  reason  to approve of it as he had believed at first, and that
M.  Roux often thought it advisable to refrain from putting it  in
practice. 
56
NEW ELEMENTS OF OPERATIVE SURGERY.
  To unite by the first intention, it is important, much more than in
the other method, that we should not leave in the wound any other
foreign  bodies except those that we  are not permitted to remove
from it.  We begin, then, by removing carefully the clots of blood
and the threads that are not indispensable, and by cleaning the sur-
rounding parts with a sponge, and wiping the whole out with dry
and soft linen.  That being done, we approximate as exactly as pos-
sible the divided  parts,  endeavoring not to leave  more  space be-
tween them towards the bottom than near the  edges.   While an
assistant retains' them in this position, the operator puts on the ad-
hesive straps, (les bandelettes agglutinatives.)  By commencing Math
those of the middle, it is generally more easy afterwards to apply
the others.  Three or four  almost always suffice.  It is a rule to
leave some space between them, and not to cover the entire cleft
with them.  The  longer they are, all  other things  being  equal, the
better they  hold  on, the less inconvenience are they to the skin,
and the better they attain the end we have in view.  To support
their action, it is often useful to have at the same time, on the sides
of the  wound, parallel  with its largest diameter, graduated com-
presses of more or less thickness, or rolls of lint,  (faisceaux,) either
between the straps and the skin, or otherwise, between the remain-
der of  the bandage  and the straps ; it is the only means in some
cases of hindering the fluids from accumulating at the  bottom of
the cavity, and of obtaining a free and regular union.
  If the ligatures have not been cut near the arteries, we fold them
back separately and fasten  them between the  adhesive straps*by
small strips  of diachylon plaster.  In the place of bandelettes decou-
ples (vide supra) or the  perforated compress that are placed on the
entire anterior surface of the stump, some persons  simply make use
of a large thin layer (gateau) of lint, smoothly spread with cerate :
in this matter each should act as he  thinks proper:  the important
point is to prevent the  too close attachment of  the portions of the
dressing with the neighborhood of the wound.   Soft pledgets (plu-
masseaux) of dry  lint are afterwards arranged so as to cover in a
convenient manner  the  sides and fore part of the  stump.  For
that purpose two or three pledgets suffice : a greater number, from
the excess of  heat  which they might give  rise  to, might be more
hurtful  than useful.
   The long compesses  vary necessarily in their number or length,
according to the  size of the part or extent of the incision.   Their
middle part ought to rest precisely on the front  of the wound, and
their extremities to be carried gently  towards the upper part of the
limb.  The one that some, after amputation, apply around or circu-
larly to the limb, to fasten the others a little above  their place of
crossing, is, for the most part, useless.
   A bandage  freed of its hem and ravelling, (fauxfil,) and which is
soft and rather narrow than too wide, completes the dressing.  After

  * Strips of adhesive plaster, elsewhere called by the author bandelettes agglutina.
tives, are here, designated as rubans emplastiques. They mean the same thing.__T. 
        THE CONDITIONS THAT ARE ACCESSORY TO  OPERATIONS.     57

having passed it, by circular turns, from the stump towards the upper
extremity of the limb, we bring it back in the same manner to the
side of the wound, on the fore part of which we may cross it several
times, so as to shape it into a kind of capeline bandage, so frequently
employed formerly ; and in order that we may thus obtain one that
is more regular and neat, but  which, however, augments the per-
pendicular  pressure at  the expense of the lateral.   As  we may
thereby compromise the  safety  of the patient, this sort of affectation
must be dispensed with, wherever we apprehend a deposite of mat-
ters at the bottom of the wound.
  Suture.—In the place  of plasters, or Mrhat is called in the schools
the dry suture, (la suture seche,) some operators employ the bloody
suture, the suture properly so called, in other words, sew the wound
up.  This method, used by Pigray, Wiseman, Fabricius de Hildanus,
Sharp, &c, with a view of holding  the integuments firm together,
has been especially lauded, in  latter times, by Hey, M. Benedict of
Breslaw, and by Delpech, Mdio asserts that he  has derived the great-
est advantages from it;  at Montpellier they scarcely ever dispense
with it after amputations.  The interrupted suture, i. e. with inter-
vals between jthe  stitches, is that which is preferred in such cases,
though  the suture of Pelletier  may answer as well.  For more
safety, and to relieve the threads, we may  also, after the manner of
Delpech, place some adhesive straps* between them. If the employ-
ment  of the suture of which we are speaking was not necessarily
accompanied with much severe pain; if the union of the teguments
was the most important part of the operation ;  and if the plasters did
not effect the same object when they are properly  applied, there is
no doubt that it would have been long ago adopted :  but the con-
trary being generally admitted,  every thing induces us to believe,
that for the future, except in a small number  of cases, the adhesive
plasters will continue to be substituted.
  When we begin like Louis, Alanson, and M. Richerand, by fasten-
ing a long bandage around the  body, that it may descend afterwards
by turns to  the base of the wound, it is upon this that the straps ought
to take their point d.appui, and with this difference from the other
parts  of the dressing, that it ought to be changed as seldom as pos-
sible.
  Open Dressing, (Plaie a Vair.)—Kern, Klein,  Walther, and most
of the German surgeons, approve neither of lint nor pledgets about
the stump,  which they slightly cover with a  few  compresses wet
with cold water.   This  practice has found many imitators in Eng-
land and America, even  among hospital surgeons; and I learn from
M. Castello, physician of Ferdinand VII., and professor in  the uni-
versity of Madrid, that it has been a long time practised throughout
nearly all Spain.   In France,  up to the present, it has counted but
a small number of partisans.   This, as it appears to me, is  to berre-
gretted, for nothing can  be more satisfactory than the results that
 * The author, varying here from his two phrases above, denominates adhesive plasters
or straps, bandelettes emplastiques.—T.
                              8 
58
NEW ELEMENTS OF OPERATIVE  SURGERY.
foreigners obtain from it.   Divested of a mass of useless dressings,
the stump is infinitely less heated.  In preventing or moderating the
inflammation Mmich must  invade it, we place the contiguous sur-
faces in the best possible condition to obtain immediate union, and
the general reaction is reduced usually to a small  affair.   The
trials I have made of it have proved to me that  cold water, though
often useful, is not always without its inconveniences.  In hot sea-
seasons, and when the patient is to remain in bed, I cheerfully fol-
low this practice, especially if the inflammation threatens to be
intense ;  otherwise, it exposes us to real dangers, and is not as good
as the ordinary method.


C. Relative Estimate  (appreciation)  of Dressings by the First and
                      the Second Intention.
  The ancient method of treating wounds endangers, it is said, the
exhaustion of the patient, by the abundance and  continuance of the
suppuration, and by the severe pains  at each dressing: it requires
three, four, five, six, and even seven or eight months to  effect  the
cicatrization, ordinarily produces only a. small cicatrix, which is torn
upon  the least exertion, and is almost always accompanied with a
considerable deformity upon the apex  of the stump,  after an ampu-
tation.  By the new method, say Alanson, MM. Guthrie, Klein, &c,
the patients suffer infinitely less; the fever is  always moderate;
there is  no debilitating suppuration ;  the stump remains rounded,
firm,  and well nourished ; and  at  the  end of  eight, ten, fifteen,
tM^enty, or thirty days, the cicatrix is solid, and the patient in a con-
dition to use an artificial limb.
  Of ninety-two  soldiers treated in this manner on the  field of battle
by Percy, eighty-six were cured in twenty-six days : out of seventy,
Lucas did not lose but five.  But while in France the chief of mili-
tary surgery defended immediate union with so much  ardor, the
chief of civil surgery endeavored to cause it to be proscribed.  Out
of six persons operated upon by Pelletan, he saved only one.  In all
there were effusions  of blood' and of pus between the lips of the
wound, in the  course of the vessels, and among the  muscles, and
the only one that was saved owed his life to  an effusion of pus
which forced off the adhesive straps : there  is danger,  then, says he,
in closing a wound which may bleed, or has need of suppurating,
either owing to the ligatures that irritate it, or because the bone, more
or less altered by the action of the saw, must necessarily exfoliate.
   The cure by the first intention is more prompt, says M. Gouraud,
who adopts the objections of Pelletan, but it is more certain by indi-
rect union; (la reunion mediate:)  by being  prolonged, the suppura-
tion prepares the person operated upon for the changes which must
supervene throughout his whole system ; and every time we operate
for an old disease, the  secondary reunion is the  only one which is
suitable.
   As for myself, I can aver, that if the accidents mentioned by Pel-
letan often occur, it is much more for want of sufficient precautions 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      59

than as an unavoidable consequence of the  operation ; allow that
there may be some danger in drying up the source of a copious sup-
puration of long date, and shutting in eight days the wound that
results from the removal of a limb which the  constitution had for
a long time transformed into a secretory organ; but are not these
exceptions ? and can reasons so feeble, and for the most part ques-
tionable, weigh down against all the perils that we risk by indirect
union ?
  In shunning one extreme, we should guard ourselves from falling
into the other.  If the bleeding surfaces may be easily brought to-
gether, if there remain in the stump nothing but sound parts, the
immediate union has immense advantages; and we ought to try it.
In the  opposite conditions, we may act otherwise, and confine our-
selves  to approximating little by little the lips of the Mround, after
having placed between them small balls or pledgets (faisceaux) of
lint, naked, or by the intervention of the perforated  compress.   It
would  be imprudent  and even dangerous to  persist  in maintaining
these in contact with it, if, in the course of the first three or four
days, blood or other fluids  should be  effused in sufficiently large
quantities to prevent the reunion from  being freely made from the
bottom towards the  edges.  It is then  that it is proper to give a
large and free issue to the matters accumulated behind the straps
or sutures, and between the teguments and divided muscles, to clean
cautiously the whole  extent of the opening, (clapier,) and to dress af-
terwards loosely, that we may look no longer but to union by the
second intention.  In acting thus we  will obtain  most frequently,
if not always, in the  space of fifteen, twenty, or thirty days, a  com-
plete cicatrization, even after the amputation of the thigh, as I have
many times myself experienced.

D.  Conclusions on the Relative Value of the  two Kinds of Reunion.
  To be understood on this point, we must consider the question as
the moderns  have laid it doMoi.  Mediate [i. e. indirect.—T] union
is no longer to-day what it formerly was.  By the present modes,
we frequently obtain a perfect cicatrization in the space of three to
six weeks.  The roller bandage with which we surround the stump,
hinders the skin around it from being drawn backward, and suffi-
ciently favors the contraction of the wound to reduce it with great
rapidity, as soon as the ligatures are separated, and it is covered
with vascular granulations.  When we can  afford to wait  for the
formation  of  pus, the lint is detached without pain and  without
the least danger; the suppuration diminishes from day to day ; the
suffering, the  inflammation, and the fever have nothing alarming,
and  have  been most strangely exaggerated.  In  permitting the
fluids to ooze  out as they form, it renders their absorption more dif-
ficult, and exposes less to inflammations, abscesses in  the stump, and
to phlebitis and metastatic deposites in the viscera, or serous cavi-
ties, than immediate union does.  Moreover, the primitive adhesion,
such as it is daily practised, scarcely leaves  the patient cured be-
fore three weeks or a month. 
60
NEW  ELEMENTS OF OPERATIVE SURGERY.
   If it be true, that in spite of the contact of substances so different,
 as bones, aponeuroses, muscles, cellular tissue, nerves, vessels, and
 the skin, the separation of some, the contusion of  others, the con-
 tinual tendency of certain others to change, the almost absolute im-
 possibility of leaving neither clots of blood, nor lamellae, nor arteries,
 nor the least foreign matter, at the bottom of the wound in amputa-
 tion, for example,—the union has sometimes been achieved Mdthout
 any suppuration, and that this, therefore, is possible, then  is it also
 true that on that account we should concede to the dressing more
 care and time than is ordinarily given to it; that the section of the
 soft parts should  be neat and regular; that the teguments should
 fall without effort on the front part of the stump, as if they were a
 head-dress;  that the bones should  not protrude beyond the  deep
 muscles; that all the arteries liable to bleed should be immediately
 tied or twisted ; that the sides of the wound, freed of foreign bodies,
 should touch throughout their whole surface, and be kept together
 in the direction that offers the least  resistance;  that the  straps
 should do no more than  preserve the coaptation, without pressing
 or exercising any drawing force, and be also wide enough and suf-
 ficiently approximated together to prevent any slackening among
 them ; that the suture should be added to them, or  even preferred,
 if the skin is thin or tends to roll up inwards; that the  diseased
 part  should be afterwards kept in the most perfect immobility, and
 that the inflammation should be moderated by every possible means.
 If blood or pus be deposited at the bottom of the wound, and if the
 adhesion of the skin prevent their escape, they soon cause a local
 reaction; from thence come swelling and redness,  and then fever,
 finally a kind of abscess Mrhich develops  itself in the centre of the
 stump, an abscess whose floor is represented  by the section of the
 bone, flesh, and vessels,  Mdiile the tegument constitutes its dome or
 plafond.   Reposing on  tissues newly divided, the  pus penetrates
 them, separates them, insinuates itself into their interstices, extends
 more and more, and spreads the inflammation through the muscles,
 vessels, and periosteum, and even under the skin.  Then the veins,
 the lymphatics, and the  absorbent system, and every thing else be-
 coming involved, it constitutes a powerful cause  of  phlebitis or
 purulent fever, and  exists in sufficient  force to determine those
 metastatic deposites which are so often followed by death.
  As soon as these dangers threaten, we should at  least  endeavor
 to remedy them.   If the ligatures  do not answer sufficiently well as
 filters, we relax one or more of the adhesive straps, which, in fact,
 must all be removed if the skin is red or  swollen.   We then treat,
 afterwards, as for a subcutaneous phlegmon.   We now envelop
 in a large poultice the stump, which latter must have been  pre-
viously leeched or not, as may seem necessary.  We also open one
 of the angles or points of the wound as soon as the presence of pus
is no longer doubtful, taking care to make this opening sufficiently
wide to prevent the matter from stagnating afterwards at the bot-
tom of the cavity which produces or retains it.  We do, in fact all
that can be done to empty, cleanse, and cicatrize the part, the same 
       THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      61

as if it were a true abscess, and to  keep the teguments in the posi-
tion which we had given them.
  It is, in fact, under such discouraging circumstances, and not under
the brilliant forms that Bell represents, that we meet with immediate
union in practice.  This, however,  does not infer that  we ought to
reject it, but that it is not always convenient, and also has its dan-
gers, and that it is often advisable to substitute for it the simple and
incomplete approximation of the lips of the wound.   Thus under-
stood, it appears to me to include the advantages of the secondary
union.  In this sense, M. Serre, following his preceptor Delpech, is
entirely right.   The  error of their school is to attach too much im-
portance to the circumstance that there is no opening for matter to-
wards the most depending part of the wound.  The suture, in truth,
is rarely required, and there would  evidently be danger in not mak-
ing a passage for the pus, as soon as it is collected in  the stump in
sufficiently large quantity.   It is easy to see from these  observations
that Dupuytren, who placed a layer of soft lint between the lips of
the wound, previously slightly approximated with straps of diachy-
lon,  and that M. Larrey, who  dresses even  with pledgets spread
with resin of styrax, differ very little in their dressing from that
of union by the first intention,  such as it is practised  and adopted
at the present day.

                 E.  Secondary  Immediate Union.

   To reconcile the two preceding methods, it is easy to establish
from them a third, by applying to  wounds from operations in gen-
eral what O'Halloran advises for the flap operation in amputation.
After having employed open dressings to the wound until it has be-
come thoroughly cleansed and uniformly covered with rose-colored
cellular granulations, there is nothing to prevent our approximating
its edges so as to effect secondarily immediate reunion.   I have used
this  mode with success in  a great number of instances.   It is a
practice  which Paroisse has strongly recommended, and that may
be qualified with the name of Reunion Immediate Secondaire.   Every
thing being thoroughly cleansed,  it is generally easy  to bring  the
edges of the  wound in  contact, either  immediately or by degrees,
and thus, without incurring any inconvenience, obtain a union in
the space of a few days.  I am of opinion that it is advisable, wdth
very few exceptions, to undertake either the simple approximation
of the edges of the wound, or even immediate reunion, taking care
not to forget  the foregoing precautions; but that if accidents evi-
dently caused by it begin to be manifested, we ought not to hesitate
reopening the wound, and deferring the union to a later period. I
would add, that the results of this mode of dressing are much more
under the control of art than those of absolute  secondary union ;
that consequently they will be favorable or unfavorable, according
to the skill or mal-address of the surgeon, according as the  opera-
tor shall attach more or less importance to certain precautions that
cannot be learned in books, and  of which those only who have 
62            NEW ELEMENTS OF OPERATIVE SURGERY.

the opportunity of putting them into practice can estimate the value.
It must not be forgotten, moreover, that the preceding remarks have
much more reference to wounds from amputations than to any other
operations.
                        CHAPTER  V.

          CONSEQUENCES  OF  OPERATIONS.

              Article I.—Natural Consequences.

  After the dressing we attend to the removal of the patient, and
to the position which it is most proper that he should have.  If the
operation has been performed upon an ordinary bed, it is sufficient
to remove the  coverings and other objects that are wet or soiled by
the blood, and to replace them by dry linen.  In the contrary case,
the patient operated upon is borne upon a litter  or upon the arms
with the least  possible motion, taking care that he receives no chill.
In cold seasons, it is desirable'to place him in a bed that has been
warmed ; in other cases, this  precaution is unnecessary.  Once in
bed, the patient should be placed in a position which will require
the  least muscular effort; that  is, on  the back, having the head
moderately elevated, and the lower limbs slightly flexed.  As to
the part which has been operated upon, we place it in such a posi-
tion that nothing can draw upon the lips of the wound or upon the
ligatures.   It consequently requires a position which must vary ac-
cording to each kind of operation.  If  the wound is in a part of the
body M'hich must remain in  bed, the coverings are raised from it
by  means of hoops.  When the  limbs are concerned, we are often
also obliged to place some cushions under them.  The patient, being
thus arranged, should be left quiet.
  Ordinarily he suffers sharp pains during the first hours, but these
afterwards diminish by degrees, and soon become quite supportable.
He also often appears pale and feels cold, or has  even a slight chill
for  some time.  These phenomena, M'hich  are accompanied  with
debility and with  contracted pulse, soon disappear,  or require no
other remedy than one or two table-spoonfuls of wine, some warm
drink, or an anti-spasmodic potion.  If every thing goes on regu-
larly, the inflammation in the wound  is developed in a moderate
degree only, and causes but a slight febrile reaction of some three
or four days.   It is this period which requires the most precautions
in the regimen.  If the operation is really severe, little as we may
have to apprehend hemorrhage, it is  advisable to leave  a skilful
assistant near the patient for the first twenty-four hours, sometimes
even for some days.  This  precaution, which the presence of the
pupil on  duty renders  almost  entirely unnecessary in hospitals, 
CONSEQUENCES OF OPERATIONS.
63
ought not to be neglected in private practice ; it inspires confidence
in the family, and powerfully contributes to the  composure of the
patient.

              § I.—Regimen for those operated upon.

  Some practitioners keep their patients who have undergone a
severe operation upon a  rigid diet  from six to ten days.  This
method, very generally adopted in France, has for its object to pre-
vent or moderate the febrile reaction, to hinder the formation of
abscesses in the vicinity of the wound, and  the  supervention of a
local inflammation in the digestive organs.  Bleedings, more or less
numerous, according to the strength of the individual, and emollient
drinks and anodynes, are united to this treatment.  Most foreign
surgeons strongly eulogize a course directly  the  reverse.   In  Eng-
land, in America, and even in Germany, many practitioners admin-
ister large doses of opium, wine, and brandy to their patients, even
the same day of the operation.  Kock allowed them coffee, strong
liquors, and nourishment the day after.  Benedict maintains that
instead of preventing unpleasant symptoms, bleeding  promotes
their development;  it is the most robust subjects who best resist   *
morbific causes, and with  them inflammations  are  most easy to
cure.  The severe diet and copious bleedings prescribed by  some
persons before or immediately after operations, are only  of advan-
tage, he says, where incidental  diseases and local inflammations
supervene in those who have been operated upon.
  These two doctrines appear  to me equally objectionable.  The
severity of the regimen is in reality carried too far in France by a
great many surgeons; but it is evident that the course pursued by
the English and German practitioners must be liable to many more
inconveniences.  For myself, I conform generally to the following
rules ; if it is  a slight operation, as that for fistula lachrymalis or
amputation of a finger,  I scarcely  change the customary  regi-
men of the  patient.  In the extirpation of tumors, and in all ope-
rations that do not necessarily disturb the  circulatory  functions, I
diminish to one quarter or one half the  quantity the patient takes
when in health, and I willingly allow  him water slightly tinged
with Mdne, (de I'eau rougie,) or some pleasant tisan  of his own
choice for drink.  If the operation is more serious, or necessarily of
a nature that must  seriously implicate  the  general system, I con-
fine my treatment to bouillons or very light broths (tres legers po-
tages)  for two or three days.  At the end of this  time, if there does
not supervene an evident febrile reaction, I allow substantial broths,
then some of the white meats, eggs, and fried fish, with a small
quantity of bread and wine.  I thus  manage to allow the patient
the quarter or half of his customary  aliments in the course of the
second week.
   I do not recur to bleeding unless the operation has required  an
extensive wound, or involves a delicate  and important organ, and
where the patient is naturally plethoric and sanguine.  Under such 
64
NEW ELEMENTS OF OPERATIVE  SURGERY.
   circumstances I frequently prescribe bleeding, even the same even-
   ing of the operation, M'hich I sometimes  repeat  the  next  day, and
   also the day after that.   I likewise employ venesection at the natu-
   ral period of the reaction, that is, from the third to the sixth day, if
   the fever seems to take on too much intensity.
     The drinks which I prefer after the  eau  rougie; which is most
   suitable in simple cases, are the light infusions of the linden, if it is
   advisable  to  favor  action upon the surface, the  poppy when the
   nervous system is much affected, chamomile in lymphatic tempera-
   ments, flowers of mallows or marsh-mallow  when there is cough,
   borage, or buglosse, or elder when we wish to promote perspiration.
   vegetable acids, citric, tartaric, &c, decoctions of barley or gruel—in
   fine, the different kinds of acidulated  drinks—if the patient com-
   plains of too much heat and thirst.  But  this regimen must be un-
   derstood only in a general sense ; for we  must not forget that all
   the accidents that occasionally succeed to operations may require
   a change of regimen or a particular treatment.
     Many patients, soon after  being operated upon, become  constipa-
   ted.  This is owing to the necessary  want  of exercise, the small
   quantity of food allowed  them, or perhaps to actual torpor  of the
•  intestinal canal.   As the accumulation and retention of stercoral
   matters, in such  cases, must increase the general uneasiness, the
   cephalalgia, pervigilium, and febrile reaction, they must be reme-
   died in proper season.  We must not, however, forget that a patient
   who has undergone a severe operation may remain three, four, or
   five days without stools, and without experiencing therefrom any ac-
   tual inconvenience.   The movements and displacements which the
   administration of enemata and the desire to void the excrements oc-
   casion, expose the patient, in certain cases, to such serious  dangers,
   that we ought not to have recourse to these means unless  they are
   urgently required ; so that we may  wait at least three or four days
   before prescribing laxative injections or mild purgatives. Enemata
   are proper M'hen the operation has been on the  upper part  of the
   body, since, in this case, the  movement of the pelvis involves  but
   little inconvenience.  For the other regions, unless it is contra-in-
   dicated by the state of the digestive organs, I prefer giving  a few
   glasses of Seidlitz water,  or two or three glasses of water of pullna
   in the morning, or a draught composed of two ounces of castor oil,
   four ounces of a weak infusion of mint, and one of sirup of lemons.
   to be taken by table-spoonfuls until it produces a purgative effect.
      Changing the linen of the patient  is a duty that must not be neg-
   lected.  If the  shirt has  not been removed  on the bed where he
   was operated upon, we must hasten, however little  soiled it may
   be, to change it before leaving him in his new position.  The nap-
   kins, sheets, and other parts  of the bed  must be changed every two
   or three days, or even more frequently, if they  freely  imbibe the
   liquid matters that exude from the wound.  In  other respects, the
   attention to cleanliness in those operated upon is not subject to any
   special rule. 
CONSEQUENCES OF OPERATIONS.
65
               § II.—Separation of the Ligatures.
  If the  flat mode  of dressing has been preferred, the  ligatures
placed on the arteries rarely fail of coming away between the fifth
and tenth days.  When immediate union  has been attempted, they
ordinarily hold on a longer time.   I have seen them remain until
the twentieth or even thirtieth day.  When they are too long a
time in separating, it is generally owing to  two principal causes :
first, because some lamellae or threads  of fibre are  caught  in  the
knot with the artery ; or, secondly, that the knot itself of the liga-
ture is at the same time imprisoned by the adhesion of the tissues
at the bottom of a narrow passage.  In other respects, it is not un-
common  to see ligatures detach themselves on the third  or fourth
day, and  that without the slightest inconvenience following.  This
is a fact that I have often been witness to after the removal of tu-
mors, and even of some amputations.  As  for the rest, I shall, when
speaking of particular operations, point  out the means of promoting
the separation of the ligatures.


                    Article II.—Accidents.

                         §  I.—Spasms.

  One  of the  most frequent occurrences observed  after capital
operations,  is spasm, or convulsive tremors.  I do not speak here
of the spasm and momentary chill which patients almost always
experience  until they are warm in bed,  but of the convulsive move-
ment which is prolonged, or tends \o be prolonged to an indefinite
period, by affecting the wounded part with spasmodic contractions
that are sometimes  exceedingly painful.  We remedy this kind of
spasm  by  giving warmth to the  part  as speedily as possible, by
making strong pressure with the hand upon the muscles near their
source, or by holding down the part by  means of a bandage attach-
ed to each  side of the plane of the bed  ; also, by  giving antispas-
modics and opiates internally, and by keeping  the dressings thor-
oughly wet with mallows-water  and laudanum.   In hot climates,
these spasms cause great uneasiness, because  they  are sometimes
the preludes of tetanus.  In our temperate climates, it is rare that
they are of a serious nature.

                      §  II.—Hemorrhage.

  After operations, the hemorrhage may still be renewed and excite
apprehensions.  This accident is owing  to different causes.  In
some cases, the hemorrhage is owing to  this : that many of the  ar-
teries, not bleeding at the time of the dressing, from being restrained
by the revulsion of the blood to the interior, have neither been tied
nor twisted; so that, dilating themselves in proportion as the circu-
lation recovers its  natural action, they finally commence bleeding.
It is generally at the end of some  days that this kind of hemor-
                              9 
66
NEW ELEMENTS OF OPERATIVE SURGERY.
rhage takes place ;  and it is with the view to prevent it that some
surgeons have advised that we should wait two or three hours be-
fore proceeding to the final dressings.  Sometimes, also, the hemor- I
rhage which supervenes the first twenty-four hours after an opera-  '
tion is excited by the irritation caused by the lint and other foreign
bodies collected in the  wound.  The blood, in such cases, rarely if
ever comes from such arteries as have been tied or twisted.  After
the first two or three days, the hemorrhage which is denominated con-
secutive never takes place  but by exudation, the premature cutting
through of the arterial  trunks, or the loosening of the ligatures.  It
has been thus  seen from the eighth to the thirtieth day. M. Guthrie
saw it on the twentieth, thirtieth, and even fortieth day.  It appear-
ed in one of M. Roux's patients  at the end of the thirty-fourth day.
It is difficult to explain its appearance in  such cases without  ad-
mitting a diseased state of the vessels.   In fact, the ligature scarce-
ly  ever requires more than two or three days for the effectual  ob-
literation of the  arteries.  In my own  practice, I have  seen  the
ligature  of the radial  and ulnar arteries, of the  dorsalis  pedis,
and even that of the brachial, both after amputations and operations
for aneurism, come away on the third and fourth days without any
hemorrhage resulting therefrom.  The accident, then, in the cases
referred to must be ascribed  to  an  exhalation from  the wounded
surfaces, or to some ulceration in the tunics of the arteries them-
selves.
  If the bleeding is not profuse, and the patient retains his strength,
we need be in no hurry to arrest it.  If it is only from  the small
arteries, they soon cease of themselves, and the bleeding from them
is a kind of  hemorrhage, which  is rather useful than injurious.  In
other cases we begin by cooling the part, and  keeping it wet with
cold water.  If that is not sufficient, M'e apply the tourniquet, the
garrot, or some other means  of  compressing  the track of the prin-
cipal artery.   Supposing that even this may not be effectual, we
take off the dressings to clean the wound, and search and tie or twist
the vessel which gives the blood. After the first twenty-four hours,
the coats of the  artery  have undergone so much  softening, (ra-
mollissement,) that they are  easily cut  through  by the  thread, so
that the  ligature can no longer effect a solid obliteration.   It might
be  advantageous  then to  imitate M. Sanson, by cutting all the tis-
sues around their bleeding extremity in a circular direction, so as to
make a cone, whose base would be formed by the wound, and whose
apex, to which the thread should be applied, would be formed by the
body of the vessel itself.
   When these means are  insufficient, or impracticable, we may try
direct pressure, with agaric, lint, or sponge, and by some means or
another stop up the wound.   Plugs sprinkled with resin, or dipped
into Rabel-water, (Feau de Rabel,) or some other astringent liquid,
or, even if it  were possible  so to do, the fingers of assistants, who
should  successively relieve  each  other, or  some apparatus con-
structed on the principle of that of J. L. Petit, and to be employed
for the  space of from twenty-four to forty-eight hours, would often 
                  CONSEQUENCES OF OPERATIONS.                67

be found to succeed.   A last resource consists in searching for the
principal artery of the part, and tying  it at some distance above
the wound.  The kind of ligature that Delpech, Dupuytren, Somme,
MM. Roux, Ghidella, and  some others have used with success, has
nevertheless failed in many cases cited  by M. Guthrie, or reported
on the authority of M.  Blandin.   Again, we should not class under
hemorrhages the exudation which almost always wets or soils the
dressing, the napkins, and even the pillows, on the first  or second
day.  This exudation, which soon dries  and produces  a great deal
of stiffness in the dressings, is composed principally of a viscid se-
rosity, rather than of blood.  Moreover, while the force of the pulse
is preserved, and the paleness does not increase, cold ablutions and
the tourniquet will  be quite sufficient, if, in fact, any thing is
necessary.

                  § III.—Various Inflammations.

  If the inflammation which naturally ensues from the wounds of
operations should  take on the character of erysipelas, angioleuci-
tis, or phlebitis, it comes under the class of accidents.
  A. Ordinary Erysipelas is in  general announced by chills, rest-
lessness, loss of sleep, acrid heat of the skin, nausea, and much thirst.
We afterwards notice, in  the  neighborhood of the  wound, red
patches, with scalloped edges, (a bords festonnes,) slightly elevated
upon  the surface of the  healthy skin.  When this kind of phleg-
masia  is not  traceable to the constitution of the patient, nor to
atmospheric influences, it is almost always  caused by morbific mat-
ters retained  or stagnating at the  bottom of  the wound.   We
remedy it by removing the plasters from the skin, if any have been
applied, and by giving free issue to the  offending collection, en-
veloping the whole part, in its naked state, with warm  poultices,
and observing the course  adopted in the general treatment of ery-
sipelas.

  [New and successful Treatment  of Erysipelas Proper by  Sulphate
                            of Iron.

  Since this edition was published in 1839, Professor Velpeau has in-
vestigated the  nature and treatment of erysipelas, properly so called,
or ordinary erysipelas, in a more special manner, the results of which
investigation are contained in a very recent paper published by him in
the journal of  the Annals of Surgery, at  Paris, for February, 1842 ;
from a cop} of which, kindly transmitted to us by the author, express-
ly for this American edition of  his work,  we make the  following
abrege'. or summary:

              I.—Nature and March of Erysipelas.

   The experience which I have had, says M. Velpeau, and the ob-
servations which I have collected during  twenty-five  years  past,
authorize me to establish, among other facts: 
68
NEW ELEMENTS OF OPERATIVE SURGERY.
   1. That  in  a surgical point of view, the predisposing cause of
erysipelas  lies much more in inflammation produced by external
atmospheric or meteorological  influences, than in the condition of
the health or general constitution of the  patient.
  2. That  the determining, or occasional  cause, may almost always
be recognised  in a wound, or in a crustaceous  condition (etat crou-
teux) of the part, or any irritation  whatever,  in  some  point upon
the surface of the integuments.
  3. That  its efficient cause  is in general a  matter coming from
without, or from degenerate (denatures) tissues, and mingling itself
with the fluids of the diseased region, either  secondarily or from
the beginning.
  4. That  the fluids thus changed produce two  orders of morbid
phenomena, viz.: general and local ; the first before the second
when there takes place at  first the introduction of the fluids  into
the general circulation; the  second before the first if the change
is effected only by direct absorption, (imbibition.)
  5. That  in the diseased inflamed  skin, the fluids changed by the
morbific element do not seem to circulate and advance  but by en-
dosmosis; so that, progressing more and more, and extending super-
ficially and not in  depth, the  erysipelas  spreads upon, or into, the
dermis, in the manner of oil on a flat surface.
  6. That a great proportion of the  morbific matter remains, even
to the termination of the disease, under  the epidermis, or in the
dermoid tissue, mingled with  the blood in the  inflamed organic re-
gion, (plaque.)
  7. That the totality of an erysipelas is almost constantly formed
of a number of small successive erysipelatous inflammations.
  8. That  an isolated erysipelatous patch (plaque)  generally dis-
appears of  itself at the end of four  to six or eight days.
  9. That the duration of the whole disease is thus  extremely va-
riable, in consequence of the number of erysipelatous  patches which
succeed, or are superadded  to the others.
  10. That the remedies, whether internal or external, intended to
remove  such a disease, should  have a special  tendency to effect a
modification of the blood.

                    Treatment of Erysipelas.

  M. Velpeau states that his experience, to the present, extends only
to external  remedies.   He has treated one thousand cases, or about
sixty per annum, at his  hospital, of  which he has taken minutes of
only four hundred.
   Since the time he has drawn the line of distinction between ery-
sipelas  and other  inflammations, twenty-five  of these cases have
been treated by compression.   In these the erysipelas continued from
six and eight to twenty days.  The redness diminished  under the
bandage, but the itching continued, and also the pain on the points
that were compressed.  The inflammation continued  to spread.  If,
says  M. Velpeau, I once thought otherwise, it was  because, like 
CONSEQUENCES OF OPERATIONS.
69
the rest of the world, I  confounded erysipelas proper with diffused
phlegmon, angioleucitis, and phlebitis.
  He made trial in thirty-three cases of the temporary blister, on the
centre, and to beyond or only on the margin of the diseased regions;
but in no  case was the  disease shortened ; and it can afford relief
only in the phlegmonous form, or in angioleucitis.
  The nitrate of silver, (azotate d'argent,) in its natural state and
concentrated, and also in all its modes of application, gave no bet-
ter results.
  Twice only he used the hot iron, after the mode of M. Larrey.
  In two hundred he used the Neapolitan ointment, and without ef-
fect.  " The mercurial ointment" he says emphatically, " neither cures
nor arrests erysipelas."  It may shorten it, perhaps, a day or two, or
render it a little less painful, the only reason for which I still  some-
times use  it, and for which it would still be in use, but  for the re-
pugnance patients have to  it, the danger of salivation, and the soil
i.ng of the linen.
  We find that, hogs' lard (axonge) in twenty-three cases moderated
the erysipelas, but did not abridge its duration—and was of less effi-
cacy than mercurial ointment.
  The disease  in  twelve cases  was  aggravated by an ointment  of
four grammes  (seventy-two grains) of white precipitate to thirty of
lard.
  Sulphuric acid in ten cases, applied as a lotion on the skin, had no
sensible effect.
  The hydrochloric (chlorhydrique) acid in ten  cases was not more
satisfactory.
  The citric and tartaric acids, the oxycrate (vinegar and water) and
salt and water, (eau salee,) or solution of chloride (chlorure) of sodium,
were each employed in six separate cases and without  effect.
  In six cases, the nitrate acid of mercury, in three  as a lotion and
in three as a caustic, proved useless.
  Camphor and the bird-peck punctures (mouchetures) were equally
unavailing.
  Professor Velpeau  had in despair renounced all the above  reme-
dies, though practitioners still believe in the efficacy of the blister,
nitrate of silver, mercurial ointment and lard, until his attention was
drawn to  the changes effected upon the blood by the preparations of
iron.

                 3.—Special Local Application.
  Impressed  with the idea  that the inflamed tissues in erysipelas
are impregnated with blood and altered fluids, he asked himself the
question, if ferruginous  applications might not have some efficacy
upon a disease  so  superficially situated.   In forty cases he deter-
mined upon a formula of the sulphate of iron  in solution of  thirty
grammes  (nine  drachms) to about forty oz. (par litre)  of water,
or as an ointment of eight grammes to thirty of lard—after having
tested it in various other proportions.
  In forty  cases  the following were the results: 
70
NEW ELEMENTS OF OPERATIVE SURGERY.
  First, In a man in  the  prime of life with an  erysipelas in  the
front part of the leg, caused by an ulcer from operation for varices,
cloths wet with the sulphate of iron effected a cure on the third day.
  Second, Same cure in a man of forty, for erysipelas in the face.
  Third, in a young  man with erysipelas on the forehead, nose,
eyelids, cheeks, and upper lip, supervening on the  tenth day, from a
very extensive pain in the head. On the day after the use of the solu-
tion of iron the redness faded, the surfaces became wrinkled, and on
the third day the erysipelas had disappeared.
  Fourth, In an old man a vast  erysipelas on the thigh and- hip,
above and below a sluggish abscess, (abces froid,) the solution of iron
was used on the first day, and the disease disappeared on the next.
  Fifth,  In a patient  aged thirty-two, with erysipelas on the right
side of the face.  On  the second day the solution  ; on the third  the
part wrinkled; the solution  is neglected; on the fourth day  the
nose, eyelids, and forehead are involved ; on the  fifth day the solu-
tion and  the patches disappear, but the left  cheek and ear are at-
tacked; on the sixth the cure was effected, and the itching ceased.
  Sixth,  seventh,  and eighth cases,  In three women  the  same
symptoms and results.
  Ninth, tenth, and eleventh, The same result in an erysipelas in
the neck of  a man in  whom M. Velpeau tied the carotid, and in a
boy who  had erysipelas on the arm and shoulder, and in a man who
had it on the thigh.
  Twelfth, thirteenth, and  fourteenth,  An erysipelas of  one, two,
and three days on the  loM'er half of the leg, with some outward  ap-
pearances of angioleucitis, disappeared in twenty-four hours use of
the solution, in three young men.
  Fifteenth  and sixteenth,  In a man—abscess in the thumb—an-
gioleucitis in  the  forearm—solution of iron ; on the  second day
forearm  redder; third day, erysipelas on the arm and shoulder—a
measles-like eruption  on the chest—solution ; on the next day there
was no redness but on the points which had not been covered by
the compresses.
  Seventeenth  and eighteenth, An intense erythema, the conse-
quence or effect of large burns in the hand in one case, and in  the
foot in another, in tM'o women, treated  by the solution, disappeared
in tM'enty-four hours.
  Nineteenth, twentieth, twenty-first,  and twenty-second, In these
four cases the disease was also immediately cured, but  as it had
already existed for many days, the author could not say that  the
sulphate  of iron had any great part in the cure.
  Twenty-third and twenty-fourth,  In  a woman  recently operated
upon for a tumor in the breast, and in a man affected with varix in
the legs,  erysipelas of great extent, after four days of previous rest-
lessness,  appeared on  the thorax in the  first case, and on the head
in the second ;  in this latter the disease continued seven  days, and
even reappeared on the twelfth day after some premonitory symp-
toms, but spreading from one point, extended over  almost the whole
of the head, chest, neck, and arm. 
CONSEQUENCES OF OPERATIONS.
71
  In these cases, as in the others, the new patches of erysipelas never
lasted over one or two days.   He  adds that the  ointment, which,
though less efficacious, is more convenient than the solution for
large surfaces on the trunk, was used in these two cases.
  Every thing succeeded in the same  way as in the sixteen other
cases.
  Unless, therefore,  says M. Velpeau, numerous and  remarkable
coincidences have on this occasion deceived me, as so often hap-
pens to others, there is good reason to believe in the efficacy of
sulphate of iron as a topical  application in erysipelas.   In no case
did the inflamed surface resist this means over twenty-four to forty-
eight hours.  It is only strange  that the spreading (ambulant) ery-
sipelas, extinguished at the point of its origin,  continued, never-
theless, under this treatment to develop itself, even upon regions
already covered and wet (enduites et imbibees) with the preparation
of iron.  Can it be  that this remedy, like so many others, may be
curative but not  preventive 1   Is it necessary, in order that the
inflammation should be modified, that it should be completely estab-
lished ?
  The researches I am continuing to make will, perhaps, enlighten
us on this subject.
  The learned professor remarks, that he has also essayed the sul1-
phate  of iron in  angioleucitis, erythema, phlegmon, phlebitis, and
acute rheumatism, and internally to reach the general infection of
the blood in  erysipelas, but all without any definite results.


           Mode of Application of the  Sulphate of Iron.
   If cases occur where we  must use  the less  efficacious form or
oinfment, the sulphate  of iron should be first triturated, that it may
m■.- veil with the lard, that it may be perfectly homogeneous, and
not give the sensation of sand when rubbed between the fingers ; the
ointment should be applied freely three times a day over  iU" --"hole
surface of the inflammation, and some distance beyond its margin.
  The solution is employed on  compresses wet  with it every six
hours, and fastened  on  by a bandage.  The essential point is, that
the skin  must be kept constantly moistened with it.
  The antiphlogistic action of the sulphate of iron has hitherto failed
in no case where M. Velpeau has used it.  An objection to  it in
hospitals, where economy is so essential, is, that it stains (rouille) the
linen to  an excessive  degree, and that no chemical reagents yet
used have been enabled to remove this color without destroying the
texture of the linen.   A solution of sulphuret of potash (as suggested
by F. d*Arcet) does it, but its odor is too disagreeable.
   When the solution of the sulphate of the protoxyde of iron, accord-
ing to  M. Quevenne, is exposed to the air, it soon decomposes ;  a
portion of its base gradually absorbs oxygen from  the air and passes
to the state of peroxyde; but as any base whatever exacts so much
the more acid to become saturated, and  to constitute it  a neutral
salt, in proportion as it is more oxydized, it results from  this law, 
72
NEW  ELEMENTS OF OPERATIVE SURGERY.
in this case, that the quantity of sulphuric acid primarily required
to constitute the neutral proto-sulphate, becomes  insufficient to
effect the complete  saturation of the base  which is partly super-
oxydized : hence Mre have new arrangements in the elements of the
salt.  The sulphuric acid separates itself into two portions, one of
which rests in solution, combined with protoxyde and peroxyde, form-
ing thus a double salt with these bases, which remains in solution
in the liquor and gives it a reddish color ; the other  portion of  sul-
phuric acid, much weaker than the preceding, unites with a large
excess of peroxyde to constitute a sub-basic sulphate  of iron, which
is precipitated in the form of an insoluble yellowish  powder.
  Such, apparently, is the process of the decomposition of the proto-
sulphate  of  iron employed in a state of aqueous solution for dress-
ings : the poM'der of the basic sulphate of iron (sulfate defer basique)
precipitates itself upon  the vegetable fibre, to which it not only
adheres, but forms with it an  actual combination.   It is to be re-
marked, also, that this is found to be favored by the  greater or less
proportion of the alkaline ley which the linen retains, which latter
may give rise to the evolution of a certain quantity of  oxyde of
iron, M'hich  also combines with the  organic  tissue.
  This combination  is so close and so  tenacious when the linen is
strongly colored, that, in order to remove the iron, we are obliged
to employ water acidulated with j]^ of sulphuric acid, and to favor
the reaction by means  of ebullition a long time continued;  but
during this  operation the tissue itself is greatly altered,  and has
afterwards lost much of its solidity.  The portions  of linen, how-
ever, which are not greatly rusted, may be bleached by boiling them
in water, containing Ti„ of sulphuric acid.
  M. Velpeau made trial also of the  citrate,  lactate, carbonate,
and phosphate of iron, but without success.
  The sulphate only proved efficacious, though M. Velpeau modestly
says his  trials, even of this,  have not been sufficiently varied or
numerous to be considered absolutely conclusive—much,  he says,
remains to be explored, and that his  only object in publishing his
experience has been to solicit  the aid of chemistry,  and to present
a new remedy to practitioners for a  disease  which has hitherto
baffled the efforts of medical skill.
  We are not  aware that this new remedy, which we trust  will
attract the general attention of the profession here, has as yet been
made trial of  in our country.   Recommended, as it  now is, by the
great success which has attended its application in the hands of the
eminent  surgeon who had the good fortune  and good sense to anti-
cipate its probable utility, by a very natural  course of reasoning,
based upon his original and sound vieM's upon the pathology of the
disease, we feel very confident that its efficacy ..will very soon be
tested in America.  Especially may we hope for this, and also that
its  curative powers may be  fully corroborated in our  country,
where, from the extreme  and sudden  vicissitudes of our climate
during the long intemperate cold season, and from the intense  dry-
ing heat of anthracite coal, in such general use for fuel in the north- 
                  CONSEQUENCES OF OPERATIONS.                73

ern and middle states during that season, erysipelas in all its forms,
especially in the one under consideration, more particularly in hos-
pitals, manufactories, &c, is probably of more extensive prevalence
than in any other country.  The late  researches of the celebrated
Liebig, on the iron of the blood, and its change from a protoxyde to a
peroxyde in  the  lungs in passing from venous into arterial blood,
favor the idea of M. Velpeau  relative  to the antiphlogistic proper-
ties of the sulphate.  General antiphlogistic treatment by the lan-
cet and purgatives, &c, though not named by M. Velpeau, must
necessarily be understood by him to be advisable in young, plethoric
subjects, &c.—T.]

                   [Leeches in Erysipelas.

   Professor  Fergusson,  of London, in his late work on Practical
Surgery, (London, 1842,) not only uses leeches with advantage, he
says, and without any bad effect, on the  surface of raw ulcers, but
on parts affected with erysipelas.  These are certainly rather novel
modes of application, and, in regard  to erysipelas, appear  to be
specially contra-indicated from the well-known  fact  that a formi-
dable erysipelatous oedema, or subcutaneous infiltration, particularly
in the loose tissues, as about the face, penis, scrotum, &c, is often the
consequence of leech-bites—and especially to be  guarded against,
as all forms of erysipelas  have a natural tendency to gangrene.

             Suppurative  or Phlegmonous Erysipelas.
   Professor  Fergusson  remarks, that he  considers one of the char-
acteristic features of the suppurative form of erysipelas to be, that
"the matter is  not surrounded by an effusion of lymph, such  as
happens in  the cellular  tissue in common abscess,  but,  on the
contrary, the [purulent] fluid seems to permeate  in  all directions
without restraint, further  than is offered by the natural firmness  of
individual texture, and thus  it will  become extensively diffused
under the skin or under an aponeurosis before it will burst through
either of those textures."   The remark is correct in so far as there
is no circumscribed boundary of effused  lymph enclosing the seat
of the abscess,  but, nevertheless,  lymph of a hard consistence  is
more extensively and freely deposited, as in long  caky ridges  or
plates in the phlegmonous form and in angioleucitis, (in which latter,
the enlarged and indurated and inflamed condition of the neighbor-
ing lymphatic glands is a further evidence of it,)  than it is in ordi-
nary phlegmonous inflammation.   In the simple or superficial form
of erysipelas proper,  Mr. Fergusson justly observes, that one  or
more small circumscribed abscesses occasionally form, surrounded
by condensed cellular substance from deposition of lymph, the same
as in ordinary phlegmonous inflammation.  After the inflammation,
too, has subsided, he remarks  with truth, that such abscesses will
continue to  form for some time.   We have, however, seen cases
of what may be called a suppurative  diathesis of this kind in the
subcutaneous tissue, where such small abscesses of an elliptical  or
                              10 
 74           NEW ELEMENTS OF OPERATIVE SURGERY.
                                                     v
 oval  shape would successively form from no apparent cause, and
 without at any time any preceding  symptoms or outward appear-
 ance  whatever, of erysipelatous or other diffused inflammation on the
 surface or in the  tissues.  I recollect two such  cases  M'hile I had
 charge of the Seamen's Retreat, [Staten Island, New York,] the
 patients being both colored persons and of adult age.   The abscesses
 in one forming at the upper and anterior part of the thigh below Pou-
 part's ligament, and in the other on the loose tissues about the upper
 eyelids.   In the first  the  patient  had been mercurialized  before
 coming into the hospital.  Neither, however, could be strictly called
 erysipelatous, except for this peculiarity of successive formation of
 small, regularly formed, circumscribed, purulent  subcutaneous col-
 lections.  They were all speedily cicatrized  by freely  laying them
 open to the bottom of their cavities, (a practice too much neglected,)
 and by generous treatment internally, and tonics.  The matter in
 these cases appeared to be more attenuated, and more  rapidly col-
 lected than healthy, well-digested pus.—T.]
   B.  Phlegmonous Erysipelas,  or diffused phlegmon, which takes
 place most frequently  from the third to the tM'elfth day, is mani-
 fested by a deep-seated, dull pain, heat and swelling throughout the
 whole thickness of the part, while  at the same  time there  super-
 venes a more or less active fever, together with all  the symptoms
 of an unrestrained inflammatory reaction.  Here the inflammation
 sets out from the wound itself, and  extends to the cellular tissue,
 which unites, surrounds, or separates, the muscles, vessels,  nerves,
 skin, and  aponeuroses.
   As it is often also caused by the retention  of pus, it is important
 to give free exit to this secretion, and therefore  to make some de-
 pending  opening  for it, by removing a part of  the agglutinating
 dressings which may have been applied to the wound.  At the same
 time  we must employ emollient  cataplasms, and it is in this kind of
 inflammation that it may be necessary to recur to large bleedings,
 and to apply a large number of leeches to the inflamed parts.
   C.  Angioleucitis, which almost all pathologists, and practitioners
 still more frequently, confound with  one of the two preceding in-
 flammations, or with phlebitis,  begins like ordinary erysipelas, by
 irregular chills, much restlessness, heat, and dryness  of the skin, -
 burning thirst, nausea, or even vomiting, and also loss of sleep, and
 sometimes acute fever.  After these first symptoms, it is found that
 the neighboring lymphatic glands increase  in volume and become
 painful;  then the vicinity of the wound becomes surrounded with
 patches and kernels, or reddish-colored bands, painful to the touch.
 Sometimes, also, similar striae extend from the wound to the painful
 glands, but this last symptom is far from being  constant.  Angio-
. leucitis is distinguished from erysipelas in this, that  the inflamma-
 tion M'hich characterizes it is deeper seated, and develops  itself
 under the form of kernels, (noyaux,) rather than of patches) (plaques,)
 that  it seems to extend itself from the parts within towards the sur-
 face, that it has no fixed and well-defined limits, nor irregular mar-
 gin elevated above the skin. 
                  CONSEQUENCES  OF  OPERATIONS.                 75

  Its causes are the same as those of erysipelas, or diffused phleg-
mon.  The  treatment  required consists  of emollient  dressings,
general  bleedings, and leeches  in the neighborhood of the wound
or the inflamed glands; but all this more sparingly than in diffused
phlegmon, while at the same time M'e  are not obliged to give as
much attention to the burrowings that may exist at the bottom of
the wound.

                   § IV.—Purulent Infection.

  The most formidable accident,unquestionably, that can occur after
operations, is that which is known at present  under  the  name of
purulent infection, and which comprises also  phlebitis.  As it is
seen quite often after small, as well  as large wounds, and as it has
been the subject of numerous' researches since I  pointed it out to
the attention of practitioners, in 1823, and afterwards, in 1826 and
1827,1 feel it incumbent on  me to treat of it here in  some detail.
What has been more recently said upon this subject by Mareschal,
Dance, Rose, Legallois, MM. Arnott, Blandin, and Tessier, not dif-
fering materially from the first descriptions and  explanations which
I gave of it, I shall, in consequence,  have nothing  to change in the
substance of the article which I devoted to this kind of accidents
in the first edition of this work.
  A. Symptoms.—The march of the symptoms  in such cases varies
considerably.  Sometimes they  commence  with  a  violent chill,
which amounts occasionally to shivering,  (tremblement,) and may
last several  hours ; at other times with horripilation,  and in other
cases with mere  coldness of the extremities.   The skin  becomes
pale, assumes a yellowish tint, someM'hat livid or bluish, and soon
after a more or less earthy aspect.  In contradistinction to marsh
intermittent fevers, which resemble this in more than  one point of
analogy, this first period is rarely followed by a perfect reaction.
If sweating takes place,  it is unequal, and  often  unctuous,  or
clammy, (poisseuse.)   After these symptoms have  reappeared sev-
eral times, under the form of exacerbations, at irregular intervals,
they  are ordinarily succeeded by a state of putridity, or adynamia,
of a  remarkable  character.   The eyes sink in their  sockets, and
become  covered with a grayish blearedness, (chassie grisatre.) The
conjunctiva, which is sometimes tumid,  becomes yellow, as well as
the circumference of the lips, while  the whole face appears more
or less dull.  The tongue, which continues generally moist, without
being very broad  or pointed, as in intestinal  affections, does  not
become  incrusted till at an advanced period of the disease.  The
teeth and  lips become merely of  a sooty color.   The  pulse is fre-
quent and hard,  without being qiiick, and afterwards  becomes
smaller  and smaller, and more feeble.   Tympanites, sometimes
diarrhoea, rarely delirium, though almost always stupor, now soon
supervene.
  In  addition to these symptoms, we find  in some patients vagui;
indications of visceral inflammations.   Sometimes a  livid redness 
76
NEW ELEMENTS OF OPERATIVE SURGERY.
 is observed at intervals upon one or both cheeks, accompanied with
 slight cough, or pains in the chest and  difficulty of breathing;
 sometimes a jaundiced suffusion, more or  less developed, together
 with pain or uneasiness in the hepatic region or right shoulder; or,
 what is more rare, desire to vomit, with  inflamed papillae (rougeur
pointillee) on the apex and margin of the  tongue, which then  be-
 comes dry, as in dothinenteritis, or typhoid fevers; there are also,
 sometimes, acute  pains in some part of  the limbs, for example, in
 one of the larger joints.   Sometimes there forms, in remarkably
 rapid succession, at different points of the surface, a series of puru-
 lent collections, or gangrenous  inflammations, with swelling of the
 conjunctiva and destruction of one of the  eyes.  The thirst is not
 generally great.  The breath, which is often fetid,  exhales some-
 times a strong odor of pus. The  progress of cicatrization  is also
 arrested in the wound; the lips  separate, and also become pale,
 like the rest of the surface.  Viscid and cream-like as the suppura-
 tion was in the  beginning, it now suddenly becomes grayish, gru-
 mous-like, or resembling vitiated serum.  It is not uncommon to see
 it wholly and instantaneously suppressed.  The swelling of the soft
 parts then subsides with  the same rapidity, and they immediately
 assume a strikingly cadaverous aspect.  The muscles, bones, &c.
 separate from one another, as if the cellular tissue, which united
them in the healthy state, had been destroyed.  At a later  period,
blood oozes out in a  more or less limpid state, which terminates,
when the disease continues a long time, by taking on the character
of washings of meat, and by causing hemorrhages M'hich  nothing
can arrest.  The patient, finally exhausted, dies from the twelfth to
the twentieth or fortieth day.
  Bt  Pathological Anatomy.—On opening  the dead  body, we find
various lesions, all traceable to one cause.   They consist chiefly of
numerous points of suppuration in the tissue proper to the viscera,
or collections, more or less abundant, in the  serous  cavities, of a
grayish cream-like serosity, more of a,purulent character than mixed
with flakes.  In some patients the large  articulations, such as the
shoulder, hip, or knee, are also found filled with the pus, which sub-
 stance is likewise frequently met with, whether as a deposite or in-
 filtration, wherever there exists relaxed cellular tissue to a certain
 extent, and also in all those localities where the  least  degree of
 pain  was noticed during  life.  The arteries  are  almost  always
 empty, or the blood they contain is found, in general, in  a state of
 great fluidity.  That in the veins is more  abundant in quantity, and
 is still more evidently changed.  The small clots that are here and
 there found in it, are of a mixed color, black, yellow, white, or
 greenish, and of a granulated texture, which is easily perceived on
 cutting into  them, or  breaking them down between the  fingers.
 They sometimes enclose globules of pus,  recognisable to the naked
 eye.  Not  unfrequently we find actual purulent centres (veritables
 foyers purulents)  in the interior  of the  larger clots.  I have  ob-
 served some of these in  every part of the venous system ; in  the
 iliac  and uterine veins, and in the inferior cava, chiefly under the 
CONSEQUENCES OF OPERATIONS.
77
liver and at its entrance into the auricle ;  also in the superior cava,
and in the  principal cavities of the heart, ,&c.   Many of these
concretions are also soft, and are evidently only of some few  days
formation.   Others have such a consistence, and are so dry, or fri-
able, that it is evident  they are  not of recent  formation.   In the
great  majority of cases they have no pathological relation to the
state of the vessel, in the region M'hich corresponds to them, in the
interior of the splanchnic cavities.   It is entirely the reverse in the
vicinity of the wound, where  nothing is more common than to see
the inflamed veins in a state  of complete suppuration, both in the
interior and the exterior, and that to a greatly variable extent, but
never, however, or rarely, involving the two cavas.
  I. Abscesses.  The small abscesses which I  spoke of in  the be-
ginning have been observed in all the organs.   A subject which I
examined at Tours, in 1818, had some dozens of them in the brain
and in the tissue of the heart.   A  young  man who died at  the cli-
nique  of  the faculty in 1825, from the effects of" amputation of the
ear, had them also in the spleen and in the kidney.  The lungs and
liver are  not less frequently the seat of them.  It is in these organs
that they have always been recognised, and where they  are found
to exist when no traces of them are discovered  elsewhere.  Their
characters are so well marked that it would be difficult to confound
them with the results  of  an  ordinary inflammation.  In the first
place, they scarcely ever exist singly, but most  frequently  a great
number are  found in the same part.   The superficies of the organs
seems to be  more favorable to them  than the deep-seated  tissues.
They  but rarely  acquire  large dimensions.   Under this point of
view, they vary from the size of a pin's  head  to  that of  a large
walnut or a small egg.  By pressure we are enabled to distinguish
them as so many tubercles, through  the  parenchyma of the lungs,
whose periphery is as it were embossed by those that are more su-
perficial.  Often they appear to have an ecchymosis for a nucleus.
In the liver, they are enclosed in an organic layer of a blackish or
livid color, which is sometimes of several lines in thickness.  They
are more usually formed in the centre of the organ, and are general-
ly larger than in the other parenchymatous structures.  The  sub-
stance of which they are composed is still more diversified;  very
limpid, and greenish, flocculent, or of a  milky  whiteness in their
centre, and very frequently grumose  or concrete throughout,  espe-
cially towards their surface.  In the lung, we are still better ena-
bled to note  their appearances.  In some points, we can distinguish
only small spots like petechias.  Further on, these spots  enclose  a
small  drop of  pus; in other places, the ecchymosis no  longer
exists, and the grumous purulent clots alone are  observable.  Then
we find nuclei, concrete, like the caseous tubercles  of lymphatic
ganglions, or of different degrees of  fluidity, as  in the liver.  The
substance of some  of them appears  to have become confounded
with the  surrounding tissues, and  to  have penetrated and become
imbedded in them   Others are, as it  were, encysted; in others, the
walls  of the sac are villous, and of a red lilach or hortensia color. 
78
NEW ELEMENTS OF OPERATIVE SURGERY.
Farther on, the organ is found again in possession of all the char-
acters it has in a normal state ;  and they are almost always sepa-
rated by intervening sound texture.  In many cases, it would ap-
pear, after removing the matter and cleaning  the  cyst, that the or-
gan had never been diseased, but had  been under the  action of a
mechanical process, for the purpose of excavating its substance into
separate compartments.
   II. The Effusions in the serous cavities are  equally remarkable;
it is the pleura, so to speak, M'hich is their common  rendezvous,
though they may form also in the pericardium, the peritoneum, the
arachnoid, the synovial cavities, &c.   After some days,  they be-
come extremely  abundant;  the  membrane  is  scarcely altered in
character, and after being emptied, remains covered with a layer
of greater or less thickness of genuine  pus, while the  rest of the
fluid, which is of an ashy or dirty color, is far from bearing any re-
semblance to the milky serum found after extensive pleurisies, (des
pleuresies f ranches.)
  In the articulations, we are surprised at the condition of the tis-
sues.  Neither the cartilages, capsules, ligaments, cellular envelopes
—nothing, in fact, presents the least trace of inflammation ;  and on
removing the pus from them, a simple washing has not unfrequently
served to create  doubts if the joint had in reality been  affected.
Also, the cartilaginous surfaces may be partially destroyed  or ero-
ded, and the synovial membranes and the ligaments  perforated,
without the contiguous parts having lost any thing of their pliabili-
ty or natural color.   The same takes place with the subcutaneous
or other deposites in the limbs.  In other cases, these  devastations
are surrounded with ecchymoses, and more  or less evident traces
of inflammation.
  If some patients M'ho perish exhibit  all  these different  kinds of
collections at the same time, and seem as  it were to  be saturated
with pus like a sponge, there are a greater number who have them
only to a partial extent.  Sometimes there are found  germs  of a
tuberculous character  only  in the lung and liver, and  no effusion.
Sometimes the collections exist only in the pleura ; at  other times,
they are only met with in  the limbs, either  within or  external to
the articulations.  In many there are none to  be found anywhere,
and we must then seek for the cause of death  in  the blood itself,
more or less profoundly altered in its own vessels.  I frequently
observed this last fact in 1835, 1836, and 1837, in  the  dead bodies
of  subjects who had exhibited in the highest  degree all the symp-
toms of infection, or, as M. Tessier calls it, purulent fever.
   C. Etiology.  Every wound that suppurates may give rise to the
changes of which we are speaking ; the trephine, a simple incision
on the head, the  section of varices, ordinary bleeding, as  well as
lithotomy, amputation of the neck of the womb, excision of hemor-
rhoidal tumors, and amputation of the limbs.  But it was not in
our times that they were first noticed.  Pare (CEuvres,  Lyon, 1633,
p. 269, in  folio)  already had  made mention  of them, and Pigrai
(Epitom., etc., edit.  1615, p. 368) says that on a certain year, almost 
CONSEQUENCES OF OPERATIONS.
79
all the sick who died of wounds of the head had abscesses in  the
liver.   Morgagni (De Sed. et Caus. Morb., epist. 51, 52) describes
them with some detail.   Quesnay and Col  de  Villars (Cours  de
Chir., Paris, 1746, t. iii., p. 36 a 41) make formal mention of them.
J. L. Petit (Maladies Chirur., t.  L, p. 6  a  11) gives a very exact
idea of them, and many modern surgeons had pointed them out in
their lectures or in their writings ; but before I had described them
they had not sufficiently attracted attention to lead any one to  an-
ticipate the importance that is now attached to them.  In limiting
themselves to saying that the pus had fallen from the wound into
the organ where it was found  deposited, the ancients reverted to
their favorite ideas of humoralism, and proved nothing.  The sug-
gestion first made by Boyer and Dupuytren, that so much disorgan-
ization may result from simple idiopathic inflammations, which have
themselves been caused by sympathetic revulsion (le  retentissement
sympathique) from the wounded  part to  the  interior of the viscera,
or be produced by the antecedent existence of tubercles, or  by  or-
ganic lesions that had not been  previously noticed, was not calcu-
lated to awaken any very particular interest.
  Struck with their frequency and  importance, when I was yet at
the commencement of my medical studies, I took an early occasion
to make them the special object of a series of researches.  Believ-
ing, from the first observation I made on this subject, at the hospital
of Tours, in 1818, that  I had conceived the true etiology, and con-
firmed in  my opinion by what  I afterwards  saw of an analogous
character  at Tours and at  Paris, I felt authorized to state  my
opinions in my public  lessons, in 1821  and 1822, and then  in  my
thesis of reception, in 1823.  I  maintained then, that the purulent
deposites which so often supervene in the viscera, after operations,
M'ounds, and suppurations of every kind, ought to be attributed,  not
to so  many distinct idiopathic phlegmasiaa, but to an alteration
of the  blood, from the entrance of pus into  the circulating mass,
and to its transportation into the midst of the organs, whether it
came  from the wound  or was  secreted by the surrounding veins.
It required some courage to advance such ideas at that time, when,
in spite of the observations of  Rodriguez, (Journ. Compf. du Diet.
des Sc. Me'd., t. x., p. 150,) Erdmann, (Dezeimeri's, Diet, de Med., 2d
edit., t. i., p. 100,)  and Ribes,  (Mem. de la Soc. Med d'Emul, t. viii.,
p. 614,)~solidism reigned despotically in the midst of our schools,
from whence the partisans of the doctrine denominated physiologi-
cal, thought they had driven humoralism for ever; in  consequence
of which  they  were,  for  the   most part, unfavorably  received.
Nevertheless, the conviction which I had arrived at, and the facts
which daily came to its support, did' not allow me  to renounce
them.   My residence at the Hospital of Perfectionnement furnished
me numerous occasions of submitting  my  first thoughts to new
proofs, of calling the attention of my pupils to them, and of show-
ing how much they might enlarge the field of general pathology.
The two memoirs  on this subject, which I published in  1826, in
the Review, and what  I had already written in the same journal, 
80            NEW ELEMENTS OF OPERATIVE SURGERY.

while treating of the alteration of the fluids, and M'hat I advanced
at the same time, or a little later, in the Archives, and in the Clinique
of the hospitals, and the discussions which took  place in the Aca-
demy, upon the  fundamental proposition  upon which these labors
were based, finally awakened the public mind, and I soon had the
satisfaction  of seeing  that Marechal, (These, No. 43, Paris, 1828,)
and M. Reynaud of Marseilles, (These, No. 232, Paris, 1828,) in their
excellent theses, and Legallois, (Journal Hebd., t. iii., p. 166 et*321,)
in a  special  memoir at the  same epoch, had arrived  at  the same
conclusions as myself.  While in a work still more complete, Dance
(Arch. Gen. de Mcd.A. xviii.  et xix.) deprived opponents of their last
pretext, opinions supported upon facts of the same kind were pro-
fessed at London by MM. Rose  (Med. Chir.  Trans., vol.  xiv.) and
Arnott, (Idem, vol. xv.).  M. Blandin,  (These, No.  216, Paris, 1824,)
who, in the thesis he supported a year after mine, had adopted the
hypothesis of pure and simple inflammations, and who  gives the
name of tuberculous masses to the abscesses in question, says, in
speaking of  one of his observations, This is a most beautiful example
of tubercles developed under the influence of inflammation.   M. Ton-
nele  and M. Rochoux have since ranged themselves under the same
standard, although their  theoretic views  are not perfectly  alike.
Finally, the pathological concours externe, which took place at the
faculty of medicine  in the spring of 1831, and which afforded an
opportunity to consider the question of metastatic  suppuration from
traumatic lesions, compelled us—to wit, MM.  Berard,  Blandin,
Sanson, and myself—to make known how public opinion then stood
on this subject, and to give unquestionable evidence that there
no longer existed any discordance of  opinion on the nature of the
principle with which I had  set out, and which I  believe myself to
have been the first to lay down,—namely,  that the metastatic suppu-
rations and abscesses caused by capital operations, are the result of an
alteration of the blood.
  One problem, however, still remains to be solved.  Marechal,
Legallois, and M. Rochoux,  find in the absorption of the pus of
which thye wound forms  the  focus, a  sufficient explanation  of all
the phenomena observed.  Dance, MM. Arnott,  Blandin, and Be-
rard, maintain, on the  contrary, that an inflammation of the veins
always precedes the general infection, and that the pus M'hich enters
into  the circulation is  always the immediate product of  the phle-
bitis, which M. Blandin, (Diet, de Med. et Chir. Prat., t. ii., art. Am-
putation,) like Cruveilhier, unhesitatingly  places in the venous ra-
dicles, (veinules,) whether of the soft parts, the medullary canal, or
the spongy tissue of the divided bones, when the principal  branches
of the venous system offer no traces of it.
  In the place of admitting a transfer without  decomposition, a
true metastatic deposite, these last authors think also that the blood,
profoundly changed by its intimate mixture with  the morbid secre-
tion, merely permits here and there the escape of some of its par-
ticles that have become more irritating than usual, and that these
globules, deposited in the tissues, are there like foreign bodies, (role 
CONSEQUENCES of operations.
81
d'epines,) which immediately become the cause of as many centres
of suppuration.  This opinion, differing from mine only in this, that
it supposes that there always exists, that which, according to me,
happens only in some cases—it is  difficult for me to comprehend
how anybody has imagined that they could adduce the opinions of
Dance and of M. Blandin to combat mine.  In fact, far from de-
nying  the phlebitis in  such cases, I had  already said, in  1826,
(Revue  Med., t. iv.,) " The veins of  the diseased limb are full of a
grayish and very limpid  pus, and inflamed from space to space, but
only up to the entrance of the great saphena into the crural."
Further on, I add:  " The phlebitis was not sufficiently extensive,
even admitting that it was primitive, to play an important part
here as inflammation.  In looking to the fluids, however, every thing
is explained  in the clearest manner," &c.  In May, 1827,1 main-
tained (Clin, des Hopit., t. i., No. 5) that, " in this frightful affection,
(phlebitis,) authors  have  paid attention to but one of the  causes of
the danger, the facility with which the inflammation is propagated
from the wounded point towards the principal venous trunks, whilst
the pus secreted by the parietes of the vessel, and continually car-
ried along with the blood, which it  alters and decomposes, consti-
tutes in reality the whole difficulty," (en constitue riellement toute la
gravite.)  Finally, in speaking of  the  same  fact, when no one
thought then  of this etiology of infection of the blood by phlebitis,
(Tome xiv., p. 504,)  I said, moreover:  " There the disease unques-
tionably was  a phlebitis ; but is it to the inflammation of the vein
that we must ascribe all the symptoms ?   I think not; the pus,
continually carried  to the heart and  distributed with the blood to
all the organs, has produced the general infection," &c.
  As to the  formation of purulent  collections, here is the theory
which I gave in  1826, (Rev. Med., 1826, t. iv.): " We may explain
in two ways  the origin of these collections, (foyers):  First—The
blood, more and more changed  from its natural composition, may
begin by disturbing the organism in general, and finish by establish-
ing a local phlegmasia of a particular species.  Secondly, The in-
flammation, developed at first under the influence of ordinary causes,
may, to a certain extent, compel the pus to be effused at the point
where the organ is  most  irritated.........It appears to me to be
demonstrated, that the inflammation, when that supervenes, is then
only secondary; that is, established by an  effused particle'of for-
eign matter, which forms  a source of irritation, (epine,) that  it is at
least a phlegmasia,  altogether peculiar, sui generis" &c.
  Thus, in my judgment, the question rested on two points: First—
The mixture of the pus with the blood, as  a cause of the visceral
alterations observed; Secondly,  The  origin of this pus, whether
from the  blood or  from  the organs.   The first  head,  which  I
anxiously desired to demonstrate the truth of, because it may have
an immense importance in medicine, is generally now admitted as
an incontestable  truth.  The other  had not for  me, I confess, the
same interest.  The aim of my  efforts being to prove that the pus
may circulate with the blood, and infect the organism in the manner
                               11 
82
NEW ELEMENTS OF OPERATIVE SURGERY.
of poisons, it was of little importance  for me at the time to show
that it entered into the  veins by absorption, or that it was simply
formed on the inflamed surface of those canals, so long as it should
be conceded to  me that it is  conveyed  to a certain distance from
the  point of departure.  The preceding quotations, however, suffi-
ciently show  that I had not altogether neglected these secondary
questions.
  The effects of phlebitis on the composition of the blood are so evi-
dent, that it appeared to me  almost superfluous to  enter into any
detail to make them more apparent.   It was not  the same with
absorption, which many sensible persons still refuse to admit, so
that it is setting out from this point that a real difference seems to
exist between Dance and myself.  According to  this  author, phle-
bitis is the first and almost only cause of metastatic deposites, and
the  veins alone  have secreted the pus which changes  the blood.  I
have  said, on the contrary, from the very beginning, and I believe
so still, that the inflammation of the veins  which we meet  quite
often, either as a cause or as an effect, is not indispensable; that
the  pus and other morbific matters of the M'ounded surfaces enter
sometimes into the circulating fluids, whether by lymphatic absorp-
tion, by imbibition, endosmosis, or by orifices of the bleeding veins
at the bottom,  for example,  of a  wound from amputation.  The
proof, according to me, that this often happens  is, that I have  a
number of times found pus in abundance in the midst of the viscera,
though the veins  which led into the exterior lesions were scarcely
phlogosed, and that there was no trace  of phlebitis on other points
of their course ; it is since the possibility of this fact has been denied,
that I have again demonstrated its  existence in a great number of
cases; among others, in a woman  Avho died  in  consequence of a
deep tsaumatic lesion of the foot, at the hospital  of St. Antoine, in
1829, and who was opened in  the presence  of  M. Dezeimeris, a
declared partisan of the opinions of Dance ;  also on one of the
wounded of July, [i. e. in the  Trois Jours, 1830,] who died on the
20th  day after the amputation  of the thigh, at  La Pitie, in  1830,
and in whom I pointed out  the total  absence of phlebitis to M.
Berard, who had  also adopted the hypothesis of venous phlegmasia
as the first  cause of metastatic abscesses ;  also since then on twenty
other different subjects.
  As to the nature of these abscesses  themselves, I have said that
the pus traversing the tissues  may be deposited there naturally, or
may  by its presence irritate  different  points of the  viscera, and
thus form as many different foci of inflammation or of pus, (autant
de foyers phlegmasiques ou purulents.)   Dance rejects the former
of these two modes, and seems  even to question its possibility.   In
spite  of the reasons and objections he urges, I cannot yield to his
opinion.  If, as  appears to  him,  the blood,  rendered more  fluid
and altered by the pus, always  commences by producing  a  small
ecchymosis, and soon after a true inflammation, before causing the
production of an abscess, a process which I have myself admitted
in a majority of  cases, it follows that he has not seen, like myself, 
CONSEQUENCES OF OPERATIONS.
83
in the brain, spleen,  kidneys, lungs,  and liver, those collections,
(foyers]) which are not larger than a hemp-seed, around which the
most attentive and minute  inspection does not  enable us to detect
the slightest lesion of the organic elements; and that he has not
seen those purulent deposites which I have so frequently met with
in the cellular tissue or in certain articulations, and which, after
having been emptied and washed, do  not leave the slightest trace
of their existence in the midst of these tissues.
  If the venous radicles which come from each purulent centre are
sometimes inflamed, it is certainly far from being true that they are
always so, or that we can admit the capillary phlebitis mentioned by
M. Cruveilhier (Anat. Pathologique du Corps Humain, xi. livr., in fol.,
fig. col.) to be  always present in such cases.  Moreover, as soon
as we admit the deposite of a molecule of morbid matter, there is no
reason to refuse the possibility of a greater number.  The pus min-
gled with the blood, is a heterogenous matter which has a constant
tendency to  separate itself from it,  and to make its way by some
channel or another towards  the surface.   So  long as it  is shut
up in the large vessels, and the circulation has lost nothing of  its
activity, it can escape nowhere ;  but in the capillary system, where
the movement of the fluids is only a kind of oscillation, where nutri-
tion, the different secretions, and a thousand new combinations, as
well of composition as of decomposition,  are elaborated, ought not
its elements  to exhibit  a tendency to become  agglomerated and
united together, and to cease to circulate with the other fluids ?
When this aggregation, which is altogether of a  chemical nature, is
once commenced, does it not tend to establish a centre of attraction
for analogous molecules 1   Can more be  required to determine the
nucleus (noyau) of an abscess?  There  is  nothing  in  this more
difficult to comprehend than in the formation of bile, urine, saliva,
and mucus.   These latter are natural secretions and  exhalations ;
the other, on the contrary, is a morbid secretion or exudation.  That
is all the difference that there is.
  It  follows, then, from these details, that Dance, M. Blandin, Le
Gallois, &c., have scarcely done more than to reproduce, while
they have  corroborated under different forms, what I had  said of
purulent infection and phlebitis  in 1823, 1824,  1826, and 1827.
Let any one compare  what these observers have written in 1828,
1829, and since, with the descriptions which I myself had given of
this kind of lesions a long time before them, and he will Mdthout
any difficulty be convinced that  their labors are little  else than
confirmations of mine.  Perhaps also  I should have a right to add
now, that the microscopic observations of M. Donne on this point,
and the researches of another  kind,  to  which M. Beauperthuis,
Adet de Roseville, Mande, &c, have devoted themselves, come  to
the support of my opinions;  that the experiments of M. Bonnet and
of M. Denis stand  in the same  relation; that  while  denying the
passage of the  pus from the  inflamed vessel into the circulating
mass, M. Tessier, nevertheless, admits the purulent infection, and
that I  alone  can,  on this question, fall  back, without  rejecting 
84            NEW ELEMENTS OF OPERATIVE  SURGERY.

the labors of any one upon  the position I maintained in 1823 and
1826.
  Prognosis.  Be that as it may, or in whatever M'ay we may explain
it, the metastatic collections of pus  produced by serious operations
are always traceable in their origin to the introduction  or forma-
tion of a certain quantity of pus in the general circulation, and the
prognosis is extremely  unfavorable.  The term  tuberculous, which
I had given to them at first,  had reference only to their form ; and I
am surprised that any one has imputed to me the intention of com-
paring them to pulmonary tubercles under  any other relation.
The obscure and often rapid march  of these lesions rarely permits
us to observe their commencement,  and is the reason why, at the
moment when  their existence  is no longer doubtful, they are in
general beyond the resources of art.   As soon as the surgeon sees
violent chills, with change in the features, continued fever, pains
or not in certain parts of the body, or that  a diarrhoea supervenes
or not in a patient who has been recently  operated upon, or who
has going on in his own system any suppurative process whatever,
accompanied with traumatic lesion, he ought to expect the  most
serious accidents, and to  apprehend that death may be the inevita-
ble result.  Nevertheless, if such symptoms reappear only for two
or three days, and at the end of this time a general perspiration, or
some other critical.evacuations, bring about the solution of the fe-
ver and arrest the organic derangements just pointed out, we have
still grounds not to despair.   I have seen  many patients recover
from genuine chills of this kind, as well as  from the  other signs of
purulent infection.  Such examples, it is true, are rare, but they do
occur, and the practitioner ought not to forget them.
  The treatment of purulent infection is not yet established upon a
firm basis.  Bleeding,  either by venesection or by leeching  and
cupping, is evidently  proper only in the beginning, and in robust
or plethoric subjects, unless  there are certain pains or local inflam-
mation clearly defined.   I have used them and seen them used, and
carried as far as possible, in  a large number  of persons operated
upon, without ever having been able to affirm any real advantage
from them.   The patients who have been seized M'ith hemorrhages
from the wound and from the mucous surfaces have not been more
fortunate.  Purgatives opportunely given have appeared to me to
 succeed in some cases.   Large blisters to the legs or thighs, or to
the parts of the chest or belly that suffer pain, are not to be lost
 sight of.  The sulphate of quinine, when there  are intermissions,
 and the stomach is not too  irritable, is also  not without its  use.
 Tartrate of antimony in large doses, extolled first by Laennec, has
 not saved the patients whom I have subjected to its use.  It is the
 same with white oxyde of antimony, in doses of from one to two
 drachms a day.  As to the preparations of opium, camphor, ether,
 acetate of ammonia, and other diffusible or exciting substances, they
 have always appeared to me to accelerate the march of the symp-
 toms, and in many cases to hasten the fatal termination.
   In fine, when we discover the symptoms above indicated, we 
CONSEQUENCES OF OPERATIONS.
85
should hasten to recall the fluids to the wound.  We first envelop
it, morning and evening, with a thick and large cataplasm of flax-
seed meal placed naked on the skin.   At the same time we apply
one or more blisters to the legs.  We give also a weak infusion of
the linden or elder, to be drunk warm as a tisan.  Bleeding, from
eight to ten ounces, may be performed, if the  pulse  is strong, and
the patient has not yet been reduced.  In case the wound is pale
throughout, and the tissues have no longer their original firmness,
we must wash it at each dressing with  a decoction of bark, and
cover it with lint besmeared with storax and  balsam of Archaeus
mixed with cerate.  Should it have SM'ollen and inflamed, or have
exhibited signs of phlebitis from  the  beginning, a large blister on
the stump would also  be indicated.   Compression by means of a
roller bandage, from the upper part  of the limb to the wound, is
another means to be employed  so  long as the  disease has not in-
fected the  system, and continues to be  local.   After these first
means,  we may give Seidlitz water as a  purgative, or  pullna
water internally, provided the tongue remains soft and is not red.
Emetics in small doses ought not to be administered till a later pe-
riod, and after the accession of stupor, tympanites, or a sooty ap-
pearance of the mouth.  Bark, in decoction or in substance,  is not
proper till the typhoid state is clearly established.   We give  it in
union with gum or rice-water  when there is  looseness, or the di-
gestive organs do not  bear it well.  The sulphate of quinine, in the
dose of from five to eight grains at once, at the end of each exacer-
bation, would be more proper when there had been an intermission
and sweat.  [If there were in  reality any similitude whatever in
the pathology of this terrific and peculiar disease, and that of fevers
of an intermittent  type, then  might we hope for benefit from the
quinine  treatment now after the proper preliminary steps of deple-
tion or otherwise have been taken, proved to be a positive specific
in such fevers, and more entitled to the name of a specific than any
other medicine whatever.  But recent experience  has also estab-
lished the fact, that to be made a specific, and to give full effect to
its virtues,  it must  be  administered, not in small, futile, and tanta-
lizing, if not irritating doses, but to the extent of at  least twenty-
five, and more frequently fifty to one hundred grains  at once> twice
in twenty-four hours.  In the intervals, the paroxysm never returns,
and the  only inconvenience following is a slight ringing or deafness
in the one or both  ears, and occasionally a little giddiness.   This
practice was first introduced by myself while  I was Physician to
the Seamen's Retreat  Hospital, N. Y., 1831-2-3, and  is now  gene-
ral in  Europe, but  more so in this country, and especially in our
army.—T.]  The drinks ought, moreover, to be varied according
to the predominant symptoms and the desire of the patient.  Vege-
table  and mineral  acids, acidulated decoctions of tamarind, &c,
will be  preferable  if  the thirst is considerable.  In  the  contrary
case,  infusions that are slightly bitter  or aromatic  agree better.
Decoctions  of rice, barley, gruel, and rhatany, and the  white  decoc-
tion, diascordium,  gum kino, and  the cashew  nut, and extract  of 
86
NEW ELEMENTS OF OPERATIVE SURGERY.
 rhatany, are also to be used when the bowels are loose, or a copious
 diarrhoea is exhausting the patient.   In  fact, the  whole  of this
 treatment, being the same exactly as that of phlebitis and purulent
 absorptions in general, cannot be but imperfectly given  in this
 place.  It is in treatises of pathology that  we must seek for its de-
 tails.  My object has been to give only the summary  of it, which
 was necessary in order to excite  the solicitude of the  practitioner,
 and to warn  him against the dangers of a  false reliance  upon a
 mode of cure whose fficacy is yet so unsettled.
   For details relative to alterations of the blood in general, I must,
 in respect to my own researches, refer to  the theses which I sup-
 ported in 1823 and  1824, to the memoirs  M'hich  I  inserted in the
 Archives de Medecine in 1824, 1826, and  1827, and in the Revue
 Medicale in 1825, 1826, 1827, 1829, as  well as in  the Clinique des
 Hopitaux for the year 1827.
   [Mr. Mayo remarks, that wounds from dissection are less  apt to
 produce the peculiar train of distressing symptoms from this  source
 than wounds from post mortem examinations, because  the subjects
 in the former case are more usually in a considerably advanced state
 of decomposition, the absorption of the products of which lead ordina-
 rily to a series of much milder symptoms than the poison from the se-
 cretion of inflamed serous membranes, in existence, even sometimes
 a few hours after death.   Mr. Mayo recommends  the student, if he
 should prick himself, to wash the wound, suck it strongly with his lips,
 and bind a  strip of adhesive plaster an inch  wide twice round the
part, and not to remove it for three days ; and if the subject be re-
cent, or have died of puerperal fever, phlebitis, or peritonitis, it is
well, also,  after cleaning and sucking the  wound, to touch it with
the point of a probe that has been dipped  in  nitric acid.   Medical
Gazette, Dec.  17, 1841.—T.]
  [Late Experiments of M. D'Arcet, M. D.,  on Purulent Infection.
  M. D'Arcet (These—Recherches sur les Abces Multiples, &c, Paris,
 1842.—See also British and Foreign Med. Review, Jan.  1843) seems
to think that purulent infection is agreed on all hands  to be owing
to the presence of pus in the blood.  According to his experiments,
however, the opinion, that where these purulent deposites are found
 none of the usual evidences of inflammation are  present, but that
 the pus seems as if deposited without  any previous process of the
 kind, is entirely erroneous.   On the contrary,  he says a red spot of
 inflammation precedes their appearance—and where pus is actu-
 ally present, coagulable  lymph is deposited  around it, which be-
 comes organized and resembles a cyst, the internal surface of which
 is as flocculent as that of the chorion.
   M. D'Arcet found that healthy pus of phlegmonous inflammation
 absorbed through living intestine, a volume and a half of oxygen gas
 producing only a fifth of carbonic acid gas—and that the pus-globules
 then ran together and formed an amorphous coat, or layer, floating
 on the subjacent liquid.  By exposure  to air the whole became of-
 fensive and putrid, without the layer becoming redissolved, which 
CONSEQUENCES OF OPERATIONS.
87
last, separated by the filter, left a yellowish green fluid, blackening
silver, and evidently containing sulphureted compounds upon which
a portion, yet not all, of the poisonous properties depend, seeing that
these remain M'hen the former have been removed by mixing lith-
arge with the fluid.  Injecting the above insoluble inert amorphous
layer, after it had been repeatedly washed, into the jugulars of rabbits
and dogs, the effects, where it did not kill immediately, were hur-
ried respiration, hard, frequent pulse, and death within forty-eight
hours, quietly and without diarrhoea or vomiting.  Phlyctcence were
found in the lungs, sub-pleural ecchymoses penetrating into the
parenchyma  Math a nodule of well-marked  hepatization in their
centre.   In two instances (dogs) where the lungs were covered
with ecchymoses, a circumscribed purulent deposite, identical with
those  met wdth in man, was  found in several of them.   In both
cases, also, there was effusion of serum in the cavity of the pleura.
None  of those terrible symptoms seen in man were present. There
was disease and death, but no diathesis.  These effects, correspond-
ing to those from  injection of quicksilver by Cruveilhier and Gas-
pard, of powdered charcoal by Magendie, of cerebral substance by
Dupuy,  of the blood of the slug by Gaspard, and of particles of gold
by D'Arcet himself, he attributes to a common cause—the insoluble,
amorphous, and pulverulent nature of the substances injected, ren-
dering them incapable of elimination, and, from their size, of circu-
lating in the capillaries.  The effect was always a local lobular
phlegmonous inflammation in the part.  On injecting, however, after
freeing  it of all insoluble matters, the yellowish, green, putrid fluid
above, which resulted from the spontaneous decomposition of the
pus, the results were, first, hiccup, vomiting, diarrhoea, rigors, fever,
dyspnoea, followed by marked adynamia, depression, stupor, invol-
untary evacuation of urine and faeces, pale appearance of the mu-
cous membrane, different hemorrhages, abdominal pains, and the
most complete prostration, and death in five hours.  On dissection,
the lungs were found of a violet color, infiltrated and indurated as
in oedema,  their surface covered with small spots of sub-pleural and
interlobular ecchymoses.  Similar ecchymoses existed in the spleen,
liver,  and intestines; the  inner membrane of the  aorta was red-
dened ;  the blood fluid, black, greenish, containing grumous portions
which broke down under the fingers, without communicating the sen-
sation of fibrine.   These effects show a  general diathesis and dis-
ease of the whole system, the poisonous liquid, like a leaven, having
communicated its deleterious  properties to the whole blood.  In in-
jecting healthy pus before it is decomposed, M. D'Arcet only twice
in eleven or  twelve experiments obtained purulent deposites.  In
most of the cases the putrid symptoms alone supervened, whether
the pus  M'as human or of the  animal.
   He  finds  in the above results an entire correspondence with those
in man, and considers purulent absorption, phlebitis, purulent infec-
tion, and purulent diathesis, a complex malady of two distinct classes
of phenomena often confounded:
   1. A disease of the respiratory, hepatic, or other organs;  a local 
88
NEW  ELEMENTS OF OPERATIVE SURGERY.
 inflammation dependent on a mechanical cause, the capillary tis-
 sue being embarrassed by insoluble or pulverulent principles devel-
 oped  in  the  pus by its exposure to the oxygen of the air, (in the
 lungs,) and not producing other constitutional effects than those of
 phlegmonous inflammations of the same-organs.
   2. A miasmatic poisoning, caused by the absorption and circula-
 tion of some  principles of the pus, itself becoming putrid, acting on
 the blood in a special manner, and producing grave general symp-
 toms, especially characterized  as adynamic—such as  indicate a
 class  of  diseases where  the entire organization is intimately de-
 ranged, as  the plague, typhus fever, purpura, glanders, &c.
   M.  D'Arcet thus explains the chemico-organic mechanism of this
 process: The purulent  matter in the vessels  reaching  the lungs
 undergoes  such changes, by the action of the  oxygen,  as would
 happen to it  as an unorganized substance out of the body.  Its ele-
 ments separate into two parts—the globules absorbing oxygen in-
 crease in size by their  reunion, and become incapable of traversing
 the capillaries, the caliber of which they obstruct, in the same way
 as mercury, gold, or charcoal, and hence the phenomena from those
 substances introduced into the circulation. The liquid part, under
 the same influences,  acquires  putrid properties, which produce
 the effects as described in those of the simultaneous circulation of
 blood  and putrid matter.   He does not think pus in substance can
 be absorbed by the capillaries—the laws of endosmosis allowing
 only soluble substances.  But the purulent serosity of the pus, de-
prived of its pus-globules, is readily absorbed, and hence, in addi-
tion to inoculation, there is another road opened for putridity en-
 tering the system.   M. D'Arcet had noticed, in cases where puru-
 lent deposites were found to have existed, that the urine had been
albuminous during life ; and to this last organic process he imputed
 the dispersion of such abscesses without producing harm.  This
 sufficiently accounts for  the serous or largest  portion of the pus.
 The pus-globules are supposed to remain in the part, constituting
the greasy,  putty-like substance met with by Dupuytren and others
 in the seat of chronic abscesses which had spontaneously disap-
 peared.—T.]
                        TITLE  II.

                   MINOR SURGERY,

                       (Petite Chirurgie.)

  Operative Surgery, such as we understand it  in  common lan-
guage, is divided into two great sections : Minor (petite) or auxiliary
Surgery, (chirurgie ministrante,) and Great Surgery.  This division
has nothing logical in it, and would, in truth, be difficult to justify on
principles of reasoning; but it is tacitly admitted, and  seems to have 
THE ART OF DRESSING.
89
for a long time assumed a place in practice.   It is, besides, impos-
sible to establish natural limits  between small and great surgery.
Guy de Chauliac, M'hose book was one of the first, if not the first,
to take the title of Great Surgery, says  nothing of what we are
to understand  by petite surgery, (small or minor surgery ;) and the
Bertheonee or  small surgery of Paracelsus  has no resemblance to
any that we to-day call minor surgery.  Since La Faye especially,
authors have  appeared to  understand under  this last  name, the
surgery which in practice we allow to be performed by pupils.
   In this section, therefore, are  consequently given the most ele-
mentary principle's of surgery ; it is  under this form that the ele-
mentary  book of La Faye, that of Mouton, and also  that of M.
Legouas have  been given to the public.  In our day petite surgery,
confined to the mechanical part of the most simple processes, has
become the subject  of works still  more  exclusive,  and of   a
nature that requires almost of necessity that it should occupy  a
place at the head of treatises upon operative surgery.
   The embarrassment which a great number of pupils experience
in the duties about the  sick or in the hospitals, induces  me for that
reason to return to the plan which I had traced out in the first edi-
tion of this work.   I have  felt more and more that minor surgery
was scarcely less indispensable than  greater surgery, and that we
cannot in reality, in a didactic work, separate these two branches
of operative surgery.
  In other respects, without restricting myself to a rigorous defini-
tion, I shall include under the name of Minor Surgery,  (petite chi-
rurgie]) every thing that relates to the dressings, bandages, ele-
mentary operations, and the employ of the means which we are in
the habit of confiding to the  care of pupils, whether out-door (ex-
ternes) or in-door, (internes,) attached to the  hospitals.
                        PART FIRST.

                     ART  OF DRESSING.

  We understand  by Dressing,  every methodical application of
the mechanical and topical means, whose object is the cure of
surgical diseases.  They are the little operations that the pupil or
the surgeon is obliged to practise every day.  The art of dressing
is, perhaps, the most useful in surgery.   Wounds badly dressed,
simple as they may have been, become/serious.  Without a correct
application of the dressings, operations that have been performed
in the best manner  succeed badly.  It is also important that we
should study these kinds  of processes with care, and devote a long
time to them, if we wish to practise the profession of surgery with
advantage. Lecat (Prix de I'Acad. Royale de Chir., edit. 1819, t. i.
P- 103) and Lombard have shown  by  their writings that this sub-
ject was not unworthy of the meditation  even of great practition-
                             12 
90            NEW ELEMENTS OF OPERATIVE SURGERY.

ers.  If students of medicine better understood the real value of
dressings properly applied, they would occupy themselves with the
subject with more ardor and perseverance than they generally do.
We would not then see them hurrying through this duty in hospitals
as quickly as  possible, as if it were a tax, thereby neglecting its most
simple requirements.
  The dressings are made with the aid of instruments, topical appli-
cations, and various bandages.
                         CHAPTER  I.

        INSTRUMENTS REQUIRED  FOR  DRESSING.

   The articles which serve for
dressing, and  which every sur-
geon  ought to carry with him,
are usually collected in  a sort
of port-folio known under the
name of the pocket-case (etui or
trousse) of the  surgeon, (Fig. 1.)
The form of this case and its
dimensions vary  according to
the taste or  wants  of  each.
We arrange it in such a man-
ner as to contain conveniently
a ring  forceps, artery forceps,
scissors, spatulas, a porte-cray-
on, probes, sounds, a  grooved
sound, a porte-meche, thread,
needles, and lancets, (Fig. 2.)
  Among these instruments, to
which a razor should be added,
there  are none which a pupil
may not stand in need of, even
for the slightest kind of  dress-
ing.   I will not, however, speak
in detail of the sounds, needles,
and lancets, until when treating
of catheterism, and of sutures

                      Article I.—Forceps.

                     § I.—Dressing Forceps,

Better known  under the name of ring  forceps, (pince  a anneaux,)
the dressing forceps, always composed of two branches which cross
and are jointed to each other in the manner  of scissors, presents
nevertheless some varieties  in its form.  The rings of the modern
forceps, instead of being  borne, as was formerly the case, (Fig. 3,)
(Fig. 1.)
^

=^
and bleeding.
(Fig. 2.) 
instruments required for dressing.
91
(Fig. 3.)
          on the extremity of each branch, are now placed entirely
          without their axis,  (Fig. 4.)  It results from this   (Fig. 4)
          that, when shut, the instrument is reduced to a
          cylindrical stem, and that in opening it, we do
          not want as much room  to obtain  the  same
          separation.
            It is well not to have the point too blunt, and
          to see that the  inside is cut into grooves, that it
          may have a better  hold upon  the objects.  In
          other respects,  we must take care that the joint
          works easy, that the instrument may be used
          without effort.   Whether there should  be any
          chasings near  the  place of  union or not, is a
          matter that must be left to choice.
            The ring forceps serves to remove the portions
of dressing which cover the wounds, to carry different ob-
jects to the bottom of cavities, and to extract from cavities or the
depth of wounds all those substances that should  be removed.   In
fact, it is an instrument designed to replace the fingers in situations
which the latter cannot reach without difficulty.
(Fig. 7.)
               § II.—Artery or Dissecting Forceps.

  The artery forceps, which are the same that we use in dissecting
rooms, resemble scarcely in any thing the ring forceps.  Separating
themselves by their own spring, and  unable to shut without the
pressure of the fingers, which generally grasp them as we do a
writing pen, the artery forceps should be sufficiently pliable not to
(Fig. 5.) fatigue the hand, and sufficiently elastic to open readily ;  also
      grooved like a file in the middle  portion, (Fig. 5,) that they
      may not slip through the fingers.  Those whose two branches
      are smooth and convex towards the middle outside are now
  I   scarcely ever used.
  * *■    The forceps called valet a patin, (Fig. 6,) and  (Fig. 6.)
      which, by means of a cross piece and double
      button, are kept open at such space as we de-
      sire, are also rarely now in use.   I shall, how-
      ever, have frequent occasion to speak of them
     in the course of this work.
       The  same remark applies to  the different
     kinds of spring forceps,  (pinces d ressort,) and
grooved forceps, (pinces a coulisse,) (Fig. 7,) that are
designated at thepresent day under the name of tor-
sion forceps.
  The artery forceps, still known under the name of
the ligature forceps, are at first designed to seize hold
at the bottom of wounds of the different vessels which
we intend to tie or twist.   They afterwards serve to remove shreds,
eschars, and foreign bodies, of which it is proper to free the wound
or injury.  In fine, we employ them to maintain or to fix in a deter-
 
92
NEW  elements of operative surgery.
minate position the edges of certain wounds, the borders of certain
natural folds, and the different layers of tissues that we find it use-
ful to divide in the course of operations.  It is true that we  can, in a
great number of circumstances, substitute the ring forceps for them,
in the same way  as this latter might be sometimes replaced by
the dissecting  forceps.  Only that we soon find from practice that
this last is better adapted to objects that are loose, (delies,) slip-
pery,  or moveable, and the other for cases  which require less force,
attention, or address.
  A dissecting forceps ending in three small mouse-like teeth, two
on one side and one  on the other, is, in  a  number of cases, of ex-
treme advantage.   It  Mould be advisable, therefore, to add this to
the others in the common pocket case.
(Fig. 10.)
                     Article  II.—Scissors.

  After the forceps, the most indispensable instrument in dressing
          is that which is called  scissors.   I do  not
          mean to speak here  of the specific kind of
          scissors required for hare-lip, staphyloraphy,
          excision of the tonsils, and  certain polypi,
          or, for example, for the different operations
          practised on the eyes.  Those which serve
          for dressing are of three principal kinds: the
          straight scissors, (Fig. 8,) (ciseaux droits,)
          the scissors curved on the flat part, (Fig. 9,)
          and those curved on the  edges, (Fig.  10.)
            Formerly the ring of all  these kinds of
          scissors was, like those of the dressing for-
          ceps,  fixed at its middle to the extremity of
          the handles.   At present, good workmen
          do not any longer make  them in that way,
          and they are now placed on  the outside of
          the handle.  These  instruments, M'hich, as
with forceps, may be made of steel, silver, or even  gold, ought to
     (Fig. n.)      be very sharp, and not catch (se macher) upon the
                blades.  As the objects placed between their blades
                tend to escape by pressure, a cutler named Meri-
                cant has contrived a scissors, one of whose cutting
                edges has a great number  of  small indentations
                upon it, (Fig. 11,) similar to those of a sickle, the
                object of which is to  prevent the slipping spoken
                of.  It is a modification that I have made use of,
                but it appears  to me  of little value.  It does not
                absolutely hinder  the  tissues from  escaping, and
                the cut the instrument  makes is not so neat.  The
                sliding that the artist Mericant  wished to prevent
                is besides often more advantageous than hurtful.
                  The straight scissors are used to cut  the differ-
                ent portions of linen, lint, or plaster that we have
(Fig. 9.)
 
INSTRUMENTS REQUIRED FOR DRESSING.
93
need of.  It is to these, also, we have  recourse  for the section  of
the tissues that are not to be divided with the bistoury.
  We use the scissors that are curved on the flat of their blades, to
remove excrescent growths that we wish to excise at the surface
of the skin, or at the bottom of some cavity.  They may also prove
of use for making holes in certain compresses, and for  giving a
particular form to certain wounds.
  As to the scissors  that are  curved on their edges, they are now
scarcely ever used.   Formerly they were frequently used, by guid-
ing their convex branch upon a grooved sound into cavities whose
external  opening it was  desirable to enlarge; but we  have every-
where substituted  the straight scissors and bistoury for them, and
with advantage.
  There  is no necessity of pointing out the manner of holding the
scissors.  Natural instinct alone, and the example of all women, suf-
fice to enable us to understand it.  Besides, we shall  speak briefly
of this under the article on incisions.

                     Article  III.—Razor.
  Almost all dressings require the use  of the razor.  In men espe-
cially, there are feM'  parts of the body where the skin is not cover-
ed with hair.  Whether  we are  treating a wound, or, for some
cause or  other, have  occasion to apply  a fatty substance,  unguent,
or plaster, &c, to  the teguments, these hairs collect  in irritating
masses, or are glued  together to portions of the dressing, so as to
render each dressing more or less painful.  It  is easy  to see from
this, that it is always proper to shave the regions destined to receive
the portions of the dressing, or  that  are to be operated upon.  If
the customs in use formerly, which, so to speak, forced  the pupil  of
medicine to learn with a perruquier the art of  handling  a razor,
tended to degrade the profession of the surgeon, do not those of to-
day, which do not exact  of the student any exercise of this nature,
possess the disadvantage of rendering him less dexterous?

                    Article IV.—Spatulas.              ( lg\

  The  spatula is a metallic blade, (Fig. 12,) slightly curved.      '
That which  we generally use in France, terminates at one
extremity, after the manner of an  elevator, in a beak with    j
which, as with a lever of the first kind or with a scraper, we
may displace  certain hard bodies.   The other extremity
represents a blade in form of a sage-leaf, with the edges
a little blunt, and shelving on both sides.                    j
  The  uses of the spatula are to extend and equalize in all   kk
directions topical applications of a soft consistence, wherever   111
they are  placed.   We  also  use it to remove  plasters and   |i|
other objects which may adhere to the skin, and to relieve   11 /
this latter of scabs and fatty matters, and all other impurities   Ml
which it may be desirable to take away.                     y 
94
NEW ELEMENTS OF OPERATIVE SURGERY.
  Myrtle  Leaf and English  Spatula.—Formerly  the (f'p■"■> <F1?-14-)
blade of the spatula resembled rather a myrtle  leaf,
which name some surgeons  gave to  it;  but under
this  form it was evidently less useful than the modern
spatula, (Fig. 13.)
  Grooved Spatula.—Still more  to increase its utility,
M. Vidal  (de Cassis) proposed to hollow out a groove
in the spatula on its concave side, (Fig. 14.)   Under
this form it  is an  excellent director  in releasing  the
stricture in strangulated hernia.

             Article V.—Porte-Crayon.
  The cases M'hich require the employment  of nitrate
of silver in  surgery are so numerous, that this  sub-
      stance is almost as necessary in the pocket-case of the ({j *
  lg-   student, as the  spatula and forceps.   As it consists of
  fl|l small cylinders that are brittle, and may tarnish the linen or
  ■I  skin, it is necessary to enclose  it in a protecting instrument.
  m I  This instrument, which is a species of case made of ebony, ivo-
  w& ry, silver, or gold, contains a sort of cleft tube, opened or shut
  If  by  means of a small moveable  ring, and intended to hold the
  HI  cylinder of the caustic, (Fig. 15.)  Some porte-crayons  are
  [I   much more complicated; but in that case, the intention is to be
  w   enabled to change them at  pleasure into a writing pencil or
  8 portable pen, and they are made with a second cavity in their
      upper part to hold the pieces of nitrate of silver.  It is near the
      middle of the instrument-case that the porte-crayon is generally
      placed. It should never be put there after the nitrate has been
      moistened, until we have carefully dried it; otherwise, the
      caustic salt which it consists of might, in decomposing, corrode
      the instruments near it.  The  manner of using it, after re-
      moving the case, is the same as in holding a M'riting-pen.
We touch with it the parts that are to be repressed or excited,  fol-
lowing the rules that cannot be conveniently pointed out but in de-
tail, under the head of each special article.


                     Article VI.—Probes.

                    §  I.—Ordinary Probes.

  The probe  is a metallic rod,  designed  for exploring the bot-
tom of wounds, or the somewhat deep passages that are found  be-
low the solution of continuity of the skin.  Almost all  probes  are
blunt pointed : that is to say, one of their extremities terminates in
a small, rounded head.  Some, however, are entirely cylindrical,
(Fig. 16,)  and end merely in a blunt point.  They should be suffi-
ciently pliable to  adapt themselves  easily  to  the curvatures we
may wish to give them.  The iron probes, however, are infinitely
less serviceable than those of silver or gold.   This instrument takes
 
INSTRUMENTS required for dressing.
95
 r1ff.i6.)(FiS.i7.)(Fi^i8.)the name of eye or  needle  probe, (stylet a fenetre
                ou en aiguille,) when it has  at its other extremity a
                large eye, (Fig. 17.)   Under this form it is used to
                pass a mesh of scraped linen or small strips through
                wounds  or openings in the skin, or the different
                kinds of ligatures under vessels.   It is  called  the
                grooved probe and whitlow probe, (stylet a panaris,)
                when, in place of an eye, it has on its upper sur-
                face a groove, which converts it into  a kind of
                grooved  sound,  (Fig. 18.)  Then it may serve to
                direct  the bistoury  into very small openings, and
                become a useful guide when we wish  to explore
                narrow  passages, or to  have a sort of axis by
                which to introduce  with safety  certain kinds of
                tubes  to a considerable depth in|:o the organs.
       o           In fact, the probe  is an instrument of which  the
 (Fig. 19.) name should be changed, because of the terror it creates in
   a\   the minds of most patients.  If it were possible to have an
       understanding on  a subject of so  little importance, I  would
       propose to substitute for it that of cylinder, which could also
       be qualified as the probe-pointed cylinder, the eye cylinder,
       and the grooved cylinder.

                      § II.—The Chest Sound.

        The ordinary probe, being only five  or six inches long, does
       not answer in all cases. Occasionally, when it is desirable to
       reach to the bottom of extensive devastations, or into some
       deep cavity, M'e feel the want of a much longer probe. The
       one we employ in such cases  bears the  name of the  chest
       sound, (sonde de poitrine.)   It is about a  foot in length, and
       to render it portable, it is  divided into two halves, (Fig. 19,)
       which may be screwed together or separated at pleasure.
       Its  name,  which was doubtless given to  it when it was
       a rule to probe wounds of the chest, would lead to  error at
       the present day; for any  surgeon M'ould be censured who
       should attempt to insert it into the thorax through a wound
      of this cavity.


            Article VII.—Catheters (Algalies) or Sounds.
        We apply the name of catheters, or hollow sounds, to tubes
      of different kinds,  designed  to  draw off  natural or morbid
      liquids  from certain  cavities.  These tubes serve also  to
      conduct medicated  substances  to the bottom of certain  or-
      gans, as M'ell as to explore the interior of certain viscera.
      Surgery, for this purpose, has sounds for the Eustachian tube,
the nasal canal, the larynx, oesophagus, and bladder, and even for
the rectum. These instruments are of gum elastic or metal.  They
take, however, the name  of catheter only when  they have  been 
96
NEW elements OF operative  surgery.
constructed for the purpose  of being  introduced  into the urinary
bladder.   Before discussing  in detail  the use of catheters, when
speaking of vesical catheterism in the male, I will confine myself
for the present to some remarks  upon the catheter, which the stu-
dent sometimes has need of in the business of dressing.

                     § I.—Female Catheter.
  The female catheter, so called, is  a  metallic  tube  of about  six
(Fig. 20) inches length, and two  to three lines in diameter, cylindrical,
      (Fig. 20,) slightly curved at its blunt extremity,  pierced with
G
      two lateral openings on that end, and at the other extremity
      slightly widened like a funnel, and furnished with  a small
      ring on each side.
        This catheter, constructed for the female bladder, serves
      also to drain the liquid contents of certain deep and extensive
      abscesses, to explore the interior  of  the nasal fossae,  and  to
      introduce,  in  the manner of a probe, into the bottom of any
      burroMdng wound.
        Thus made, the vesical catheter is an instrument that can
      rarely be  dispensed with.   In pregnant women,  and Mrhen-
      ever the bladder is  forced up into the hypogastric region from
      some disease in the pelvis, it is neither long  enough nor suf-
ficiently curved to be introduced  with ease.   In  those cases, the
male  catheter, which may equally be substituted for it in ordinary
cases, is manifestly more convenient.

                    § II.—The Male Catheter.

  The male catheter differs  from the  preceding only in being  a
  (Fig. 21.)  third or a half longer, and in having a much       (Fig. 24.)
         greater curvature.   This form,  which ren-
         dered it difficult  to place it  in  the instru-
         ment-case  until  a mode was found of divid-
         ing it, renders it applicable to a great varie-
         ty of uses.   At  the present day, it  may  be
         said that the catheter,  with which  every
         student should provide himself, is composed
         of three pieces :  one the stem, and two be-
         longing to the beak.  The first, common  al-
         so to the two others, resembles in some sort
         a sleeve, (Fig. 21,) that is, the straight por-
         tion of the instrument.  The other varies
         according as it is a female or male catheter.
         For a female, it  consists only  of a segment
of a circle of two inches in length, (Fig. 22.)   For a
male, this segment may extend to five inches,  (Fig.
23.)  In screwing the stem upon one of these portions,
we obtain at pleasure a short and almost straight ca-
theter, that is, a female catheter, or a long  and curved
one, (Fig. 24,) that is to say, a male catheter.
 
INSTRUMENTS required  for  dressing.
97
   In the instrument-case, it should be carried in the form of a fe-
 male catheter, while the curved half of the male catheter is kept
 separate.
   This catheter should have  walls  sufficiently thick and solid to
 prevent its being easily indented.  The orifices known under  the
 name of eyes, and which are placed near the beak, should be at a
 certain distance from one another, and sufficiently wide to give free
 issue to the liquids.  The place of division is a point that should be
 guarded.   When the two pieces of the male catheter are loosely
 screwed together, they lead to an inconvenience which it is impor-
 tant to understand, and of which I shall again speak in treating of
 vesical calculi.   The beak of the instrument, when obstructed by
 some resistance in the bladder, is unscrewed at the bottom of  the
 urethra, while we are endeavoring to turn the broad end in another
 direction.  There is then noticed a sound which might readily con-
 vey the idea of a calculus, and induce us to believe that we had
 explored all the regions of the  bladder, when, in fact, the curved
 part of the catheter had not moved at all.  It is true that, by means
 of a particular  kind of grooving, the artist  named  Charriere  has
 contrived to remedy this inconvenience.   But  however improved
 we may suppose them to be, the catheter in  two pieces can  never
 have, under a given volume, the same strength  as ordinary cathe-
 ters ; so that if it is advisable to have one of the first kind for con-
 tingent cases, this is no reason for neglecting the others when  we
 have it in our power to choose.
  The species  of punch (mandrin, called stylette in English) or little
 probe that every metallic catheter has connected with it, being of no
 other use  than to clear out the eyes  of the catheter when they are
 stopped up, should always be withdrawn before sounding the pa-
 tient, or at least when we desire to ascertain the absence or pre-
 sence of calculi in the bladder.   To conclude, I cannot here  con-
 veniently  point out the manner of employing catheters.  I will on-
 ly remark that gum elastic catheters should be added to those of
metal in the surgeon's instrument-case.

                                                       (Fig. 25.)
       Article VIII.—Director, (Sonde Cannelee.)

  The instrument known as the  Director,  resembles in no
respects the catheter, properly  so called; it is a stem of
 steel, silver, gold, or silver gilt, which has scarcely one to
 two lines in diameter, and but four to six inches length. It
 is rounded upon its lower  side, and has channelled upon
 the  other  a groove  of considerable depth, (Fig. 25.)   One
 end is  shaped  into  a cleft plate with blunt edges, to be
 used in securing certain bridles, such as the framum  of the
 tongue, which we are obliged to keep in a  state of tension,
 while the  surgeon divides them.  At the  other  end, the
 channel of the  grooved sound  ends  sometimes in a cul-
  VL'-at  °ther  timeS witnout  any st0P-   Tnis  sound,
which is often  substituted for  the probe  as an exploring
                           13 
98            NEW ELEMENTS OF OPERATIVE SURGERY.
instrument,  is principally used for directing the bistoury or the
scissors into incisions in the neighborhood of organs which it is im-
portant to avoid.   We then hold it in the left hand as a  lever of
the first kind, the thumb being applied to the flat plate, and the fore-
finger extended upon the middle portion, while the  point serves to
support or raise the parts, (Fig. 26.)   It is used also to break down
those tissues that make but  little resistance, or to  detach and re-
move certain vessels.  In this case, the point of the sound ought to
be a little curved on its concave part; and the surgeon holds it as
he would a pen, taking care to keep it horizontal,  and to commu-
nicate to it, while pressing it  firm, slight motions  backwards and
forwards.  Upon this instrument, also, we pass the porte-ligature
probes, and different meches, and cylindrical stems which it is im-
portant to introduce through certain  passages.  It is, in fine, the
most useful director instrument we have in surgery.
  The director also presents  numerous varieties.  Some persons,
for example, approve of  having it perforated near the point  with
 (Fig. 27.) several holes.   Others  give to its groove a  consider- CFig.2«.)
       able depth and a form  nearly square, while, accord-   m
       ing to some  others, this groove should be triangular
       and nearly superficial; and others again prefer hav-
       ing it in form of a gutter ; but none  of these  differ-
       ences are worth discussing.
         English Director.    In  place of terminating in a
       bifurcated plate, the English Director (Fig. 27) has
       on its extremity a lateral ring, situated like the ring
       on one branch of  a scissors.  It is evident that under
       this form, the director is less convenient in  handling,
       gives less power to the surgeon, and loses some of its
       advantages.

                   Article IX •—Porte-Meche.
   The instrument called Porte-Meche (Fig. 28) is a sort of
 probe, terminating at  one extremity  in a small fork, and at the
0 
INSTRUMENTS REQUIRED  FOR DRESSING.
99
other in a lenticular button.   Its use is very limited, and might be
more so, seeing that the ring  forceps may,  in most cases, be easily
substituted for it.  To use it,  we fix  the bifurcated  extremity on
the middle of the meche, M'hose flattened extremities ought to cover
it, so that it  can push them  before it to the depth that is desired.
The right hand also embraces its other extremity in two different
ways.  Sometimes, in fact, the button,  fixed in the palm of the
hand, permits us to hold the stem with the two middle  fingers and
the thumb flexed, while  the fore-finger is extended and placed in
front.
   In other cases, and this is the mode  I prefer, the two middle fin-
gers reach and press the meche against the instrument, while the
thumb, supported on the button, (Fig. 29,) makes it advance in the

                            (Fig. 29.)
direction of the organs.  The button of the  porte-meche has also
the advantage of enabling us to introduce certain portions of dress-
ing into the midst of resisting tissues, and of thus replacing an in-
strument formerly employed under the name of Meningophylax.

               Article X.—Needles and Thread.

  We must have in the case ordinary thread and needles, to sew
different pieces of linen ; silk threads, and some that are waxed,
to serve  for ligatures, as accidents may require ;  suture needles,
straight and curved, of different sorts, for the union of wounds; but
it will be under the head  of particular  operations that we shall
treat of these objects. 
100           NEW  elements of operative surgery.
                        CHAPTER II.

                             LINT

  Lint is among the articles most  frequently required in dressing.
It is a spongy and pliable substance, made out of linen that has
been partly worn.  To make it, it  suffices to destroy the texture of
the linen, and to separate its threads from each other.   Lint is seen
under two forms: one composed of threads extracted from  small
pieces of old linen, and the  filaments more or  less intimately min-
gled with them; the other, obtained  by scraping with  a knife or
some other metallic blade portions of the linen extended between
two fixed points, or on some solid body, (Fig.  30.)  The first is lint
properly so called, and the  second  takes the name of scraped lint.

                             (Fig. 30.)
  Lint is employed in a crude  state, or  in masses of particular
forms.   Crude lint exists in the form of unequal masses, made  up
of threads intermingled in every sort of M'ay, such, in fact, as it ap-
pears when taken from bags or other places where  it is kept.   To
have it good, it is necessary to select such as is pliable, porous, and
white, deprived of all mixture with crude substances, clean and not
too old, with the threads not too large, and made of linen neither
new nor too much worn.
  Some have supposed that lint made of new  linen absorbs  better
and quicker than such as I  have  just described.  Not only is this
erroneous, but lint of  new linen  is too irritating to the surface, by
the hardness of its threads and its roughness,  ever to  deserve the
preference over lint made of old linen.
  When we employ lint, it  is  to cover certain wounds, or to favor
uniform pressure by padding certain vacuities, or to absorb morbid
fluids, or to compress  some  surface  or cavity, or to  keep asunder 
LINT.
101
the lips of a wound which we do not wish to cicatrize.  If it is to
fill up certain depressions upon the surface of the body or limbs, we
confine ourselves to the crude lint, taking care to equalize the  pe-
lotons.   In other respects, the lint is arranged in pledgets (plumas-
seaux), or in layers (gateaux), in small balls (boulettes), dossils  (bour-
donnets), cushions  (pelotes),  rolls  (rouleaux), wicks  (meches),  plugs
(tampons), or tents (tentes).

    Article I.—Pledgets (Plumasseaux) and Layers, (Gateaux.)

                      §  I.—Plumasseaux.
  Plumasseaux are so formed as to give them a shape conformable
to the surface that we wish to cover.  Generally they are in pledgets
       (Fig.31.)       (plaques)  of an   elliptical form,  (Fig. 31,)  of
   ^r::/j is ;^ ._   thickness  and dimensions necessarily very varia-
 Ijjpgs:^ r "  __^  ble, so  constructed  however, that they may ex-
 feJSJ^^gl^  tend in every direction beyond every part of the
  ^MMSBsS^^  circumference of the wound, and  be sufficient for
the absorption of all the fluids that may exude from it in the  space
of twenty-four hours.  The plumasseaux are  made of the lint pro-
perly so called, and the surgeon  arranges them in the following
manner : holding in his right hand a mass of crude lint, he places
the loose end of it between the upper portion of the fore-finger and
the thumb.  Held firm by the pressure of these two last-named fin-
gers, the threads thus pinched become detached from the others.
The common mass, thus treated successively for a great number of
times,  finally  parts with all  its fibres,  and  produces  a regular
layer of nearly parallel threads, and  of the thickness of from  three
to six lines or an  inch.   In general, the plumasseau ought to be a
little thicker towards the middle than at the circumference.  To
add to its  regularity, some surgeons trim its edges with a scissors,
while others merely fold over the edges or loose ends with their
hand.  All this is a matter of but little importance.   Provided  the
contours of the plumasseau are freed  of borders (bourrelets) or knots,
(nodosites,) it is all that  we  can desire.  Whether they  are  after-
wards  trimmed with scissors or merely turned back, is left to  the
option  of our taste.  Their regular form itself, also,  is a matter  of
fancy rather than of real  utility.  It is nevertheless true, that the
pupil who would  desire to arrange speedily  and in a proper man-
ner a  plumasseau which shall be  soft, uniform, and  sufficiently
porous, should practise the art frequently and with care.
   Arranged in this manner,  the lint  readily receives  the different
kinds of greasy substances and ointments that we wish to apply to
it.  Applied upon wounds, it covers  without irritating them, pro-
tects them against the action of atmospheric air  and the  shock
of foreign bodies, preserves them in a mild temperature, and guards
them from all painful pressure, at the same time that it imbibes
their secretion in proportion as it is given out. 
102          NEW elements  of  operative surgery.
                        § II.—Gateaux.

  In reality, the plumasseaux of lint might well bear the name of
gateaux also.   We reserve, however, this name for  the pure and
simple agglomeration of coarse lint that we M'ish to apply to M'ounds
under the form of layers (plaques)  of more or less  regularity of
     (Fig. 32.)      shape.   To make a gateau, we take a sufficient
                 number of masses of crude lint, spread them out
                 Mdthout altering  the  irregular mixture of their
                 threads, thin them so as to increase its pliancy,
                 and give  nearly everyM'here the same thickness
                 and density to the  layer, so that the whole may
                 resemble in character a slice  (lame) of sponge.
                   At the  present day,  when lint  is  scarcely ever
                 applied naked to the edges of a wound, the form of
the gateau is generally more suitable than that  of  the plumasseau.
We obtain by it an arrangement more porous, pliable, and advan-
tageous in every respect, than by placing the threads of the lint in
any systematic order whatever.  The gateau presenting an areolar
aspect, which  manifestly resembles that  of the sponge, is more ab-
sorbent and less irritating than the plumasseau, which is but  slight-
ly changed from the fibrous form of the linen.   It is,  however, pro-
per to recollect that the gateau does not answer so well for the ap-
plication of ointments and unguents, and that the plumasseau only
is conveniently adapted to receive those matters.


        Article II.—Different Rolls (Rouleaux) of Lint.

  In place of arranging lint in layers, (plaques)  there are also other
forms given to it.

                  § I.—Boulettes, (Small Balls.)

  Boulettes of lint, a sort of small globes, (Fig.  33,) that are made
  (Fig. 33.)   by rolling this substance between the palms of the  hands,
          should in certain  cases be made extremely soft and po-
          rous, when, for example, we wish to  fill up suppurating
          cavities, or the bottom of a fresh  wound that does not
need compression.   In that  case, they  should  resemble so  many
small pieces of sponge, which should be  made as uniform as pos-
sible as to their density at every point.   At other times, on the con-
trary, the boulette  should be sufficiently  solid to become rather a
compressing than an absorbent body.  They are used in this form
when we apply them in greater or  less  number upon vessels that
we do not wish either to tie  or twist, at the bottom of cavities thai;
it is important to support, and upon  points whose  exuberance we
desire to repress.   Different sizes are  given to them, according as
they are to be applied to such or such  a  surface.   In general, how-
ever, the size of boulettes is scarcely ever less than that of  a pea,
and  rarely reaches that of an egg.   Having  the advantage of 
LINT.
103
moulding themselves with ease to all the inequalities of the wound
or cavernous passages, the spongy boulettes are of frequent use  in
surgery.


                 § II.—Rolls properly so called.

  We may give the name of rolls  (rouleaux) to masses of crude
lint gently rolled into  a cylinder, (Fig. 34,) or into the form of a
                   spindle.   Sometimes, however, these  rolls are
      }Il*'J^l____    a little  more flattened on  one side than   on
                   another, or contracted at some point of their
                   length.  We apply them between the edges  of
any large wound,  or along the lateral grooves of certain abscesses,
at the bottom of any  M^ound  from amputation, between  the  labia
majora and the upper part of the thighs, and on the sides of the
scrotum in certain diseases.   As in the  construction  of boulettes,
the lint, when their object is to absorb the fluids, should be rolled
in a manner to resemble rather an elongated sponge, or like a cyl-
inder of linen when we wish, on the contrary, to establish a certain
degree of compression.

                  § III.—Bourdonnets, (Dossils.)

  Formerly surgeons  made frequent use of bourdonnets.  Now they
are scarcely ever employed.  They are a kind of hard boulettes, a
little lengthened, bulging in the middle, (Fig. 35,) where they are
                  frequently tied by a thread.  Also they should  be
                  made of crude lint,  and their principal purpose is
                  to make pressure from the centre to, the circum-
                  ference, or from  before  backwards, from below
                  upwards, or from above  downwards, also  upon
                  the interior of certain natural passages, the nasal
                  fossae for example,  or some  morbid cavity, such
as that of an abscess.
                        § IV.—Pelote.

  We apply the name of pelote to a mass of lint enclosed and press-
ed in a piece of linen, which is tied in the manner of a sack, and
M'hich has thus the appearance of the larger extremity of a gourd,
or of a head included in a narrow collar, (Fig. 36.)   To  make a
 (Fig. 36.)  pelote, it is sufficient to place  on the middle of a square
        piece of linen a mass of crude  lint, according to the size
        we wish to give the pelote.   After having raised up the
        linen on every side, it is tied by several turns  of a thread
        between the free portion of the linen  and the cul-de-sac
occupied by the lint.  In some cases, it  is made in another way:
the, lint, being previously introduced into the cavity where we wish
to place it, remains free outside  We then, piece by piece, force
 
104
NEW  ELE3IENTS OF OPERATIVE  SURGERY.
into the bottom, as into a purse, all the lint required, until  there is
enough to prevent its coming out, and to give it the form of a col-
lar, when we draw upon  the portion outside. With this precaution,
we introduce without difficulty pelotes of a sufficiently large  size
within openings of the most narrow and difficult character.  It is
when we wish, therefore, to obtain pressure from the interior to the
exterior,  to arrest hemorrhage, in wounds of the intercostal artery
for example, or operations on the lower extremity  of the  rectum,
that the pelote of lint is specially indicated.

                    § V.—Tampons, (Plugs.)

  When  boulettes or numerous masses of crude lint are to be ac-
cumulated, either at the bottom of a wound to distend it, or at the
bottom of some cavity to compress it, whether they are naked or
enclosed  in linen, they generally take the name of tampon.   We
see, then, that tampons may in turn resemble boulettes, bourdonnets,
rouleaux, or pelotes of lint.


               Article  IV.—Meches and Tentes.

                         § I.—Tentes.

  We  give the name of  tents to rolls which are  sometimes cylin-
drical, sometimes conical, (Fig. 37,) or  a kind of lint-stopper.  In
       .  37.       general, the lint is, in that  case, rolled between
                 the fingers, so that its threads, which are at first
                 parallel, are thus made to twist around  each
                 other in spirals.   The most  common way  of
                 forming a tent consists in folding double a bun-
dle composed of a greater or less quantity of the filaments of this
substance.   There results from this a cone whose base answers to
the point of flexion,  and the  apex to the free  extremity of the
threads.
  We also sometimes form tents by rolling up a piece of old linen,
or by cutting out some pieces of prepared sponge, or some porous
root, like that of gentian, for  example.  Though  formerly much
used, tents at the present time  are scarcely ever employed.   De-
signed for keeping open fistulous passages, and to dilate certain open-
ings that are too narrow, and to prevent the too rapid  adhesion of
certain circular apertures, they have the inconvenience of obstruct-
ing the exit  of fluids, of painfully compressing the  parts, and per-
forming the office of a stopper.   We should do  wrong, however,
absolutely  to proscribe them  in practice, since there are cases
where the effects which they produce are precisely such as we wish
to obtain.  Lint is much more suitable when we desire to  have a
gentle pressure.   Sponge, on the  contrary, should be preferred
when our object is to dilate speedily some opening which is too
contracted, particularly the neck of the uterus.   Tents of  gentian
and of carrots hold in some sort an intermediate place in this re-
 
LINT.
105
spect between sponge and lint.  The  tent  of gentian may also be
replaced in some cases, either by the  extremity of a sound or of a
gum-elastic bougie, by a bit of bougie-plaster, or a  piece of com-
mon taper,  called by the vulgar name of rat de cave.  Finally, we
may substitute for all these articles a  cone of diachylon cerecloth,
rolled  upon the surface M'hich is free  of the  plaster.  It is in
this manner, for example, that we may keep open the  meatus uri-
narius in certain cases of wounds, and that we might  compress a
vessel opened by a puncture through the  walls of the abdomen.

                        § II.—Meches.
  There are three  principal kinds of meches in surgery—meches
of lint, meches of ravelled linen, and those of cotton.
  A.  To make a lint meche, we take  a bundle of greater or less
size  (according as  is required) of the threads of this substance,
which we double after the manner of  an ordinary skein cut off at
one of its extremities.  A band restrains  the whole at the point of
flexion, and prevents the threads of lint from being displaced. We
thus obtain a regular cylinder, Avhich is now scarcely ever used but
for dressing diseases of the  anus, or  to dilate  the nasal canal in
some operations for fistula lachrymalis.   We, however, use meches
of lint for some other  fistulas, for certain kinds of abscesses, and
also for certain cases of diseases of the urethra.  Sometimes these
meches are drawn by means of the thread which is tied to the loop
—more frequently  they  are  introduced  by means of  the  porte-
meche.
  B.  The linen meche  is made with  a strip of pliable linen, half-
worn,  ravelled on  the edges, so as to  leave  a
breadth of two to four lines of fringe, and a middle
and unaltered portion of three to six lines wide, (Fig.
38.)   This meche, whose edges are very pliant, is em-
ployed under the form of a seton in a  great number
of cases.   When one extremity only is to  rest in the
(Fig. 39.) interior of a cavity, M'hether  that cavity is
       natural or the effect of disease, it  is often
       unnecessary to ravel the edges.
         C. The cotton meche  is nothing else than
       a cord of threads of the same kind, arranged
       in the manner of wicks for bougie or other
       candles, and for small oil lamps, (Fig. 39.) We
       find them,  therefore,  all prepared in com-
       merce, and their use is the same  as that of
       the preceding.


                 Article V.—Scraped  Lint.
(Fig. 38.)
         Though it is taken from linen, either of flax or hemp, the
       scraped  lint differs  nevertheless  in essential  particulars
from ordinary lint.  Deprived of threads and every kind of filament,
                             14 
106
NEW ELEMENTS OF OPERATIVE  SURGERY.
it is in reality composed only of down or hairs.  So also is it very
absorbent, and infinitely more pliant than ordinary lint.   Applied
to M'ounds, it becomes speedily glued  to them, and tends to dry
them much more than the other kind.  For this reason, it  evidently
irritates the edges of the M'ound, and cannot be used but in a small
number of cases, as, for example, for suppurating surfaces in flabby
tissues of pale color.

                   Article  VI.—English Lint.

  For a long time the surgeons of England and of many northern
countries  have substituted for our  lint (charpie) a particular tissue,
               which they call lint, (patent lint, Fig. 40.) and whieh,
               according to them, they have had much reason to
               extol.   This  tissue,  in  some  respects  resembling
               M'adding, (ouate,) is villous,  like ours,  on one  of
               its  sides, and smooth  or glossy, (lustre.)  like fine
               linen, on the other side.  Under this form it appears
               in commerce, in rolled bandages  like linen.  When
               Mre M'ish to use it,  we cut off portions of it of such
               form and  dimensions as we desire.   The plumas-
               seaux  and gateaux are thus made  with  care and
               despatch.   We may compare this tissue,  as to  its
               form, to velvet, whose  villous   surface has  been
               much thinned out,  or to those mats of down used in
               our rooms for wiping the feet upon.
                 If it is admitted  that the patent lint is more con-
venient than the French, it is also true, from its thickness not being
susceptible of increase  or diminution  at pleasure, or  in  one point
more than another, that it  cannot accommodate itself so M'ell to
the form of parts.  Moreover, its glossy face renders  it less adapted
than ordinary lint for the  drying of the wounds, the absorption of
pus, &c.;  so that, every thing considered, the patent lint  is not so
good as ours, or in reality preferable to simple pieces of linen.

                     Article VII.—Filasse.
  The difficulties that are sometimes experienced in obtaining good
lint, have induced persons to seek for substances that might take
the place  of it.  Flax, (la filasse,)  wool, (la bourre,) tow,  (Vetoupe,)
moss, (la mousse,) employed on all occasions  by country people,
when they have nothing better, were the first that offered.
  It is true that filasse really represents lint under its two princi-
pal forms. In the state of prepared flax it is similar in some meas-
ure to lint in the form of plumasseaux.    In that of  tow,  (I'etoupe,)
it would be coarse lint, or the same as gateaux.  The  difference is
this, that  tow and flax have  not been  made pliable by friction, or
that they retain  a  spring, and elasticity, and hardness in each of
their fibres, M'hich render them at the same time  irritating, and not
sufficiently M'ell adapted to the absorption of liquids.
  M. Ganal, it is true, thinks that we may remove these defects
 
LINT.
107
of flax by beating it and then submitting it to chlorine gas.  But
the trials to which I have subjected this kind of lint, called Vierge
by its inventor, have convinced me that it was far from being equal
to ordinary lint.   In respect to the skin and wounds, tow and flax
are to good lint, what coarse new and rough linen would be to that
which is fine and half-worn.  Those  substances, however, answer
very well  for lint when we wish to pad or fill up certain voids or
cavities in the neighborhood of parts that  require gentle pressure.
Thus, in the apparatus for fracture, or beneath  certain compressing
bandages, or to distend some natural cavity, we may employ them
under the form of pledgets, rolls,  tents, and gateaux, in the place
of lint, which, in all such cases, has the disadvantage of knotting
(de se pelotonner)  and lumping (de se grumzler) more easily than
tow or flax.  In  fine, these  substances being cheaper and easier to
procure than lint, it is advisable to use them among the poor, when-
ever lint is not indispensable, or where we can do no better.  Wool,
or the hair of the single-hoofed animals, the ox, camel, &c, is much
inferior to flax, and ought not consequently to be used, except where
nothing better can be had.

               Article VIII.—Typha, (Cat-Tails.)

  The plant known under the name of typha bears upon its free
extremity, when  fully grown, a sort of cylindrical mass, whose ef-
florescence furnishes a down somewhat  analogous to lint.  Other
plants afford a similar down ; but typha is that which furnishes by
far the greatest quantity.  This plumage of typha, M'hich may serve
for making cushions, and even small  paddings, has been  for a long
time in use, in place of tow or lint, among the peasants in the marshy
districts of France.   Nevertheless, surgeons  have not attempted
to employ it until it M'as ascertained that it cured with sufficient
celerity certain wounds of the skin.  It appears, also, that  in the
department of the Aube, typha, among others, (Vignal, These, No.
152, Paris, 1832,) has been for twenty years the domesiic remedy
for different kinds of burns. KnoMdng that this substance had been
used in some of the hospitals of Paris, particularly by M. Cloquet, and
that much success was  imputed to it, I wished to make trial of it
myself.  Unfortunately, I soon became convinced that the fibrils of
the typha were more irritating and evidently less absorbent than
lint; that  if it M'as possible to  substitute them for  any thing, it
could be only for scraped lint.  If we had  neither lint nor flax, ty-
pha would be  better than  nothing, or even better perhaps than
wool; but certainly lint and tow, M'here we are permitted to choose,
should always be preferred.

                    Article IX.—Cotton.
  Cotton, like lint, is seen in commerce under two principal forms
—carded cotton  (carde)  and the crude (ouate) or glossy cotton,
(colon lustre.)   It is a substance whose introduction into surgical
practice ought to be encouraged. 
108           NEW ELEMENTS OF OPERATIVE SURGERY.

  The orude or glossy cotton could be easily substituted for English
lint—[that is, M'hat is commonly known as patent lint]—and would
certainly in many circumstances answer much better ;  being more
fibrous and pliant,  it would have the  advantage of more readily
imbibing fluids, and of not so readily rolling itself up on the surface
of wounds.  Carded cotton has yet more resemblance to crude lint,
and like this,lint may be adapted to the construction of gateaux or
plumasseaux, intended as coverings for all kinds of M'ounds; it is
also undoubtedly practicable to form it into tents, rolls, bourdonnets,
pelotes, and tampons.
  As cotton is cheap, and to be procured everywhere, the question
has been proposed, M'hether it should not  eveiyM'here be substitu-
ted for lint. An American  surgeon, M. Anderson, has maintained
that it is a sort of specific in burns, and M. Larrey was  in the use
of it for a long time in many of his dressings ; but no one has more
strongly  insisted than M. Mayor (Nouveau Systeme de Deligation
Chirurgicale, etc., p. 71, Paris, 1838) on the virtues of this material.
If we  may  believe the surgeon of Lausanne, cotton is much better
adapted for use than lint;  once put on,  it does not become dis-
placed, and adheres f;o exactly to the wound that we may dispense
with a bandage ; furthermore, that it is found everywhere, and is
so well adapted to all  purposes,  that  nothing  can be  compared
with it.
  Cotton is preferable to typha, and to wool and flax ; it may al-
most always take  the place of scraped lint, and can often be sub-
stituted for ordinary lint in making gateaux and plumasseaux.
  In the treatment of extensive burns upon the surface, it is of un-
questionable  advantage ; applied  to the  suppurating  surfaces, it
becomes  adherent to them, and protects  them from contact with
the external air; absorbs the  fluids and prevents all painful pres-
sure, and finally transforms  itself, by combining with the excreted
matter, into a  crust, which dries and permits the cicatrization of
the M'ound to go on underneath.  Nor  has it the disadvantage of
rolling or  lumping, (se  tasser,)  or of  readily forming into  small
balls  (pelotons) and hard and  irregular  knots, under the action
of the humidity M'hich  escapes from the skin or wounds;  com-
posed, however, of a sort of down of extremely  fine short hairs, it
becomes  too closely adherent to the surface of wounds,  so that it
is more difficult to remove than lint, and also irritates and dries
faster.
  In fine, without sharing  all the enthusiasm of M. Mayor,  I am
bound to  declare that cotton  is  preferable to lint in some cases;
that it may be substituted for it in an  infinity of others ; but that
it is less adapted to ordinary dressings, or to ulcers and wounds in
general.
   [With all due deference, we must beg  leave to differ altogether
from the too favorable recommendation of the author on the pro-
priety of substituting cotton for lint.   He has been  rather mis-
led, we judge, by the warm eulogies of others than enlightened by
his own personal  experience.  So far as the experience of Dr. 
LINT.
109
Mott goes, and it  accords fully with mine, cotton never should be
used as a direct application to any incised, abraded, or wounded
surface whatever, whether in a state of suppuration, ulceration, or
otherwise.   In this  cotton-growing country its uses are familiarly
known; and if it is in general employment as a common applica-
tion, the most readily to be had in sudden emergencies of scaldings,
burns,  &c, so frequent  in  steamboat  explosions, that does not
prove that the same  surfaces would not have done much better
under the use of lint, or whatever soft substance there may be of a
similar nature to lint, and fabricated out of flax, or even hemp.  It
is unquestionably true, that there is something peculiarly irritating,
acrid, and unfriendly, either in  the short  mechanical  form of the
spiculEe themselves of cotton down, or in the qualities of the plant,
to all wounded surfaces; and no better test of this could be given
than the manifest  injury and inflammation almost always excited
in the wound in the vein in  the arm  after ordinary bleeding, if we
apply a pledget of cotton cloth, or cotton  itself, instead of linen—
even wool or tow of flax or hemp being, as is well known among
the poor and in our dispensary practice, greatly preferable to cot-
ton. As to the possibility  of  substituting cotton for English or
patent lint, that we think entirely out  of the question, as much so
as the latter is of fine fibrous threads and down of linen, &c, and
the other of cotton; in truth, it is far more probable that the con-
venient, light, smooth form of prepared patent lint will, on the con-
trary, from its great and manifest utility, (as far as we can judge
from much use of it,) entirely supersede the employment of scraped
or crude lint.   Another evidence of  the injurious effects of cotton,
and the more  injurious  from its external application over  large
scalded surfaces, is, that, in those disasters where  there.is  so wide
a field for testing its value,  it has now for the  most part been to a
great degree laid aside, to give place to the mild, soothing applica-
tion of pure SMreet oil, or other equally pure oil.   Even the lubri-
cating qualities of spirits of turpentine, it is found in such cases,
better  compensates for its  stimulating properties, than the more
soft feel or lightness of weight in cotton coverings can neutralize
the chemical or mechanical irritation of  a very acrid  and heating
nature, produced by the minute short spiculas of the cotton down,
which in truth, from their  close juxta-position and variant direc-
tion, give  a peculiarly confined  interstitial texture to the cotton
fibre, and by thus  making it a powerful non-conductor of caloric,
as all the world familiarly know it to be, add greatly  to the reten-
tion and increase of heat in the wounded surfaces.  Many persons
in truth, as is familiarly known, in summer, in our country and in
the more permanently heated latitudes of the West Indies, have their
 skin naturally so sensitive that they  cannot endure the heating, ir-
 ritating effect of even a cotton shirt, or sheet, or pillow-case.  We
 must for ourselves proscribe cotton in any shape in surgery, except
 occasionally only as an external covering, or padding, or matting,
 as the author has indicated, and then with this reservation, that it
 must never come  in contact with the naked surface, and must be 
110
NEW ELEMENTS OF OPERATIVE SURGERY.
used chiefly for warmth or wadding, or, as we term it, filling—
taking care to dispense with it in hot M'eather, or wherever much
inflammation exists in the Mround or reaction in the system.—T.]

               Article X.—Substitutes for Lint.

                           § I.—Silk.
  Silk, which some persons have also advised, might, in case of
necessity, be  also employed;  but its  high price on the one hand,
and its long compact threads on the other, and  its M'ant of porosity,
will never permit it to be compared as a dressing to lint, cotton, or
even tow, (etoupe.)

                      § II.— Wool, (Laine.)
  The extreme fineness and irritating qualities of wool, joined to
the high price of this article, are  alike obstacles to its ever being
substituted generally for the substances of which we have been
speaking ; so that fine  lint, as  it appears to me, will triumph over
the objections that have been directed against it for years past, and
maintain, as an article of dressing, the preference which it has en-
joyed for near a century.

                        § III.—Sponge.
  Some other substances, however, are still  employed in certain
cases in the place of lint; sponge, for example, separated into frag-
ments, serves for small balls, bourdonnets, or plugs, M'hen Me wish
to compress or dilate the interior of a wound, and to absorb  the
liquids of certain openings.  By  selecting wide  and large sized
sponges, we may effect moderate  pressure upon certain flaccid or
uneven regions of the body—for example, the  abdomen ; neverthe-
less, sponge cannot be  compared to lint but in a very few points of
view, and it is scarcely other than in the first dressings that it can
be indicated.   [It is, in the opinion of Dr. Mott, a  valuable and
powerful absorbent,  and very  serviceable in  extensive  suppura-
tions, compound fractures, &c.—T.]

              § IV.—Agaric and  Punk, (VAmadou.)

  These substances are nearly  similar in character.   They are use-
ful for equalizing the contour of the articulations, and as a filling in
for all uneven surfaces, and of  more decided advantage still when
it is desirable to repress any large or projecting part—the mamma,
for example, or some  point which is exceedingly circumscribed ;  but
are rarely suitable,  after the first dressing, for covering wounds
properly so called.  In using them, we must select such pieces as are
smooth, pliant, and of uniform  consistence throughout, and also in
good preservation.  They are shaped into pieces of different dimen-
sions—sometimes very small, sometimes very large ; at other times
applied in a single piece on the diseased  part, more  frequently by
piling pieces together, placing  one on the top of the other, so as to 
LINEN.
Ill
form a sort of pyramid, the apex of which either rests on the skin,
or is situated externally.  In  general, we use agaric or punk to
replace the different kinds of graduated compresses, while sponge
is rather intended as a substitute for cotton or masses of lint, ga-
teaux or boulettes.
                        CHAPTER III.

                            LINEN.

  The kinds of linen that we employ in dressing are the same as
those used in domestic life. Thus we use the tissues of thread, flax,
cotton, silk, and wool.
  Hemp cloth is that in most  frequent use.  It should neither be too
thick nor too fine.   That of coarse thread, like the new, would be
too irritating and inconvenient.  The very fine, or that which has
been loo much M'orn, has not sufficient strength and tears too easily.
Linen cloth would be better than all, if its price made it attainable
by every body.  Ordinary  linen, therefore, when  made pliant by
being worn, is the best, and in general best adapted for  use.
  It  is  generally thought  that  linen for  dressing  should not be
washed with ley, except in some cases, since, when thus prepared,
it draws (tire) the humors with more force and dries up  the wound
too much.  This common opinion is based on a fact which the pupil
ought to be acquainted M'ith: linen washed in pure water is much
harder and rougher and  infinitely less porous than that washed in
le}';  so that  it does not so easily allow fluids to penetrate it, and is
better adapted to serve as a  plaster to the wound.   It  is easj', in
fact, to conceive that the alkaline salts dissolved in the ley must re-
move from linen M'hich has been soaked in it many of those impu-
rities that cannot be got rid of by M'ashing in ordinary M'ater.
  Other things being equal, M'hite linen, which has been soaked in
ley, is the best for dressing; and M'e ought not to use any other but
from necessity.
   Cambric muslin, calico, and all the tissues of cotton, may also be
used for that  of hemp in  a great many cases.   People who attrib-
ute to cotton cloth (linge du coton) poisonous qualities, and are re-
luctant in applying it to M'ounds, are not so entirely in error as one
would at first think.  We find in  fact in cotton cloth  a fine and
penetrating down, of which  I  have just  spoken.   Owing to this
texture, the cloth quickly becomes adherent to the Mound, and is
certainly more irritating to its edges than  ordinary linen.  This,
however, only holds true if the  textures be applied directly to the
wounds themselves; for, if they are to be employed as an enve-
lope, filling in, or bandage, we may very well substitute cotton tis-
sues for those of hemp, and vice versa.  [See inserted note on cot-
ton,  page 108—supra.] 
112
NEW ELEMENTS OF OPERATIVE SURGERY.
   Wool in the state of cloth is used but in few instances, and al-
most always under the form of flannel.  In this form it is used only
for applying to a part, by means of friction,  the  oily substances
known under the name of liniments; it is thus used for embroca-
tions, oily, emollient, or mucilaginous ;  in other cases for the pur-
pose of maintaining a sufficiently elevated temperature about the
part; but in no case is it directly applied to wounds.

                Article I.—Dry or Wet Linen.

  Ordinarily portions of linen for dressing are applied in  a dry
state.  It is thus* they serve for wiping the skin, cleansing off the
matters formed on the  surface of wounds, and in  this way are in
daily  use in most dressings.   Sometimes, however, Mre use wet
linen.  Then it may be moistened in different ways—sometimes by
merely dipping it  in tepid or cold water, that it may shape itself
better to the parts, or press them gently as it dries.  I wall speak
further on of the virtues of moistened linen in the treatment of surgi-
cal diseases.  When the linen  is not wet until after M*e place on
the dressings, it  cannot be compared with-that above mentioned,
but belongs  evidently to the description of dry linen.  A point not
to be forgotten is, that the pressure is less under linen that has been
wet before applied, whilst it  increases under that which is M'et
afterwards ; and this is because the  fluids, by swelling the threads
of the linen, necessarily shrink  and thicken this substance,  (s'epais-
sissent,) which, for  the same reason, must resume its original di-
mensions, and become thinner [and looser] by drying.

      Article II.—Perforated and Fringed (Decoupe) Linen.

  There is now consumed an extraordinary quantity of perforated
linen, (linge troue.)   This is nothing more than pieces of the finer
      (Fig. 41.)      kinds of old linen that are perforated with holes,
  ^ _.__;r—_^__T^_r., so as to give the appearance of a  skimmer or
 jj§||jj|||^^3d watering-pot.  These holes are  cut out by scis-
                 sors, or  by  means of a punch,  (emporte-j/ieces,)
                 or by machines constructed  for this  purpose.
                 The manner of doing this  is,  in other respects,
very simple, and has no other inconvenience than requiring a good
deal of time and causing considerable fatigue.  We take a piece
of linen, folded twice or four times, and cut out with the  scissors
each  angle  that is thus made upon the  principal fold. We may
accomplish the same by cutting, by means of the flat curved scis-
sors, portions of this linen on one of  its sides, (faces.)  The way to
make this perforated linen with most precision, is to draw out from
space to space two or three threads, first in one direction, then in
another, so as to convert it in this manner into a sort of net-work,
having a great number of square holes.
   This kind of dressing is of very great  utility ; greased with ce-
 rate,  or clothed with any fatty substance whatever,  and placed
 
LINEN.
113
upon wounds, this does not prevent their being covered with absorb-
ent gateaux and plumasseaux, while it protects them from painful
adhesions and from too rapid a desiccation. By this means, we run
no risk of leaving a painful traction upon wounds in dressing them.
The holes by which it is pierced permit the suppuration to escape;
the oily matter which covers one  of its surfaces  hinders it from
drying, and sticking, and forming a crust with the  edges of the
wound; the lint M'ith which we cover it is thus freed of one of its
most serious inconveniences.
  Lawn, gauze, or muslin, M'hich, in case of necessity, might be sub-
stituted for the perforated linen, have not, however, all its advanta-
ges.   Forming a simple net-work, these tissues can retain no fluid,
and are  incapable of preventing the desiccation and agglomera-
tion of the dried matters, as the lint that we often have occasion to
apply to them  does; but (as  I shall  mention farther on) they are
better adapted than perforated linen to the surface of cataplasms
that we do  not wish to apply  next to the skin.
  Fringed  linen (le linge decoupe) is a small bandage of six lines
to an inch in width, which is cut by the scissors from space to space
upon one of its edges, so as to convert  it into a      (Fig 42)
species of fringe or border, (Fig.  42.)  This small  Jt^^ ssrtllk
bandage, previously covered with cerate, is applied  \^    \ j|l||P^
upon the  edges of wounds, so  that its fringed bor-
der extends outside, and the  other overlaps by a  line or two the
edge of the wound.  The gateaux or plumasseaux, applied over it,
are thus prevented from the possibility of unpleasantly adhering to
the edge of the suppurating surface. Within the last half century, the
perforated linen has superseded them in almost all those cases where
they were formerly employed. I think  they have  been  too  much
excluded from use; for they are better than the perforated linen for
ulcers  and  wounds of a  pale and  flabby character,  and for  all
wounds that require the use of scraped lint or carded cotton.

   Article  III.—Linen  spread  with  Ointment, (Linge  enduit de
                         Pommade.)

  We no longer use now, in the dressing of wounds, those numerous
medicated compounds  to which  so many virtues were ascribed in
former ages.  Thus the linen  applied on wounds is scarcely ever
covered with any ointment, unguent, or plaster.   At  the present
time we use it in the natural state, and either dry or wet; or if we
desire to  prevent its adhesion to  the  subjacent parts, it is with ce-
rate only that we besmear one of its sides.  The linen, which then
takes  the name of cerated linen, (linge cerate,) exists under  three
forms—in the natural state, when we wish to cover an inflamed or
naked portion of the integuments where there is no wound; in the
state of perforated  linen, as I have just described it, and in that of
fringed bandelettes.
                             15 
HI
NEW ELEMENTS OF OPERATIVE SURGERY.
CHAPTER IV.
                         COMPRESSES.

  The name of compresses is given to various pieces of linen used
in covering wounds.  They are also of very different forms.  They
are made of the cloth of hemp, flax, or cotton, or of silk, or flannel,
but especially with linen.

                Article I.—Form of Compresses.

  When the linen M'hich takes the name of compress has the same
             dimensions in its two principal diameters, (Fig. 43,) it
             is called a square compress.  If  this linen is twice as
             long as it  is  broad, so as  to  form a square  when
             doubled on its length, it is called an ordinary com-
             press.  We call it by the name of long compress (lon-
             guette) when  it ex-              (Fig. 44.)
             ceeds by twice or
thrice in one direction its other
diameter, (Fig. 44.)  The trian-
gular compress is made with a square piece of linen, folded so as to
     (Fig. 45.)
(Fig. 43.)
(FiR.46.)
                 bring two of its angles together, (Fig. 45.)  If this
                 triangle is afterwards tM'ice or thrice folded from
                 the apex to the base, it is transformed into
                 a cravate compress, (compresso en cravatc-
                 Fig. 46.) The fichu compress, (compresse en
fichu,) requiring more pliancy, is ordinarily of silk, cotton, or
muslin.   All these forms of compresses having a special ap-
plication, I shall be obliged to recur to them again.

                Article II.—Divided Compresses.
(Fig. 47.)
  We are sometimes obliged to divide, to greater or less ex-
tent, the free edges or extremities of compresses.
  The Cross of Malta.  If we cut upon a small square piece
of linen, formed of four folds, in a direction  from the most
salient free angle to within some lines of its folded angle, M'e
              obtain a Maltese cros"s, (Fig. 47.)  This cross,
              which it may be useful to perforate in the  jj/;
              middle, to  fix it by its centre upon the ex-  K
              tremity of projecting parts of the body—upon  f i
              the extremity of the fingers, for example,  or  li j
              on the wound which  succeeds to  the opera-  \/
              tion of  phymosis, or from amputation of the
              penis, or upon the apex of  the  mamma, or, as was
formerly used, on the stump in most  cases of amputations—ought
to be small, and not  to have a  diameter greater than  from four to
five inches.
1546 
COMPRESSES.
115
  The half-cross of Malta (Fig. 48) is a piece of      (Fig- 4B->
linen divided like the preceding, but after having
been doubled once only.   It is particularly adapt-
ed to the stump of the shoulder.
  Cleft compresses,  (compresses fendues.)  If  we
merely divide into two equal halves the extremity of a long com-
press, which is either single or double, to the extent of a third or half
of its length,there results a compress cleft into
two heads, (Fig. 49.)  This compress, one of
the  halves of M'hich remains  undivided, is
chiefly used to draw up the flesh in amputa-
tions of the limbs, at the moment when the
surgeon performs the section of the bone. In
some cases it is necessary to divide it into
three heads, (Fig. 50,) as in amputation of
the leg or forearm.  The middle head is then
passed through the interosseous space, while
the two lateral heads are drawn up  outside the bones.  [This last
is the retractor of English and American surgeons.—71.]
  Sling, (fronde—Fig. 51.) The long, narrow, single compress takes
the name of sling, if it is divided throughout its whole length, with
                             (Fig. 51.1
		(Fig.	49.	)
EH?-_-	;		-^	fHUKgi
		"	"	
(Fig. 50.)
the exception of a few inches of its middle part which are left un-
cut ; it is often»useful to pierce a hole through the central point  of
this middle part.  It is  scarcely ever used but in diseases  of the
chin and of the lower jaw.
  The window compress,  (compresse fenetree.)   Some persons un-
derstand by compresse fenetree the perforated linen (le linge troue)
of which M'e have already spoken; but it is better to reserve this
name  for compresses which are to have large perforations on one
or more  points of their extent, in order to be adapted to particular
kinds of ulcerations.  We have thus compresses Math circular open-
ings, (compresses en lunette—Fig. 52,)  those  with
               square openings,  (Fig. 53,) rhom-
               boidal, ellipsoid, &c.; for example,
               for  the dressing  of blisters upon
               the  arm, the application of some
    ¥^---=-4  kinds of caustic, and the dressing of certain ulcers.

               Article  III.—Folded  Compresses.

  All compresses that  are not folded may be denominated single.
Iney are used in this manner in a great number  of cases where
(Fig. 53.)
 
 116           NEW ELEMENTS OF OPERATIVE SURGERY.

 the linen is not separated from the skin or wound by any other sub-
 stance.   But the compresses most  generally employed are once or
 several  times doubled.  If the linen is folded only once, the com-
 press is  said to be only doubled ; if this double is folded upon itself,
 the compress has two doubles; and so on in succession.
  A kind much used is the graduated compress ; it  is made with a
 square double, or with a wide long compress.   The  linen is then
 folded a great number of times upon its base, so that each new fold
                       is a little less in width than that which pre-
                       ceded it, (Fig. 54.) In order to maintain the
                       shape of the graduated compress, it must
                       be immediately moistened,  or  its centre
                       stitched together by means of thread from
 space to space.  The graduated  compresses which have much
 more length than breadth, resemble a kind of prisms, pyramids, and
                        staircases, (Fig. 55,) and are intended to
                        fill  up cavities, or to compress certain
                        parts of the circumference of a limb in
                        the manner of wadding.
  [Amadou, or Punk.  Mr.  J. Wetherfield recommends amadou, (or
punk,) from its soft elastic nature, as a graduated  compress in um-
bilical hernia in children, and over fistulous ulcers.  Also, when
spread with soap plaster, it is, he says, a good application over the
sacrum and ilium, to prevent inconvenience from long confinement
in one position.  Also, in this way, it forms a good  corn plaster,
and to support varicose veins.—T.—Vide Med. Gaz. 1841.]
                        CHAPTER V.

                    BANDS,  (BANDES.)
  The  name of bands, in the art of dressing, is given to certain
kinds of ties which  are used for fastening the other pieces of the
dressing, (appareil,)  and which ordinarily make many turns on the
diseased part.   These portions of the dressing may be of different
tissues.   They are  made of tissue of hemp, or flax, or of muslin,
calico, flannel, or caoutchouc.   For a  piece of one of these  sub-
stances to acquire the name of band, (Fig. 56,) it is necessary that
                            (Fig. 56.)
its length should be at  least six times greater than its breadth;
otherwise it would only  be a bandeau or long compress.
 
BANDS.
117
  The length of bands is extremely variable.  Some are not over
a yard; others exceed ten; nevertheless, they are most generally
from three to six yards—that depends upon the size of the diseased
part, and upon the number of turns or circuits we wish  to  make
with it.   The width of bands is rarely less than that of the finger,
and rarely exceeds that  of four inches.  The wide bands of  three
fingers breadth are the most common, and at the same  time the
most  convenient.   The  narrowest are only used for the fingers,
ears, or penis.   The  widest are employed about the belly and
chest.
         Article I.—Linen Bandages, (Bandes en Toile.)

  Being designed to hold the other parts of the dressing, or to  make
pressure on some region of the body, these bandages require a cer-
tain degree of strength.  The ordinary linen cloth (toile ordinaire)
also has the preference.  Only it  is necessary, as for compresses,
not to make use either of new linen or that which is of too coarse
texture.  Old linen is the best: we cut it in the direction of the
warp, (a droit fil,) and we  thus cut up into strips our sheets, shirts,
napkins, and table-cloths, that have already served their household
purposes.
  As the strips  resulting from this division of the pieces of  linen
are rarely sufficient for each of them to form a bandage, it  becomes
necessary to unite several of them together by their ends.  This
union, which might in cases of necessity be made by means of pins
placed crossMdse, ought to be effected by means of a whip-seam
pressed down, so that as  little inequality as possible may result
from  it.  The linen bandage thus prepared should be freed  of its
hem and of every other seam.   Then, however, it has the disad-
vantage  of  readily unravelling  on its edges, and of incommoding
the bandage with troublesome filaments while we are unrolling it.
If, to avoid this inconvenience, we protect the edges by a hem, it
becomes  hurtful in another respect.   Each  one  of its edges thus
arranged, presenting a greater  degree of firmness and resistance
than the middle portion, is sure to compress and restrict, in the
manner of a cord, the  points that it embraces.  If in the place of a
hem we merely have a selvage, (un faux fil,) we avoid the unrav-
elling of the bandage; but there still  results from it a compression
less regular  and less uniform than with a bandage that is entirely
plain.  It is, however,  true, that the employment of bandages  with-
out selvage  or hems involves serious difficulties for certain  kinds
of dressings; it would be desirable,  therefore, that an article of
such general use might be made in some other way.
  It appears that in Germany surgeons have contrived a way of
making bandages without being obliged to  use linen, properly so
called.  They are made like the ordinary bandage, but with a softer
and more porous thread.   They are so arranged that the transverse
thread leaves, at intervening spaces, small loops on the  edges of
the bandage, by which means nothing is more easy than to attach
the edges of such bandages together.  I cannot conceive why in 
118
NEW  ELEMENTS OF OPERATIVE SURGERY.
France art has not yet profited of this contrivance.   The only rea-
son that can be given is, that bandages, such as are used amongst
us, may everywhere be made as M'e want them.   It is  neverthe-
less true, that  if we had not contracted the habit, it would be much
more handy to take from a roll of bandage the portion that we re-
quired for dressing a wound, than to cut it from a sheet or napkin.

  Article II.—Bandages of Cambric  Muslin or Calico, (Bandes en
                     Percale ou en Calico.)

  The tissues  knoM'n under the name of cambric muslin, or calico,
being finer than ordinary linen, have, therefore, appeared to some
persons more  suitable for bandages.  This is but partially true.
Before having been washed or  used, this tissue is  not sufficiently
porous to answer the principal indications that we have in view;
it  also slips too readily  for the bandage to be easily kept in its
place.   If we  do not  employ it until after it has been softened by
use or washing, it has no longer sufficient firmness, and  plaits or
rolls up into a cord with extreme facility ; whence it folloM's, that,
with few exceptions, the bandages of cambric muslin or calico are
not so good as those of ordinary tissue.
  Cotton bandages would be preferable, if their down was less irri-
tating, and if old cotton cloth retained the solidity of linen.

               Article III.—Woollen Bandages.
  Woollen cloth, which  is but  rarely employed under  the form of
compress, would often be preferred  to linen for bandages, if it was
less dear.  Though M'e might  for  this purpose make use of  any
kind of woollen cloth, or stuff, M'e generally, however, prefer flan-
nel, and  that almost exclusively, for woollen  bandages.  Pliable,
porous, and resistant at the same time, flannel bandages have the
advantage of adapting themselves  exactly to the  parts, and with
very little tendency to become  displaced, or to plait or roll up upon
themselves ; also,  they increase the temperature of the  part,  and
readily absorb all its fluids ; they are, besides, very extensively used
in England.  There is, however, the objection, that they keep up a
certain degree of irritation upon the skin, uselessly heat the parts,
and soon become  badly soiled; also, that they do  not answer as
well for the  establishment of reverses (renversees) as linen banda-
ges, and are, besides, too distensible, and of a  kind that cannot be
readily had on all occasions.

              Article IV.—Caoutchouc  Bandages.

  Gum elastic, or caoutchouc, which has  been a long time used in
commerce under  various forms, and advantageously employed in
the making of suspenders, gaiters, cinctures, corsets, &c, may also
be used for the construction of bandages.   A young physician, M.
Barthelemy, (Theses, No. 322, Paris, 1836,) has discovered  a mode
of flattening and  attenuating (filer)  caoutchouc, so as to convert it
readily and at pleasure into pieces as thin, wide, or long, as may be 
BANDS.
119
desired.  He has shown me bandages made in this manner, and I
have remarked that they roll and unroll with the same facility as
those of linen.
  The pliancy and elasticity of caoutchouc would seem to ensure for
it a more uniform compression upon all  the parts without any re-
striction anywhere.   There is no necessity of reverses or folds, and
we have no trouble  from creases, (les godets;) if any reaction takes
place under the bandage, its flexibility permits it to yield on a given
point, while it is making the proper  resistance required upon the
others.  There  is*no doubt then that the caoutchouc bandages
would be an incalculable acquisition  in  practice, if they could be
brought into use, and if it were possible to procure them at a cheap
price.  They are nevertheless not free  of disadvantages.  Liable to
relax under the influence of heat, and  to contract during cold, they
easily give rise to dangerous inequalities.  Yielding, too, without
difficulty to muscular action, and to the different movements of the
articulations, they might, in elongating themselves in an unequal
manner, fold over crosswise, and in a great number of dressings
not answer the purpose  intended.
  [Caoutchouc ligatures and bandages.  In addition to what is given
in the text, M'e must add here some further details: Mr. Thomas
Nunneley, of Leeds, England, has introduced caoutchouc ligatures,
and extols  their  advantages over all o'hers.  Their superiority con-
sists in these particulars : They may remain on a much longer time
without producing irritation of any kind; from their elasticity, they
hold the divided parts in contact with much less stretching and in
a more natural manner, and at the same time keep up an equal
degree of tension, for, if the part swell, the ligature gives way in
proportion to the pressure; so, too, when the parts contract, they
also contract, and an equal approximation is maintained.   From
their smooth and unirritating properties, also, a greater number may
be applied, and  as they do  not induce ulceration, the scars left are
much smaller than after silk ligatures, which is an important con-
sideration in wounds of the face  and neck.
  As they become  smaller by  stretching, they should be larger
where much pressure is to be used.  The ends  should  be knotted
three or four times to prevent  their giving way, and to effect that
better, the  cord  should  be  tM'isted twice before making the first
knot.  But the very properties of caoutchouc ligatures  which give
them the  advantage for wounds, obviously make them most unfit
for tying vessels.
  The thickness of the thread should be one-sixteenth of an inch in
diameter when cold.  The  application of the warmth of the hand
contracts it to one-sixth  its  length.  In his experiments, Mr. Nun-
neley found that a cord of  one-sixtieth of an  inch diameter, when
stretched out to eleven feet  long, contracted by warmth (of 90° F.)
to eighteen inches, but no farther by any addition of temperature
up to 212°.  Hence, before the suture is applied, he recommends it
to be immersed in warm water of not less than 90° F.  A uniform
degree of elasticity  is thus  obtained, and we thus adapt it to  the 
120           NEW  ELEMENTS OF OPERATIVE  SURGERY.
tension required by the part.  Thus, if we apprehend much swelling,
it should be drawn so tight only as to keep the parts in apposition;
if, on the contrary, there be much tumefaction, it should be drawn
so tight as to anticipate the subsidence of the swelling.   The dan-
ger, however, is of4 draM'ing the  ligature rather too tight than not
enough so.  If they make too great tension, they soon cut their way
out. The eye of the  needle should be large, and of the character of
the seton needle,  as the cord wdien  contracted is bulky.   The su-
tures should all be introduced with one thread, which is to be after-
wards cut into the separate ligatures.
  Mr. Nunneley thinks the caoutchouc ligature  especially advan-
tageous for dressing wounds M'here the adhesive  plaster cannot be
retained, or is too irritating to the skin, and m here it is desirable to
apply lotions.  In  lacerated wounds of limbs, Mr. Nunneley pro-
poses to bind up the wound with caoutchouc thread, thus dispensing
with sutures and plasters, while intervals are left for the free dis-
charge of matter and the application of emollients and lotions. In
the event of using  cold lotions, goldbeater's leaf may be interposed
upon the raw surfaces of the wounds.  Mr. Nunneley suggests that
this method of bandaging might be of great  use in reducing old
hernias when the  ring  is large.   The turns of the thread should
commence at the bottom of the hernia, and pass uninterruptedly up
to the  neck. The thread should be double the thickness of ordinary
sutures, and also wound around the hernia spirally. He thinks this
mode of graduated pressure much preferable  to the taxis, the irri-
tation of which latter, he is of opinion,  often does great injury.—T.
Vide London Lancet, March 13 and July 3, 1841.]
  [Caoutchouc bandages. The same properties of caoutchouc which,
in the opinion of Mr. Nunneley and others, should induce us to give
a preference to  cord or tape ligatures of this neMT, useful, and re-
markable material in the art, may, in the opinion of M. Rigal, of
Gaillac, be urged in favor of caoutchouc bandages under certain cir-
cumstances.  He has used both for some years, and he  particularly
instances hare-lip and operations  for the restitution of lost parts as
adapted to the ligature ; M'hile he remarks that the elastic banda-
ges are very useful in maintaining oblique  fractures of the lower
extremities in perfect apposition, opposing a force in constant op-
eration to the irregular  action of  the displacing muscles.  In this
way, also, they may assist in the replacement of parts after tenoto-
my.—T.—Vide British and Foreign Med. Review, July, 1811.]

             Article V.—Thread-Riband Bandages.

  There  are ribands of common  thread,  also those of flax or cot-
ton, and of all sorts of tissues, and of different thicknesses.  Among
these ribands, which in domestic life  have  altogether a different
destination, there are some  sufficiently wide to use for bandages.
These riband-bandages, however, are  generally unpleasant, hard,
and stiff, as if glazed by ironing,  or by the starch with which they
are impregnated.  They are without  porosity, and slip so easily
that they can scarcely ever be kept  in place.   Their edges, like 
BANDS.
121
cutting instruments, wound the skin; the reverses with these are
difficult to be made, and they generally adapt themselves badly to
the form of the parts.   I should not advise them, therefore, unless
no better can be had.
                Article VI.—Roller Bandages.
  Almost all bandages are presented to the surgeon under the form
of a cylinder; they are then  called roller bandages.  One of the
extremities is found on the surface of the cylinder, M'hile the other
occupies its centre.  Bandages are thus rolled up into one head, or
into two.  Every bandage has two extremities or heads and a mid-
dle part, (le plein.)  The manner of rolling a bandage is an essen-
tial point for the student of medicine.  It is important, in fact, that
he should perform this small operation M'ith ease, quickness, and
some degree of dexterity, if he does not wish to  be excelled by the
nurses.  For that purpose, we are to fold the internal extremity or
central head of the bandage four or five times  upon itself, that it
may form  a sort'of axis.  We then hold this nucleus of the cylin-
der between the thumb and fore or middle finger of the right hand
by the two extremities of its greatest diameter.  The loose portion
of the bandage, being thrown across the radial side of the fore-finger
of the left  hand, is held flat in that  position by  the thumb of that
hand, while the  other hand, draM'ing  the  bandage towards it by
half-turns, successively M'inds it upon the initial pivot,  and thus
forms it by degrees into an entire roll of bandage.   Two methods
may be followed to arrive at this result—in one the belly or bulging
part of the first cylinder looks downwards, and the right hand rolls
it from the beginning to the end by drawing it from below upwards
and from behind forwards, (Fig. 57.)  In the other, on the contrary,
                            (Fig. 57.)
the free part of the cylinder looks upwards, and the hand which
moves it draws it from above  downwards, and at the same time
from before backwards. The bandage thus wound up to its termi-
                             16 
122
NEW elements of operative  surgery.
nation is said to be rolled into a head, (globe—Fig. 58.)    (F'B-M)
        .            To roll a bandage  Mith two heads,
                    (Fig. 59,) it is held as in the prece-
                    ding manner, only we stop for the
                    first  cylinder at the middle of the
                    length of the bandage, so as to do
                    the same with the other extremity.
In this case, the bandage with its two ends in the centre has no free
extremity.  The portion of the bandage M'hich unites the two heads,
and holds the place of its outer extremities, takes the name of the
middle (plein) portion. We generally give less volume to one of the
rolls than to the other.

                 Article VII.—Wet Bandages.

  Bandages are  ordinarily applied in the dry state; it  is generally
preferred, however, to have them a little damp.  If it be true that
dry bandages are very generally employed  at  the  present  time, it
is also true that  damp ones are likeM'ise often useful.  We dampen
bandages by dipping them into various kinds of liquids.
   With water. Impregnated with water only, they adapt themselves
to the parts with more  facility than in the dry state. Adhering
slightly to the skin, they render the reverses more uniform, and are
less liable to puckers. The wet bandage, however, unravels easier,
and soon shrinks a little by drying.   [Bandages tighten or shrink
when wet, and vice versa. See above, where M. Velpeau admits
these  well-known facts.   So in ships with new rigging, it has to be
slackened when  wet, or it breaks.—T.]
   With medicated solutions. If we dip  the bandage into medicated
fluids, it transmits their properties to the diseased parts.  It is thus
we may make it emollient by impregnating it m ith marsh mallows,
or slightly resolvent and anodyne with the aid of  lead water, still
more resolvent and desiccative by spirits of camphor, and narcotic
by preparations of opium.  We, however, rarely employ bandages
dampened in this way, because it is generally  preferred to sprinkle
the medicated liquor upon the bandage, after the latter is once ap-
plied, than  to saturate the different pieces of the dressing with it
beforehand.

       Article VIII.—Glutinous Bandages,  (Bandes Collees.)

   It may become useful to impregnate bandages with matters M'hich,
in drying, harden and glue them together in such manner that the
M'hole bandage becomes converted into one homogeneous substance.
We shall see, farther on, that bandages applied in  this manner are
suitable to almost all kinds of fractures, as well as to a great num-
ber of other dressings.  The materials  that  are used in such cases
vary much.
   White of Egg. A mixture of the white of  eggs, spirits of cam-
phor, and lead water, beaten  together, soon gives to the tissue a lig-
neous hardness.  It is the liquid eulogized by M. Larrey. 
BANDS.
123
  The essence of turpentine, with which linen is easily impregnated,
has the same effect.  Veterinary surgeons have long used it in their
dressings. It is a substance which has the disadvantage of sticking
with tenacity to the skin and hair, and of being  more  difficult  to
detach than  the liquid of M. Larrey.
  Flour.  Rye, and all other flour dissolved in  vinegar or water,  so
as to form a clear bouillie or glue, also causes the turns of the ban-
dage to become adherent to each other and to acquire a great hard-
ness.  This  application,  which I have  employed, and which M'as
shown to me by M. Bretonneau at the hospital of Tours, was used
as the base  of the plaster called calotte, of which I gave the  for-
mula in 1823, (Theses de  Paris, No. 16.)  It may be substituted for
the other applications I have  mentioned, and  also, in cases of ne-
cessity, for those of which I am now going to speak.
  Glue, (colle.)  A solution of gum in  M'ater, or a solution of Flan-
ders glue, produces a result nearly similar.
  Starch.  It is the same  with starch, boiled in  the manner it is for
the  purposes of washerwomen and for starching.   It is in that case
well to besmear the turns of the bandage with it, as we unroll it.
  Dextrine.  In the place of starch we may use a solution of dex-
trine. One part of dextrine, gradually diluted in as much pure wa-
ter, or in a mixture of water and brandy, cold or hot, furnishes  a
solution into which we may dip and saturate the bandages, which
afterwards glue together and harden, in the space of two days,  to
the  point of  acquiring the  solidity of wood.   Thus prepared, they
serve to form all kinds of immoveable bandages, and are destined,
if I am not deceived, to be of great utility in surgery. Up to the present
time, diluted dextrine has the advantage, over all other substances
that I have tried, of being at a low price, of requiring no prepara-
tion, and  of gluing the  linen when  cold; and the  power, also, of
penetrating it like M'ater, of hardening rapidly, and of allowing it-
self to be readily softened again by means of hot water.

  [Dr. Van  Buren on Glutinous, Starch, and Dextrine Bandages.
  A very interesting paper on the different kinds of glutinous, starch,
and dextrine bandages, the  history of their origin, and their present
modes of  application, was published in the American Journal of
Medical Sciences, (Philadelphia,) for May, 1840, by William H. Van
Buren, M. D., formerly an eleve of M. Velpeau, and  now of the
city of New York.  We  avail ourselves with  pleasure of the val-
uable practical remarks  in Dr. Van Buren's learned paper, an ac-
curate summary of which is here subjoined.—T.
  It is not only of late  years that the attention of the profession
has been  directed to this subject.  The inefficiency of the ordinary
apparatus for fractures was asserted by Hippocrates: " Nam neque
in quiete, ut  putant,  crus continent, neque dum reliquum corpus  in
hanc vel illam partem convertitur, canales prohibent quominuscrus
sequatur, nisi homo ipse diligenter advertat," (Hippocrates: De Frac-
turis,)—and by a later and more familiar authority, Boyer: " Mal-
gre l'opinion generalement adoptee, il est facile de demontrer, que les 
124
NEW ELEMENTS OF OPERATIVE SURGERV.
bandages ne servent que tres peu, ou meme point, a maintenir les
fragmens dans leur rapport naturel."—(Dictionnaire des  Sciences
Medicales, tome xvi., p. 535.)
  We have evidence that the Arabians, and some of the eastern
nations, were in possession of an "immoveable apparatus" M'ith M'hich
they treated fractures.  It is generally believed that the idea was
first suggested, in modern times, to M. Geoffroy, on the inspection
of some  ancient Egyptian relics.   M. Sedillot, in the early part of
the past  year, exhibited before the Royal Academy of Medicine, of
Paris, an apparatus used by the Arabs for fracture of the fore-arm;
it  consisted of numerous  narrow splints made of split cane, each
less than an inch in width—these M'ere firmly attached to a sheep-
skin with the wool on it, and bound to the arm.   Of this the splint
recommended by Benjamin  Bell (Bell: Surgery,  Philad. ed., 1814,
App. p.  15)  is but a modification;  it  is a thin strip of light wood
glued on leather, and afterwards split longitudinally at intervals of
half an inch.
  A splint consisting of strips of whale-bone, attached by linen in
the manner of women's  stays, formerly much used by the English
surgeons, is also on the same  principle.  This plan calls to mind
the instructions of Ambrose Pare, when suffering from  a fractured
leg, to his  friend Richard Hubert, who attended him : "You must
fortify," said he, " the sides of my limb M'ith junks made of tents or
little sticks, and lined with linen cloth." (The Works of that famous
Chirurgeon, Ambrose Pare, translated by T. Johnson, London, 1642.)
According to M. de Bouqueville, (Voyage dans la Grece, Paris, 1820,)
the modern Greeks habitually use a consolidating mixture for curing
broken bones—gum mastic  is said  to form its principal ingredient.
A similar though essentially different expedient is adopted in Spain,
Corsica, and the  Brazils, introduced most probably by the African
Moors.
  The Italians have long made use of an immoveable apparatus,
which has been brought into notice by Assalini, in the modifications
which he applied to it, consisting chiefly in the substitution of moist-
ened pasteboard for the original materials.  The itinerant boneset-
ters of Switzerland and  the  southwestern provinces of  France,
some of whom have become quite notorious for their  success in the
treatment of fractures and sprains, employ pasteboard and willow
splints, and solidify their apparatus by means of resin, pitch, mas-
tic, and other varnishes.   Guy de Chauliac, one of the earliest wri-
ters on surgery in France, speaks of a composition  he employed,
consisting of slaked lime with  different gummy and resinous sub-
stances.   Ambrose Pare (Op. Citat., p. 584) recommends at length
the following " Plaster to holdfast restored bones:—B^. Thuris,mas-
tich, aloes, boli armenii. ana, 5 j ; aluminis, resinae pini sicca?, ana,
 3 iij ; farinas,  !jss; albi  ovorum,  q. s.—make thereof a medicine,
and let it be applied all around the leg."
   Among the English surgeons, Cheselden (11th ed.,Lond., 1778, p.
38) is the first who makes mention of an apparatus.  In his "Anato-
my," he  speaks of a bonesetter of Leicester, who employed a mix- 
BANDS.                          125
ture of wheat flour and whites of eggs, with which he smeared his
bandages  to  render them  solid; subsequently  he adds:  "I think
there is no better way than this to treat fractures, for it maintains
so perfectly the position of the limb."*
  Mr. Lawrence,  the  celebrated surgeon of London, in a lecture
which I heard him deliver  on this subject, (Jan., 1839,) ascribed the
first employment of whites of eggs and powdered chalk, as a solid-
ifying mixture, to  a namesake of his, a Mr. L., of Brighton, Eng.,
within a few years past.  He recommended the practice very highly,
and went  through  the process,  before his class,  of  applying the ap-
paratus.
  Mr.  Alfred Smee has lately  published an  account of certain
" moulding tablets for fractures," consisting of a  composition of gum-
arabic and whiting interposed between tM'o  layers of coarse linen.
(V. Phil. Med. Exam., vol. ii., No. 14, from Lond. Med. Gaz.)  These
appear  to  be equal, if not superior to those splints made of felt
soaked  in gum-shellac, which, on account of their being  patented
by  the  inventor, are placed, to a certain degree,  beyond the reach
of the profession.  Lecat, a French surgeon, in the year 1735, in an
essay on the treatment of  fractures, to which a prize  was awarded
by the Acad.  Royale of Paris, asserts that a "simple fracture, when
reduced, requires only to be maintained ; and need be examined but
once before its consolidation—oftener is unnecessary."  In 1768, M.
Moschati, acting on these  principles, presented  to the notice of the
Academy  several cases of  fracture M'hich  he had treated success-
fully by means of  an apparatus consisting of compresses and ban-
dages saturated with the whites of eggs.  The idea was again neg-
lected until resumed by Baron Larrey, in his M'ell-known apparatus
employed with  so much success after the battle of Mo'skwa, (Lar-
rey's European Campaigns;) this  consisted of cushions and com-
presses, retained by the 18-tailed bandage, and rendered immoveable
by saturation with camphorated spirits, acetate of lead in solution,
and whites of eggs ; this apparatus, thus  applied, remained undis-
turbed until the consolidation.   Of its efficacy  and advantages, es-
pecially in military surgery,  Larrey speaks in the highest  terms.
  The use of plaster of Paris, made to set around a limb, generally
in Europe ascribed to Dieflenbach, who employed it extensively,
was originally derived from the Moors of Spain, (Eaton's Travels in
Arabia,) and  first  noticed  in Europe  by Prof. Kluge, of Berlin, in
1829,  and Drs. Muttray and Rauch, (Muttray—de cruribus fractis
gypso liquefacto curandis, Berlin,  1831,) who  M'rote theses upon the
subject. I saw several cases of club-feet, M'hich had been operated
upon by a section of the different tendons, retained thus in  a plas-
ter-mould,  in Middlesex Hospital, London,  under the care  of Mr.

  *  In Galaker,s translation  of Le Dran's Operative  Surgery,  with observations by
Cheselden, p. 543, the latter surgeon recommends the same mixture for contorted or club
feet. He also gives a case in which he applied it to a fracture of the fore-arrn which
happened to a gentleman while travelling: he continued his journey, and, at the^nd of
forty days, the bandages were removed, and the cure found perfect.   At a much later
period, John Bell recommends the  same materials, under similar circumstances. Vide
Principles of Surgery, p. 137, New York, 1512. 
126
NEW ELEMENTS OF OPERATIVE SURGERY.
Mayo.  This plan has some advantages, but many inconveniences.*
In the year 1834, M. Seutin, Professor of Operative Surgery in the
University of Brussels,  and Surgeon of the  Hopital  St.  Pierre,
having under his care many of those wounded at the siege of Ant-
werp,  made  trial of the different varieties of the  immoveable ap-
paratus, and finally chose starch as the  material best  adapted for
surgical purposes.   His practice and success are published.   This
material has been variously used by different surgeons since its first
application by M. Seutin;  for  instance,  M. Laugier, of Paris, em-
ploys stout wrapping-paper, cut in  the form of the eighteen-tailed
bandage,  in  place of linen  or cotton  rollers;  M. Lafarge de St.
Emilion uses a mixture of boiled starch and plaster of Paris, and
others substitute tin,  lead,  zinc, and  carved M'ooden splints for
those of pasteboard.   M. Seutin called his starch bandage I'appareil
amidonne.    Among the surgeons of Paris who  gave to  the im-
provement of M. Seutin the  fullest and fairest trial, the celebrated
Velpeau stands first; and alter much experience, he has substituted
for the starch a substance known by the name of dextrine, as being
superior in many respects, and equally firm.  (For a description of
the dextrine, vide Dr. Van Buren's paper—ut supra.)  Dextrine is
one of the proximate elements entering into the composition of all
amylaceous vegetables and plants, in combination M'ith fecula, ami-
dine, diastase, gum, &c.; it is used to a considerable extent in com-
merce and  manufactures, especially in Paris.  It is  sold by the
quantity in Paris, at about eight sous per pound.
  The following is  the  manner in  which  M. Velpeau applies it:
For a fracture of the tibia, about 5 iv of the powder of dextrine are
necessary; this is to be moistened  with camphorated spirits, and
dissolved in sufficient water  to form a solution of the consistence
of molasses.  In applying the  apparatus to the leg, after reducing
the fracture, a dry roller is passed from the toes to the knee; two
splints cut from the common binders' board, and previously moist-
ened, so as to  mould ihemselves exactly to the inequalities of the
limb, are  then placed one  on either side ;  these are smeared over
with the mixture, and then a second roller, thoroughly soaked in the
solution, is applied over  them, and afterwards perfectly covered ex-
ternally by a coat of it.   The  limb should then—in the case before
us—be suspended from a fracture-bridge, and surrounded by vessels
of hot water to dry the  apparatus, which, in  about six hours, will
become as  firm  as  a case of sheet-iron.   When the period  has
elapsed necessary for consolidation of the fracture, it  is easily re-
moved by soaking for a  few minutes in warm water.
   In the use of dextrine in this manner, M. Velpeau has been  grat-
ified Math excellent  success.   During a period  of  eight months of
constant attendance in  his wards, in which time  upwards of fifty
cases of fracture came  under  his care, I  saM' there no apparatus
but that of  dextrine, and the  bandage of Scultetus for immediate

  * Strange as  it may seem, two English surgeons, Messrs.  Beaumont and Sweeting,
were contending a year or two since for the honor of having first used the plaster. The
latter gentleman speaks in the highest terms of his success. 
ADHESIVE PLASTER.
127
use in compound fractures.  Partwof the time I was actively engaged
in his service, and had frequent opportunities of applying the ap-
paratus under his inspection, and of closely watching its action
during the whole progress of cure:]
                        CHAPTER VI.
             ADHESIVE PLASTERS, (BANDELETTES.)
  The word bandelettes seems to imply a mere diminutive of bandes,
[or bandages.]  It  is true that we might give the name to ribands
of linen of the width of the finger, and from one to three feet long,
for example ;  but use confines the application of the word almost
exclusively to certain strips of plaster, (lanieres emplastiques.)
          Article I.—Plasters of Vigo or  Diapalme.
  The  Vigo plaster  and the diapalme plaster, spread upon linen,
known under the form of cerecloth, (sparadrap,)  may be cut into
strips or ribands of variable length and width. Strips obtained in
this manner may be applied around the  limbs and upon all parts
of the body.  The diapalme does not  adhere with sufficient firm-
ness ; and  it breaks and falls too easily into scales to have any great
efficacy under this form.
  The  Vigo plaster,  more adhesive, and of a closer texture in  its
composition, would be better for compression  and to fasten certain
parts of the dressings.   Perhaps, also, it irritates the skin less, and
favors  less the development of  erysipelas, than diachylon plaster.
But its greenish color, and tendency to liquefaction by heat, and the
difficulty of removing it from the skin, will always render its em-
ployment  inconvenient.
   Article II.—Adhesive Plaster, (Bandelettes de Diachylon.)
  The  cerecloth with diachylon is almost the only one we  use at
present.   The strips of this plaster are employed  in the treatment
of ulcers,  in the following manner: they ought to be  sufficiently
long to make a turn  and a half upon the part, and we give them a
breadth of from eight to  twelve  lines.  The first strip is applied one
or two  inches below the ulcer, and without its being as important,
as some surgeons pretend, to place its middle portion (leplein)  on the
side where the ulcer is,rather than on the opposite.  We then succes-
sively apply the others from below upward, and in the same man-
ner, taking care that they lap over each other by  two-thirds or at
least a  half their width on their inferior  edge, like the tiles of a
roof.   The highest  must also be an inch or  two above the suppu-
rating surface.  An important precaution here is, that each strip
should be applied in a direction exactly perpendicular to the surface
that they are to compress or embrace.   It is also necessary that
they exercise  a uniform  moderate compression,  the  same  as  an
ordinary bandage, and that they should, when they are all applied,
act like a kind of gaiter  or buskin, as regularly as possible. 
128
NEW  ELEMENTS OF OPERATIVE  SURGERY.
  These strips of diachylon are also used as a means of union for
most Mounds, and after a multitude of operations; they are  also
known under the name of adhesive plasters, (bandelettes agglutina-
tives.)   I shall return, then, to the manner of using them in treating
of dressings, properly so called.
  There is another mode of using strips of diachylon:  as a means
for fastening the pieces of linen which serve in the dressings, they
are ready substitutes for bandages.  Thus, strips of diachylon, of
sufficient length to go several inches beyond the  limits of all the
compresses or gateaux with which a wound is covered,  attaching
themselves to the skin, take the place of every other sort  of ban-
dage, because we may apply thus any number  of them, and cross
them in various directions.  It results from this, that the portions of
the dressings cannot be misplaced, and that no compression is made
on the diseased part.  This is an important advantage, upon the face,
cranium, chest, and abdomen, and also in some cases of wounds of
the limbs.  Under this form, the strips, which may also be made to
make the entire circuit of the  part, have nevertheless the disad-
vantage  of favoring the development of erythema and of erysipelas
upon the skin, and of causing in  some patients an insupportable
itching.  The bandages imbued with dextrine may, as it appears
to me, often be substituted for adhesive plasters.
  [Isinglass Plaster.—Mr. Liston  has been in the habit of using,
for many years, a plaster  made  M'ith oiled silk covered  with  a
coating of isinglass.  An ounce  of isinglass is moistened by  two
ounces of water, and let to stand  for an hour or tM'o till quite soft;
then add three  ounces and a half of rectified spirit, previously
mixed with one ounce and a half of water.  Plunge the vessel into
a saucepan of boiling water, and the solution will be complete in
a few minutes.   Having  perfectly stretched out  and  securely
fastened the oiled silk on a board, apply the isinglass smoothly and
uniformly with a brush, as in applying a coat of varnish.  When
hard and dry, apply another layer in an opposite direction, and so
on to a fourth or fifth;  the last layer should be reduced in strength
by adding a little more water.  The isinglass must be well soaked
in the water before the spirit is added.  The brush used  is a flat
hog-tool.  The solution, when cold, should be of the consistence of
blanc-mange.  Gelatin will not answer as a substitute for isinglass.
Mr. Liston has now substituted for the oiled  silk,  the peritoneal
covering of the ccecum of the ox, rubbed down and carefully  pol-
ished in the manner of goldbeater's skin.   Mr. Ancrum, assistant
of Mr. Liston at the  North London Hospital, states that, from the
extreme thinness of the membrane plaster, the wound  can be ex-
amined without its removal—that  it adheres much better than when
the isinglass is spread on oiled silk, and becomes firmly joined im-
mediately—that its tenuity makes it as unirritating as goldbeater's
leaf, and when once applied, it is so accurately adherent that  it
need not be changed for many days—finally, that ample experience
proves it to be the best uniting material ever produced!   In making
it, the same precautions are observed as  above for the oiled  silk, 
VARIOUS ARTICLES.
129
except that a layer of drying oil is to be spread upon the other side
of the membrane.—T. —Vid. Pharmaceutical  Transactions;  also
Med. Gazette, Oct. 15,  1841.]
                       CHAPTER VII.
                   VARIOUS  ARTICLES.
  Dressings demand also some  other  articles  for certain special
cases: for example, in treating diseases of the bones or joints.  It is
for this purpose that they have devised fanons, the false (faux) fanons,
cushions, splints, fracture-boxes,  (gouttieres,) tapes, (les lacs,) cords,
hoops, (cerceaux,) and also beds that might be  called surgical beds.
                      Article I.—Fanons.
  Fanons comprise three principal varieties: 1. The drap fanon ;
2. The fanon properly so called ; 3. The false fanon.
  § I. The  name of drap fanon,  or  splint-holder, (porte-attelle,)  is
given to a piece  of linen somewhat  longer than the fractured
limb, and upon which the other parts of the dressing are first laid.
Properly speaking, this is a simple aleze, or  a napkin, destined to
envelop the different objects that are placed about the fractured
leg  or thigh.  In other respects, the use of the  drap fanon is easy
to understand.  If, for  example,  it is the leg  we  are  treating, we
spread out a napkin, deprived of its hem; upon this napkin we
place the strips of Scultetus; and upon these strips we place, op-
posite to the fracture, some long compresses.  When these latter
are placed upon the limb, and then fastened by the strips of Sculte-
tus, we roll up the lateral splints, from right  and left, in the edges
of the primitive napkin, or drap  fanon; we thus bring each splint.
by degrees, up to the distance of an inch from the surface of the
limb ; the cushions are then introduced between the limb and the
tFi"  eo) sPnnts tnus arranged; the cushion and the splint  in front
      are also  placed; and we  then fasten  the whole  by means
  I of circular bandages.
        It  is easily conceived, that in treating a fracture of the
      thigh, the drap fanon must be of much greater length,  and
      also that less length would be required for the armor fore-arm.
        Meanwhile, the  drap fanon is nothing more  than the en-
      velop of linen  (la  toile d'enveloppe) which we sometimes
      have occasion for in dressings somewhat complicated.
        § II.  The ancient surgeons frequently made use of fanons,
      properly so  called.   They understood by them, cylinders of
      coarse straw, (de forte paille,)  (Fig. 60,)  designed to take the
      place of splints, in fractures of the inferior extremities, espe-
      cially of the  leg, still employed in our day by some practition-
      ers, especially by M. Larrey, senior. These cylinders, which
      have the advantage of bending and accommodating them-
      selves easily to  the  elevations and depressions of the parts,
      while they at the  same time present  a  certain degree of
                             17 
130
NEW ELEMENTS OF OPERATIVE SURGERY.
(Fig. 61.)
resistance, have been for a long time past  generally abandoned.
Their tendency to be displaced, their cylindrical form, the pressure
which they necessarily make upon a very narrow space, their want
of solidity when it is important to guard against powerful causes of
displacement, are the reasons wjay the splints
used  at  the  present day are almost always
substituted for fanons.
  § III.  The false fanons (Fig. 61) are nothing
but linen folded upon itself a certain number of
times; in a word, a species of graduated com-
presses.   These faux fanons, chiefly employed
for the leg, serve at the same time for cushions
and fanons, but principally for cushions.  That
which has been preserved in practice under the
name of the anterior tibial compress, was placed
in front, and  a little to the  outside, while the
others were introduced  on each side, between
the bandage  of Scultetus  and  the drap fa-
non, the splints, or  the bandages.  They were
made to reach, the first, from the  tuberosity of
the tibia  to the instep, the tM'o others, from
the sides of the knee to below the ankles.  In
reality, the fanons  and the false  fanons cannot be useful but in a
very small number  of cases, since cushions or splints are with rea-
son everywhere preferred.   Now, however, when  the dressings for
fracture have undergone  a  complete revolution, it  is  to be hoped
we shall no more have occasion to call these objects to our aid but
for certain kinds of dressings of an altogether peculiar description,
and which I have not now under consideration.
                Article II.—Cushions,  (Coussins.)
  We employ in surgery two kinds of cushions, or mats, (paillassons.)
Sometimes we place cushions beneath the diseased parts, or between
the bed and other portions of the  dressing.  These are a species of
pillows, filled with the chaff of oats; in a case of necessity we could,
instead  of oat-chaff, use feathers, wool, cotton, bran, sand, cows' hair,
or leaves of certain plants;  but the cat-tails, (typha,) and the oat-
chaff, are infinitely better than the other substances. The form of
these paillassons varies with that of the parts they are intended to
support;  that of a  simple square, (Fig.  62,) or  of  an oblong, (earn
long) (Fig. 63,) however, is the most convenient.   It is important
        (Fig. 62.)
                                           (Fig. 63.)
 
VARIOUS ARTICLES.
131
(Fig. 64.)
not to fill them too full, but  only about one-half, for we  almost
always find it necessary to increase or lessen their thickness, some-
times on one part, sometimes  on another, so as to place them, in
fact, in perfect relation with the form of the part that they are
intended to support.   To prevent their irritating the skin, it is well
to enclose them in a single or  double fold of linen, a sort of aleze,
or tick,  (taie,) before insinuating them under the wounded part.
   At other times, the object of cushions is to adjust and protect cer-
tain parts which M'e think require to be supported by means
of more solid substances, or by a considerable degree of
pressure.  Thus,  according to  the ancient  mode, they
alM'ays placed some between the bandage and the splints
around  the fractured limbs, while they arranged one be-
tween the chest and arm in fractures of the  clavicle, or
neck of the humerus, &c.  Then they resembled a kind
of wedge, (coin,) or cylindrical sacks, a little longer than
the broken limb, and from three to six inches in diameter,
(Fig. 64.)   As it is scarcely ever found necessary to place
them in contact with the integuments, there is no absolute
necessity to have them enclosed, as the others should be,
in a linen case.
   The new method of treating fractures will soon also
do away with this kind of paillasson.  It is right to say,
however, that certain wounds, also certain diseases of the
joints,  and some kinds of inflammations,  requiring  one
side of the limb to be exposed at pleasure, while the other
is left in a state of perfect immobility, will make it neces-
sary to retain them in practice.
   As  to cushions  of sand,  or  bran,  or  ashes,  substances
ployed  formerly to increase  the heat of the  parts, and designed
to prevent limbs operated upon for aneurism  from becoming  cold,
they have scarcely  any value  at the present day.   Like  the
satchels (sachets) of medicated powder of herb  leaves, they will
continue to be used  remedially for certain cases, but not  among
the usual  articles employed  in  dressings.   In fine, paillassons
are in truth pillows, either square-shaped, cylindrical, elongated,
         (Fig- 65.)                            (Fig. 66.)
em-
rounded, spectacle-shaped,  (Fig. 65,) or  cuneiform,  (Fig. 66,)
adapted, in a  word, to the part which we desire to raise up, 
132
NEW ELEMENTS OF OPERATIVE SURGERY.
envelop, or support,  and,  when  they are  small, denominated
coussinets.
                      Article III.—Splints.

  Already used in ages past, under the name of ferules or eclisses,
splints acquired a great reputation under the patronage of the Royal
Academy of Surgery, and  in the  school  of Desault.   They are
pieces of wood whose form would be  sufficiently well represented
by a portion of bandage.  Destined to maintain in a state of immo-
bility the fragments of the broken bone, and to serve as a point of
support to the bandages used to envelop the fractures, and to sup-
port  certain diseased parts  that  we are fearful of disturbing,
splints, like cushions, present a number of  varieties.
  Some are plain, (Fig. 67,)  that is, entire (pleines) throughout their
length, and devoid of notches, (echancrures;) others have at one or
                                       the other of their extrem-
                                       ities, and sometimes  on
                                       both ends, a notch in the
                                       shape of a half moon, of
                                       greater   or less depth.
These latter often have also one or two mortices  (Fig. 68) in the
                (Pig gg j                 vicinity of each notch, in
                                       the same manner as some
similar   openings  from
space to space throughout their whole length, or at least  in their
middle portion.  These notches and mortices serve for the  passage
of bandages, and to keep these latter from being displaced.
  In fractures, the splints  should, as far as it is in our power, be
made to  extend a little beyond the length of the affected limb.
Their M'idth varies from two to four or five fingers' breadth.  Their
thickness should scarcely be less than a  line and a half, nor have
more than three  to four lines.   If too narrow or too thin, they would
have the disadvantages of fanons;  if too thick  or  too broad, they
would have too  much weight, and  would  sit badly on the parts.
All this, however, is applicable only to splints of wood, iron, or tin;
for those of pasteboard, leather, or  lead, must be considered under
another point of view.
   Leather splints, which some English surgeons make use of, mould
themselves admirably upon the organs; but they have  the disad-
vantage of not making sufficient resistance, and of being at  too
high a price to come  into general use.
   Lead moulds itself to the parts still better than leather;  but as it
retains the inflections that are given to it, and  is  destitute of any
spring, it does not fulfil, or at least but very imperfectly, the object
we have in view in using splints.
   Pasteboard (carton) is free of all these objections; by wetting it,
we can mould it like lead; when once dry, it becomes hard and re-
sisting like wood.   It is in very general use, and may be had every-
where cheap; and, unless there should be  immediate necessity of
��2667393384���760��8226325548��228788109���801980676118 
VARIOUS ARTICLES.
133
considerable resistance in the  dressings of the fracture, the paste-
board, in my view, will for the future supersede wooden splints, in
the small number of  cases where these latter  might still offer
certain advantages.
  It is easy to conceive that the pasteboard of which the splints are
to be made should be of variable thickness, and that it is necessary
to dip  it in water so  as  to soften it properly before applying it.
[Felt, says Dr. Mott, made into slabs, sheets, &c, often half an inch
thick, is much better than pasteboard, and when wet in warm wa-
ter, or over steam, perfectly soft and flexible.   When dry, they are
as hard as a board, and  harder than pasteboard.  They are very
cheap and serviceable.—T.]

            Article IV.—Trough-Boxes, (Gouttieres.)

   Troughs  (gouttieres—literally, gutters or troughs) are  a sort of
half-tunnels (demi-canaux) designed  to  support  some  parts of
the limbs.  They are made for the forearm, arm, leg, and thigh.
Some have extolled them as a substitute for splints in the treatment
of certain fractures; but they are chiefly intended to place the
diseased articulations  in  the  state of immobility  in which it is
proper that they should be preserved.   It is impossible to conceive
how advantageous it is for patients laboring under arthritis, whether
from gout, rheumatism, syphilis, or other cause, to have the painful
part supported in a properly padded trough.  This contrivance,
from which M. Champion, of Bar-le-duc, has for so long a  period
derived such important advantages, has procured for me  also  ex-
tremely fortunate results.   Enclosing half the circumference of the
limb, trough-boxes have over  splints  the  advantage of not  being
displaced, and  of exacting no compression,  serving at the  same
time, in some degree, as a cushion and splint to the part.   In other
respects, the troughs that are  made of tin, iron plates, (tble.) paste-
board, or even wood, should be as light as possible, and sufficiently
long to extend at least to the middle of the limb,  above and below
the diseased articulation.   Those which the natives of Brazil or
America make  with flexible stalks or  reeds, and which have been
improved upon by M. Smith, have the advantage  of being widened
or narrowed  at pleasure, and of even being transformed  into a
cylindrical  canal; but they  are not so  convenient  as ours of
pasteboard.

  Article V.—Hand-Board (Palettes) and Foot-Board, (Semelles.)

   In connection M'ith plain and grooved
splints and trough-boxes, are to be con-
sidered the articles known under the
name of palettes and soles.
   The palette is a plate of wood (Fig. 69)
designed to support the hand and fingers.
Ordinarily divided like the fingers when
they are expanded, it  ought to  be of
(Fig. 69.)
 
134
NEW ELEMENTS OF OPERATIVE SURGERV.
sufficient length to be prolonged in the  form of a splint to near
         (Fig. 70>)             the elbow upon the side of the fore-
                            arm.  The  semelle is another plate
                            (Fig. 70) perforated M'ith morticed
                            openings near its edges, and shaped,
                            it may be said, to the sole of the foot,
                            which it is intended to support or
protect in certain cases.

        Article VI.—Tapes (Lacs) and Strings, (Cordons.)

  Certain dressings require the use  of  cords.   These generally
consist of ribands, and pieces (des bouts) of bandage or strings.
Tapes (les lacs) of riband or thread, in fact have the same uses in
surgery as in domestic economy.   They are designed to fasten the
different pieces of certain apparatus, as, for example, in the case of
fractures.   At other times their purpose  is to stretch, while they
retain uniformly in their place, particular portions of the bandages,
such, for example, as  the  suspensory, triangular, and  square ban-
dages, and the clavicle  cushion.   For this purpose we generally
make use of ribands of coarse thread, or such as are new or half
used, according as they are to press next the skin or not.  We may
employ also the common riband; the important point  is, that they
should be sufficiently  strong to resist the traction that we may have
occasion to use upon  them  with  the  hands.  We also use bands
made of bandages, sheets, or napkins folded cravat-fashion, wher-
ever we desire to make extension or counter-extension, as, for ex-
ample, in the reduction of fractures or luxations.   In that case it is
necessary to choose bandages sufficiently strong, or to double them.
  Cords maybe made of bandages  or ribands  rolled upon their
axes ; but it is more easy to  employ merely the ordinary cord. This
kind of cord is rarely employed to retain the dressings about the
limb, but for want of better.  But they are used with advantage in
fastening certain parts, either to  the  edge of the bed, or to some
solid substance in the neighborhood.  We have recourse to them
in the strait-jacket, to secure patients whom we M'ish to restrain
while laboring  under  a furious delirium, also to exercise extension
when using tackles or pulleys, in  cases of luxations, for permanent
extension in certain apparatus for fracture, &c.  Finally, we may
use them wherever it is desired to employ great force, and where
the band (le lien) cannot be  applied directly to the body itself.

                 Article VLL—Surgical Beds.

  Almost all patients should be dressed in bed.   In general, they
are dressed in the ordinary  bed;  if, however, it were permitted to
the surgeon to make choice  for this purpose of the most convenient
bed, he should prefer  one  that is narrow rather than wide, that the
surgeon and his assistant, being placed one on  either side, might
act without being fatigued, or obliged to move the patient.
 
VARIOUS ARTICLES.
135
   Metallic beds, being light, and  less liable to bugs, and more
favorable to ventilation, are infinitely better than those of wood.
The upright and horizontal shafts  with which  these beds  are
constructed, resemble  a kind of arbor-work with large windows,
which is of great advantage where a number of  assistants  are
obliged to work together upon the same M'ounded limb.  Extension
and counter extension may be thus made permanently, and secured
upon the frame of the bed, without the necessity of  recurring to a
special apparatus.   It is the same with  all the articles that we
wish to preserve immoveable about the patient.
   It is important that the bed of the  patient should  be sufficiently
firm to prevent it from being easily  depressed ; and that the bottom
be furnished with  a  thick straw bed, unless Me can procure those
elastic mattresses which have been introduced  into commerce for
some years past.  Above this mechanical hair quilt, or straw bed, we
place one or two ordinary mattresses, and not a feather bed. If it were
desirable to have still greater solidity, and to prevent every kind
of projection or depression upon the plane which is to support  the
wounded part,  M'e might, as is  still practised sometimes for frac-
tures of the  lower extremities, slide a wooden board between  the
mattress and the straw bed.  But it is rarely that this last precau-
tion is indispensable, and the surgeon should keep  in view that a
too great hardness of the bed fatigues and disturbs the repose of
the patient.
   If the surgeon had constantly  at his disposal a sufficient number
of assistants, or persons capable of  understanding him clearly,  the
bed of which we  have just  spoken would fulfil every indication.
But as the contrary is too often the  case, and as it  is essential in
certain patients that we should  be  enabled to  change  them with
the least possible disturbance  or movement, there have been  de-
vised certain mechanical beds, M'hich might be  denominated Sur-
gical Beds, (lits chirur gicaux.)  Among these beds, there  are two
that are distinguished at the present day above all others : that
of Daujon, and that  of M. Nicolle.
  Daujon's bed is a sort of sacking bottom, (fond sangle,) supported
by four cords which suspend it to so many pulleys, and which may
be raised entire at the head, or the foot, or  at one or the other of its
angles, or on the right or left side only.  Having also a part which
is  a kind of moveable  cushion towards the seat, it allows the pa-
tient to have his stools without moving him the least from his place.
Its simplicity, and the  real advantages it  procures for the patient,
have contributed in a remarkable degree to bring  it into general
use for the last twenty-five years.
   It is nevertheless true, that the newly devised bed by M. Nicolle,
is  manifestly still more useful.   With this, in fact, we  may have
successively, and temporarily or permanently, all the comforts  of
a  chair, or an arm-chair, upon a plane more  or less inclined, and
in whatever direction we  may wish;  we  may raise or lower the
head or foot Mdthout being obliged to incline the rest of the body.
With this bed, we displace this  or that part without difficulty, and 
136
new elements or OPERATIVE surgery.
nothing is more convenient for patients who suffer, and whom we
do not wish to disturb.
  Many other mechanical beds have been constructed; but those
of Daujon and M. Nicolle, up to the present time, appear to unite
all the best qualities in this kind of article.
               Article VIII.—Hoops, (Cerceaux.)
  After the dressing is finished, it is sometimes required to protect
the wounded parts from the pressure of the sheets and bedclothes.
In such cases, we use an apparatus known under the name of Cer-
ceaux, and whose design is, to keep all the surrounding objects at a
distance from the dressings.   In the country, or where it is neces-
sary for us to construct one  on the spot, and  to have it immedi-
ately, we generally use a cask hoop, cut off at one of its extremities;
this allows the two extremities to  be separated  and fixed between
the edges of the bed and  the sides of the straw bed or mattress;
while the ordinary hoop (Fig. 71) rests upon the bed.  We have
                             (Fig. 71.)
thus a large or a small arc, (Fig. 72,) which sufficiently well sup-
ports the bed-covering that we wish to surround the patient with,
leaving the wounded part in a kind of void.  If a  single arc, thus
arranged, should not suffice, nothing would be more easy than to
place a second, or even a third, at some distance above.
  The hoop, arranged as in figures 71 and 72, is, in part, the pre-
ceding one systematized.  It is made  with rods of metal, or some
splittings of a bushel me'a,sure,(quelques plaques de boissellerie,) joined
together by transverse pieces somewhat more solid, so as to resem-
ble two or three arcs fixed together, and which should rest with
their base upon the mattress on
each  side of the injured limb;
other cerceaux resemble more a
kind of square, (Fig.  73,) which
is constructed  in  the shape of
a box or cage. The important
point is, that  they should be of
height, width, and length suffi-
cient effectually to isolate and
protect the diseased  part.  It is
also evident  that the cerceaux
ought to be divested, at their
 
BANDAGES.
137
base, of every kind of cross-piece, that we may raise or remove
them  without being obliged to disturb the rest of the dressing.
[Common wire, says Dr. Mott, makes an excellent cerceau.  Take
three  or four pieces, and bend them into semicircular arcs,  and
then fasten them at the base with  a piece on each side running
horizontally; and  this makes a light and capital cradle in a few
minutes.—T.]
                       CHAPTER  VHI.

                         BANDAGES.

  It would be quite difficult  in the present day to give a definition
of the term bandage.  We indifferently use, in fact, the words ban-
dage and appareil to designate the same thing.  It, however, seems
to me that we ought, by the word appareil, rather to understand the
ensemble of the  articles which we may have occasion for in the
dressing, while bandage should be applied to the containing pieces
only, or to all the portions of the dressing, after their definitive ad-
justment.
  However this  may be, the bandages are intended to fasten, and
retain in their place, the different portions of the dressing, or of the
diseased part.  Moreover, bandages have been divided by surgeons
almost to infinity, according  to the purpose for which they are to be
used, or the  form or figure they present.  There are those which,
fulfilling every indication, are applied in every case, and merit the
name of general bandages.  Others,  having  been rather designed
for certain parts or regions,  should take the name of special ban-
dages.

                 Article I.—General Bandages.

  We find, in works that treat of this matter, uniting, preservative,
dividing, expulsive, compressing, retaining, (retentifs,) suspensory,
and containing (contentifs) bandages ;  but it is evident that a great
number of bandages may serve, at the same time, for all these  in-
dications.  There are none of them, for example, which may not be
preservative and have other  qualities at the same time.
  The uniting (unissant) bandage, which is  intended for  approx-
imating divided  parts; the dividing,  (divisif)  which is for keeping
them separate ; the retaining, (retentif) for restraining their protru-
sion ; the expulsive, (expulsif) which is intended to expel them ;  all
exercise, at the  same time,  a certain degree of compression, and,
therefore, come,  more or less, under the compressing (compressif)
bandage.
  The suspensory, (suspensif) the object  of which is to give gentle
support to parts  that are naturally pendent, is moreover preserva-
tive, (preservatif) and containing, (contentif.)  This last, intended to
                                18 
 138           NEW ELEMENTS of operative surgery.

 fasten the other pieces of the dressing, is found equally comprised
 in all the others.  It  differs  from the  compressing bandage, how-
 ever, in this, that it has no other use than to prevent the displace-
 ment of the parts.  All these bandages may  be made out of bands,
 (bandes,)  from which, in fact, they receive  their name.  Some of
 them may be made with simple pieces of linen or compresses, as
 there are others in whose construction enter ribands, tapes, (des lacs,)
 or twine, (des cordes.)   Certain bandages, such, for example, as are
 employed for containing hernia, include also  other substances, such
 as  steel springs, pieces of leather, gum-elastic, or caoutchouc, &c.
 In fact, the ancients had so multiplied the number of bandages, that
 they  created confusion, while  M'e seem to   have fallen into  the
 opposite extreme.   If it  is true, that it is useless to have fifty spe-
 cies of bandages for  the  head alone, as in the time of Galen, it is
 no less certain, that the pupil M'ho knows how to make  useful ban-
 dages properjy, dresses better and quicker, and is more serviceable
 to patients, than he who acts wiihout rule and Mdthout principles.
  In the application of the dressing, we must not sacrifice the use-
 ful  to the agreeable ;  but, if  it be possible to give some elegance
 to the bandage, while we have made it at  the same time better,
 M'hy should we not do so ? If it belongs to the surgeon to manipu-
 late the objects M'hich he uses with more address than the world in
 general, M'hy should he not seek to distinguish himself also from the
 vulgar in the matter of dressings ?

                   § I.—Containing Bandage.

  In more general  use than any other, the containing bandage is
employed everywhere.   Applied around M'ounds, its  intention is a
very moderate compression, which  has no other object than to fix
the compresses, lint, &c, in their place, while it renders them im-
moveable.  This bandage sometimes represents a spiral  around the
limb, (Fig. 74,) and sometimes lozenge-shaped turns, (losanges,) or a

                             (Fig. 74.)
double spiral crossed, (Fig. 75,)  as  the  ancients  often  made  it;
sometimes a true roller bandage.
  It is the containing bandage that  we apply after luxations:  al-
most all hernia bandages are of this description ;  we may say the
same of certain pessaries supported in the vagina, and of some pe-
lotes that are kept in the anus.   Many of the dressings of fractures
are also containing bandages.   There is  scarcely, properly speak- 
bandages.
139
ing,'any other in surgery but  the containing and compressing ban-
dage.
(Fig. 75.)
Compressing Bandage.
   We apply the term compressing to a bandage, as often as, in ad-
 dition to its constraining qualities, it is intended so to act upon some
 points of the diseased region as to cause pressure upon it, and ap-
 proximate some of its tissues.  This bandage comprises the simple
 compressing bandage, the expulsory,  the  retaining, the uniting,
 and the dividing bandage.   By it, we effect on the circumference
 of the limb, a  pressure sometimes  circumscribed, sometimes  dif-
 fused, often partial, and occasionally general.
  When the pressure is exercised only upon a circle of the part, it
 takes the name of  strangulation, (etranglement,) or ligature.  Com-
 pression, in fine, has for its general object, to force the fluids into the
 interior—to moderate their afflux to the part—to flatten and re-
press vegetations and tumors, and to bring into contact parts that
have a tendency to separate—to destroy morbid  growths from
 openings or dependent parts where they tend to accumulate—to
 restrict  others  of  them to the cavities where we have confined
 them—to  arrest or  suspend the circulation in certain vascular
 trunks, and to cause mortification by producing an eschar upon some
point of the skin.   But the compressing bandage  may, like the con-
taining, assume an infinity of different forms.  Hence we employ
it under the form of a circular, roller, crossed,  (croise,) or  recur-
rent bandage, that of a T bandage, or cruciform, (bandage en croix,)
suspensory, sling-shaped, (fronde,) or special bandage.
§ III.—Circular Bandage.
(Fig. 76.)
  If, with a bandage of greater or less
width, we make several circular (Fig.
76) turns around any part whatever,
so as to give  it the appearance of a
collar,  as is  sometimes done  at  the
wrist, arm, bottom of the leg, and un-
der the  knee, at the inferior part of
the thigh, and at  the elbow, whether
for the  dressing  of certain wounds,
blisters, or cauteries, the bandage takes
the title of circular bandage ; it is with
this also that we begin a great number of other bandages;  but it
then soon loses its primitive name.
 
140
new elements op operative surgery.
  The circular bandage alone is suitable to all  regions  that  are
throat-shaped, (en forme de gorge) that is. to say, to all parts of the
body that increase in size above  and below the region which  we
wish to dress.   For the purpose of a compressing bandage, it is
scarcely suitable to  any part, seeing  that its action may be  so
quickly changed into that of strangulation; in  that case, it M'ould
be necessary to associate the roller bandage with it.


                     § IV.—Roller Bandage.

  The most  common  of all bandages,  the roller bandage, is,  in
respect to dressings, in some sort what  the  bistoury is to operative
surgery; therefore I shall describe it with more detail than any of
the others.
  By roller bandage, (bandage roule) we mean a  series of turns of
bandage which lap over each other by  the half or two-thirds [their
breadth,] and which, in their ensemble, constitute a sort of stocking,
or gaiter.
  This bandage answers all kinds of indications; often it is only
containing, at other times uniting, and  it may equally be  dividing,
expulsory, or retaining; but the purpose  which  it best fulfils is
compression.
  To be enabled to apply the roller  bandage well, it is necessary
that we should have been  much practised in the expert use  of
bandages.

A.—Rules which  should govern in the application  of  Bandages in
                            general.

  The bandage rolled into a cylinder, (globe,*) and the only one almost
in use at present, should be held in the  hand by the two extremities
of its axis.  Its end, that is, its head, which is free—and which we
often find  in  hospitals, by a reprehensible custom, fastened with
several pins to the other part of the roll—should be applied by its
outer surface on the point opposite to that  on which the wound is
situated.   While the fingers or thumb  of the left hand retain this
head in its place, the right hand draws moderately upon the rolled
head to unroll  it while traversing the circumference of the limb.
   To prevent the free head of the bandage from slipping, or being
displaced, it is well to fasten it by two or three circular  turns,  or,
what appears to me better, to fold it back on the first turn, in order
to  cover it by the second, that we may afterwards have no more
trouble with it.  In continuing to unroll the rolled head of the ban-
dage, we must take care to hold it as little  distant from the surface
as possible, and never to unroll more of it  at one  time than is  re-
quired for half a turn.
  * Though the term globe may be specific enough in French, it is, in our language, too
constantly and intimately associated with the mathematical idea of sphericity, to ba used
in English for the true cylindrical shape of a roller bandage.—T. 
BANDAGES.
141
  We proceed in this manner until the cylinder in the hand is ex-
hausted, and that the central head becomes free.  Then we have
only to fasten that, and it  is ordinarily by means of pins that the
operation is terminated.
  In this respect, we may adopt three modes:  1. With a single pin
on the middle of the length of this edge, we attach it to the subja-
cent turns; in this case, the pin should always have the head turned
toward the free side of the edge; otherwise  it would  constantly
tend to be displaced, and its point would soon  become  entirely
detached before the next" dressing.  2. If the bandage has more
than two fingers' width, the edge of its free extremity being fastened
(Fig. 77.)
(Fig. 78.)
(Fig. 79.)
only at the middle  part, soon
turns up  at  the  angles,- and
gives it a disagreeable  look.
It is better, therefore, to place
a pin near each extremity of
this edge, (Fig. 77,) or still bet-
ter, after doubling in its  two
corners, so as to shape it into a
triangle, to fasten on the point
(Fig.78) as in the first case.
  3. Some persons prefer attaching two strings to the end of the
bandage, with  a view of fastening
this  latter by a  bow  knot,  in  the
manner of ribands.  When the band-
age  is narrow, like that, for exam-
ple, which is used for the fingers, it
is easy, by slitting its free extremity
to the extent of four to six inches, to
convert it into two strips, which will
ansMrer for ribands, and  M'hich we
must take care to cross  under each
other, (Fig. 79.) before tying them.
  4. The student also should not forget, that in placing the pins
crosswise, (Fig. 80,) or the head  turned towards the middle of the
bandage, (Fig. 81,) he proves
(Fig. 81.)
(Fig. 80.)
that  he has never  studied
the art of  bandaging.
  In  unrolling a  bandage,
we make—1. Circular turns,
when the  turns are placed
directly over each  other; 2.
Portions of  a  spiral, when,
acting on a conical part, we proceed from one end to the other of
the surface of the limb, by making all the points of the outer surface
of the  bandage bear perpendicularly upon the limb;  3. These
turns, which are also called oblique, and by means of which we
form crossed (croises) bandages, take the title of doloires when they
lap by a third, two-thirds, or a half [of their width.]
  To make the manner of applying the roller bandage understood, 
142
NEW  ELEMENTS OF OPERATIVE SURGERY.
I will suppose that we are treating the lower extremity.  We must
procure a bandage of the proper length, rolled into a cylinder, three
fingers wide, dry or wet, according to the indication, and begin by
surrounding the foot Math it.  If the surgeon  is  accompanied by
assistants, one of them holds the heel fast M'ith one of his hands,
and the digital extremity of the foot Math the other, M'hile a second
assistant, placed near the pelvis of the patient, supports the ham,
or lower part of the thigh,  so  that the whole leg is sufficiently
raised to permit the different turns  of the  bandage to be freely
passed around it.  If we are deficient in assistants, it is  necessary
that the heel of the patient should be supported upon the knee of
the surgeon, on the  edge of a chair, or some other insulated prop.
These precautions being taken, we throw the free  head of the
bandage upon one of  the malleoli,  the  external malleolus if  it
is the right limb, on the internal, on  the contrary,  if it is the
left, on the supposition, meanwhile, that the^urgeon uses his right
hand better than his left. Arrested upon this point by the left hand,
the bandage is passed  by its free surface  upon  the dorsum, the
inner edge and sole of the foot, and brought to the root of the little
toe.  We then make a first turn; then a second, which covers two-
thirds of the first;  then a third and fourth, folloMdng  the same
rules, till we approach  the instep. There the  bandage is  carried
back by the inner side, and  passed by the  outer  side around the
lower part of the leg, on a level with, or a little above the ankles,
so that the  turns upon the foot resemble the figure of 8 in their
connection with those of the  leg.
  Here difficulties  present, which practice alone enables us to
surmount.  The  malleoli and the heel  form  three  projections,
separated by unequal depressions.  If the roller bandage is to be
purely a containing one, we  can proceed without any real incon-
venience ; but however little may be the compression it  exercises,
these  parts are to be covered by it uniformly; the best mode, then,
is to employ a glutinous bandage,  (bande collee)—(Vid. supra.)  In
this case we always unroll the bandage perpendicularly to the sur-
faces ; and the reverses (renverses) that we are obliged to make to
change its direction  having no longer a tendency to slip, we are
thus  not compelled to  leave  any vacant space, but cover every
point  of the entire region without difficulty.
  Supposing that we do not wish to have recourse to the linen satu-
rated with  glue, we  must fasten the bandage, in proportion as we
unroll it, to the turns over which it laps, and that by using  pins at
each circular turn M'here we wish to change the direction.
  There is also here a difficulty of which young surgeons  should be
advised ; it is, that the  instep, from the metatarsus to the base of
the malleoli, represents a sort of neck, which necessarily requires
a great number of turns, (doloires,) and which, being  the point of
departure to a great number  of compressing radii, seems to accu-
mulate  upon it a more considerable  share of  pressure  than any
other part in the neighborhood.  Hence it is there that patients
chiefly feel  the pain; that phlyctaenae, sores, [escarres,)  and gan- 
BANDAGES.
143
grene form, if the bandage has not been properly applied.   It is
necessary, therefore, to be careful that we press as little as possible
on this spot, and to endeavor not to concentrate upon it the differ-
ent turns of the bandage that are to envelop the heel.   It is a point
of practice on which I cannot too much insist, so often has it hap-
pened to me to see it neglected by pupils, even by those who have
been the best instructed.
  Reverses, (renverses.)   Before arriving  at the  instep, and espe-
cially in order to continue the bandage  in the direction of the leg,
we are obliged to make reverses, (Fig. 82.)  In the act of bandaging,
                            (Fig. 82.)
they give  the name of renverses to a fold which makes the upper
edge of the bandage become  the lower, and its outer surface, the
inner one.  To  render them as little inconvenient as possible, these
reverses should be abrupt, that the oblique edge  they make  may
not be  much longer than the width of the bandage ;  otherwise, it
would represent a species of cord, which would wound the parts by
rendering  the compression unequal.  To make these folds, whether
from above  downward, or from below upM'ard, according to the
place where we apply them, the surgeon fixes the last point of the
bandage that has been unrolled, to the surface of the limb, while
with the other  hand, M'hich has not separated the cylinder but to
very little extent from the  bandage, he turns  it  suddenly  upon
itself, without drawing upon it, and as if to cross its two edges.
That being done, he continues  to unrol it, until he comes back to
the same point, following the rules above indicated, so as to repeat
the same manipulations a certain number of times, if the form of
the limb requires it.
  These reverses are  everywhere indispensable where the  parts
contract in the form of a cone.   In fact, whether it be at  the foot,
leg, or  fore-arm, the parts enlarging, from the inferior extremity
towards the upper portion, render it necessary, in order to bear per- 
144          NEW ELEMENTS OF OPERATIVE SURGERY.
pendicularly on all the points of their surface, that the turns of the
bandage should be made to stretch out in a spiral manner. To ob-
tain, then, a regular roller bandage, it is necessary, in these regions.
that the upper turn, which otherwise would fly off in a diagonal di
rection, should be brought back by a fold, made as quickly as possi-
ble, to the inferior turn, which latter is to remain in a circular posi-
tion, if we desire that it should be in part lapped over by the other.
  Puckers, (godets.)  The pupil  who, in  a case like this, fails in
      (Fig. 83.)         making reverses, produces what are  called
                    puckers,  (des godets—Fig. 83 ;) that is to say
                    the bandage, applied circularly, does not then
                    bear  or press but by one of its edges, while
                    the other edge  flares  out, and remains open,
                    and tends to be displaced. These puckers not
                    only take away from the bandage every thing
                    that it might  possess of elegance, but they
                    also cause  the limb to be  strictured  from
                    space to  space, and the dressing to become
                    displaced from  the moment of its application.
                    Thus, to  arrive at the roots of the little toes
                    on  the instep,  it is absolutely necessary to
                    make three, or four  reverses.   From the mal-
                    leolus to  the lower part of the calf these re-
                    verses may not be  necessary, but  thence to
                    some fingers'  width below the  tubercle  of
                    the tibia they are  absolutely
                    necessary and require extreme
care.   In approaching the knee, the limb, becoming
cylindrical, or rather somewhat contracted, does not
exact the same precautions. To give some elegance
to this arrangement, we endeavor to place the re-
verses on the same line, on the anterior  surface of
the limb, for example, from the small toes to the
knee ; there results from this a crossed appearance,
which gives the bandage some resemblance to the
ancient buskin, (cothurne—Fig. 84,)  or to the stalk
of an ear of wheat.                         /
  Nevertheless, we must  guard against making un-
equal pressure on  any part, merely for the purpose
of giving greater regularity to  the dressing.  As the
cylindrical  or conical form of the part is  not the
same in every individual, it would be manifestly in-
jurious to  wish  to submit the application of the
roller  ba'ndage to rules  too  precise.   The law
which ought, above all other things, to govern the
surgeon in such a case is, that the plane of the ban-
dage should always press perpendicularly upon the
skin ; add to this, that the compression should every-
where be equal; that there may be no void between
the turns of the bandage ; that these  turns lap over
(Fig. 84.)
A
i* 
BANDAGES.
145
 each other in the manner of tiles or slates upon a roof; and you
 then have, for every intelligent  person, the key to a roller ban-
 dage.                                 %
  Padding, (remplissage.)  The roller bandage, when used also for
 compression,  often  requires  that paddings  should  be associated
 with it.
  The leg. If it is the foot, we place, first, on the sole, at the inner
 part and middle ; secondly, on the dorsum, upon the outer part and
 in front, pliant compresses, pieces of lint, cotton, tow, (Vetoupe,) or
 agaric; the same precaution is necessary between the heel and the
 ankles, and on the  sides of the tendo-Achillis.  Without this, the
 compression, in fact, would bear almost entirely upon the edges of
 the foot, and would soon fatigue all the articulations of the metatar-
 sus, at the same  time that it  would favor the engorgement of the
 tissues directly beneath.  In the tibio-tarsal region, it would be the
 heel, malleoli, and tendons  of the  ankles, that would be compressed
 precisely in that part where the compression is useless, whilst the
 intermediate  portions, the  only ones which we generally desire to
 make pressure upon,  would remain perfectly free.  It is apparent
 how the tendo-Achillis would be pressed towards the posterior face
 of the tibia, if we did  not take the precaution to pad its sides.
  I will  add,  that with  the roller bandage, as with all others, an
 equal amount of pressure produces infinitely less effect, on the re-
 gions abundantly supplied with flesh, than on those that are depriv-
 ed of it;  therefore it is well, when we wish to have exact pressure,
to increase its force about the calf, and to place upon this region a
large compress folded four to six  times, while around the tibio-tar-
sal  articulation the compression should be much more moderate. "
  Fore-arm.  What I  have said of the roller bandage, in regard to
the  leg, is precisely applicable to the fore-arm, except that the hand,
being well covered with  flesh on  both its sides, does not, therefore,
involve as many difficulties as the foot, and has no tibial crest, like
the  leg, endangering too severe a  pressure upon the teguments in a
right line.
  In conclusion, when we wish the roller bandage to remain in its
place for  a certain length of time,  it is often necessary to fasten the
looser turns of it by a few stitches or pins;  but if this  fastening
should  be a matter of much  importance, nothing could  be com-
pared in  this respect  to  a  solution of dextrine, or Flanders glue,
with which the bandage should have been previously saturated.
  The  roller bandage is  of such  general use, and yields so many
advantages when it is  well made, that I cannot too much urge upon
pupils to practise themselves in it.  Let those who have  it not in
their power to practise upon it in hospitals, get a manikin, or, what
is as well, procure some bandages, and among themselves, on their
own limbs, familiarize themselves  to the use of it, so that they may
comprehend and overcome all its difficulties.   Being the only dres-
sing for a great number of severe diseases, and associating itself to
almost  all other bandages, and to a great variety of dressings, it
rarely fails to make a part of even those that  are the most trivial.
                             19 
146
NEW ELEMENTS OF OPERATIVE SURGERY.
         § V.—Tail Bandages, (Bandages a Bandelettes.)

  Tail bandages are of two kinds—one composed of tails of greater
or less width and number, and which are fastened by the middle;
the other formed of narrower tails,  simply imbricated or lapping
over each other.   To  the  first kind belong the different sorts of
cleft compresses,  and  especially the bandage with eighteen tails,
and that of Pott; the second comprises, at the present day, scarcely
any other but the bandage  of Scultetus.

           A.-^Bandages with eighteen tails, (Fig. 85.)
                            (Fig. 85.)
  Though frequently employed formerly, the bandage with eighteen
tails is now almost totally forgotten; it is composed of three pieces
of linen nearly square, and laid over each other; they are after-
wards slit on each side into three portions—a middle, a lower, and
an upper one: we have thus nine compresses, each with two tails,
consequently, in all eighteen  tails.   With this  division of three
whole pieces of linen M'e  may envelop the leg  in a uniform man-
ner, without making  either puckers or perceptible folds, because
the lower  tails slightly cover  over the  middle  tails when  they
are brought  forward, and the same with the upper tails when
we bring them round from the  lower part of the calf to the  crest
of the tibia;  but this bandage has this  disadvantage, that we
cannot remove it but as a whole, and of presenting ends of com-
presses that are too wide.  The bandages that have been substituted
for if are manifestly better.

 B. 2? Bandage with the tails united, (Bandage a bandelettes reunies.)

  Desiring to unite the  security  of the eighteen-tailed bandage
to the regularity of the bandage with separate bandelettes, some
surgeons have devised a  dressing composed of wide bandages of
three to four fingers' width, and  sufficiently long to make a turn
and a half around the limb. These bandelettes, previously arranged
upon a drap fanon so as to  lap over one another to two-thirds of 
BANDAGES.
147
their width, should be sewed together along the whole median line
on the back of the bandage, (Fig. 86.)  We obtain thus, when it is
                            (Fig. 86.)
applied, a species of roller bandages, whose parts, fastened behind,
cannot in any manner be displaced, and which, being  sufficiently
narrow, do not oblige  us to  make  any fold or pucker capable of
irritating the parts.  This bandage, nevertheless, has not come into
general use ; from the union of its portions behind, preventing us
from changing the bandelettes separately, the bandage with sepa-
rate bandelettes, or  that of Scultetus, is generally preferred.
  C. Bandage of Scultetus.—Next to the roller bandage, the dressing
of Scultetus  is the  one most employed in surgery, when we are
healing wounds of the limbs; that of Pott, or the preceding, differs
from it only in the stitches which fasten the different pieces behind.
It is made, therefore, like the  bandage  of Pott,  with  a variable
number of tails.  These bandages being designed to make a turn
and a half upon the part, will necessarily vary also in their length
and breadth, according to the size of the limb.  If it is  the thigh,
we give them a breadth of four fingers, and a length of twenty to
thirty inches ; for the leg, they ought to have at least six inches in
length, and only three fingers breadth. We take care also to make
them a little shorter opposite  the narrow parts of the limb.   All
these tails (bandelettes) being prepared, we place them on the  drap
fanon, or on  a napkin spread  out.   We commence by the upper
                            (Fig. 87.)
one, and the others are afterwards arranged from above downward,
so that they may lap over each other two-thirds, (Fig. 87.) 
148
NEW  ELEMENTS OF OPERATIVE SURGERY.
  Most generally it is useful to  place  on this dressing some long
compresses, half as wide as the bandelettes of Scultetus, and which
are the first that are raised around the wounded part.
  To apply this bandage, we roll up its sides on two splints, which
connect the whole into  a  species  of cylinder, which are easily re-
moved without displacing any thing.  If we are treating a fracture,
M'e first surround this bandage  with  the ties wjiich are thought
necessary.  The diseased limb being raised, the surgeon  slips the
whole underneath, loosens the ties,  unrolls, the splints, and  then
spreads out  all the bandelettes of the  dressing.   After having
lowered the part as exactly as possible upon the middle of the ban-
dage, he proceeds to the dressing.   An assistant  supports the foot
by  the  heel  and the roots  of the toes,  while a second  assistant
fixes the knee.  The perforated  linen, the lint, the compresses, and
the cataplasms, are immediately arranged, if the state of the wound
requires it; nothing more is left  to be done than to apply each ban-
delette  of the bandage;  an assistant, who should be  in front,
stretches the  extremity of one of these bandelettes, in proportion
as the surgeon draws on the other, and raises it.  We must begin
with the long compresses,  and always at the lower part.   We then
come to the bandelettes of Scultetus. properly so called, beginning
also with that from below.  In fact, the pieces of linen of the whole
bandage ought to be applied in an inverse  order to that of their
position on the drap  fanon.   Below, we  cross them so that their
ends reach the plantar surface of  the foot.  Upon the leg, on the
contrary, it is necessary that each of their extremities should be
pressed against the side of the tendo-Achillis, or upon the calf, be-
tween the teguments and the fanon.  We continue thus to the last
of the bandelettes, that is to say, up to the knee if it concerns the
leg only, or to the hip if the thigh  is to be included.
  Composed of a multitude of pieces, the bandage of Scultetus ac-
commodates itself to every variety of form and size of limbs. It
has the very great advantage of enabling us to arrange the dressings
without obliging us to disturb the part, whereas, in  order to raise
the part up to apply  the roller bandage, we are forced to  hold the
limb in the air.  Moreover,  this  bandage may be put together or
taken apart in portions.  Should some of its pieces become soiled,
and require to be taken away, they are removed without disturbing
anything.  By fastening, by means of a stitch or pin, a clean ban-
delette to the extremity of that which is soiled, we draw with the
same movement the  first into the. place of the second.  It is then
the containing or compressing bandage par excellence, for all parts
that  require  to be dressed  frequently, and which it is important
should be disturbed as little as possible.

                      § VI.—T Bandages.

  The T bandage is composed of  two portions, one  horizontal, the
other vertical.  The horizontal branch of the T, a portion of the
bandage whose length ought to  be in relation with the size of the 
BANDAGES.
149
part to be embraced, is nearly always arranged in the same
manner.  The vertical branch                 w
of this bandage presents, on
the contrary,  many varieties.
Ordinarily single, it may be
double up to its  root, or  only
to within some inches from the
horizontal branch,  (Fig.  88.)
Formerly, surgeons  used  also
a T, with three or four vertical
branches; but, at the present
time, we no longer  use those
complicated  bandages.   In
short, it  is a bandage which
is made by sewing,  or simply
fastening by pins, one or two
ends  of  bandage  upon  the
middle of another portion of
bandage. The T bandages are
never employed now, but for
diseases of the anus,perinaeum,
and genital organs.  We shall
see,  however,  that  they are
useful also for other regions.
            § VII.—Square and Triangular Bandages.

  A piece of linen, of medium  strength, cut into a square shape,
and having a riband at each  one of its angles, constitutes  the
square bandage, (Fig. 89.)  This bandage, which may be suitable

                            (Fig. 89.)
for certain diseases of the breast, hip, upper part of the thigh, and
sides of the chest, is so simple that it  has no need of being de-
scribed. 
50
NEW  ELEMENTS OF OPERATIVE SURGERV.
   It is the same with  the  triangular bandage, (Fig.  90,) which
              (Fig. 90.)               we employ on the same regions,
                                  and sometimes on the scrotum.

                                    § VIII.—Uniting Bandages.

                                    Since adhesive plasters have
                                  been modified and improved so
                                  as  to  be made  applicable to
                                  the greater number of M'ounds,
                                  the uniting bandages  have al-
                                  most entirely disappeared from
                                  practice.  With some strips of
                                  diachylon and the simple con-
                                  taining bandage, we  fulfil, in
                                  fact,  the  greatest part of the
                                  indications that  gave  rise to
                                  these different sorts  of band-
                                  ages.
                                   It is, however, necessary to
                                 know some of them: 1. Because
                                 adhesive strips cannot be borne
                                 on the skin  of some persons;
                                 and 2. Because the approxima-
tion of the lips of  certain wounds is, in reality, better effected by
a bandage than by  plasters.

            A.  The long uniting Bandage for wounds.
  To unite a wound, whether of the limbs or trunk, in a direction
parallel to the great  axis of the body, we have need only of a bandage;
excepting that it is necessary that this bandage should be rolled into
two unequal cylinders.  In arriving at the sides of the wound, after
having placed, for a point d'appui, the middle part of the bandage
on the region diametrically opposite, the two heads should be con-
ducted in such manner that the smallest passes through a slit pre-
viously made in the bandage of the other.  They are thus crossed
in front of the  wound, whose  two lips are drawn together.  They
are afterwards  conducted backward, where the small head must
be made  to  terminate, and in such manner that there are still
some turns to spare of the larger one.   It is often, also, useful to
place under this bandage a graduated compress, of greater or less
thickness, on each side, and at some distance from the wound.  We
thus force the deeper tissues to come  into contact as well as the
superficial layers.
  A more regular bandage than  the preceding, is that which is
made with a long  bandage, the extremity of which is  converted
into two strips,  (Fig. 91,)  and which present, at a variable distance
from  each other, two kinds  of long openings.  We make a small
head with the divided extremity of the bandage, and  a  large one
with the other portion.  The  measurements ought to be so made, 
BANDAGES.
151
that while the middle of the bandage is supported on the point op-
posite to the wound, the openings and the root  of the strips may

                            (Fig. 91.)
be found united  together on reaching near the wound.   Passing
through each other,  and properly crossed, the two portions of the
bandage are then drawn upon, unrolled, and fastened, as in the
preceding case.
  With this arrangement, the strips fill  up exactly the holes pre-
pared beforehand, and the whole makes in reality but one  piece.
which draws in an equal manner, and in an opposite direction, upon
the parts that  we wish to keep in contact. It is to this, then, that
we must have  recourse when we wish to undertake the immediate
union of a wound of some length, in those cases where  adhesive
plasters do not seem applicable or sufficient.
  When the wound is narrow, or M;here  it is of no consequence to
effect a perfectly exact coaptation of its  lips, we may make use of
a more simple uniting bandage ;  that is, of one somewhat narrower,
and rolled like the other into two heads, and whose two  portions
are obliquely crossed without being  slit,  or without crossing upon
the front part of the wound.  This form of bandages is useful when
we are treating  parts, for example, of small dimensions, as the
fingers, where we make use of bandages  extremely narrow.

           B.  Uniting Bandages for transverse wounds.
  To approximate the edges of a transverse wound, we must draw
upon it in directions parallel to the axis of the body.  The bandages
then necessary  not being enabled to act in a circular direction, we
are obliged to employ special pieces, that are fastened by means of
a roller bandage.   Thus, we have an upper piece represented by
the extremity of a bandage of greater or less length and M'idth ; in
the portion of this bandage which is to rest on the wound, we make 
152
NEW ELEMENTS OF OPERATIVE SURGERY.
long slits or openings; we then have a second piece of linen, of
nearly the same dimensions, and M'hose upper extremity is to be
divided into two or three strips. In joining and crossing the divided
parts of the two pieces of bandage, we obtain nearly the same
figure as by the uniting bandage for longitudinal wounds.
  When we wish to apply this bandage, we fasten the inferior part
to the lower part of the leg if we are treating the  abdominal ex-
tremity, and the superior  portion around the  thigh, by means of
circular turns, (Fig. 92,) taking care to fold the unperforated ex-
tremity under  each turn of the bandage, in order to fasten it as

                            (Fig. 92.)
firmly as possible.  When  the  roller bandage reaches both above
and below to the neighborhood of the wound, the surgeon, having
charged two assistants with the head of each bandage, passes the
strips of the lower piece into the openings of the upper piece, slips
the graduated compress underneath and across, draws upon these
two pieces in an opposite direction, and applies to the wound the per-
forated linen, lint, or any other object he judges necessary; when all
the parts of the  dressing are properly crossed, and each one prop-
erly applied in its place, he continues to unroll the upper bandage
from above downward, until it is entirely exhausted.   He does the
same with the lower bandage, which enables him thus to complete
the roller bandage, by enveloping what  may remain uncovered
of the  uniting slips.   This bandage  might be replaced  by two
bandages in T, with two to three or four vertical branches.   But
then it would be necessary also to use a bandage of great length, in
order to establish a roller bandage from the extremity of the limb
to its upper part; it would, also,  have the inconvenience of too
strongly pressing upon the parts at the root of each T.  The uniting
bandage for transverse wounds is  still employed by some for frac-
tures of the patella and of the os calcis, and for rupture of the
tendo-Achillis; but in  those  cases it  should be replaced by some-
thing more  simple and full as efficacious.  On the arm and thigh
we add to its solidity by fastening the superior portion with one or
two turns of the spica bandage on the upper part of the limb. 
BANDAGES.
153
Article II.—Special Bandages, or such as are adapted to those re-
          gions OF THE BODY IN WHICH THEY ARE REQUIRED.

  The form of the different parts of the body, obliging us to vary its
bandages and portions of dressings, makes it proper that we should
examine special bandages  successively from the head to the foot.

                § I.—Bandages for the Cranium.

  The ancients had become so practised in  the application of ban-
dages, and had so diversified their forms, that for the head alone
Galen  describes, an upper divided bandage, one  cut in front, an-
other general bandage, also divided, a covercle cut in eight divis-
ions, the covercle with three heads, and three other varieties of co-
vercle, two rhombs, a  half-rhomb, the scapha, with many varieties,
the thais of Perigenes, the anonymous thais, the discrimen, the tie
of Glaucius, the royal bandage, different sorts of chevestres, the
hare without ears, the upper joint, the  helmet, &c, &c. These ban-
dages, of which Vidus Vidius  (De Chirurg.,  lib. quat. in fob, pp. 46-
72; lib. tert. Venet., 1611) has carefully given us the figures, are
at the present day abandoned.  There is scarcely a wound of the
cranium that cannot be  conveniently dressed with the aid of a ker-
chief, (couvre-chef) a  bandeau, triangular handkerchief, a T ban-
dage, a bandage M'ith six tails, the sling bandage, the packer's knot,
and the capeline.
  Even among these last there are many that are generally dis-
pensed with in practice. The great kerchief, (le grand couvre-chef)
for example, M'hich is formed with  a  napkin folded double, but in
such manner that one of its  edges extends some fingers' breadth
beyond the other, and two heads of which are tied under the chin,
while the  other two are carried upwards towards  the occiput, is no
longer thought  indispensable. The head-dress which country wo-
men sometimes wear, to protect them from the cold or sun, M'ould
give a tolerably correct  idea of it.  The head-dress, called serre-tete,
would equally well replace it.
  A. The  bandage with six heads, (Fig. 93,) or the poor man's ban-
dage of Galen, is more  worthy of preservation.   It is, in some re-
spects, like one  of the bandages with  eighteen tails.  The  middle
part is placed on the vertex of the head ; the two middle heads are
then brought down and  fixed  under the chin, after which we bring
forward horizontally the two  posterior heads, and carry  backward
its  two anterior heads.   We have, in this way,  a bandage suffi-
ciently simple and firm, and which allows of our making a certain
degree of pressure on almost every part of the head.
  B. The  sling  bandage, (la fronde—Fig. 94,) of  the head, differs
from the preceding by only one piece less.  It may serve, for exam-
ple, for dressing blisters on the neck, provided two  of its heads may
be  easily fastened on  the  forepart of  the forehead, while the two
others circularly embrace the  nape.  We perceive how this sling
                            20 
154
NEW  ELEMENTS OF OPERATIVE SURGERY.
bandage, when placed on the anterior portion of the cranium, might
readily take the place of the great couvre-chef bandage, and also
of the bandage with six heads.
  C.  The T bandage, single, double, or triple, often formerly em-
ployed in the treatment of wounds of the cranium, is almost totally
(Fig. 93.)                             (Fig. 94.)
rejected at present. So also with the discrimen, the figured, (figure,)
and the knotted, (none,) bandages.
  D.  The packer's knot, (nceud d'emballeur.)  When bleeding by the
temporal artery was  much  practised formerly, they had recourse,
in order to stop the hemorrhage, to a sort of compression, which
was rendered exceedingly solid by forming, upon graduated  com-
presses, different crossings called  the packer's knot, (noeud  d'em-
balleur.)  For that purpose, it was  necessary to have a bandage of
five yards in length, about an inch in width, and rolled up in two
heads.  The  middle of the bandage M'as placed on the sound tem-
ple, in order to bring its two heads, the one in front, the other to the
occiput, opposite the point of compression.  Here they were crossed
in order to change hands, making each perform a half turn, and
bringing them back  on the sound temple by conducting one to the
vertex of the head, and the other under the chin. Crossing them then,
as before, they were brought horizontally back to the wounded
temple to be crossed again, and so on till the two heads were ex-
hausted.
  This bandage, which could be of no use at present, had also the
inconvenience of making painful pressure by its knots, and of be-
coming readily loosened,  in consequence of the little security  of its
vertical turns.
  E.  Capeline. The head bandage most  in vogue is that which is 
BANDAGES.
155
still known under the name of capeline, (Fig. 95.)  To make it, the
surgeon placed on the forehead the middle  part of a bandage of
ten yards  length, rolled  into two
heads.  On reaching the nape, the              (Fjg- 950
heads change hands ; after having
made a reverse with the smallest,
it is brought to the forehead, fol-
lowing the median line;  it is fast-
ened there by a circular turn with
the other head ; it is then carried
to the back part of the head, fol-
lowing a  line  a  little upon  one
side ; again fastened behind, then
brought forward  upon the other
side, and so on in succession till
the whole cranium is covered with
it, this head of the bandage is ex-
hausted in bandelettes, having the
appearance of the  ribs  upon  a
melon, whose terminations, in fact,
are concealed by means of the cir-
cular turns of  the larger head of
the bandage.
  The  capeline, which we  shall meet with again in speaking of
bandages for the clavicle, shoulder, and thigh, is a bandage of great
regularity, and of extreme  elegance; but one which is deranged
with great facility, difficult to make compression with on the vault
of the cranium, and by its lower folds and numerous circular turns
is, to a considerable degree, oppressive to the forehead, occiput, and
temples; moreover, we can substitute for it, Mdthout any sort of in-
convenience, the most simple bandages, and it could only arise from
affectation, that  a preference, in any case, should still be aM'arded
to it at the present day.
  F. The handkerchief.  All bandages that were  formerly used for
the head have, at the present day, finally yielded to the triangular
handkerchief, (mouchoir.) Applied by its  base, either upon the fore-
head, or under the occiput, this bandage, the point of which is fixed
in an opposite position by bringing  it up  from  under the  edges
which are to make the circular turn of the head, has the immense
advantage of being everywhere accessible, of being capable of ap-
plication by every one, of possessing great security, and of permit-
ting moderate  compression,  whether by one of its turns only, or over
the whole surface of the cranium, if we take the precaution of draw-
ing in an equal or unequal manner upon the point or lateral edges
of the triangle, after its base is properly fixed.
  For some cases, a simple bandeau might also replace the hand-
kerchief bandage—in  all cases where the uniting bandage on the
cranium is not indispensable.   The triangular handkerchief may
take the place  of all the others.  If we really required bandages for
any wounds of this region, it would be rather one of  the  forms of
 
156
NEW ELEMENTS OF OPERATIVE  SURGERY.
the chevestre, than of the capeline,  or bandages with six or four
heads, that it would be most proper to use.

                  § II.—Bandages for the Face.

  There are four regions of the face, the nose, eyes, lips, and chin,
for which particular bandages have been contrived.

                  A.—Bandages for the Eyes.
  The frequency and number of the diseases to M'hich the eye is
subject, and the great number of operations that we are obliged to
perform on this organ, sufficiently explain the number and variety
of bandages which surgeons have contrived for it.  It is neverthe-
less true, that all the  dressings required by diseases of the eye or
eyelids may be  reduced down to four or  five—the handkerchief,
the bandeau, the eye bandage, (I'aeil,) single  or double,  the mono-
cle, (le monocle,)  and the T bandage.
                           I.  Handkerchief and bandeau, (Fig. 96.)
                         When we wish only to attach  gently
                         upon  the forepart of  the orbit  some
                         pieces of linen,  or lint, the  handker-
                         chief,  in form of a triangle, applied in
                         the way we have mentioned  in speak-
                         ing  of bandages for the head,  is gen-
                         erally quite  sufficient.  It is evident,
                         that by lowering the  base of this tri-
                         angle  to  the  point of  the nose, the
                         two eyes must  be completely covered
                         by it.
                           The handkerchief, covering, as it does,
                         at the same time, the whole head, and
                         pressing too much on the bridge of the
                         nose, is advantageously replaced by the
                         bandeau.  We give the name of ban-
                         deau to  a piece of linen, which is a
                         long  compress' of five to six  fingers'
                         width,  and sufficiently  long to make
                         a  turn round  the head,  to  be  fast-
ened behind with pins.  This bandeau differs in no  respect from
the handkerchief, except that it sends off no point from the forehead
towards the nape.  To render it more useful, it is well to make a
T-shaped hole in it near the middle and close to its edge. For that
purpose we  fold it double, and,  with the scissors, cut its fold to the
extent of about an inch through, and at the distance of about half
an inch above its lower edge.   Another incision, perpendicular to
the first, and which is to represent the vertical branch of the T, is
also made, from below upwards, upon the upper edge of the hori-
zontal incision. This cleft, which is to receive the nose, when once
in its place, prevents  the bandage from  either rising up towards
the forehead or descending towards the mouth, and  allows of its
being  applied much better upon the surface of the eye-lid.  We
(Fig. 96.)
 
BANDAGES.
157
should, therefore, prefer it in most cases.  Also, in arranging either
the handkerchief or bandeau obliquely or diagonally, in place of ap-
plying it circularly about the head, we convert  it into a kind of
monocle in place of using a bandage for the two eyes.
  These bandages, however, which are almost the only ones that
are used at present, are not  suitable, if the object is to make direct
pressure, and with a certain degree of force, upon some points  of
the contour of the orbit, rather than upon others.  It is in such cases
that the monocle, or the bandage called the eye bandage, single  or
double, might still be of some  utility.
  II. Monocle.  To make the monocle, we apply the free extremity
of a bandage, two fingers wide and four to five yards long, upon the
angle of the jaw.  This extremity of the bandage should hang
down to the  extent of three quarters of a yard in a direction towards
the chest; we then carry the  rolled head of the bandage upon the
cheek, the internal angle of the eye, the parietal  bone  of the oppo-
site side, and to the nape, that we may circularly surround the  base
of the cranium.  Brought back to the nape, this rolled head is passed
under the jaw, in order to fasten the pendent head, which we  then
immediately raise to  the  forehead, where another circular  turn
fastens it, while  it allows us to bring it under the jaw and fix it
there by another turn, that we  may bring it up for the last  time
upon the forehead, where it is to be finally attached by some addi-
tional circular turns.  We have, thus, four oblique bandelettes im-
bricated upon the front part of the orbit—bandelettes which, firmly
fixed  on the forehead and under the jaw, cannot in  any manner
slip ;  so that, after the bandeau, the monocle is, in fact, the  most
secure of all the bandages of the eye ; only it has the disadvantage
of impeding the  movements  of the lower jaw,  and of making a
greater degree of pressure  on the forehead and supra-hyoidean re-
gion than on the forepart of the orbit.
  III.  We may advantageously substitute for it the single or double
eye bandage.  To make the single eye, the bandage, having passed
round the base of the cranium,  is brought back upon the angle of
the jaw, and conducted thence towards the upper part of the nose ;
then upon the parietal of the opposite side, and again on the nape.
After  having thus made three  or  four diagonal circulars, which
must lap over each other half their width, as in the roller bandage,
we let out the rest of the bandage by horizontal circular turns
around the head.
  IV.  If we wish to make the double eye, we proceed in the same
way, with this difference, that we pass the diagonal circulars upon
the right and left  eye  alternately, and in such a manner that the
whole represent an X on the forehead and occiput; that is, an X,
or sort of cross, (croise,) which is encompassed besides by a certain
number of horizontal circulars.
   V.  The new eye,  (azil nouveau.)  The  single or double eye,  such
as I have just described it, is very liable  to be displaced.  Its diago-
nals scarcely ever fail to ride up by their lower portion towards the
ear, or to slide either upward or downward in their parietal por- 
158
NEW  ELEMENTS OF OPERATIVE SURGERY.
tion.  We may, however, make it sufficiently secure, by modifying
it in the following manner; that is to say, by fixing the free head
of the bandage near the ear, so as to leave a portion of it hanging
down like  the  monocle.  The rolled  head of the bandage is then
passed under the  jaw, and to the  nape, and passing under the ear
upon the opposite side, and going circularly around  the base of the
cranium, and afterwards brought from the nape to the angle of the
jaw upon the outer surface  of the free head, then repassed  diago-
nally upon  the internal angle of the eye and to the  opposite parie-
tal bone, is afterwards carried back to the nape, then to the angle
of the jaw, to the front of the eye and on the parietal bone, and in
this manner successively for three or four times.   By this means
we obtain a single eye, which may easily be made immoveable, by
bringing back the free head of the bandage, in the form of a bridle,
upon the outer surface of  the turns of the ear, under the jaw,
and in such manner as to make a vertical circular, which is fastened
by means of a pin upon the fold or root of the bridle. If we M'ished
to have a double  eye, the two free portions of the bandage should
be brought down towards each  other, and tied  together, by a knot
under the chin.
  These  three  varieties of bandages for the eyes, however, are
rarely demanded.  To make a moderate degree of pressure on the
forepart of the orbit, it would be much better still to use circulars
from the upper part of the  forehead  to  a level with the  cheek
bones, taking care to protect the bridge of the  nose by padding,
rather than to attempt the monocle, or the other bandages which I
have described.
  The T bandage which some  surgeons, David,  for example, for-
merly applied in place of the monocle, merits in reality the  disuse
into which it has  fallen.

                   B. Bandages for the Nose.
  The principal bandages for the nose still in  vogue, at the com-
mencement of  this century, were, to judge of them by Thillaye's
book, (Traite des Bandages, etc., 2d edition, Paris,  1809,) the double
T, the hawk, (epervier,)  the  drapeau,  the  sling, (fronde,) the rele-
veur, the twisted nose, (le nez tortu,) and the fossa (fosse) of Amintas.
   I. The double T deserves to  be retained; its vertical branches,
each from  eight  to  twelve lines  in  breadth, should be separated
near an inch apart at their root.  We begin by placing its transverse
branch upon the  upper lip; we then  raise its  two vertical heads,
first upon the sides, then to the  upper part of the nose, M'here we
cross them to carry them to the nape by passing obliquely over the
parietal bones.   The two heads of the horizontal branch, which
are made to fasten them there,  enable us to raise them again, and
then return to the forehead, to fasten  them there again, and to be
completed by one or two circular turns.
   II. Epervier, or Drapeau.  With the T bandage  we easily dress
wounds on the sides or upper part of the  nose ; but for wounds of
the point of the nose, (lobule,)  it is better to have  recourse to the 
BANDAGES.                        159
epervier, which is nothing >lse than a kind of purse, the two late-
ral ribands of which  are passed from before backward under the
occiput, to fasten the upper riband of the  bandage  (drapeau) at
this point, and to be brought back to the forehead.  We have thus
a small sack, more or less exactly fitted to the nose, which enables
us to apply upon this organ all  the portions of dressing we may
have occasion for.
  III. The sling (fronde)  of the nose should have only an inch
width, and be provided with a hole in its middle to hold  the point,
(lobule.)  Its two lower heads are raised up, and carried above the
ears towards the occiput, while the  upper heads are brought down
towards the nape.  This small bandage does not  close the nares
like  the preceding, but it has the  disadvantage of being less secure,
and  of tending to flatten the nose.   No person, at the present time,
attaches any further importance  to  the  releveur of the nose, or to
the  tM'isted nose  bandage, nor the fossa of Amintas, nor to  the
seventeen varieties of bandages figured in the book of Vidus Vidius.
With the aid of the double T, that of  the  epervier, whose lower
part may also be easily perforated near the nares, and with the ban-
deau perforated at the point of the nose, we  have enough to satisfy
all the wants of practice.  At the present day, moreover, when the
adhesive plasters are attainable by all surgeons, we rarely feel the
necessity of bandages for the nose,
               C. Bandages for  the  Lips and Chin.
  Diseases of the lips scarcely require  any  other than the uniting
bandage; but as this bandage, which comprises the three kinds above
described, will be referred to again, under hare-lip, I will only re-
mark here, that we often associate pe-
lotes with it, to compress and push for-
ward the anterior part of the cheeks.
  In some cases, however, we use the
sling for  diseases  upon the contour  of
the mouth.  This sling should be slit,  in
fact, or notched,  on a level M'ith the
mouth, and cut out in a crescent un-
der the nose.  Its two inferior heads are
carried obliquely under the ears to the
projection of the occiput, where  they
are crossed, and then brought forward
and united on the forehead.  The supe-
rior heads, also passed under the  ears,
may  be fixed upon the nape, or crossed
at this point,  and  afterwards brought
to the forehead.
  Wounds in the interior of the mouth
scarcely ever  requiring dressings, pre-
sent, on that  account, no occasion for
the employment of bandages.
  Wounds of the tongue only, have claimed  some attention under
this point of view, and the small purse (bourse) of Pibrac, (Fig. 97,)
 
160
NEW ELEMENTS OF OPERATIVE SURGERY.
which, enclosing the apex of the tongue, has at its base two silver
threads, which are turned under the chin,*andto which ribands are
attached, which should go to the nape and return on the forehead,
is the only dressing we can in such cases require.
  Bandages for the Chin.  It was in some measure for the chin that
the sling was contrived; so also is it the only bandage used at pres-
ent for Mounds of soft parts of this region.  Sometimes perforated in
its middle portion, at other times entire, the sling for the chin ought
to have about four fingers' width.  Its two inferior heads are raised
up in front of the ears, to be crossed at the vertex of the cranium,
and afterwards brought down to the temples.   Its upper heads, on
the contrary, are passed horizontally under the ears to the nape;
crossed on this point, they are then brought to the forehead, where
they are crossed again,  to  be  returned  to the  nape, and there
fastened.
                        D. The Mash
  When it  is necessary to  cover  many parts of the face  at the
same time, we use, under the name of mask, (masque) a piece of
linen shaped to the face, cleft into a T, or perforated opposite the
eyes, nose, and mouth, and having attached to it four ribands, two
above and two below, for the purpose of fixing it around the head.

              E. Bandages for the region of the Ear.
  Wounds  of the ear, or the parotid region, are dressed with the
aid of the  ecusson, the T bandage, the oblique, the  sling,  or the
chevestre. ,
  I.  The Ecusson.  A piece of linen, sufficiently large to cover either
the expanded portion of the ear (pavilion) only, or both the pavilion
and mastoid region, and to which three ribands are attached, behind,
above, and below, constitutes the ecusson for the ear. This bandage,
which is fastened by a vertical circular turn by means of the upper
and  lower ribands, and by a horizontal circular turn by means of
the posterior riband, conveniently holds the lint, or other portions
of dressing that we wish to apply, either upon the irregularities of
the payillon of  the ear, or between the pavilion and the mastoid
process, or even in the parotid fossa.
  II. T Bandage.  When we wish  to  leave the  ear  free, and the
disease is in front of the  pavilion or the mastoid region, or if we
have to dress a blister, for example, the T bandage is  preferable to
the ecusson.  We fix the horizontal branch of it around the base
of the cranium ; then bring down its vertical branch either behind
or in front of the ear, according  to the seat of the wound, in order
to pass it under the jaw in the form of a bridle, and thence to fasten
it to the horizontal circular  on the opposite side.  This bandage,
though without contradiction the most  simple that could be applied
to the ear, is, nevertheless, but little employed; this  is because it
does not always answer, and that we can substitute for it, without
inconvenience, temporary bandages, or, what is as well, a simple
cravat to be fastened on the top  of the head. 
BANDAGES.                       161
  ID. Oblique Bandage for the Ear.  If the dressing of the auricu-
lar region requires some degree of security and many turns of the
bandage, the oblique bandage is indicated,  which is  made as
follows:  a bandage, five  yards long,  is first fastened circularly
around the base of the cranium, then brought from the nape under
the ear and jaw;  it is then carried up perpendicularly in front of
the ear upon the sound side, to be brought down upon the diseased
ear,  and to return under the jaw; then around the cranium on the
sound side, to return obliquely from the occiput to the affected ear;
then under the jaw, and vertically to the top of the head, to make
a new vertical  circular; then another horizontal circular,  and so
on, successively, three or four times.
  The oblique  bandage of the ear, which we should  not  restrict ~
ourselves to making with too much precision in one mode rather
than another, is decidedly preferable to all the preceding, and may
be, in almost every case, substituted for them.
  IV. Chevestres.   Of the seven chevestres represented in figures
16, 17, 18, 19, 20, 21, and 22, of  Vidus Vidius. there remain but
three in  modern practice: the simple chevestre, the double with
one rolled head, and the double with two rolled heads.
  These bandages, whose object is to support  the pieces of dress-
ing that  may be required for fractures or luxations of the lower
jaw, do not differ sufficiently from the oblique  bandage for the ear
to require that they should be any longer separated from it, at least
if we take  care to simplify them, as I shall presently point out.
  a. The simple Chevestre, (Fig. 98,)  requires  a bandage of three
fingers' width and  five  yards long.
Two  compresses,  cut in  the man-             (Fie- 98)
ner of a sling, are  first applied upon
the chin and under the jaw.  The
bandage, being fixed by a circular
turn around the cranium, is carried
obliquely behind the ear and the an-
gle of the jaw on the sound side ; then
under the jaw and in front of the ear
on the diseased  side, to the top of the
head, behind the sound ear, under the
angle of the jaw, and so on, in succes-
sion, so as to make three vertical cir-
culars open in front.   We then pass
the bandage circularly around the up-
per part of the neck, then on the front
part of the  chin, so as to fasten the
sling  compresses,  after  which we
make another vertical circular, ter-
minating  with a horizontal circular, with  which the bandage is
permanently fastened.
  b.  The double  Chevestre requires a bandage eight yards long. We
apply it first like the preceding one, and are then careful to pass
it obliquely and vertically,  alternately  to the  posterior part and
                               21
 
162
NEW ELEMENTS OF OPERATIVE SURGERY.
front of each ear, and as many times to the right as to the left,
The circulars designed to envelop the chin being terminated, we
make, as M'ith the simple chevestre, one  or two vertical circulars,
and terminate it by one or tM'o horizontal circulars.
  To obtain a double chevestre as regular as possible, it M'ould be
much better to make use of a bandage  with two rolled heads.
We place  the  middle of  this bandage on the forepart of the lore-
head, then cross  the two portions of it upon  the  nape; we then
bring them out under the  ear on each  side to cross them under the
jaw, and to pass them vertically betM'een the ear and the orbit up
to the top  of the head; there we cross them again, to carry them
back to the nape, change  hands with the heads, bring them under
the ear, cross them, repass them to the vertex as at first, and thus
recommence a third vertical  circular.  We proceed afterwards to
form the circulars of the neck and chin, and then to  make tM'o more
vertical circulars, in order to terminate in like manner with one or
two horizontal circulars.
  These bandages, often employed formerly for fractures and com-
plete luxation of the jaw, are scarcely ever used at this day in such
cases; but something similar is still frequently found useful for cer-
tain wounds or diseases of the parotid, masseter, temporal, auricu-
lar, and mastoid regions.
  c. Chevestre of the Author.  Without restricting  myself, then, to
the exact representation of one form more than another of the ban-
dage which is used, I believe the  following will ansM'er for all the
wants of practice, and render useless the oblique bandage, the ecus-
son, the T bandage of the ear, and the different sorts of chevestres,
of which, in fact, it is only a more  simple modification.  I fix the
bandage by a circular upon the base of the cranium; I afterwards
pass it from the nape under the ear  and under the jaw, either upon
the  sound  or  diseased side—it is generally a matter of no conse-
quence  which ; I then carry  it  upward, as with the chevestre,
towards the temple on the sound side, in order to  pass it  directly
over the vertex to the temple of the diseased side ; I thus multiply
its vertical circulars, inclining them sometimes in one direction,
sometimes  in another, so that they soon cover the M'hole of the
dressing.   Those which I pass upon the forepart of the  chin are
made to cross each other upon  the nape ;  when it is necessary to
place some under the jaw, I cause  them to pass in  a spiral line
around the vertex of  the head, in order to bring them back to the
nape, and afterwards to make more vertical circulars; I finally ter-
minate with one or two horizontal circulars.
  It is evident  that the bandage  may be  applied in this manner a
little more behind or before, on  one or on both sides of the head
and face, and that nothing is more easy than to space out, (espacer,)
or to gather together the turns  of the bandage a little more on one
point, or a  little less  on another, according to particular indications.
I will add, that in making this bandage glutinous, we  may form a
dressing, as simple as it  is  solid, for  all  kinds of fracture of the
lower jaw. and that, with this modification, nothing is so easy as to 
BANDAGES.                        163
 establish a permanent compression on whatever part we desire in
 the regions above mentioned. It is the only one that I have retained
 of all those that Galen speaks of, and of those that have been pro-
 posed since.
                  §  III.—Bandages for the Neck.

   The region of the neck generally renders the  dressing of its dis-
 eases somewhat difficult, at least as respects wounds, operations,
 and deformities.  For inflammations, tumors, and other diseases,
 which require only  containing bandages, the  neck accommodates
 itself very well to the circular bandage, or that in the form of a
 cravat.  It  is in this manner  we  dress a seton, blister, moxa, or
 cautery, M'hich we  occasionally find it  necessary to apply to the
 nape.   But in order to unite a transverse wound, or to keep open
 the lips of a wound of that kind, situated upon some part of the cir-
 cumference of the neck, we occasionally feel the want of certain
 bandages of a particular description.

          A.— Uniting and Dividing Bandage, (Fig. 99.)
   Longitudinal wounds on the  neck re-           (Fis- "■)
 quire only adhesive plasters of diachy-
 lon, or the circular bandage.  Transverse
 wounds, where we do not wish  to recur
 to the suture, but prefer to approximate
 their edges, require a bandage  which
 should keep the head inclined to the side
 of the wound.
   The most convenient uniting bandage
 one can employ in such a case is the fol-
 lowing :  We fix securely upon the head
 of the patient a cotton cap, or a serre-
 tete, kept in place by a chin-cloth, (men-
 tonniere;) we  afterwards  fasten upon
 this cap, by means of a sufficient number
 of circular turns, a bandelette slit in two,
 to some distance from its fixed point, and
 from.which the two halves are left hang-
 ing down upon the diseased side.  The
 wound being  properly  dressed,  we  de-
 press the head of the patient by drawing
 upon the two  bandelettes,  which  act
 upon it like a double hook; then  we at-
 tach them upon a body bandage which
 surrounds the  chest,  and which latter
 has been made secure above by a scapu-
lary, and below by bandages under the
thighs.

  If it concerns the  anterior region of the neck, the bandelette
snould have its fixed point upon the occiput; and its two branches
coming out in front, and brought down to the external orbitar an-
 
164           NEW  ELEMENTS  OF OPERATIVE SURGERY.

gles, should be made to descend to a level with the mammae, where
thev are to  be fastened  to the  body bandage.   For a wound of
the opposite region, it is upon  the  forehead that we must fix the
root of the bandelette, and behind and between the shoulders that
we should attach its branches to the body bandage.   A wound of
the lateral region M'ould require to have this kind of dressing fixed
upon the temple of the sound side, and to attach its two branches
on the body  bandage, the one before, the other behind the shoulder
of the wounded side.
  It has always appeared to me, that this bandage could  also re-
place the dividing bandage for the neck.   It is evident, in  fact, if
it was required to keep apart the lips of any wound in this region,
that it would be sufficient to draw the branches of the bandelette
backward when the wound is in front, and forward when it is be-
hind, &c, &c. This indication might possibly be presented in some
cases of m ounds of the larynx or trachea, or after the destruction
of certain bridles and accidental cicatrices.  Nevertheless, we must
not deceive ourselves by supposing that this bandage can be made
to keep in place for any length of time, or that  the patients will
endure it without inconvenience or fatigue.  Supported upon a col-
umn extremely moveable, the head almost always finds means, by
inclining itself in  one direction or  another, or by turning on its
axis, to  escape from  the  torsions made by the dividing or  uniting
bandelette.   All  that we can say is, that it is less fatiguing, and
wholly as efficacious, as the extremely complicated bandages which
have been contrived to fulfil the same indications.

                  B.—Redressers of the Head.

  Winslow, Thillaye, and some others,  proposed  bandages for
straightening the head in  cases of contortion of the neck.  At the
present time, M'hen the section of the retracted muscles or tendons
is performed with surprising  facility, bandages proper for righting
the head will not fail to come again into  much use.   As I do not
M'ish to occupy myself in  this place with the different apparatus
known under the name of machines,  I will confine myself to saying,
that, with a simple bandage fixed around the  head by some circu-
lar turns, and passed from the inclined side to the forepart of the
forehead, then to the temple of the opposite side, then  to the nape,
we are enabled to straighten, M'ith a considerable degree of force,
the  cervical region  of the spine, while we elevate the face and
chin.
   The end of this bandage  may afterwards be fixed upon a body
bandage under the  arm-pit,  or the bandage passed over the arm-
pit itself, properly protected, to be  afterwards brought above the
shoulder upon the posterior part of  the neck, then in  front, under
and behind  the other arm-pit,  then again  around the head and
under the arm-pit behind the shoulder  of  the  inclined side;  if
these bandages be interlaid with pieces of pasteboard .saturated
with dextrine, they become extremely solid. 
BANDAGES.
165
  The  bandages used  after opening the jugular vein, and after
bronchotomy, will be described in the chapter on those operations.

                § IV.—Bandages for the Thorax.

  A. Body bandages, (bandages de  corps.)   The chest, properly so
called,  rarely requires any other than this bandage,  (Fig. 100.)  It
is the only one employed as a containing bandage in the treatment
                            (Fig. 100.)
of wounds.   Fractures of the ribs, and all diseases that require the
employment of any topical application, or any portions of dressing
equally well adapt themselves to this bandage.  It is made with*a
napkin folded thrice, or, if we wish to have it prepared beforehand,
by sewing, in the form of a napkin thus folded, two  folds of linen,
of sufficient width and length, upon their free edges.  This bandage
is applied circularly.  We should take  care to tighten it a little
more below than above, in order that it  may be displaced as little
as possible, and that it may not pucker into a cord from movements
of the chest or arms; we fasten it on its upper edge by a scapulary,
and on its lower by sub-crural bandages, [i.e., under the thighs.]  The
scapulary, formerly, was a piece of linen slit so as to let the head
pass  through, and attached, on the anterior and posterior parts of
the chest, to the body bandage.  At the  present time, we replace
this bandage by the end of a bandage which is doubled, the fold of
which is fixed, between the shoulders, to the body bandage, and its
two heads brought, in the manner of suspenders, upon each side of 
166
NEW ELEMENTS OF OPERATIVE SURGERY.
the neck, to be attached in front, either separately or together, upon
the circular bandage.  It is even better, when it is desirable that
the patient should be as little moved as possible, to attach this ac-
cessory piece to the body bandage before passing the latter around
the chest;  so also, in reneM ing the dressing, we may confine our-
selves to detaching these suspenders and the .bandage in front only,
Mdthout taking them entirely off.

                  B. Quadriga for the Thorax.
  If we should require a more equable and diffused pressure, and
a more uniform constriction than  it is possible  to procure by the
aid of a body bandage, we should, in the place of the bandages de-
signed by Butet for supposed  luxations of the ribs, and by David
for  luxations and  fractures of the  vertebrae, and  fracture of the
sternum, have recourse to the  bandage  called the quadriga of the
ribs.  In short, we no longer employ at present the quadriga with
two heads, nor the different sorts of stellated bandages (etoilcs) of
Kiastres, &c, as used by the ancients.
  The bandage which I am about to describe differs, also, essen-
tially from the quadriga or chariot of the ancients;  composed of a
kind of posterior stellated bandage (d'etoile posterieur) and thoracic
circulars, it resembles, in some measure, the cataphrast of Galen.
A long bandage of three fingers' width ansM'ers, in this respect, for
every purpose.
  In place of applying it in the manner of the roller bandage, from
below upwards, afterwards to terminate by one or two figures of 8
around the arm-pit and shoulder, it is better to proceed as follows:

                  C. Cataphrast of the Author.
  We leave hanging behind the thorax about half a yard of the
free end of the bandage, the  rolled  head of  which  is passed
to  the shoulder of the sound side, in front of the chest, under the
arm-pit of the  diseased side, and back of the thorax, so as to make
circulars which, in  passing over the free head of the bandage,
should, while they lap over each other to two-thirds their width,
extend upM'ards to the hollow of the arm-pit in the manner of a
roller bandage.  We afterM'ards surround the arm-pits with a pos-
terior figure of 8, to terminate upon the chest by a circular, either
from below upwards, or from  above downM'ards.  We then raise
the reserved head of the bandage to the  shoulder opposite to that
M'hich first received it, in the manner of suspenders, to fix it in
front  upon the lower circulars, (Fig. 101.)  We  thus prevent the
separation of the turns of the bandage, and give great solidity to the
whole dressing.

                 D.  Bandages for the Mamma.

  Subject to numerous diseases, and frequently  requiring serious
operations, the mammary region has suggested the contrivance of
a great number of bandages, which may, however, be replaced, in
most  cases, by the body bandage, or by the preceding quadriga. 
167
  I. Square Bandage for the Breast, (Fig. 102.) There are two spe-
cial bandages which are occasionally used for diseases of the mam-
                            (Fig. 102.)              ,
mary gland—one the square bandage, which is a piece of linen six
to ten inches in diameter, having a riband or a band at each one
of its angles; in order to  fasten this bandage, we pass its two lat- 
 168           NilW ELEMENTS OF OPERATIVE SURGERY.

 eral ribands, the one above and the other under the arm-pit of the
 affected side, to tie them behind with those of the sound side, which
 should also pass, one above and the other under the shoulder.
  In place of  the  square bandage, we may use  a triangular one,
 whose horizontal part should be  fixed around the chest, while its
 vertical should be  made to join the other behind the diseased side,
 in the manner of  suspenders.  A double  T bandage, with large
 branches, would fulfil the same indication, but  with less regularity.
  II. The suspensory bandage  for the mamma is also made with a
 square piece of linen, from which we cut off a triangle, in order to
 sew the two edges of the division, and thus speedily form a kind of
 purse with a large opening to  enclose the mamma.  The angles of
 this suspensory, being  also supplied with  straps, are then applied
 and fastened like the square bandage.  But these bandages, though
 suitable for supporting a simple dressing,  are  not sufficient when
 we wish to make pressure, or undertake the approximation or sep-
 aration of the lips of a  wound.
  III. Uniting and compressing bandage for the  mammary region.
 Wounds of the mammary region may be united by means of adhe-
sive  plaster, or simple  uniting bandages, like those for any other
region.   If, in  addition, the  approximation of their edges should be
 clearly indicated, it would be sufficient, in order to effect this object
without difficulty,  to make some regular  turns  of the cataphrast
in their neighborhood, and to arrange at a certain distance gradu-
ated compresses.
  To suspend the mamma by means of a bandage, we may do as I
have described in speaking of the quadriga, except that some turns
of the bandage ought then to be passed in a diagonal direction from
the lower part of the diseased breast over the shoulder of the op-
posite side.  If these diagonals were only on the diseased side, we
should have only a single suspender ;  in applying them on the two
 sides, we would have the double suspender.   Some circular turns,
placed first  above, then below the breasts, secure the turns of the
 suspensory.  The head of the bandage, which has been left free be-
 hind,  being  brought in front in the manner of suspenders, forms,
 altogether, one of the most simple and secure  dressings.
  The compressory bandage for the mamma  does not materially
 differ from the preceding; for whether we do or do not apply at
 first pieces of agaric or gateaux of lint upon the organ to be com-
 pressed, there is, if the  mamma be large, not  the less necessity of
 diagonals, the  same as in the suspensory, and  also of a  greater or
 less number of circulars, as with the roller bandage, and of an ex-
 tremity of the bandage to serve as a suspender to restrain the whole.
  The compression of the mamma might also, in certain cases, be
 effected by means of strips of adhesive plaster applied circularly, and
 from before behind, about the  chest, when the gland is, as it were,
 flattened (plaquee) on the thorax, or we may apply the strips circu-
 larly around the breast itself, and from its base to the nipple, when
 the organ is extremely globular, pendent, and easy to be separated
 from the thorax; with this exception, that  we rarely find that the 
BANDAGES.                        169
conformation of the parts allows us to give to this dressing all the
firmness which it requires.
  We see, then, that, in adding a  posterior and an anterior figure
of 8, a single or double turn of the  spica, and one or two diagonals,
the roller bandage of the  chest is converted at pleasure into a
quadriga, a cataphrast, a figure of 8, a star, (etoile,) or a spica ; so
that it may, in reality, answer for all the dressings of the mamma-
ry, axillary,  sternal, dorsal,  and supra-clavicular regions.
               § V.—Bandages for the Abdomen.

  Whether we desire to make pressure upon the abdomen, to dress
or unite its  wounds, or to make any dressing  whatever upon this
region, it  is always possible to effect this object by the aid of the
body bandage, the roller, the cincture, corsets, or uniting bandages.
  I. The body bandage (bandage de corps) itself is more frequently
employed than all the others put together, for  the purpose of sup-
porting the portions of the dressing around the  belly;  only that we
have to give it a little more width for this region than for the chest,
and are more frequently obliged, also, to secure it by bandages un-
der the thighs, (sous cuisses.)  This bandage is adapted, at the  same
time, to diseases of the epigastric, umbilical,  and hypogastric re-
gions, and to the sides and loins.
  II. The  roller bandage.  It M'ould not be necessary to substitute
the roller for  the  body bandage,  except where it  should appear
requisite to make a  uniform  pressure, or pressure  on distinct and
numerous points, in the different regions upon the anterior part of
the abdomen.
  III.  Cincture and Corsets. When it is required to make upon the
abdomen a uniform, unchanging, and permanent pressure, the cinc-
ture or the  corset sometimes replaces the body or roller bandage.
The cincture, which, in fact, is nothing but a stuffed body bandage,
somewhat narrow, and ordinarily supplied with leather straps, or
other elastic materials, is peculiarly adapted to  support the different
kinds of ventral or abdominal hernias.
  Corsets may be very useful for dropsical patients,  and for certain
females who suffer in the  hypogastric region.  For this purpose,
Monro devised a kind of bandage which enveloped the whole belly,
and which was laced  behind like a corset, and the object of which
was to compress the abdomen in the operation of paracentesis, to
prevent the  too sudden relaxation of the digestive  organs.   Now
generally no longer used in such cases, Monro's corset might, nev-
ertheless, be exceedingly well adapted for producing compression
of the belly to promote absorption  (a  litre de  resolutif) in ascitic
patients.
  IV.  Suspensory, or Cincture of the Hypogastrium.  Women who
have had  many children, and  those who have the uterus  inclined
forward, with  a very large pelvis, often experience uneasiness,
drawing-down pains,  and weight,  in the lumbar region,  kidneys,
iliac fossae, groins, and hypogastrium, sufferings for the relief of
which they are often  subjected to all kinds of useless  treatment,
                           22 
170
NEW  ELEMENTS OF  OPERATIVE SURGERY.
but which generally yield to the use of a suspensory to the hypo-
gastrium,  (Fig. 103.) But this suspensory may be the ordinary cor-
set, provided, in place of being widened below, it bends inward (se
recourbera) in the direction of the pubis, so that, when applied, it

                            (Fig. 103.)
moderately presses upon the lower region of the  abdomen from be-
low upwards and from before behind, instead  of pressing from
above downward, as it usually does.  The busk of this cors.et would,
moreover, answer, better than any other bandage, to secure a pe-
lote or graduated compresses upon  a fistulous opening, or some tu-
mor, that M'ould require to be compressed upon the median line ; an
artificial anus, for example, (of which I have had an instance,) and
that without occasioning any uneasiness.
  In general, women put their corsets on over their chemises; if it
is necessary that the bandage should press directly on the skin, it is
better to have one made especially.   In this case, I use a  sort of
belly-band, (Fig. 103,) shaped  to the hypogastric region, furnished
with or without stuffed pelotes, and which are fastened about the
trunk on the side of the loins, or in front, and then below, by the aid
of bandages under the thighs,  (sous-cuisses.)
  In truth, the suspensory of the hypogastrium should be used much
more frequently than it is;  it  is the means of preventing miscar-
riage in a great number of pregnant women.  Many indispositions,
attributed to the condition  of the  womb  or intestines, would be
made to disappear entirely, purely by its mechanical action, and
without any medical treatment.
  V.  Uniting bandage. In no part do wounds that we wish to unite 
BANDAGES.
171
 immediately, more imperiously require the suture  than in the ab-
 domen.  Supposing that  this means should not be applicable, we
 should, at  least, have the resource of adhesive plasters.  If, how-
 ever, we preferred making trial of uniting bandages, we have only
 to recall what  I have said of them above, to understand how, by
 giving them a breadth proportionate to the extent of the Mound or
 region, and having care to fix them by a scapulary  above, and sub-
 crural bandages (sous-cuisses) below, we possess all that is necessa-
 ry to know on this subject.

             § VI.—Bandages for the Genital Organs.

   The  diseases of the genital organs  have suggested but  a very
 small number of bandages, to wit:  Some  for the penis, others for
 the scrotum.
               I. Bandage for the Penis, (Fig. 104.)
  Whether we wish to  dress  a             (Fig. 104.)
 wound, or  an ulcer of the penis,  or
 to compress this organ, the Maltese
 cross, or the roller bandage, with  or
 without lint, are generally quite suf-
 ficient.   Sometimes the  Maltese
 cross is merely perforated opposite
 the urethra; at other times it is pro-
 vided with  a hole, M'hich alloM's it
 to embrace the glans penis, and  to
 push back  the prepuce.  A  narrow
 bandage serves to fasten it  by its
 circulars, and  to  cover the  whole
 extent of  the  penis with a roller
 bandage, which should terminate at  the pubis, either by a knot by
 means of the bifurcated extremity of the bandage, or by the  aid of
 a pin, or, better yet, by attaching it to a suspensory.

        B.  Bandage for fixing the Catheter  in the Urethra.
  When it is desirable to leave a catheter in the urethra, or blad-
 der, it is indispensable to retain it there by means of bandages ; it
 is a precaution  that pupils rarely  know  how to carry into effect in
 a proper manner;  which,  however, it is very useful not to neglect.
We possess for this purpose a great  number of peculiar processes :
the best of all consists in fastening, near the handle of the catheter,
by means of a double knot, and by their middle  portion, two cords
of cotton wick (cordons de colon a meche) about  thirty inches long ;
the  two branches  of each of these cords are then taken, pair by
pair, and brought two of them forward and two behind, or, what is
as well, two of  them to the  right and tM'o to the left, to a level
 with the base of the glans  penis, (de  la racine du gland.)  We then
 connect the two branches  of one  side with  each other to form a
 noose, (anse,) then the two heads of this noose are exhausted in cir-
 
172           NEW ELEMENTS OF OPERATIVE SURGERY.

culars upon the teguments behind the glans, and fastened by a bow-
knot, (rosette;) the same is done with the two cords on the opposite
side.  We thus obtain four rays, united by their apex near the han-
dle of the catheter, and fastened on the penis by their base, (Fig.
105.)
      (Fig. 105.)          To give greater firmness  to this little ap-
                    paratus, and to render it less inconvenient to
                    the patient,  we may previously include  the
                    penis in a small double compress,  as M'e may
                    also fasten the four heads by some circulars
                    of adhesive plaster.
                      Those who recommended fastening the ca-
                    theter by two cords  under the prepuce, and
                    around the corona glandis, made use of linen
                    ribands ; but it is a practice too objectionable
                    to be retained.
                      Many surgeons,  fearing  pressure  on  the
                    penis, fix the four cords, of which I have been
                    speaking, to the cincture of a suspensory, or
                    of a T bandage, (Fig. 106,) above, and to the
body  of the suspensory, or to the sub-crural  bandages of the T
below.
  Finally, there are those who begin by fixing to the  root of the

                            (Fig. 106.)
penis, on the front part of a suspensory or T bandage, a ring slightly
wadded; it  is to this ring, (Fig.  107,) which remains fixed in this
position, that the four cords of which I have just been speaking are
attached.
  The process which I have first described is  unquestionably the
most convenient of all.  When properly applied, it causes, in most
patients, no  inconvenience ;  if, however,  the state of the penis, or
some other special reason, should deter us from using it, the wad-
ded ring could be most advantageously substituted for it.
  When it is requisite to fasten a catheter in the bladder of a fe-
male, we can only do this conveniently by attaching the four cords
 
BANDAGES.
173
that are fastened  near its handle, to the cincture and sub-crural
branches of the T bandage.
                            (Fig. 107.)
§ VII.—Bandages for the Scrotum.
  Bandages are used to support the scrotum or testicles, even where
there are no wounds of these parts.  They are also used as a means
of compressing them, and for dressing their wounds.

                        A. Suspensory.
  We give the name of suspensory of the scrotum to a kind of bag,
designed to sustain gently all the parts of the dressing we may have
occasion for in the treatment  of diseases of the testicles, or of its
envelopes.  This purse, which should vary in size or depth,  accord-
ing as it is to enclose a greater or less number of objects,  is com-
posed of a piece of linen fastened above to a bandage of sufficient
length to  go twice around the pelvis. Below, the suspensory has
two cords called  sub-crural, (sous-cuisses;) near its upper part it
has an opening  through which the penis is to pass.   To apply it,
we first neatly adjust all the dressing; then, by means of the cinc-
ture, we fasten it around the body; the two  sub-crural branches
are  then passed into the sub-ischiatic groove, then on the  side of
the  great trochanter, and fastened by a bow-knot, or by the aid of
buttons, to the cincture of the bandage near the hip.
  This manner of applying the suspensory has, in a great number of
cases, the inconvenience of pressing  or croM'ding the scrotum to-
wards  the anus, or against the upper part of the thighs.  I  have
also been in the habit, as practised  also by other surgeons, when
there is nothing to be done but merely to support the scrotum, and
there is no particular indication  to the contrary, to bring the sub-
crural bandages forward along the groins,  (Fig.  108,) in place of
making them pass behind.  In this manner the  testicles are kept
gently suspended, and free from all traction or painful compression.
  When the dressing is for wounds, the arrangement of the suspen-
sory is difficult.   In that case,  in fact, it is convenient to give to it 
174
NEW ELEMENTS OF OPERATIVE  SURGERY.
sometimes the form of a triangular or square piece of linen slightly
hollowed out, while at other times it must represent a sort of child's
                               bonnet, or a purse, of greater or
            (Fie-108>             less depth.   It  is rare, also,  that
                               they are  well  made in hospitals,
                               and mc often find ourselves obliged
                               to  substitute extemporary band-
                               ages for them.
                                 When M'e have only to  support
                               the scrotum, to prevent its becom-
                               ing fatigued or involved in disease,
                               M'e generally find in the shops sus-
                               pensories that  answer sufficiently
                               well, some being of hemp cloth, lin-
                               en, or cotton, others of caoutchouc,
                               or even leather, or in form of a bag-
                               net or truncheon, (de tricot.)   The
                               only inconvenience of these suspen-
sories, is that of their presenting a harder border than the rest of the
dressing, and M'hich often irritates the parts in the manner of a cord.
  We sometimes replace the suspensory by a long compress, which
embraces the scrotum under its middle part, and which is fastened
by its  extremities  to a cincture  around the  hypogastrium.   A
more convenient mode  still, consists in folding a pocket handker-
chief into a triangle, the  base of which rests on  the  root of the
scrotum, while the extremities are brought in front of the groins, to
be attached to the cincture of the hypogastrium, and the  apex of the
purse raised in front, to be fastened at the median line on the same
cincture.  But these substitutes are in  reality neither as secure or
convenient as an ordinary suspensory which has been properly made.
  B. When  we have to dress wounds of the  scrotum, after the
removal  of  the testicle, we may find  it useful to employ the T
bandage.  We may also use, equally well, the triangular bandage
in place of the suspensory ; if we have to make unequal pressure
on various points of the scrotum, we may have  recourse to a  kind of
quadriga  for the pelvis.  In the two first, we pass the horizontal
portion of the bandage  around the lower part of the trunk; we
then depress the vertical branch of the T, or the triangle of linen,
on the  diseased side of the region, in order to encircle the upper
part of the  thigh with it, and thus fasten it to the cincture on the
side of the body.
  Certain engorgements  of  the testicle,  blennorrhagic   orchitis
among others, are  advantageously treated by  compression.  But
to make exact pressure on the testicle, nothing is more  commo-
dious than adhesive plasters made with diachylon.  Depressing the
swollen part with one hand, as if  to detach it from the ring, the
surgeon surrounds it with adhesive strips of the width of the thumb,
so that all the parts of the tumor may  be covered or enveloped as
by a sac, the  opening or apex of which should  be arranged with
care around the root of the cord, (Fig.  109.)
 
BANDAGES.
175
  [A scrotum bandage, which I contrived while phy-
sician  to the Seamen's Retreat, (New York,) where
the class of patients  and diseases were such as to
require great attention to this part of surgery, and
in which I found this apparatus of eminent service
in completely  supporting this part  in  an isolated
manner, giving great relief,  and neither  pressing
on or wedging between the thighs,nor drawing back
painfully, as in  the  ordinary clumsy  suspensory,
was the following, (Figs. A and B,) which I would
recommend to  general use:
                   (Fig. A.)
(Fig. B.)
  Fig. A represents the  suspensory as applied, being a bag of
broM'n holland, (hemp  tissue,) of  four trapezoidal pieces, tapering
downward, and firmly sewed, with the  seams outside,  as seen in
Fig. B.*  There may  be  six or eight strips of narrow  bandage,
  * Brown holland is mentioned as a cheap tissue for public institutions, and easily
attainable everywhere.  When made of that or similar stuff, (always excepting cotton,)
large eylet-holes, in rows, should be worked into it, each one at least a third of an inch
in diameter, to admit of ventilation.  A more perfect mode of attaining ventilation, as
preferred by Dr. Mott, would be to make a netted bag of flax, hemp, or silk cord, as
being far cooler, and equally well calculated to answer the object. 
176           NEW ELEMENTS OF OPERATIVE SURGERY.
                         /
about an inch M'ide, attached at pleasure to the corners and sides.
Each one of the two coming from the middle portion of the upper
edge of the two lateral sides of the bag, is to pass backward under
and  around the  thigh, to  be fastened to the cincture around the
waist, farther back than  the  others, which latter four or  six, ac-
cording to the number the bag has, are all to be fastened on the
broad girdle of  brown holland in front, in the space on  the belly
between the hips,  the patients shifting the  same  as  they would
the rigging of a ship, (and which the  sailors at the Retreat Hos-
pital above mentioned did with great expertness,) until each band-
age was arranged to  suit their feelings, in such manner that they
all drew with an easy and consentaneous force upon the bag, which
latter, Math the contained testicles, is thereby raised gently upward
and  forward, or to one or the  other side, at pleasure,  and, at the
same time, kept in a firm  and steady  position, especially by the
two straps going backward, which, to use a nautical phrase, might
be called the back-stays.   The great superiority of this suspensory
over all others was effectually established  by me at the Seamen's
Retreat, as it has been in private practice since.  The size of the
bag  must be proportioned to  the dimensions of the scrotum and
testicles, whether the latter are diseased or not.  It is of eminent
use and comfort to patients with hydrocele, varicocele, and espe-
cially scirrhous and hydatid testicles, which, by their weight and
size, are so distressing upon the cord.   The floor of the bag may be
made so as to be slightly concave within.—T.]
     § VIII.—Bandages for diseases of the Anus and Perinceum.
  The T  bandage  is almost the  only  one in use  at  the  present
                               time  for  dressing  affections  of
                               the anus and perinaeum.  It is
                               almost always the double T that
                               we require.   As it is  from the
                               lumbar region that  we  set out
                               with the vertical branch,  it is ne-
                               cessary to give  to this  portion.
                               which should be from four to six
                               fingers wide, a length in its undi-
                               vided  portion of from six to ten
                               inches, in  order  that the two
                               branches may not be separated
                               from  each  other  except  in the
                               neighborhood  of  the anus.  We
                               apply it first around the trunk.  It
                               is advisable, in fact, to fasten it in
                               this manner before commencing
                               with the dressing.  The wound be-
                               ing dressed, we bring the  T down
                               upon the portions of the dressing;
                               we then  cross the branches on
 the perinaeum, so as to bring that on the right between the  scrotum
 
BANDACE?.
177
and the left thigh, and that of the left betM'een the scrotum and
the right thigh, in order to fasten them by a knot or by pins to the
cincture above the groins.
  The  triangular bandage, which was used formerly for certain
wounds in the neighborhood of the anus, and which is in frequent
use at  present for diseases of the inguinal region, (Fig. 110,) is in
fact the same as that of which I have spoken in  pointing out the
bandages for the mammary region.  It is, therefore, unnecessary to
recur to it here.

         § IX.—Bandages for the upper part of the limbs.
  The  upper part of the arm is subject to so many diseases, that it
has given rise to the suggestion of a number of bandages.  Among
these, however, there are scarcely any other than the figure  of 8,
the different varieties of the spica, the stellated, (etoile,) and the cape-
line. which it can become necessary for us to be  acquainted with
at the present day.
  A.  The bandage, called Figure of 8, was formerly employed in
the treatment of fractures of the  clavicle, (Fig. 111.)    We place

                             (Fig. ill.)
under each arm-pit a long compress, whose ends are crossed on the
apex of each shoulder.  We then, by means of a bandage of three
fingers' width, make an 8, which surrounds the upper part of each
arm, and crosses betM'een the shoulders, to be  repeated thus three
or four times, while an assistant, having his knee fixed against the
dorsal portion of the spine, forcibly draws the two shoulders back.
In order that the turns of the figure of 8, thus made, might rest se-
cure, some surgeons  placed under their point of crossing a long
compress,  or a strip  of  bandage,  the extremities of which were
                             23 
178
NEW ELEMENTS OF OPERATIVE SURGERY.
(Fig. 112.)
turned back upon the median line.   This bandage irritates, and is
altogether useless.
  B. Spica, (Fig. 112.)  The bandage known under the name of Ear
of Wheat, (epi,) or Spica, is a kind of figure of 8 wilh unequal turns,
                             which are applied on the upper part of
                             the arm, the apex of the thorax, and on
                             the upper part of the thigh and pelvis,
                             also on the root of the thumb. On the
                             arm and  thigh the bandage requires
                             to be from five to ten yards in lenglh,
                             and at least three fingers' width.  To
                             render it secure, and to prevent its
                             displacement, I  am in  the habit of
                             making it thus : I pass the free head
                             of the bandage aroud the arm-pit or
                             thigh of the diseased side, either from
                             before backward, or from behind for-
                             ward, and then  continue it in an op-
                             posite direction, so as to leave a por-
                             tion of it hanging down about  two
                             feet long.  This  precaution  being
                             taken, M'e pass it over either surface
                             of the chest, under the arm-pit of the
                             sound side, and bring it back by the
                             other surface of the chest to the dis-
                             eased shoulder.  We  then pass it
                             under the arm-pit to make a  turn,
                            and thus cross  it on  the shoulder,
carry it back under the other arm-pit, and bring it in the same
manner upon  the shoulder and  under the arm-pit of the diseased
side, repeating this manipulation four, five, or even  six  times, ac-
cording to the extent of the  surfaces we wish to cover.   It is then
that the  reserved head of the bandage should be raised up, in the
form of a bridle, to the whole dressing, as I have said in describing
the cataphrast.
  This bandage bears the name  of  the descending spica, when the
turns which  compose  it lap over each other from  above down-
wards, that is, from the shoulder towards the arm.  It takes, on the
contrary, the name of ascending spica when the turns go upM'ard
from the arm to the lower part of the neck. If it should be necessary
to prolong it downwards to a level Math the insertion of the deltoid, it
would be much better to  make some circular turns upon the hume-
ral portion of the shoulder, than to give it the form of spica in its
whole extent.
   Finally, to make the spica in the groin, it suffices to apply to the
pelvis and upper part of the thigh what  I have said of the  chest
and shoulders.
   The spica which I have described is the simple spica.  If it M'as
required to have it double, we may understand, without the neces-
sity of a particular description, that it would be necessary to  make
 
BANDAGES.
179
on each side what I have said of one of them.  The roller bandage
with two rolled heads, which was formerly employed for this purpose,
is wholly useless ; surgeons of the present day are, for the most part,
satisfied with the bandage with one head for the different kinds of
spica they may have occasion for.
  C. The Stellated, (etoile—Fig. 113.)  The  stellated bandage is a
sort of figure of 8, crossed in front of the chest, and associated with

                            (Fig. 113.)
some turns of spica.  Thillaye describes three varieties of it—the
single stellated, the double stellated, and the stellated with a bandage
of two rolled heads.
  To  make the first, we place the  free end of the bandage under
one of the arm-pits—that of the right, for example—then pass it in
front of the chest and left clavicle,  behind the shoulder, and under
the arm-pit of the same side, to return in front upon  the clavicle,
behind the shoulder, and under the arm-pit of the right side, so as to
complete the 8;  after having  repeated this  crossing two or three
times, we carry it in front of the arm-pit, on the clavicle, and behind
the corresponding shoulder, in order to reach the posterior part of the
opposite arm-pit, as in the spica. We at length terminate by repeat-
ing the figure of 8 and  spica  turns, till the bandage is  exhausted,
unless we should prefer unrolling it  circularly around the chest.
  This bandage, which advantageously replaces  the quadriga  and
the spica, has the inconvenience of being very  easily displaced.
Embracing the upper part of the arm in front, it slips with the least
movement, and readily  becomes  detached,  in the manner of the
sleeves of a dress that opens behind. 
180
NEW ELEMENTS OF OPERATIVE SURGERY.
    The double stellated is composed of anterior and posterior figures
 of 8, whose scapular crossing is  not unlike  a double  spica.  We
 make it with a  long  bandage, proceeding first as above.  After
 having  made one or tMro figures of 8 in front, and carried them in
 the rear, the bandage serves to make an equal number of figures
 of 8 behind.  In  continuing thus, Mre soon have three or four turns
 of the 8 crossed on the top of the sternum, on the posterior part of
 the thorax, and on the clavicular portion of each shoulder.
    This  bandage,  which is much more solid than the preceding, con-
 veniently retains the dressings we may require under the two arm-
 pits, or on  the  supra-clavicular regions.   It is,  in fact, only the
 quadriga bandage without the thoracic circulars.  But it is  evident
• that the single spica is much better for one arm-pit, or one shoulder
 only ; also, that,  for  a double lesion, we ought to prefer the double
 spica to this ;  and that, for diseases of the front  part of the chest,
 or for the back, the cataphrast is preferable to the stellated. It is,
 in fact,  therefore, a bandage comparatively useless.  The making it
 with a  bandage with two rolled heads renders it neither better nor
 more solid, and generally interferes with its construction.
                   § X.—Bandages  for the Hand.
    Diseases of the hand may all be dressed with the roller bandage,
 the  circular, or the spica.  The  spica  answers  scarcely for any
 thing but the thumb, M'hich in that  case represents the shoulder,
 while the M'rist corresponds to the chest.  By the aid of this band-
 age, the thumb,  the thenar eminence and metacarpal bone, which
 corresponds to it,  as well as the wrist, may be dressed Mdthout  the
 hand participating in it.  The fingers have a kind of bandage adapted
 only to them, and bearing the name of gauntlet, presenting two
 varieties : the gauntlet,  properly so called, and the demi-gauntlet.

                           A. The  Gauntlet, (gantelet,) (Fig. 114.)

                           The object of the gauntlet is to surround
                         each finger with a kind of roller bandage.
                         It is always useful when we wish to make
                         a certain degree of pressure, preventive or
                         curative, on each of the fingers separately.
                         A mode of doing this, which I  have found
                         very convenient, is as follows :  take a ban-
                         dage of about an inch or one finger's width,
                         and eight or ten yards long ; fix it securely
                         by two circulars on the wrist; then bring it
                         diagonally on the back of the hand to the
                         root  of  the little  finger;  then wind it
                         around this finger to its free extremity;
                         then make turns which lap over each other
                         two-thirds, in proceeding from the nail to
                         the  metacarpus; return to  make  a circu-
                         lar about the wrist, then by the dorsum of
                          the  metacarpus, to  do on the ring finger
 
                           BANDAGES.                        181

what has been  done on the little finger;
proceed a second time to the wrist;  bring
the bandage to the middle finger, which is
to be surrounded like the  preceding; re-
turn a second time to the wrist, to surround
also the forefinger.  There is then nothing
more to do  but to pass some  transverse
circulars  upon  the metacarpus,  and  to
finish  by  fixing the  bandage  upon the
wrist.

  B. The half-gauntlet (Fig. 115)  differs
from the preceding, in being limited to one
turn of the bandage upon the root of each
finger, and  fastened by the like number
of circulars upon the wrist.  It is  a sort
of multiple of the spica, sometimes dorsal,
at other times palmar, but scarcely ever
used at present.


              C.  The Scarf, (echarpe—Fig. 116.)

                           (Fig. 116.)
  Almost all diseases of the upper extremity require the bandage
commonly known under the name of the scarf.  Formerly there
 
182           NEW ELEMENTS OF OPERATIVE SURGERY.

was a large and a smaller scarf, the medium scarf and the grand
scarf of J. L. Petit.
  The ordinary scarf is made with a triangular piece of linen, gene-
rally with a napkin, or pocket-handkerchief, folded from one angle
to the other.  The forearm is placed in the middle of this piece, so
that the point of the triangle is directed toM'ards  the  elbow.   Its
two extremities are raised up, one in front, the olher behind, as it
were to form a loup (anse) at the root of the neck ;  the extremity
of the triangle passing from below upward, and from before back-
ward, under the healthy armpit, in order to return to rejoin the an-
terior extremity in front of the shoulder of the diseased side, would
make a diagonal, as in the preceding bandage.   After having fast-
ened the two ends of the scarf by a knot or a pin, the middle por-
tion of it is spread out under the forearm; we afterwards raise up
the point in front or behind, to fasten it  upon that  portion of the
triangle M'hich is situated in that part.
  The scarf, M'hich in fact is nothing but a suspensory of the fore-
arm, and which the diagonals of the preceding bandage could in a
case of necessity replace, may be arranged in a great many other
ways.  Thus, in place of being turned in the  direction of the hand,
its base may be carried backward;  and in place of mounting to
the neck, it may be attached to the forepart of the vest or coat; it
is thus we obtain the different kinds of scarfs which  I have noticed
above.  Provided that it supports, in an equal manner, the elbow
and the whole length of the forearm, and permits the  parts to be
easily withdrawn from, or replaced in it, it is all that M'e can ex-
pect of it; the rest is only a matter  of taste.

           § XL—Bandages for the Lower Extremities.

  The different bandages which the diseases of the  abdominal ex-
tremities may require, are the roller, the circular, the bandage of
eighteen heads, and that of Scultetus.   The stirrup  (etrier) m ill be
described in speaking of bleeding in the foot.  The uniting band-
ages for longitudinal and transverse M'ounds, have no special  ar-
rangement for these parts.  The figure of 8, the kiastre, and the
bandage of Ravatan, like all other kinds of bandages devised for
fractures of the patella, have no claim to our attention at present;
so that the lower extremity has, in fact, no special bandage.

                § XII.—Bandages for Fractures.

  It is in treatises upon surgical pathology, that we can properly
discuss in  detail the different  kinds of dressings designed for  the
treatment  of fractures;  but as the bandage necessary for these
descriptions of disease is, owing to  the new  improvements, nearly
everywhere the same, I propose to  speak a few words of it in this
place.  Thus, in every case it is the bandage of Scultetus, the body,
clavicular, or roller bandage.   Wherever we desire compression,
and do  not wish to remove the  dressing frequently, the bandage
must be previously saturated in a solution of dextrine.  To do this, 
BANDAGES.                        183
we pour, little by little, into a large vessel, one portion, a tumbler
full, for example, of dextrine in powder, then a portion of water to
dilute the powder.  When we have carefully diluted  the dextrine,
breaking it  up by means  of the fingers  and by trituration,  we
pour into the mixture, gradually, a third of brandy or alcohol; the
unrolled bandage is then dipped into this liquid.   When it is satu-
rated with it. and we are ready to make use of it, we roll  it  up
as we do a wet bandage, without rolling  it too tightly.   If it is
the bandage of Scultetus, M'e should  saturate it after it is in  its
position with the same mixture.   It  is in  this solution,  also, that
we must dip the graduated compresses, or the pieces of pasteboard,
if it  should be found advisable to make use of them.
                   A. Fractures of the Hand.
  I.  Fractures of the fingers.  In the case of the  fingers, after hav-
ing properly reduced the portions of the  phalanges,  we surround
the part with a piece of fine  linen, then with turns  (plan) of the
roller bandage which has been  saturated with dextrine ; a gradu-
ated  compress, or a long, narrow strip of pasteboard, is then placed
on the palmar and dorsal surfaces, from one extremity to the  other
of the fractured finger.  We then apply over this a second or third
series of turns of the roller bandage, after which we conduct the
bandage to the back of the hand, to make two circular turns there,
and  then proceed to form  it into a collar around the root of the
finger.  Left exposed to the  air,  the bandage thus arranged dries
and acquires the hardness of  wood in twenty-four hours.  Thus it
is protected from all displacement,  and has no  necessity of being
renewed before the consolidation is completed.
  II.  For the  metacarpus, whether it concerns one or more of its
bones, we proceed nearly in the same manner: a dry piece of linen
being applied on the part, is immediately attached there by one or
tM'o  turns  of the bandage.  The surgeon  proceeds  then  to the
reduction, if he has not effected it before, and applies immediately
upon the back of the metacarpus a square piece of linen folded upon
a piece of pasteboard saturated with dextrine, (carton  mouille,) then
a similar square, or one a little  thicker, on the palm  of the  hand,
which latter must be fastened by some additional turns of the band-
age.   After  having  surrounded the wrist with turns, the bandage
is brought back to the root  of the finger, which corresponds to the
fractured bone as in the  gauntlet.  It remains then to place the
graduated compresses upon the  palmar and dorsal surfaces of the
finger ami of the metacarpal bone. One or two series of turns of the
roller bandage, which should envelop the whole length of the finger,
then  the whole hand, and also the wrist, complete the dressing.  The
important point here, is to make pressure in a very gentle manner
upon the edge of the hand near the root of the fingers, and to avoid
all strangulation at the wrist.
                 B. Fractures of the Forearm.
  I.  Fracture of the lower extremity of the radius.   Having restored
to the wrist its natural direction, the surgeon applies upon the  linen 
184           NEW ELEMENTS OF OPERATIVE SURGERY.

which is to go next to the skin, a portion  of roller bandage, from
the root of the fingers to the elbow; over that he places the two
graduated compresses, the anterior and the posterior, folded upon
pasteboard which has been saturated m ith dextrine, (doublecs de
carton mouille,) down to the corresponding surfaces of  the  hand;
a second and then a third series of roller bandage, from the elbow
to the root of the fingers, and  from the  root of the fingers to the
elbow, terminate the bandage.   The solidity of this bandage, and
its desiccation being effected by degrees only, allows of the inferior
portion of the forearm, during the first days of its application, be-
ing gradually adjusted, and with as much exactitude as we could
wish.
  II. Fractures in the body of the limb.  The coaptation being made,
and the limb surrounded with linen, it is enveloped in one series of
turns of the roller bandage.   The graduated compresses, with the
pasteboard, are applied before and behind upon this layer of turns,
{plan de bandage;) a second layer  of turns of bandage  is brought
from  above, from the elbow to the M'rist; the bandage is then
passed once or tMdce around the metacarpus, between  the thumb
and the root of the fore-finger, and then terminated by a third series
of turns with the roller.   For greater security, if we  were treating
an intractable subject, or a fracture very high up, it would be M'ell
to prolong the layers of bandage, the limb being flexed, to some
inches above the elbow; because, when it has become dry, the
humero-cubital articulation  is by this means rendered  altogether
immoveable.
  III. Fractures  of the olecranon.  No bandage hitherto proposed,
can with certainty prevent the  separation of the fragments of the
bone in a fracture of the olecranon ; unless this separation exceed
an inch,  it causes very little  inconvenience.   The  best  thing to
do in such a case, is to keep the limb in a very moderate state of
extension, and completely immoveable, for about a month.  We
obtain this result in the most perfect manner possible by means of
a bandage saturated with dextrine ;  nothing then prevents our de-
pressing  the  fragment  of the  olecranon by placing above it a
transverse graduated compress, then some oblique turns (arcs) of
the bandage, provided we take care to make but little pressure, and
to place over the whole, in a uniform manner, the roller bandage,
with two large  pieces of pasteboard saturated m ith dextrine, ex-
tending from the root of  the fingers to the neighborhood of the
shoulder.
                  C. Fractures of the Humerus.

  For the humerus, properly so called, there is no need of graduated
compresses; the simple roller bandage, attached above by  some turns
of the spica, with two pieces of pasteboard, suffices, without any
other precaution, for all the  fractures of the body of this bone.  If
it is its lower extremity, we must  place  a graduated compress in
front on the bend of the elbow, and another behind  upon the ole-
cranon.  One of the assistants making extension by drawing upon 
BANDAGES.
185
the hand, the other counter-extension and coaptation by pushing
the olecranon  forward with his thumbs,  and drawing the lower
fragment backward with his fingers, enable the surgeon to apply
the saturated bandage in the form of a  roller with three layers, (a
triple plan,) with the saturated pasteboards, and to multiply its cir-
culars around the elbow; here, as at the M'rist, we must lake care
to watch the desiccation of the bandage, and by making the proper
degree of pressure  upon the parts, gradually to restore them to
their natural position.
  I have already said that the fractures of the neck of the humerus,
whether in an anatomical or surgical point of vieMr, do very well
with the bandage for the clavicle, described further on ; I will add,
that the roller bandage, accompanied with four or five turns  of
spica, provided M'ith a thick piece of linen, or with any other material
adapted to filling the  cavity which separates the  two principal
walls (parois) of the axilla, is still more convenient,  and ought
generally to be preferred.

           D. Fractures and Luxations of the Clavicle.
  Of all the bandages contrived since the time of Hippocrates to
the present day, to  remedy fractures or luxations  of the clavicle,
scarcely any now remain  but the bandage of Desault and  the
single scarf.  The  bandage of Petit, those of Duverney, Boyer,
Boettcher, Brasdor,  and Meslier, the sling (frondc) of Flamant,  the
ancient brassiere  of Ravaton, and a great number of others, in no
way answering the end proposed,  merit  the oblivion into which
they have fallen.
  I. The bandage of Desault itself is scarcely any longer employed.
The difficulty of applying it well, the necessity, so to speak, of re-
placing it every day, and the irritating pressure which results from
it, upon the chest and brachial plexus, have caused it to be generally
discarded ;  which is so much the less to be regrelted, as it scarcely
ever prevents the riding upM'ard (chsvauchement) of the fracture, and
the deformity of the callus.   This bandage, which seems to have
taken its origin  in  the spica of Glaucius, delineated in figures 75,
76, and 77, of Vidus Vidius, deserves, therefore, no further mention.
  The  scarf that M. Mayor desires to  have substituted for it, is
not sufficiently solid, and permits too much motion to the limb, to
have any other advantage than that of supporting the elbow and
forearm, and of leaving the cure of the  injury to nature.
  II. Bandage  of the author, (Fig. 117.)  There is no doubt that
a simple scarf is much more valuable than the bandages and differ-
ent machines extolled of late.  It causes infinitely less fatigue, while
it accomplishes full as regular a union.  But 1 have contrived a
bandage, by means of a simple  band,  which is  adapted  both to
sterno-clavicular luxations, for M'hich I had at first designed it, and
also to acromio-clavicular luxations, fractures of the clavicle, acro-
mion, and scapula, and evert to fractures of the neck of the hume-
rus* For this purpose Me procure a bandage of eight to ten yards
in length.   The head  of this bandage  is  first  applied Under the
                              24 
18J           NEW ELEMENTS OF OPERATIVE SURGERY.

armpit of the sound side, or behind, as with the cataphrast; it is
then passed diagonally upon the back and shoulder to the clavicle,
upon the side affected.  The hand of the  patient is then placed

                            (Fig. 117.)
upon the acromion of the sound shoulder, as if embracing this last.
The elbow thus raised is brought in front of the point of the ster-
num, and the affected  shoulder is  pushed upM'ard, backward, and
outward, by the action of the humerus, which, taking its point d'ap-
pui on the side of the chest, acts like a lever of the first kind, or by
a swing-like  motion, (mouvement de  bascule.)  While an assistant
keeps the parts in place, the surgeon brings down the bandage upon
the anterior surface of the arm, then outside and under the elbow, to
bring  it upward and forward under the sound armpit.  He repeats
this three or four times, in order to have that  number of diagonal
turns, which  obliquely traverse the wounded clavicle, the  upper
part of the chest, and the middle portion of the arm.  In place of
bringing back the bandage to the affected shoulder, it is afterwards
passed horizontally upon the posterior surface of  the  thorax, and
brought back upon the  external  surface  of the  arm, elbow, or
forearm, in the form of  circulars, which are  repeated until  the
hand which is on the sound shoulder and the stump of the affected
one alone remain uncovered.  We finish by one or two more diago-
nals, and by a similar number of horizontal circulars. 
BANDAGES.
187
   Another bandage, well saturated with dextrine, and applied ex-
actly in the same manner over the first, makes a kind of immovea-
ble sac, in which the elbow rests without effort, and without  hav-
ing the power to move itself either backwards, outM'ards, or for-
wards.  I  have already employed it a great number of times, and
it has appeared to me so simple, and of such easy application, that
I do not hesitate to offer it as preferable to all those that have  been
hitherto proposed.  It is unnecessary to add, that some paddings
and thick compresses may be placed under it in the supra-clavicu-
lar region, sometimes nearer the sternum, at other times nearer the
acromion, according as it seems proper to make  pressure on one
point rather than another.   It  is well, also, in order to avoid exco-
riations of the skin, to place a piece of linen folded double between
the chest  and arm ; and it will be  also necessary to adjust a  kind
of wedge  into the arm-pit, of half the thickness of that  of Desault,
if it is a case of fracture of the neck of the humerus.

              E.  Fractures of the Ribs and Sternum.
   All fractures of the  ribs  and sternum may be  dressed M'ith the
body  bandage, (le bandage  de corps) or equally  well  with three
layers of the roller bandage, or, better still, with the cataphrast satu-
rated with dextrine.  The first answers when the fracture is  sim-
ple, and without  displacement; the second or third will be prefer-
red in other cases, because it enables us to increase or diminish
at pleasure the pressure on this or that point, and, consequently, to
force  back, during the desiccation, and in such direction  as we  may
desire, the projections that M'e wish to flatten down.

               F.  Fractures of the Lower Extremity.
   All the  fractures of the abdominal extremity, like those of the
thoracic, may be treated by the bandage of Scultetus, or the roller
bandage, saturated with the desiccatory glue ; on which account, I
have, for the last three years, discarded all extensor and  containing
splints, and the dressings of Desault, Boyer, &c, &c, in the treat-
ment  of fractures of the leg and thigh.
  I. Fractures of  the Foot. For the foot  we proceed as with the
hand; that is to  say, a dry piece of linen is first applied upon the
skin;  the  reduction being well effected,  the  anterior  external de-
pression of the dorsal region, and the  posterior internal hollow of
the sole of the foot, are adjusted with graduated compresses and
pieces of pasteboard ; and the whole  is  afterwards covered with
two or three layers  (plans) of the roller bandage, with which we
surround both the lower part of the leg and the malleolar regions.
  II. Fractures of the Leg.  In complete fractures of the leg, one as-
sistant, seated at the foot of the bed, grasps the heel with one hand,
and the digital extremity of the foot with the  other, in order to
make  the extension ;  a second assistant, having his back turned to-
wards the  face of  the patient, grasps the lower part of the thigh,
and the posterior surface of the ham, to  rriake the counter-exten-
sion: the two together, thus holding the leg slightly raised up, ena- 
188
NEW ELEMENTS OF OPERATIVE SURGERY.
ble the surgeon to effect the coaptation; to surround the limb with
dry linen—then with a layer of roller bandage reaching from the toes
to above the knee ; to apply a long graduated compress on the an-
terior  inter-osseous fossa, and another on each side of the tendo-
Achilli?, and behind the malleoli; or to substitute  three pieces of
pasteboard for these compresses—one behind and one on each side—
to descend again with a layer of turns upon  these compresses, or
pasteboards, and to pass another layer of them upwards to the knee.
This being accomplished, we  may, in order to have a  more rapid
desiccation, suspend the leg upon loops of bandage, (anses de bande,)
or by straps fixed to the circles of the hoop m hich is to  support the
bed-coverings.   If the direction of the parts should not seem cor-
rect, we must carefully look to it, and adjust it, in proportion as the
bandage hardens and dries.
  III. Fractures of the Tibia.  Fractures of the tibia being  scarcely
ever accompanied Math displacement in the direction of the length
of the bone, are still more easy to dress than complete fractures of
the leg.  We proceed in the same manner as I have just described,
except that, in  most cases, we may dispense  with the anterior and
external, and even with the internal, graduated compresses.
  IV. Fractures of the Fibula. There are  three principal kinds of
fractures of the fibula : those of the three upper fourths of the bone,
those of the  external malleolus, and the fractures  opposite to the
tendo-Achillis.  The first and  second require  only the simple roller
bandage, with the bandage saturated with dextrine.  Those of the
third kind, or the supra-malleolar fractures, and M'hich interest sur-
geons the most, require that the  foot should be forcibly raised up
and directed inward by the assistant, who makes the extension, that
the hollows (gouttieres) of the tendo-Achillis, that is, the malleolar,
as well as those of the  anterior inter-osseous  fossa, should be M'ell
adjusted with graduated compresses, and that the pieces of paste-
board should accompany the rest of the bandage ; they require that
we should, from time  to time, take care to adjust the inclination of
the foot inward and forwards, until the desiccation of the dressing
is completed.   We thus  procure, Mdthout  any effort or fatigue on
the part of the patient, all the advantages of Dupuytren's dressing,
united to those of the bandage  of Scultetus, and the ordinary splints
and compressing bandage.
  V. Fractures of the  Patella.  Like those of the olecranon, the frac-
tures of the  patella are scarcely ever united by immediate contact;
like them, also, they allow the limb  to resume its functions when
they are not followed by a separation of more than an inch. I have
even seen fractures of the  patella accompanied m ith a separation
of two or three inches, and which had not prevented the functions
of the leg from being  re-established.  If, on the other hand,  we con-
sider that all bandages, without exception,  and  all the methods
adopted for  this injury, lead to a great number of inconveniences,
we should be allowed, as I conceive, to subject it to the  application
of a bandage which causes no fatigue, which permits  the patient
to take considerable exercise, and procures a definitive result  as 
BANDAGES.
189
satisfactory, at least, as any of the others.  This bandage we have,
and it is no other than the roller bandage saturated with dextrine,
and provided behind with a piece of pasteboard, which may go from
the upper part of the thigh to the heel.   The only precaution to be
taken in employing it consists in this, viz.: To hold the two frag-
ments of the patella as closely approximated as possible ; to apply to
their unfractured (adherent) margin graduated compresses  placed
crosswise ;  to draw them towards each other by means of turns of
bandage passed obliquely  under the ham ; to prolong the roller
bandage to the  upper part of the thigh, and to re-descend  to the
foot.
   VI. Fractures of the Thigh.  The thigh, when it  is fractured  in
the body of the femur, accommodates itself still better than the leg
to the roller bandage saturated M'ith dextrine.  The fractures in the
neighborhood of the trochanter do, also, exceedingly M'ell with  it.
So also do  those of the lower part, provided we take care to place
graduated  compresses in the hollow of the ham.  In all cases, it is
requisite that the bandage should be prolonged as high as possible
in the direction of the hip, and that it should be carried many times
around the pelvis, in the form of  spica, upon the upper part of the
limb.  To  increase its  solidity still  more, we  must not forget  to
place two  large splints of pasteboard, one before and the other be-
hind, between the  great trochanter, or  the  ischium, and the knee,
or, what is as M'ell, one on the inside and the other on the outside,
extending  up to the iliac fossa.  If the necessity of holding the
limb raised during the application of the roller bandage should dis-
quiet the  surgeon, or seem to fatigue  the patient too much, we
might,  without any difficulty, substitute for the roller bandage that
of Scultetus.
   VII.  Fractures of the neck of the Femur.  If it is true that intra-
capsular fractures of the neck of the femur cannot be consolidated,
it is useless to subject patients who are afflicted with them to the
employment of any fatiguing application.  Thus I have, for a long
time, been in the  habit of permitting such patients to leave their
bed and move about on crutches, after the tenth or fifteenth day
of the  accident.  On the supposition, however, that there may be
reason  to  hope for consolidation, a bandage, saturated with  dex-
trine,  (bandage  dextrine,) when  properly applied, in  the  form of
spica, and  associated with a roller bandage, which should  extend
from  the foot to  the ischium, would assuredly be better  than the
bandage of Desault,  or that of Boyer, or than the half-flexion of
Bell or Dupuytren; in fine, than the thousand modes M'hich have
been proposed, and M'hich  are still at this day proposed, with the
intention of curing fractures of the neck of the femur without short-
ening the limb.
   If, after  all, it M'ere necessary to keep the limb extended  during
the desiccation of the dextrine bandage, nothing would be more
 easy.  A bandage, passed as a noose (en anse)  above the heel and
 instep, serves to make the extension  by fixing it to a cross-piece at
 the foot of the bed, while another bandage, passed under the thigh 
190
NEW ELEMENTS OF OPERATIVE SURGERY.
and ischium, serves to make the counter-extension, by being fixed
to a post at the head of the bed.   As soon as the dressing is com-
pletely hardened, these  accessories are useless, for the limb is no
longer susceptible of any displacement, and the patient is at liberty
to turn and move himself without danger.
  G. Thus, then, have wo all that concerns the bandaging (deliga-
tion) of fractures at the present time, if all practitioners would im-
itate what I have done  at  La Charite since the month of January,
1837.  In every case, we perceive that the bandage saturated with
dextrine answers  the  purpose.  When we consider that, by this
means, the patient  is enabled to  move and to turn himself in bed,
even to raise himself up, and to walk M'ith crutches from the third
or fifth day, it ma)' be asked if henceforward there M'ill be any need
of cushions, splints, fracture-boxes, (gouttieres,) inclined planes, leath-
ers, ties, and foot-boards, in the bandages  designed for fractures.
  [With every degree of deference due to  so  high an authority as
M. Velpeau, the unqualified preference given by him to the appareil
amydonne, or dextrine, as  first, adopted and lauded to so great an
extent by M. Seutin, of  Brussels, should, in the opinion of Dr. Mott,
be taken with considerable allowance, or  subjected  to important
exceptions.  There is no question, ceteris paribus, of its superiority
over all other modes in effecting and preserving perfect coaptation
and immobility.   But there is unquestionably, and lamentable ex-
perience proves it, great danger  in its immediate application.  For
its unyielding nature under such circumstances must, in every in-
stance, aggravate the consecutive local inflammation, or inflamma-
tory reaction, (often violent,) which must necessarily, and should,
by every sound curative principle in  pathological and therapeutic
surgery, take place as a consequence to the injury, and an essential
remedial  process for the accomplishment, of consolidation.   The
.memorable and recent instance of Prof. Dubovitsky, of St. Peters-
burg, Russia, wherein this  appareil amydonne was immediately ap-
plied, and the devastating  effects of which  Dr. M. Mas himself an
eye-witness to at Paris, has been  descanted upon at length, as also
all  the objections  to Seutin's mode, in Dr. M.'s  recent book of
" Travels in Europe and the  East."   This case, if no other existed
on record, would demonstrate the danger of the immediate applica-
tion of this method of treatment of fractures.   Among the dreaded
results M'hich the inelastic character of the dressing produces upon
the inflamed parts, and which may be developed insidiously to the
most mischievous and alarming extent under this masked battery,
and be thus concealed from the possibility of inspection by the sur-
geon, are great augmentation of  pain, heat, and every other symp-
tom and consequence of inflammation,  from the  inability of the
parts to have free distension ; and thence follow quickly ulcerations,
abscesses, sloughing, gangrene, and sphacelation, or, should the vi-
tality of the parts survive, permanent and incurable thickening and
contraction of the tendons, aponeuroses, and fasciae, and hypertrophy
of the bones and callus, and total destruction often of the use of the
limb.   After the reduction of the primary inflammation, there is no 
PROVISIONAL DRESSING FOR FRACTURES.
191
doubt that the  apparatus may often be eminently beneficial and
decidedly indicated ; but, until all preliminary inflammation is sub-
dued or past, the open mode of dressing by the modern improved
methods of jointed splint-boxes, with well-regulated means of  ex-
tension and counter-extension, and especially the flexible cylinders
of straw,  as improved upon and sanctioned by the Baron Larrey,
should be rigidly persisted in. We shall recur to this subject of the
dextrine bandages under the head of Tenotomy.—T.]
                       CHAPTER IX.

           PROVISIONAL DRESSING FOR FRACTURES.

  For all the different  portions of linen  which I have  hitherto
spoken of-—that is to say, for bandages, compresses, straps, &c.—a
Burgeon of Lausanne,  M. Mathias Mayor, proposes to substitute
simple  pocket handkerchiefs.   Square pieces of linen, pocket or
neck handkerchiefs, folded  in the form of a triangle, cravat, or in
any other manner, are sufficient, says M. Mayor, for all our wants.
These articles, which M'e have always at hand, have, moreover, the
advantage of being afterwards restored to their uses,  as  portions
of dress  in the domestic economy.   With them we have no need
either of bandages, bands, (liens,) or compresses ; all the dressings
may be applied by the first person who comes.  Without sharing in
the repugnance which M. Mayor has to bandages and compresses,
or concurring exactly in all the praise he bestows upon handker-
chiefs and square pieces of  linen, I ought to declare that we may,
by means of these articles of dress, extemporaneously and without
difficulty, make a much greater number of more simple, convenient,
and even more solid bandages than with the ordinary kinds of ban-
dage.   I will add, that for all kinds of dressings, we may, in a case
of necessity, in fact, substitute for the bandage the  handkerchief,
folded in different ways, as  a pro visionary dressing.  If it were only
then under this last point of view, the method of dressing by the
surgeon of Lausanne deserves to come into general use, and to be
better known. It so frequently happens in the army, in campaigns,
and on the occasion of sudden accidents, that we are under the ne-
cessity of dressing the wounds  immediately, without having at our
command either bandages or compresses, that the surgeon  will find
himself fortunately situated, if he can have it in his power to borrow,
either from the assistants, or from the patient himself, whatever can
be made into a temporary dressing.

              Article I.—Bandages for the Head.

   We have already remarked, that the handkerchief, folded in tri-
 angle, was frequently employed for covering the dressings designed 
192           NEW ELEMENTS OF OPERATIVE SURGERY.
for wounds of the cranium ;  it is, therefore, useless to recur to that
at present.

              Article II.—Bandages for the Face.

  Having shown how, in lowering the base of the triangle, on one
or both sides, or upon the eyes or nose, we obtain  with the hand-
kerchief a  bandage preferable to the different bandages of the nose
and orbitar  region,  I have only to call attention to the facility of
applying the same processes to diseases of the temple and ear.
  For hare-lip, or any other division of the upper lip, we obtain a
uniting bandage by bringing  from the occiput under the nose the
two heads of a handkerchief,  (Fig. 118,) the point of which has been
                          fastened  to the cap.   These two por-
                          tions are then crossed on the front part
                          of the lip, and  passed, one above or
                          through the other by a button-hole, and
                          to be then passed in the opposite direc-
                          tion  towards the temples, where they
                          are to be fastened with a pin. We may
                          also  place  the  middle  portion  of the
                          handkerchief upon  the forehead, and
                          carry the tM'o  heads  to the  occiput,
                          crossing them there, then bringing them
                          back on  the front part of the lip, and
                          fastening them   as in  the   preceding
                          mode. In adopting this last mode, there
                          is no use  in placing a cap on the head,
                          for the handkerchief, whose point is ex-
                          tended to the nape behind, answers that
                          purpose sufficiently well.

        Article III.—Sling (Fronde) for the Lower Jaw.

  To  cover the wounded portions of the cheeks, lower jaw, or even
the lips—to take the  place, in fact, of the sling or chin-cloth, (men-
tonniere)—we adjust  the triangle towards the vertex, M'ith its point
turned forward.   After having brought down  and crossed  its two
branches under or before the  chin, we carry and fix the extremities
of this triangle toM'ards the temporal regions.  By placing the mid-
dle  of the handkerchief, which is on the top of the head, a little far-
ther forward, it is easy to bring down its two halves upon the paro-
tid  regions, cross them under the  jaw, (Fig. 119.) and afterwards
raise  them towards  the temple.  In this case, we  may  place the
middle  part of the. triangle on the auricular or on the parotid re-
gion itself, in order to fix its tM'o extremities upon the opposite tem-
ple.    But,  the handkerchief,  folded as a cravat,  is  manifestly
much better fitted for diseases either of the cheek, ear, or parotid
region, than the handkerchief in the shape  of a triangle.  Applied
ky its middle portion under the jaw, the cravat intended for this
 
provisional dressing for fractures.
193
use is afterwards raised, either directly upward, or obliquely back-
ward, and carried towards the vertex of the head, where it is fast-
ened, either by a knot or by the aid of pins.
                             (Fig. 119.)
              Article IV.—Bandages for the Neck.
  The ordinary dressings for the  neck are made by a neck hand-
kerchief, (mouchoir en cravale;) this has been the practice for ages.
                             (Fig. 120.)
If this kind of lesions require a certain degree of solidity in  the
width of the bandage, nothing is  more  easy than to  adjust, after
                              25 
194
NEW ELEMENTS OF OPERATIVE SURGERY.
the manner of M. Mayor, a thin piece of pasteboard or of coarse
paper betM'een the folds of the handkerchief.
  The uniting, dividing, and straightening (redresseurs) bandages,
for the neck, are made by means of a handkerchief, the middle part
of which is placed on the vertex, (Fig. 120,) if it is necessary to in-
cline the head forward; on  the forehead (Fig. 121) in the contrary
                            ^Fig. 121.)
case; and on one of the parietal regions, when M'e Mash to incline
the head towards one of the shoulders.  We afterwards bring down
the extremities of the handkerchief to attach them, before or behind,
upon a body bandage, or,  on  the side  to  a  sub-axillary cravat,
of which we shall speak presently.

             Article V.—Bandages  for the Arm-pit.

  The diseases of the arm-pit (or axilla)  may be easily dressed by
the aid  of a  handkerchief, folded cravat fashion.   We place the
middle of the cravat under the hollow of the arm-pit itself, in order
afterwards to cross its  two halves upon the corresponding  supra-
clavicular region.  We then conduct  one of these in front, the other
behind,  to  beneath the sound arm-pit, where they are  fastened,
(Fig.  122.)  If the handkerchief should  be too short, we lengthen it
by means of pieces of ribands, or, what is as M-ell, by placing  under
the sound arm-pit a second cravat, which we should then tie  to the
first on the shoulder of the diseased  side.   We may also, m ith the
same facility, make a figure of 8 with  these two sub-axillary cra-
vats ; each one represents a species  of  ring around the upper part 
provisional dressing for fractures.
195
of the limb, and nothing  is more easy than to unite their ends be-
hind, and fasten them between the tM'o shoulders.   With the same
ease, we could, if we had  a very long handkerchief, arrange it first
in the manner of a scarf, as worn by women, making its two halves
pass from before backv/ard under the arm-pits, then fixing them af-
terwards to the middle of the scarf betM'een the shoulders.

      Article VI.—Bandages for the Thorax and Abdomen.

  The cravat could also serve to surround the chest or belly, and
take the place of the body bandage.  But, as it is almost always as
easy to procure a napkin as a cravat, I am of opinion that the body
bandage  will, for the most part, render the substitute M. Mayor
speaks of, useless.
  The handkerchief has the advantage of being capable of con-
taining the portions of the dressing for all the regions of the thorax
or abdomen.
  To the chest we fasten it  below, in the manner of a  cincture;
MTe then raise up its point,  to which  having attached a riband, we
conduct it, in the manner of suspenders, above the shoulder, attach-
ing it  to the cincture of the handkerchief.   This forms a triangular
bandage, which  may be applied to the right or left, in front or be-
hind, according  to the indication, and in such manner as  not to be
disturbed either by the neck or shoulders.
  If we were treating the abdomen, and especially its lower part,
we should arrange matters so, that the base of the bandage should
be turned upward, and that its point, furnished with a riband, could
serve the purpose of a sub-crural bandage below.
  We obtain a scapulary by means of a cravat, one portion of which 
196
NEW ELEMENTS OF OPERATIVE SURGERY.
embraces the loM'er part of the neck, and the other the anterior or
posterior part of a thoracic cincture, (Fig. 123.)
  I have  mentioned above how the handkerchief, or cravat, might

                             (Fig. 123.)
replace the suspensory of the scrotum.  I will add, that the dressings
of the  anus and perineum may be very well made with the aid of
a cravat, which is fastened behind and before to another cravat.

            Article VII.—Bandages for the Pelvis.

  For  diseases of the  hip, or breech, it  is sufficient to fasten a cra-
vat around the pelvis, then to attach the base of a triangle-folded
handkerchief about the  upper part (la racine)  of the thigh.  The
point of this  handkerchief, raised and  fixed to the pelvic cincture,
(Fig. 124,) enables us  to cover all the portions of the  dressing which
we wish to support, either in front of the groin, opposite the great
trochanter, or  on the breech.  If we  are treating ulcers, wounds,
(plaies,) or injuries, (blessures,) of the region of the sacrum, the tri-
angle,  fixed by its base around the pelvis, and brought back by its
point between the thighs, (Fig. 125,) and up to the pubis, would
fulfil every indication.

           Article VIII.—Bandages for Amputations.

  After amputations of  the  limbs, we  have  often occasion for
bandages that are purely containing,  and of dressings that will 
PROVISIONAL DRESSING FOR FRACTURES.
197
prevent any motion of the  stump.  The handkerchief, folded as a
triangle, may serve for this double indication.
  If it is an amputation of the arm, for example, we pass a cravat
(Fig. 124.)                           (Fig. 125.)
  For the amputation of the thigh, the handkerchief, arranged in
the manner described for the abdomen, and properly adjusted, would
very well answer for tlje principal indication.
  For an  amputation upon the  body of the limbs,  (dans la  conti-
nuity des membres,) at the middle of the thigh, for example, M'e should
embrace the stump, at some inches above the wound, M'ith the tri-
angular handkerchief.  The other portions of the dressing  being
applied, there would be nothing to do, but to raise from behind for-
ward, and from below upward, the point of the handkerchief, (Fig.
126,) in order to attach it to the  circle formed by the base of the
bandage.
  Adjusted in this  manner, the  bandage for  amputations is ex-
tremely simple.  As it requires only to detach and lower the point
of it to uncover the  wound, the dressings may be renewed without
causing the least movement to the stump.
  What I have just said of amputation of the thigh, is applicable
to amputations of the leg and foot, the arm and forearm.   I will
only add, that  the handkerchief thus arranged, is only to be pre-
ferred when used as a purely containing bandage, or for treating
stumps that are exceedingly painful, or  keeping in their place sim-
ple gateaux of lint, or different kinds of cataplasms.   EveryM'here
else, in fact, the bandage exposes to less risk of strangulation, and
allows  of more regularity in the distribution of the dressing. 
198
NEW ELEMENTS OF OPERATIVE  SURGERY.


                (Fig. 126.)
(Fig. 127.)
           Article IX.—Scarfs.

  The  different kinds  of scarfs, whether
of the leg, (Fig. 127,) or for the forearm,
(Fig. 128,)  may be  replaced by a  cravat

                 (Fig. 128.)
 
PROVISIONAL DRESSING FOR FRACTURES.
199
and a handkerchief, in form of a triangle.  Embracing in this man-
ner the  nape, the cravat ought to  be tied upon the side or front
part of the chest.  It thus represents a ring, to which are fastened
the two extremities of the triangle that embraces the elbow or the
knee.
  It is also easy to  understand how  cataplasms, sinapisms, and
blisters, may be  supported upon different regions of the limbs  by
means of handkerchiefs and cravats.   It is the mode instinctively
followed by the world generally, and which M. Mayor has taken as
the point of departure for his  whole system  of bandaging, (deli-
gation.)

                Article X.—Uniting Bandages.

  What I have said  of the handkerchief, as a uniting bandage in
hare-lip, or M'ounds of the upper lip,  shows also that we could,
in a  case  of  necessity, convert the  handkerchief or the cravat
into  a  uniting  bandage,  both for longitudinal  and  transverse
wounds.

            Article XL—Bandages for Fractures.

  It is evident,  also, that by the aid  of handkerchiefs, folded in
triangles, oblongs, cravats, or cords, we may make almost  all the
dressings required for fractures. It  is thus that three or four hand-
kerchiefs, (Fig. 129,) in the form of cravats, may take the place of

                            (Fig. 120.)
a bandage  with eighteen heads, the bandage with bandelettes,
[vide supra,] or that of Scultetus.   In multiplying them still more,
we would obtain a part of the results procured by the roller band-
age ; and we can easily  perceive  in what manner, when placed
around splints and bundles of straw, (des paillassons,) they might
advantageously replace the different sorts of cords.  However, this 
200           new elements of operative surgery.

part of the  popular mode of dressing by M. Mayor, (Fig. 130,)
would lose much of its value if the mode  of dressing which I have
adopted in the treatment of fractures came into general use.

                            (Fig. 130.)
  In conclusion, then, the square pieces of linen, the handkerchiefs,
and cravats, folded in different ways, may, in cases of necessity,
replace bandages, ties, and compresses, as the surgeon of Lausanne
maintains; but they will never do but as substitutes; for in employing
them, we go back to the  surgery of former times, and no one can
deny that  compresses or bandages, properly applied,  allow much
better than handkerchiefs of being adapted to the indications that
different wounds  present.  On  this point, then, I feel constrained
to say, that M. Mayor has deceived himself about the importance
of his system of bandaging.
                        CHAPTER X.

                   HERNIA BANDAGES.

  Hernia  requires particular bandages, known under the name of
trusses, (brayers.)  These bandages  having become the patrimony
of certain  surgeons or manufacturers, I am not allowed to treat of
them at length: I will remark only, that the ordinary truss is formed
of an elastic cincture, a sort of steel spring, well padded, (rembour- 
HERNIA BANDAGES.
201
ree,) which terminates on one  side in a leather piece, and on the
other by a pelote, sometimes circular, and at  other times oblong,
and occasionally triangular.  To apply this bandage, we pass  it
around the pelvis, then carefully adjust its pelote in the fold of the
groin, on the opening of the crural canal, or above the pubis, so as
to cover the  track  of the inguinal canal, according to the nature
of the hernia, taking care, hoM'ever, to avoid the scrotum and sper-
matic cord.  The  leather is then brought,  forward and fastened
upon the external surface of the  pelote, by means of small hooks.
The bandage then represents a cincture passing between the crests
of  the  ilium and  the great trochanters.  A  subcrural bandage,
brought from  the  posterior part of this cincture  to  the external
surface of the pelote, gives to the apparatus all the proper degree
of solidity.
   If it is an umbilical hernia, M'e proceed in the same manner, ex-
cept that the cincture passes upon the sides betM'een the false ribs
and the bones of the pelvis.   Moreover, whether the pelote of such
bandages is filled with astringent substances, like  those of M. Ja-
lade-Lafont, or is elastic and full of air, like those of M. Cresson,
or simply padded with elastic materials, as in  the ordinary truss,
we must always expect irritation, fatiguing compression, excoria-
tions, and displacements, difficult to be avoided.
  The best that  I am acquainted with to the present time, are the
bandages of M. Fournier.   For inguinal hernia, the trusses of this
surgeon, which,  as has been recommended by MM. A. Cooper and
A. Thompson, and which I have also demonstrated  to be necessary,
press upon the whole track of the inguinal canal,  in place of sim-
ply closing its anterior opening, have an especial efficacy.  Keeping
the two principal  walls of the  passage  in contact, they retain
the viscera in  the  belly; by the  somewhat forcible pressure they
exercise, they present, moreover, a chance of the  radical cure  of
the hernia.  I have seen some  of those made  by  M.  Fournier for
umbilical  hernia, which had an extremely large  plate, (plaque,)
furnished behind with a long thick crest, projecting more than an
inch.  Applied upon the hernial aperture, this crest reverses  the
two portions inwardly, and soon destroys the tendency of the organs
to protrude into it.   It has always happened that patients who had
derived no advantage from other kinds of bandages have  always
found themselves perfectly well accommodated M'ith that of which
I  speak.   The umbilical bandages, also, generally have need of a
wide cincture.   To keep them steady, they also require sub-crural
bandages and a scapulary.
                             26 
202
NEW ELEMENTS OF OPERATIVE  SURGERY.
                        CHAPTER XL

                 VARIOUS KINDS OF DRESSINGS.

  Besides the pieces of linen, bandages, and  different objects we
have  hitherto mentioned, we sometimes  use medicinal substances,
under the character of dressing.   Among the topical applications,
the management  of which it is the usual practice to assign to the
pupils of the hospital, are to be found cerates, cataplasms, pomades,
unguents, balsams, salves, different liquids, fomentations,the douche,
(les douches,) fumigations, liniments, &c.

               Article I.—Dressing with  Cerate.

  Of  the different topical applications which the ancients used in
the treatment of surgical diseases, scarcely any remain in practice
except cerate and some of the unguents.
  The cerate most in use is a composition of oil and white wax, if
we desire to have that  of Galen, and of yellow wax, if we wish
to have  the  ordinary  cerate.   With this  cerate we make Gou-
lard's ointment, by the  addition of the extract of lead; an anodyne
cerate, by the admixture of laudanum; the sulphur ointment, by
uniting with it sulphur  and a small quantity of the essence of
lemon ; mercurial ointment, by mixing wiih it the Neapolitan oint-
ment ; and the ointment of belladonna, by associating with it a
small quantity of the extract of this plant.
  Cerate is used in various M'ays.   It is  almost  the  only ointment
that should be used in simple dressings.
  When Mre have under treatment ulcers, wounds, or any kind of
solutions of continuity M'hatever, we  mean by simple dressing, the
methodical application of the folloMdng arlicles:  1st.  A perforated
piece  of linen, (linge crible,), or fringed  bandelette, (bandelette de-
couple) or a  gateau of lint  besmeared with cerate, is first placed
upon  the diseased  part,  or  upon  its  circumference, according to
the rules established above,  (see  linen spread with  cerate ;) 2d.
One or several compresses are then applied over the lint; 3d. Then
one of the bandages above described, for the  purpose of securing
the first articles in a proper manner.
  The plumasseaux ought not to  be spread over but with a very
thin covering of cerate, and only  when, as rarely happens at the
present time, we are to apply them naked to the  skin.  The perfo-
rated linen itself ought not to have  any of this cerate, except to
prevent  its adhering to  the edges of the wound.  It is  the  same
with  the fringed bandelettes.   The cerate, in fact, is for no  other
purpose than to render easy the removal of the inner pieces of the
coverings at each dressing.
  The simple cerate may be used  on plain pieces of linen, or by
simple friction, when we M'ish to soften the skin, to cover excoriated 
various kinds of dressings.
203
surfaces with it, or those regions that we  are fearful of irritating,
or parts  enveloped with scabs, which  require to be softened,  or
these places upon the body that we wish to shave.   Fresh butter
and oil could, in fact, in such cases, be  substituted for it.  But M'e
must not fall into the error which pupils too often commit, that  is,  in
applying the linen spread with cerate  over the lint, unless specially
directed, or that of covering the  perforated linen with gateaux
spread with a thick layer of cerate, since the object in such cases
is to clothe with a greasy substance that piece of linen or dressing
only which is to be in  immediate  contact with  the wound  or  its
circumference.
  The  dressings  with the  Goulard, opiate,  mercurial, sulphur, or
belladonna ointment, are made after the same rules, when we are
treating wounds, wdth this single difference, that the plumasseau
placed next to the parts, is then preferable to the perforated  linen.
But these different ointments are most frequently employed as fric-
tions.  It is thus we treat certain affections of the skin, tumors, and
inflamed regions.

             Article II.—Dressings  with Pomades.

  The  pomades  used at  present are  but  few in number.   As topical
applications, they differ so little from unguents and certain balsams,
that they are  scarcely to be distinguished.  We employ them in the
treatment of wounds in the same manner as cerate.  But as it is
for frictions they are most  usually prescribed, the pupil ought  to
know that they are not always applied in  the same manner, nor in
the same quantity.  The anti-ophthalmic pomades, for example, are
employed in two very different modes. Some, whose object is direct-
ly to subdue certain kinds of ophthalmia, are applied to the ciliary or
glandular part of the free edge of the eyelids, or even to the surface
of the eye, according to  the kind of ophthalmia, but never upon the
skin in the neighborhood.   It is in  this manner that M'e apply, of
the size of a small bean, (lentille) the pomades  of Janin, Desault,
Lyon, Regent, Dupuytren, white precipitate, nitrate  of  silver, &c.
The important point  here is, that  the  pomade should  reach the
diseased surfaces, and not be retained by the scales  and  scabs, nor
by the  hairs on  the edge of each eyelid.
  If, on the contrary, we were using resolving or specific pomades,
the mercurial, opiate, or belladonna, for example, we should take a
quantity of the size of a pea or small nut, (noisette) and rub it in—
not upon the  edge of the eyelids, but  upon the skin of these  parts,
or, better still, upon the  forehead or temple of the diseased side.
  The pomade of Autenreith, which is composed of one to  two  gros*
of tartar emetic to an ounce of lard, is used only in friction upon
the epigastrium, or some other  region, morning and  evening, until
it has produced an eruption which  has  much resemblance to that
of the small pox.
 [* A gros in French weight is four grammes, and a gramme is eighteen grains English
weight, so that a gros is seventy-two grains English weight.—T.\ 
204
NEW  ELEMENTS OF OPERATIVE  SURGERY.
  The pomades of iodide of lead, hydriodate of potash; hydriodate
of mercury, white precipitate, and  calemel, almost  all of which
contain half a  gros  to a gros of the substances in question to an
ounce  of lard,  are also  employed in frictions, principally in the
treatment of certain eruptions and a great variety of tumors.
  The mercurial pomade, M'hich we sometimes spread upon the per-
forated linen, fringed bandelette, or  plumasseaux  of lint, is often,
however, much more frequently employed in frictions, or as an unc-
tion.   When,  however,  we desire its action to be purely indirect,
we must prescribe it in the quantity of a scruple to two gros each
time, repeat the application once a  day, or even once only in two
days, and spread it over a large extent of surface, rubbing the part
for  the space of from ten  to twenty minutes.   If the mercurial oint-
ment, on the contrary, is employed as a topical application, it is not
necessary to rub for  so long a  time;  but it is advisable then to use
larger quantities.  It is thus in peritonitis  I have  applied  two to
three gros of it to the belly every two hours; and in acute inflam-
mations of the  cutaneous surface, or subjacent cellular tissue, we
use, in the same manner, as much as two ounces in twenty-four
hours.   It is necessary that the patients  subjected to the employ-
ment of  this pomade, should  be protected  from  exposure to cold,
and that  they should not carry on their persons  pieces of jeM'ellery,
either  of silver, gold, or any other metal, in contact with the
skin.
  To free the skin of these different pomades, simple washings are
not sufficient;  first,  we have  to dissolve  the pomade with oil, or
with a weak solution of soap and water.   We must also bear in
mind that the  mercurial pomade has  a strong tendency to the
mouth, and  easily causes salivation ; that  pieces  of linen which
have been touched by it easily turn black  in ley,  and that  these
spoil, in  the same manner, all other linen with M'hich they have
been placed in contact; and that we ought, therefore, to throw into
the  fire, after having used them, every thing which may have been
impregnated with this ointment.
  The  pomade  of  iodide  of lead, which I have called chrysochrome,
(color of gold,) from its  beautiful yellow hue, and to conceal its
nature from certain timid patients, is exposed also, in a certain de-
gree, to the same inconveniences ; so that, under this point of view,
pomades with mercurial preparations, or preparations of lead, exact
more caution than others.
  The balsam of Arceus,  or digestive ointment, whether simple or
mixed  with  an equal part of cerate,  is  applied  only  to wounds.
For that purpose, we spread a layer of it, of greater or less thick-
ness, upon a plumasseau  of lint.  It is the same with the storax
ointment.
  The white rhasis, or camphorated  ointment, is employed like the
simple cerate, or the sulphur ointment.
  The basilican ointment should be employed  like the balsam of
Arceus.  It has the disadvantage, like this last, of adhering strongly
to the parts, and of sticking unpleasantly to every thing it touchf"" 
VARIOUS KINDS OF DRESSINGS.
205
  The canette, or red ointment,  should be employed like the cerate,
or the white rhasis, if it has in  reality any greater efficacy than
those in general use in hospitals.

             Article  III.—Dressings with Plasters.

  In regard to plasters, we rarely now use  in surgery any other
than the simple plaster, called plaster of diachylon, (sparadrap) or
the Vigo plaster, the blister plaster being reserved for  particular
cases.  We hear no more of the plaster of Andre de Lacroix, of the
mother plaster and ointment, (empldtre ou onguent de la mere) of the
diapalme plaster, and so  many  others which were formerly in use.
Also, when we wish to use these plasters as topical applications,
we take a certain quantity of them, which we soften by the heaU of
the hands or tepid water, and  spread the same with the  thumbs,
rendered pliant with  oil  or water, upon a piece  of fine linen or
leather, so as  to form a plaster a little larger than the part which
is to be  covered with it.   Among those plasters, there are  some
which, like  the mother plaster, the diapalme, and the diachylon,
may be  separated and  removed daily without  much  difficulty.
Others, on the contrary, like the pitch and the Vigo plasters, adhere
so strongly to the tissues,  that they easily remain  in place from
eight to fifteen days.  We  also often envelop buboes, the  testicle,
and certain  tumors, with a Vigo or hemlock plaster, so as to renew
the dressing only every eight or ten days.  By  sprinkling the pitch
plaster with tartar emetic before applying it to the skin, we obtain, at
the expiration of four to eight daj-s, nearly the same result as with
the pomade of Autenrieth.
   Plasters,  under  the name  of diachylon plaster,  (sparadrap)  are
employed to dress  cauterizations, certain ulcers and  blisters, and
for forming adhesive  straps, (bandelettes)  In the first case, we cut
out, every morning, pieces of different shapes, which are applied
upon the diseased part after it  has been properly  cleaned.  In the
second, the strips are cut into different forms and lengths, according
to the kind of dressing they are to compose.
   The adhesive plasters (bandelettes emplastiques) which are used
in dressings should be pliant, but firm and moderately adhesive.  It
is advisable to take off the free edges of each roll, as we do those
of the  seams  of the linen, of which we wish to make compresses
or bandages.  To cut them rapidly and accurately, we seize with the
left hand the free or unrolled head of the roll of plaster, while an
assistant holds the roll itself apart, at a suitable distance.   The
scissors, passed quickly and on  the line of the thread (en droit fil—
Fig. 131) from the surgeon towards the assistant, will, by their
mere  pressure, and without  the  necessity of approximating  the
blades, divide  the plaster into as  many strips as we wish.  These
strips, (bandelettes)  which for the most part  do not  require  to be
heated, are employed in the character of a uniting or compressing
bandage, (Fig. 132.) 
206           NEW ELEMENTS OF OPERATIVE  SURGERY

                            (Fig. 131.)
§ I.—Adhesive Strips.
  To apply strips of adhesive, plaster properly, it is necessary, after
the lips of the wound are  sufficiently approximated, to carry and
attach one of their extremities to an opposite point, in  order that the
remaining portion may be  placed directly across the wound; also,
we must give them great length, and not slacken the ends before
they have become closely adherent to the skin.  Though it is the
custom to commence with that which is to cross and  unite the mid-
dle of the wound, there are, however, cases where we begin rather
with that which is to be placed below or above it.
  To remove the uniting strips, we begin by detaching their ex
tremities; we afterwards  separate  them up to the edges of the
wound, from which part they are to be removed last, and by a per-
pendicular traction, for fear of disturbing the union,  which as yet
has but little solidity, (Fig. 133.)  This precaution would become
useless  if they had been employed  to hold the lint, compresses,
or other portion  of the dressing in  the character of a containing
bandage. 
VARIOUS KINDS  OF  DRESSINGS.
(Fig. 133.)
§ II.—English Court-Plaster, (taffetas.)
  In treating small and  superficial wounds, and when we wish to
dispense with all dressing, M'e prefer the English taffeta to the ad-
hesive strips, (bandelettes.)   This taffeta, which is  a kind of tissue
spread with gum, and capable of being preserved for a long time,
is in the first place cut into convenient strips.  After having moist-
ened  one  of its  surfaces with saliva, it is sufficient  to apply and
press it for some moments on the skin, and as it were astride and
in front of the cuts, to enable it to attach itself immediately, and
become quite  firm.   To take  it off afterwards, it is requisite to
moisten it again, until it is all softened. [See supra on Caoutchouc
bandages, &c]
 § III.—Strips of Adhesive Plaster employed as a Topical or Com-
                      pressing  Bandage.
  A new mode of dressing has entered into surgical practice during
the last thirty years.  It  consists in enveloping  the parts that M'e
wish to act upon (modifier) by means of superincumbent strips of
adhesive plaster. This dressing, first proposed in England by Bayn-
ton for  ulcers of the legs, is made in the  following manner.  We
have strips of diachylon  sufficiently long to make  one and a half
turns  around the part we  wish  to envelop-   These  strips, M'hich
ought to have a width of from eight to ten lines, and to be cut from
pliant, tenacious  plaster of sufficient firmness, and little disposed to
break or scale off, are applied according to certain rules, M'hich it
is useful not to lose sight of.   If we are treating an ulcer, we com-
mence by having it well cleansed ; the first strip is  then applied, by
its middle portion, upon any point whatever of the circumference
of the limb, at an inch or two below the ulcer.  We then bring
back the two halves to a  point diametrically opposite, where they
are crossed, and then prolonged  to their terminal extremity, and
always perpendicularly to the surface they are to cover.  A second, 
208
NEW  ELEMENTS OF OPERATIVE  SURGERY.
third, fourth, fifth, sixth, seventh, or even a greater number still, are
thus applied successively, so as to cover or lap over each other to
two-thirds their width, and to form altogether a sort  of bracelet,
gaiter, (Fig. 134,) buskin,  or roller bandage, which extends, bolh
               above and below, several fingers' width beyond the
               limits of the diseased part.
                 It  is important that these strips should not pro-
               duce strangulation, and that they should be confined
               to moderate pressure upon the parts. Instead of being
               placed naked upon the ulcers, it is often advisable
               to cover the latter with some thin layers of lint, or
               compresses, and afterwards to use also a roller ban-
               dage, to extend from one extremity of  the limb to
               the other.   We renew this  dressing every day, or
               every other day,  or even at much longer intervals,
               according to the  nature or abundance of the suppu-
               ration.   The  most general rule is, to renew them
               every three or four days only.  To  remove them,
              they  are cut at the point  opposite to the M'ound by
              means of blunt-pointed scissors, one of the blades
              of which is insinuated flatwise, and from below up-
              ward, between the adhesive bandage and the skin.
              If the scissors were brought  from  below  down-
              ward, their point M'ould encounter the edge of each
              strip, and might thus render the operation longer.
  These  strips are in no May intended to approximate the lips or
sides of the ulcers;  they act at the same time as a cleansing and
compressing bandage;  the  ulcers beneath are cicatrized by the
conversion  of their  cellulo-vascular  surface into new tissue, and
into cuticular pellicle, much  more than by  the approximation of
their edges.  After having removed them, we cleanse off by means
of a dry linen the purulent or other matters remaining on the limb.
If the skin should appear glossy, elastic, and pale ; if the edges of
the wound seem firm and of vermilion hue, and exhibit no trace of
erythema or excoriation, the bandage will succeed ; and it must be
applied again.  In the contrary case, that is, when erythema, exco-
riations, separations  (soulevements) of the epidermis, itching, and an
ichorous  exudation, are  seen under the strips,  we should lay them
aside at  least for some days, and in the mean while substitute  for
them either simple dressings, or dressings with some kind of topical
application.   But we must not allow ourselves to be alarmed with
the dark color which the suppuration then puts on ; for it is the ef-
fect of the combination  of certain ingredients in the plaster M'ith
some of the matters  which escape from the diseased surface.  We
diminish the acridity of these exuding matters,  and the tendency
of the surfaces to become inflamed, by more frequently renewing
the strips, and by washing, before we reapply them, all the surfaces
of the wound with  some emollient liquid,  or a solution of lead-
water.
  This kind of  dressing, which Baynton rarely applied,  except to
 
VARIOUS KINDS OF DRESSINGS.                209
varicose ulcers of the legs, is fully as efficacious, at least, in a great
number of other lesions,  Thus I  have frequently employed it in
chronic pains of the joints, (arthropathies chroniques.)  In that case,
I surround the knee,  elbow, wrist, or even instep, with them, as if I
was treating an ulcer, and then apply over them the  proper pad-
dings, and a moderately compressing bandage.  I employ them in
the same M'ay in almost all kinds of wounds or ulcers that we can-
not, or do not wish to, cicatrize by approximation of their edges.  It
is, for example, for ulcers denominated syphilitic, which are so fre-
quently developed upon the limbs, the best  dressing I am acquainted
with, after those ulcers have been previously changed in character
by  cauterization with the nitrate of mercury, and that the patient
has also undergone a suitable mercurial treatment.  I have seen an
infinite number of patients thus cured in fifteen or twenty days of
numerous ulcers which  had resisted  all sorts of remedies for many
years.
  Every kind of simple wound, also, which  continues for some
weeks, and which, in our opinion, requires flat dressings, is gen-
erally  cured better under a bracelet  of adhesive strips than by any
other dressing.
  There are, also, no phagedenic ulcers, even  those of a cancerous
aspect, which do not often yield to these plasters with promptitude,
when the ulcers  have been previously cauterized with chemical
substances of a certain degree  of activity.
  [Nothing, according to the judgment  of Dr. Mott, can be more
proper or true than these eulogiums  and directions in regard to
the justly celebrated mode of dressing by  strips of adhesive plaster
of  diachylon, which, in the United States, have nearly superseded
all other kinds of bandages whatever.   The opinion of all practi-
tioners of any experience in this country is in full accordance with
these recommendations.  At the Seamen's Retreat Hospital I have
obtained rapid cures by these dressings, M'hen nothing else had the
least effect, especially of those extensive  phagedenic, deep-seated,
chancre-like ulcerations which are so apt to succeed to syphilitic bu-
boes ; and the cure is  more certain in fresh young subjects than in old
or broken down, worn out mercurio-syphilitic constitutions.  These
 ragged-edged perforations, that go often from two to three inches'
depth  into the groin, are  also  far more conveniently reached and
 controlled, and their  borders infinitely better approximated, by these
 strips than by any other mode.   They should cross over each other
 from the belly down along through the hollow of the  groin back-
 ward to the breech, and some of them down the thigh, forming al-
 together a stellated dressing, the centre of which is directly over
 the ulcer and at the  point where the radii converge. They succeed
 when  nothing else will.  Also in old chronic mercurio-syphilitic
 ulcers on the limbs, if not too  large ; but  in these latter, when ex-
 tensive, and also in those terrific and destructive carcinomatous ul-
 cers which make such havoc in their rapid and deep-seated devas-
 tations upon the face, nose, eyes, and now and then on the massive
 fleshy tissues  of the upper part of  the thigh and  glutei  muscles, 
210
NEW ELEMENTS OF OPERATIVE SURGERY.
where I have seen them near a foot in length and near half a foot
deep, where they had nearly quite destroyed the under part of one
gluteus and parts of the muscles of the posterior part of the thigh
below,  a strong and constant application of chloride of lime, or
linen cloths wet M'ith it and often renewed during the day, together
M'ith tonic treatment internally, I have  found to effect  a cure that
might almost by some be  thought marvellous.  Dr. Vache, at the
hospital at Bellevue, N. Y., and M'here among the poor these fright-
ful cases, especially upon the  face and in  females,  are not rare,
effected perfect cures by similar  constant pledgets of strong solu-
tion of sulphate of copper, and a drink of the decoction of the root
of our indigenous yellow dock.  Even some, in whom it may be
said the whole  side of the face had been carried away, extirpating
M'ith it the eye and half the nose and mouth, were entirely cured.
In all cases of ulcers  M'here the  adhesive straps can be used, and
the cicatrizations do not progress rapidly, we should use at each
removal of the dressings a  wash of strong chloride of lime mixed
freely M'ith rain-wa^er till it has the appearance of diluted milk, as
water dissolves too little to  depend on the solution.  This is cheap
for hospitals, and, perhaps, has. in this state of mixture of its grains
of powder Math the M'ater, and M'hich grains afterM'ards settle upon
the surface of the ulcer, and thus continue  their slight  escharotic
action,  more efficacy than the  more elegant, and clear, and costly
solution of chloride of soda in use in private practice.  Good food,
and especially  the  compound sirup  of  sarsaparilla as a constant
drink, must not be neglected in the  general treatment.   Dr. Mott
remarks, that the great benefit of adhesive plasters to old ulcers of
the legs is, that they give tone to the limb  by their mechanical com-
pression, repress exuberant  granulations, and thereby promote cica-
trization, and especially diminish the size of  the cicatrix, which is
not effected by  the ordinary modes of treating.—T.]
  Burns.   Wounds produced by bodies  preternaturally  charged
with caloric, in fact burns, do also admirably well with these strips.
For a burn of the first degree, an application of strips supported by a
bandage slightly compressing, and which may be reneMed from the
fourth to the eighth day, is  quite sufficient.   If the burn is of the
second degree, that is, with phlyctenae and without phlegmonous tu-
mefaction, I cause the separated cuticle to be removed, and cleanse
off the exuded matters.   The strips are then  applied, and the cure
generally takes place at the end of the  second dressing, sometimes
of the first, almost  always of the third; so that, if it has not been
effected by the  fourth, this dressing must  be  abandoned.  If there
is engorgement and tendency to erysipelas, I commence by combat-
ing these symptoms, by means of emollient cataplasms or bleedings,
and then apply the strips.  If the burn is in the third degree, that is,
with alteration or destruction of the surface of the cutis, we proceed
as in  the preceding case, and the cure is not  the less certain ; only
it exacts from ten  to twenty days.   When the burn is yet deeper,
when it involves  the entire thickness  of the dermoid  tissue, the
strips not being enabled  to prevent the  necessary destruction of 
VARIOUS KINDS  OF  DRESSINGS.
211
the parts by the elimination of the eschar, are of no use until after
the removal of this latter, until, in fact, after the cleansing of the
ulcer.  In other respects, their application to burns is  subject to
the same rules as for the treatment of ulcers.
  I have  applied adhesive strips, also, in the treatment of phlegmon,
of inflamed varicose tumors, and certain  ganglionous tumors, (tu-
meurs ganglionnaires) and I am satisfied that we may derive real
advantages from them in these cases.
  " Scrofulous ulcers, whether of the neck or limbs, treated at first
by nitrate of mercury,  (nitrate acide de mercure) to destroy their
burrowings and loose  edges, are generally cured better by the
use of these strips  of adhesive plaster, than by any other dressings.
In fact, I have used this kind  of dressing with remarkable  success
for different wounds, or ulcers of the chest and mammary region,
whose cicatrization was tardy.
  In speaking of bandages for the scrotum, I have mentioned  what
benefit we  may expect to derive from adhesive plasters  as a com-
pressing application to the testicle.
            Article  IV.—Dressing with Cataplasms.

  We give the name of cataplasms to the different sorts of paste,
pulp, or pap, (bouillie)  with which diseased parts  are  sometimes
covered.   Cataplasms bear the name of emollients when they are
made of flaxseed  meal, the soft part of bread, or of the fecula or
leaves of mucilaginous plants boiled in plain water, milk, or water
of marsh-mallows.  They are called astringents if there enters into
their composition the powder or decoction  of some kind of bark, as
that  of the oak, Peruvian bark, or gallnut, or the roots  of bistorte,
tormentilla, &c.  They are called excitants when we combine with
them ammonia, alcohol, an acid, or some  antiscorbutic substance.
Maturating cataplasms  contain, more especially, leaves of the sor-
rel, boiled onions, basilican ointment, or  honey.
  In  gangrene, or  hospital gangrene, (pourriture  de I'hbpital) we
sometimes add to emollient cataplasms the slices or juice of lemons.
By boiling white soap and barley flour in water, we obtain a lique-
fying cataplasm.  The pulp of certain roots, the carrot, for example,
becomes a resolvent cataplasm when boiled in M'ater. Grated, and
in the crude state,  it  forms at the same time a refrigerant and dis-
solvent cataplasm, in the same way as the pulp of potato applied
cold is a calming and resolving cataplasm for a burn.  Irritating cat-
aplasms are chiefly made with mustard flour:  I shall recur to them
in speaking of sinapisms.  We obtain narcotic cataplasms by add-
ing the decoction of poppies, nightshade,  (morelle) hemlock, (cigue)
henbane, (jusquiame) belladonna,  or some  other  preparation  of
these plants, to ordinary cataplasms.  [A very valuable application
of this kind, in  our country, says Dr. Mott, is the fresh  leaves  of
the stramonium mingled in a common bread and milk poultice, or
tf themselves after being dipped in hot water.—T.]  But we may
use these plants themselves, after  having saturated and softened.
them by boiling water, and then placing them between two pieces 
212
NEW ELEMENTS OF OPERATIVE SURGERY.
 of linen upon the diseased part.   It is in  this way I often  employ
. the pellitory (la parietaire) upon the hypogastrium, in certain cases
 of retention of urine.   In this manner, also, Mr. North informs me
 he has often employed the leaves of the tobacco, to assuage pains
 and certain inflammations complicated with spasm.
   In respect to emollient cataplasms, unquestionably the most im-
 portant of all, I am convinced that none can be compared to those
 of flaxseed meal; so  that the crumb  of bread, barley meal, and
 different feculas, ought not to be used but when that cannot be pro-
 cured.  Boiled and reduced to paste, the flaxseed meal possesses an
 unctuous, viscid, and soothing quality, which is not found in the others.
 This cataplasm, also, must not be either so liquid as to spread out
 into pap, nor so thick  that it does not moisten the fingers.   In gen-
 eral it is advisable to  renew it often, especially in hot seasons, as it
 rapidly ferments, and then soon acquires irritating properties. Cat-
 aplasms are employed in two  different ways—bare,  or between
 two pieces of linen.   [Dr. Mott always applies poultices bare, and
 he considers the  practice  of enclosing them between  linen ineffi-
 cient.— T]

                  § I.—Cataplasms applied bare.

   To apply a cataplasm bare, we place a suitable quantity of the
 ingredient upon  a compress, or a square or oblong piece of linen;
 after which we raise the edges of the linen upon the naked surface
 of the paste, which latter is then spread out uniformly by bringing
 back each edge of the linen towards its fold. We thus obtain a layer
 of cataplasm encased, as it were, in a compress, (Fig. 135.)  It is the
 uncovered portion of this form of poultice that we place upon the
 diseased part.  If it is intended for wounds, ulcers, or  uneven sur-
                    faces, whose suppurations we wish to modify,
                     (modifier) it is advisable to cover it with a thin
                     layer or with some  flakes of lint, which will
                     prevent the cataplasm from making deposites.
                     In such cases, of course it would be ridiculous
                     to place upon the surface of wounds the per-
                     forated linen, plumasseaux, or other dressings,
                     spread with cerate.  All such applications, be-
                     ing designed to prevent  the linen from adhe-
                     ring  to the  wound,  become perfectly useless
                     under a cataplasm.
   We may make an emollient cataplasm, thus prepared, resolving,
 by spreading upon its surface, immediately before applying it, a
 spoonful of extract of lead.  In covering it with a spoonful of lau-
 danum, we convert it  into a narcotic  cataplasm, and  in the same
 way make a sinapism of it by sprinkling it with mustard flour.
   Once in place, the cataplasm should be kept there by means of a
 large  compress, which extends on every side beyond  its edges and
 prevents its running  upon the neighboring linen. This compress,
 crossed and fastened by pins, is often  sufficient when  the  patient
 can remain quiet.  Otherwise we  occasionally surround the com*
 
VARIOUS KINDS OF DRESSINGS.
213
press itself, with the  bandage of Scultetus, the roller bandage, or
some of those already described.

          § II.—Cataplasms between two pieces of Linen.

  When placed bare on the parts, the cataplasm has the disadvan-
tage of escaping, or running out  in a state of pap, beyond the lim-
its to which we would wish to restrict it, making a dressing of a
very unpleasant  and  uncleanly kind.   On this  account, many
surgeons are in the habit of enclosing it between two pieces of
linen ;  that is, they spread upon  the surface of the paste laid upon
the first  compress another similar piece of linen, which  is to be
placed next to the diseased part.  This is a modification upon which
it is well to have correct notions.  The cataplasm does not act only
as many persons suppose, merely like compresses saturated with
tepid water.   Applied bare (or naked) on the skin, or on wounds, it
places itself in contact with every indentation, furrow, or uneven-
ness on the cutaneous surface.  Its marrowy and pultaceous* con-
sistence enables it to adapt itself infinitely better than any kind of
linen to the inequalities of the parts ; so that, all other things being
equal, the naked  cataplasm is much better than that placed be-
tween two pieces of linen.  Nevertheless, there are some regions,
like those of the eyes, lips, and face in general, M'hich scarcely per-
mit the employment of the naked cataplasm. As, on the other hand,
there are a great number of patients who would be exceedingly
annoyed  to  see their linen or  bed  soiled by a  cataplasm, and
others on whose tractableness we cannot rely, we ought, in private
practice at least, to know how to enclose  a cataplasm between two
pieces of linen.   We proceed then in the following manner :  The
cataplasm is  first  arranged like  the preceding ; we then cover the
surface with a square piece of lawn, tulle,  or         ,Fi  1361
gauze, (Fig. 136,) or very open muslin.  These
tissues, representing a net-work with large
spaces, suffice to restrain the oozings of the
paste without in any manner interfering with
its action upon the diseased surfaces.  If we
have neither  tulle, lawn, gauze, nor muslin,
we should at least make use of  linen that is
old, or as thin as possible.
            § III.—Remarks on the use of Cataplasms.

  Temperature.  Cataplasms should be  applied  hot;  that  is, at a
temperature  of from 25 to 30 degrees of Reaumur, [that is, about
90 to 100 of  Fahrenheit.]  Below this temperature they are chilly
and cold, and  become easily  converted into  revulsives,  (reper-
cussifs,) or resolvents, (rtsolutifs.)  Above it, they are excitants, or
even rubefacients.
  Re-application.  Simple cataplasms  should be  renewed  every
twelve hours at least, and applied in layers  sufficiently thick to re-
main moist during this lapse of time.   Kept on for longer periods,
 
214
NEW ELEMENTS OF  OPERATIVE  SURGERY.
they might dry and irritate the parts in the manner of hard irregu-
lar bodies.   In applying a cataplasm, it is well to recollect, that by
its weight it tends to run and spread upon descending surfaces; and
that it is better, therefore, to apply it from the projecting points to
the  deep-seated  parts, or  from the anterior region  to the posterior
region of the diseased surface, than in the contrary direction.*
  Removal.  To remove them, it is generally quite sufficient to seize
them by their longest border, and then gently and  quickly to turn
them back by making  them roll, as it  M'ere, upon  an axis to the
opposite border.   If the folds of linen on the poultice should be ad-
herent in any place, we moisten  them  with tepid water before de-
taching them.  When the cataplasm is too soft, or adheres to the
cutaneous  tissue  rather than to the compress, we liberate  the skin
from it by  drawing  upon  it gently M'ith  the  border of the plaster
which is first detached, or by the aid of a spatula.  When we have
no fear of  wetting or softening the parts too much, or when there
is to be any advantage gained by cleansing  them carefully, we do
not reapply the cataplasm until  after having bathed them, or left
them to soak some minutes in hot M'ater.
  Irritating  action.  Emollient cataplasms  frequently occasion a
grayish colored puffiness (boursoufflement grisatre) of the ulcerated
surfaces; but that does not, in general, prevent the cicatrization
from going on : it is even remarkable, that an infinite number of
wounds and  ulcers cicatrize much better and more rapidly under
the use  of  cataplasms  of flaxseed meal, than by any other kind of
treatment.
  [On this subject  of poulticing  wounds, and especially ulcers, we
beg leave to refer to a note we have made in the author's prelimi-
nary appendix of additional  new matter at the commencement of
this volume.   We must venture  to reiterate here our dissent from
so respected an authority as Velpeau, and our entire distrust of
these relaxant applications in all  wounds or ulcers where the prim-
itive  acute  inflammation  has  been  subdued by proper active
remedies, and has passed into that familiarly known atonic condi-
tion of the parts, in which, from immemorial time, and consecrated
by universal usage, the stimulative  or corroborative course, in
topical  as  well as  internal medicaments,  has been adopted and
substituted.  In  the worn-out  constitutions  of hospital patients,
more particularly, do we see the  pernicious results of obstinately
protracted emollient poulticing, not only in retarding, but in vitia-
ting the efforts of  nature to produce healthy florid granulations.  It
does, certainly, for the moment, assuage the mere nervous irritation
and pains; but in so much exactly as it is the reverse, for example,
of the improved and more rational and effective modern modes of

  * [This sentence seems at first rather obscure. It is thus—" Qu'il vaut mieux en conse-
quence le poser des parties saillantes vers les parties profondes, ou de la region ante"rieure
vers la region postirieure du point malade, que dans le sens oppose""—that is, as we under-
stand it, the poultice should be of such variant thickness that it should have a thicker
layer of paste where it comes in contact with the deep-seated surfaces of the cavity, and,
vice versa, should be proportionably thinner where it rests upon the projecting or prominent
parts of the wound,—T.} 
VARIOUS KINDS OF DRESSINGS.
215
compressing adhesive plasters, does it increase the difficulties, by-
augmenting the sensibility and tenderness of the parts, and thus
cause debility and retrograde action.  Poultices can, under such
circumstances, be only temporarily and occasionally applied upon
accidental accessions of severe pain, interrupting the opposite and
true mode of treatment.   Gangrene is one of the frequent  conse-
quences of protracted  poulticing,  an event not uncommon in its
application to blisters, burns, &c.   Dr. Mott is fully of opinion that
continued poulticing of wounds, after the inflammatory symptoms
are reduced, greatly diminishes the vitality and tone of the part,
retards  or  vitiates the granulations, and cannot  be  sustained in
practice.—T.]
  When these  cataplasms have been a long time on, and ferment
and become rancid,  they irritate the skin and the wound, readily
produce erysipelas, or at least very frequently cause a sort of vesic-
ular eruption, which, though they oblige us to suspend this topical
application, are no just cause for alarm.
  Cataplasms of plants should generally  be  placed between  two
pieces of linen; those  of potatoes, carrots, lilies,  (lis) onions, ap-
ples, &c, require, on the contrary, to be applied bare.
  Cataplasms made with honey, yolks of eggs, and wine, should be
applied in the same manner as those of flaxseed meal.  Moreover,
almost all special cataplasms should be renewed more frequently
than the emollient.  For this reason we ought to change, three,
four, or five times a day,  the opiate cataplasms, those of the pulp
of fruits or of roots, the herbaceous, and almost all those of a medi-
cated description.

    Article V.—Dressings Saturated with Various  Liquids.

  Surgical diseases are sometimes dressed with applications satu-
rated with liquids: it is thus, in order to rouse, (animer) excite, and
give tone to ulcerated surfaces, we impregnate with aromatic wine,
decoction of bark, solution of sal-ammoniac, &c, the lint or  pieces
of linen with which we wish to cover them.   So, also, we saturate
with lead-water, brandy, camphorated spirits, or pure water,  cer-
tain bandages by which we wish to aid resolution.  In such cases,
we  sometimes impregnate the different portions of those bandages
before applying, as is generally done, for example,  in fractures; in
other cases, on the contrary, the bandage is applied first, and after-
wards saturated, when in its place.
  But there is  a  mode of saturation in  extensive use at present,
and which I ought to notice in this  place : I mean, dressing with
wet compresses as the only application.  It is a method which has
been adopted, for a long  period, by various surgeons in Germany
and England, and which I myself have often made use  of during
the  last ten years.  In place of covering wounds with linen spread
with cerate, or applying gateaux of lint, compresses, and bandages,
we  simply place over thern a folded compress, which we take care
to keep  constantly wet, and to change every twenty-four hours. 
216
NEW ELEMENTS OF OPERATIVE  SURGERY.
  We dress in this way with advantage those wounds which we are
fearful of becoming inflamed ; also, the greater part of incipient su-
perficial or sub-cutaneous inflammations.  By saturating with cold
water the compressing bandages, also, about inflammatory engorge-
ments, we have a powerful resolvent remedy.   I have used it with
signal success in the treatment  of certain fractures, phlegmonous
erysipelas, burns, and of various wounds from contused or cutting
instruments, the operation  of cataract, many amputations, and  a
crowd of other operations; but if it is true that cold water, employed
in this manner during the hot season, is an excellent topical appli-
cation, it is also true,  that  in cold weather  it is much better to
have recourse to tepid water;  §o also is it  true, that  the Mater,
whether cold or tepid, almost  always  wets  some region that we
would have  wished to protect; that it  exposes to chills, colds,
rheumatisms, inflammations of the chest, and a great  number of
affections, often  more  serious than  the disease itself.  It is also
proper to say, that, applied  indifferently to all kinds of wounds,  it
may produce as much evil  on the one  hand as good on the other.
By  retarding the circulation, it favors gangrene of the contused or
divided tissues ; and by deranging the phenomena of inflammation,
it frequently  vitiates (denature)  the  suppuration, and rarely admits
of immediate adhesion of the lips  of the wound.  It is, in fine,  a
kind of dressing useful to be preserved, but  not meriting all the
eulogiums that have been lavished upon  it since Schmucker, aiid
which it has  very recently received  among ourselves.
                               •
                    Article VI.—Irrigations.

  To render the application of cold wet dressings  more uniform
and efficacious, irrigations have  been proposed.  The dressing then
consists only of some pieces of linen spread over the diseased part,
and of gentle currents of water falling incessantly upon the linen,
or between the linen and the wound.  We use, for that purpose,  a
vessel, or  some  sort of reservoir, such as a basin,  pail,  or small
cask, which  is suspended either to  the bed, or some piece of fur-
niture or fixture in the neighborhood, above the plane which sup-
ports the body.  A spigot, ending in a certain number of tubes,
either of gum elastic or tin, is fixed near the bottom of the vessel;
the tube or tubes are prolonged to a level with the diseased part, so
as to allow the water contained in the reservoir (Fig. 137) to fall upon
it drop by drop, or in a minute stream.  If the diseased part is very
circumscribed, a single tube  suffices.  In the contrary case, we
increase the  number more or less, so as not to leave  between them
more than three to four inches, in  order  that the liquid  may fall
without interruption on the principal inflamed points.
   To obtain from  this treatment every possible advantage, it  is
necessary that the irrigation should be constantly  kept  up; that
is to say, that it should not be interrupted and renewed at intervals;
that it should be made sometimes drop by drop, and at other times
in jets, according  to the degree  of cold we wish to  produce; that 
VARIOUS  KINDS OF DRESSINGS.               217
the temperature of the liquid should be  sometimes under, some-
times above that of the atmosphere, according as we wish to subdue
(Fig. 137.)
or merely to moderate the inflammation.   It is, therefore, an appa-
ratus that we must watch with care, and not permit the reservoir
to become entirely empty, and which requires, also, a sufficient de-
gree of docility on the part of the patient.
  The continued irrigations brought into vogue among us by Josse,
o  Amiens, (Melanges de Chir. Pratique, etc., 1835,) often since em-
ployed under the direction of MM. Berard, (Arch. Gen. de Med., 2e
f/o.'xVY11-' P- 5' eJ 317j) Breschet> (Roberty, These, No. 323, Paris,
III ') C17?(lue7t'  ^nd others>  at Paris, (Gaz. Med. de Paris, 1832, p.
576; Bullet, de Therap., 1834;  Jour, des Conn. Med. et Chir., t. I. et
11.; IhesedeParis, 1835-1836,) have also  been often made trial of
by myself.  Josse regards them as the sovereign cure for fractures,
complicated luxations, simple and phlegmonous erysipelas, phlegmon,
contused wounds, and  for all sorts of general wounds that may be
complicated with serious inflammation.   M. Berard, junior, and M.
Berard, sen., have extended these applications to many diseases of the
articulations, and especially to certain kinds of white swellings, (tu-
                             28 
218           NEW  ELEMENTS of operative surgery.
meurs blanches.) For my own part, I have but little confidence in their
efficacy. I have seen from the beginning, and I have often so stated
in my lectures, that to make them really effective, the incessant irri-
gations exacted a care and attention which it is almost impossible to
procure in the large hospitals; that without this they might endan-
ger alternations of action and reaction, and of heat and cold, which
might greatly aggravate the disease ; and that, by profusely wet-
ting the bed and the clothes of the patient, they might become the
actual  cause  of rheumatism,  or  some  serious affection of the
chest.   I have remarked, also, that  they  readily promoted a morti-
fication of the parts, when the wound Mas accompanied mith ex-
tensive separations, (decollements) or that it occupied some part of
the fingers or the hand,  or  the extremities in general.   I have ob-
served, in fact, that while they prevent or diminish the redness of
the  skin,  and the  tumefaction  of  the deeper tissues,  they often
masked inflammation, rather than prevented or destroyed it; that,
therefore, they do not prevent the purulent discharges, (fusees pu-
rulentes) and that there finally resulted from all this a thin suppura-
tion of a bad aspect, a general condition of things of a more serious
nature, and a disposition  in the wound less favorable to cicatrization
than by the other kinds of dressing.  In conclusion, continued irriga
tions have not seemed to  me to be useful, except in inflammations of
the skin, or those that were sub-cutaneous, and before the establish-
ment of suppuration ; after this first period they are attended with
more inconveniences than advantages.  The dressings with simple
saturations of water (les  simples imbibitions) may, therefore, be sub-
stituted for them, without danger, where  the disease  does not seem
to allow of the employment of strong mercurial unctions, the com
pressing bandage, or large temporary blisters. I think I may predict,
from what I have observed, that continued irrigations will not long
remain  in practice, except  as  an  occasional treament,  and Jov a
small number of special  cases.                            w
  In short, it is a system  of treatment whose origin goes back to an
early period.   I have seen in many treatises  on popular medicine,
I  have learned in my youth from common people, and I have myself
noted, that streams of common water constitute  a treatment for
certain  inflammations, and especially for ulcers of the legs.   It is
thus that, for an affection of this kind, I  went, when fifteen years
of age, to receive upon my leg, for the space of near six weeks, and
from two to four  hours a day, the water which turned the wheel
of a mill; and it is thus that the peasants of my native village were
in the habit of holding their limbs under the  rapid streams of run-
ning water.
  [The practice  of saturating light dressings  of  linen with con-
tinued imbibition of cool  water, is, nevertheless,  on the same prin-
ciple as cold  ablutions to the whole  surface in the highly ardent
and violent  fevers of hot climates,  of eminent  practical efficacy,
also, in such latitudes, in all local inflammations,  bruises, sprains,
&c, after the reduction  of the more  acute symptoms by bleeding,
&c. In the continued elevated temperature of intertropical regions, 
                   VARIOUS KINDS OF DRESSINGS.               219

and the consequent rapid tendency to putrefaction, we have a pow-
erful counteracting antiseptic remedy in this application, preferable,
under all circumstances of constitution, disease, climate, or season,
to the shock and  revulsions  which may be caused by continued
irrigations, which  cannot be regulated.   In addition to cold water
dressings, the additional impregnation, with diluted alcohol, (aguar-
diente of the country,)  soon becomes necessary  and  most efficient,
the moment  the second stage  is arrived.  So  also the  chloride
lotions.   In cold climates and  seasons, the cold wet dressings are
generally to be avoided under any form.—T.~\

             Article VII.—Application  of Hot Air.

   M. J. Guyot, a very ingenious young physician, of extensive sci-
entific attainments, proposed  some years ago a mode of dressing
altogether  opposite to the preceding.   M. Jules Guyot,  in  fact,
wishes  that wounds, or solutions of continuity in general, should
remain dry, and under a temperature of 25 to 40 degrees Reaumur,
(i. e. 88° to 122° Fahrenheit.)   For  that purpose, he encloses the
wound or diseased part in a sort  of box, which is hermetically
sealed, and the air of which is kept at the proper degree of tempe-
rature by means of a tube and a lamp.  To fulfil the intentions of
M. Guyot, the  temperature of this  species of stove, in which the
wound is confined, must always be nearly the same, and generally
a little more  elevated than the natural temperature of the body.
Some trials  of this dressing have been made in my department in
the hospital of La Charite ; but  they have neither been sufficiently
numerous nor varied to allow of my making an  exact appreciation
of their value.  I fear only, from what I  have seen, that the effica-
cy of such a treatment may not be in proportion to the irritation it
occasions, the attention it exacts, and the expense it would involve.

            Article VIII.—Application  of Liniments.

  Dressing with liniments is so simple, that we almost always leave
it to the patients  themselves, or the persons charged with taking
care of them.   We mean by this term, a liquid topical application,
which has  oil for  its vehicle, and certain active medicated  sub-
stances for its curative ingredients.  It is in this manner we make
liniments of olive oil, oil of sweet almonds, (amande douce) &c, to
which we sometimes add camphor, or ammonia, or preparations of
opium, phosphorus, soap, ether, extract  of belladonna,  henbane,
&c. &c.   Certain  compounds, in which there enters no oil, have
also taken the name of liniments.  It is  on this account that the
mixture  of the ointment of mallows, (althea)  of camphor, and of
laudanum of Sydenham, and the solution of a certain quantity of
camphor or ammonia in yolk of  eggs, are prescribed under the
title of liniment, though oil may be excluded from it.
  Liniments are applied as unctions or frictions, twice or thrice a
day. We saturate with them a piece of flannel or woollen stuff,
which serves for rubbing the part gently, and which it is often  use- 
   220          NEW ELEMENTS OF OPERATIVE SURGERY.

   ful to leave upon it in the interval from one application to another.
   Sometimes we merely spread them on the diseased part with the
   fingers, such liniments, for example, as do not contain oil.  We
   afterwards apply over the part a soft piece of linen, or a piece of
   flannel, or blotting-paper.

             Article IX.—Employment of Embrocations.

     Embrocations differ but slightly from liniments.  They consist of
   applications  of different kinds of  oils  impregnated with certain
   medicinal substances, and which  are rubbed  upon the skin, and
   retained there by means of pieces of  linen or some other stuff.
   Thus, the application of a piece  of  flannel, saturated with cam-
   phorated oil of chamomile or any  other  oil,  and   placed on the
   abdomen, bears the name of embrocation.  It is the same with oily
   unctions that are  applied to the face, breasts, or any other region
   of the body, where we desire  to renew them  often.  In fact, em-
   brocations which  are scarcely other than liniments on  a  large
   scale, might, strictly speaking, be made to include, also, certain
^  applications  of alcohol or ether, employed upon the  surface of the
   body.

                     Article X.—Fomentations.

     When we  wish to heat a part, or to keep it  in a moderate, uni-
   form degree  of temperature, by means of substances charged with
   caloric, we  make  use of fomentations.  [The smoothing-iron, tin
   boxes  filled  with  hot water, or a brick  previously heated and
   wrapped in linen cloths, and then placed near the limb, serve also
   for convenient modes of fomentation.—T.~\  The same applies to
   bottles  of hot water, flannels,  napkins, and every other piece of
   linen that we heat and afterwards apply upon the trunk or limbs.
   It is, therefore, a kind of dressing that we assign  to  the nurses,
   or to the patients themselves.  Nevertheless,  there are also wet
   fomentations, that consist of pieces of linen or other  stuff saturated
   with simple  or medicated liquid,  and which are sometimes  used
   instead of poultices.  These liquids, M'hich are sometimes of plain
   water, and at other times of emollient, tonic, astringent, resolving, ir-
   ritating, narcotic, or other decoction or infusion, are employed tepid,
   or even a little hot, and serve as applications, which differ so little
   from ordinary wet dressings as to make  it unnecessary to  dwell
   longer upon them here.

                       Article  XL—Lotions.

     Lotions form distinct applications in themselves,  or constitute a
   part of  several kinds of dressings.  It is  in this way we employ
   liquids upon the surface.   We thus bathe (lotionner) or wash, seve-
   ral times a day, the surface of diseased eyes, with collyria of lau-
   danum, belladonna, lead, &c.  In  the  same way, we  wash  most
   wounds and injuries, and even inflamed surfaces, either with tepid 
VARIOUS  KINDS OF DRESSINGS.
221
water, lead-water, or some medicated liquid, every time we uncover
them, before renewing  the dressing.  It is important, in applying
lotions, not to be too particular in removing the plastic matters,
which are apt to become adherent upon the bottom or towards the
circumference of the wound, and to be careful only in cleansing its
surfaces from irritating matters that may be attached to it.

                    Article XII.—Gargles.

  Those  liquids, simple or medicated, which we use to wash out
the pharynx, and also the mouth, are prescribed under the name of
gargles.  A gargle is generally composed of from four to six ounces
of liquid, and the patient should make use of it from four to six or eight
times a day, in order to consume, in the  space of twenty-four hours,
the quantity of  liquid which I have just mentioned.   The patient
first fills his mouth with it;  then, by throwing the head backward,
he forces the liquid to pass into the pharynx, while, by a series of
moderate and alternate efforts, (par saccade) he drives out the air
which  a  long inspiration had  accumulated  in the  lungs.   This
expiration, preventing the liquid from descending, forces it forward
by slight  movements, producing a certain sound, which character-
izes this particular kind of lotion to parts.  Gargling is combined,
often, with what might be called  a snuffing up, (reniflement) or
washing  out  of the  nostrils.  Liquids employed as lotions or gar-
gles, may be  snuffed up,  and thus  carried through the nasal  pas-
sages to the pharynx, and voided by the mouth; in the same  way
as when  introduced by the  mouth  into the pharynx, they may be
forced up and ejected outwardly through the nostrils.

            Article XIII.—Collutories, (Collutoires)

  Collutories  are  applications  of a  liquid, or  sirup-like consist-
ence, principally intended for diseases of the mouth, or pharynx;
that is, medicinal substances that are applied by means of a pencil
of lint, linen, or  sponge, to  the different  ulcerated or  inflamed
regions of the mucous membrane lining the bucco-pharyngeal pas-
sages.  The substances used for gargling, snuffing up, and for col-
lutories, are almost always employed cold; they are, in fact, lotions,
fomentations, or washes of the nasal, pharyngeal,  and buccal
cavities.

                 Article  XIV.—Fumigations.

  The  employment of fumigations is made in  a great variety of
ways, both as to the nature of the substances used, and the manner
of applying them to the parts.   Sometimes the fumigation is com-
posed only of the vapor of water, or this impregnated with sulphur
or any other medicinal substance.   At other times, however, the
fumigation takes, more particularly, the name of vapor bath.  We
have thus fumigations of various kinds—aqueous, sulphurous, mer-
curial, &c. &c. 
222           NEW ELEMENTS of  operative surgery.

   Fumigations to the nose are  composed of M'ater, milk, or the de-
coction of different plants.  To  effect  this, it is only necessary to
cover the vessel which holds the ingredients that are boiling, by
means of a large pasteboard horn, (cornet de carton) and to keep
the point or apex of this horn in the opening of the nostrils, taking
care to change it alternately from one nostril to the  other.   By
placing the beak of the horn in the mouth, opposite one of the eyes,
or any other given point upon the face, in the place of directing it
towards the nose, we  have a fumigation for the  mouth, pharynx,
eye, forehead, cheek bone, &c.   If it is unnecessary to direct  the
vapor precisely upon one point of the face more than another, we
have no occasion for the horn ;  the patient has only to cover him-
self with a sheet or any large piece of linen  that may enclose him
and the heated liquid as it were both in  one chamber.   He inclines
his face toM-ards the vessel from whence the vapor is exhaling, and
in this manner receives the fumigation.
  If the fumigation is to be made with liquids, decoctions, infusions,
&c, we may either remove the vessel from the fire, and inhale its
vapor while cooling, or keep it at a sufficiently elevated tempera-
ture, either upon a chafing-dish or a furnace.  If we  are fearful
about the respiration in covering the head as I have just indicated,
the fumigation may be  made in  the open air, prolonging it to a
somewhat  longer period.   Certain kinds of  fumigations, as those
that are composed of vinegar, camphor, benzoin,  cinnabar, dried
plants, or powders in general, as belladonna, henbane, tobacco, &c,
are made by sprinkling some of those substances upon a chafing-
dish of burning charcoal, or upon a strongly heated piece of metal,
a fire-shovel, (pelle a feu) for example.  Cinnabar, often employed
formerly in venereal affections  of the  scrotum  or anus, was first
placed upon coals, and its smoke then conducted upon the  dis-
eased part, by means of a pasteboard funnel, (entonnoir en carton)
Vinegar thrown upon the fire, or a hot shovel, escapes in the form
of vapor, which it is easy to direct in the same way.
        We obtain fumigations  of the dried leaves of plants by
      smoking them in the manner of tobacco.  We have thus, at
      the  present time, prescriptions of cigars of belladonna, hen-
      bane, digitalis, &c, in various diseases of the chest.

                   Article XV.—Injections.

        The term injection is  applied  to the washing of certain
      deep-seated regions.  It comprises all  liquids which we are
      obliged to force  with a syringe  into the  interior of certain
      canals, or the bottom of certain cavities.  Strictly speaking,
      the term injection is synonymous with a liquid thrown by a
      syringe.
        Injections for  the  ear are  made with a small syringe ter-
      minated in an olive-shaped form, (Fig. 138.)  Those of  the
lachrymal ducts require Anel's syringe, of which we shall speak
under the article fistula lachrymalis, (Atlas, pi. VIII., figs.  9 and 10.) 
various kinds  of dressings.                 223
  To inject between the lids and eye, it is better to use a <Fis-139•>
small  syphon syringe,  slightly  conical  in  shape, like the
urethral syringe, (Fig.  139.)  For the mouth  and nose,  if
we v/ish to inject copiously, we have need, sometimes, of
a syringe of larger size.  The same remark applies to ab-
scesses, and fistulous passages in all the regions of the
body.   If the cavity to be  washed is very large, we  have
recourse to an enema syringe.
   Injections of the urethra are made with syringes to contain
about an ounce of liquid, (Fig.  140 ;) the syphon portion  is
introduced completely into the canal, which latter is held
so that it closely  embraces  the  instrument,  while  with
the other  hand the piston  is forced upon  the liquid, (Fig.
140.)   It  is  important that  the  finger making the  com-
pression should not go beyond the point  of  the syringe, and
that the injection thus forced in should be retained  a minute or
two in its place, or,  if it is  not  of a very active nature,  that it be

                            (Fig. 140.)
repeated two or three times at each sitting.  The tendency of these
injections is rarely to penetrate into the bladder.  Supposing, haw-
ever, that there may be something to  apprehend in this respect, we
should prevent it by supporting the perinaeum upon the angle of a
chair, or a hard pelote, during the whole period of the operation, or
by cjusing some  one  to make pressure on this region  with the
finger.
  Injections into the bladder could readily be made with the same
syringe, which should  be filled  several times;  but it is decidedly 
224
NEW ELEMENTS OF OPERATIVE SURGERY
(Fig. 141.)
preferable to use one of greater dimensions.  We begin, then, by
introducing a catheter, (sonde) to which we afterwards  adapt the
syphon of the syringe.  Nevertheless, this syringe, applied as for
injections of the urethra, or simply prolonged by a canula of gum-
                 elastic to beyond the fossa navicularis, will suc-
                 ceed nearly as well.
                   Injections of the Vagina.  Diseases  of the va-
                 gina and uterus often require the use of injections.
                 The syringe used in such cases contains from four
                 to six ounces, and is known under the name of
                 the toilette syringe, (seringue de toilette—Fig. 141.)
                 This instrument is a straight syphon, like the hy-
                 drocele syringe,  if the injection  is to be made by
                 any other person than the patient.   On the con-
                 trary, this syphon must be bent in the form of an
                 arc, or almost at a right angle, if the female her-
                 self is to  be charged with the  operation.  This
                 syphon, which may be  terminated by  an olive-
                 shaped extremity, perforated  in its  top  in  the
                 manner of a watering-pot, is sometimes made of
                 pewter, at other times of gum-elastic.  Injections
                 of the vagina should be  made three or four times
                 a day.  To obtain the  object we  have in view
                 in using them,  the  female should lie upon  her
                 back, with the  epigastrium somewhat lowered,
                 the nates raised by a cushion, and the legs and
                 thighs half flexed.   In this position she makes a
                 first, and  sometimes a second injection, in order
                 to wash the  parts.   She holds the next injection
                 for some minutes, to prolong a  little the contact
                 of the liquid wh% the diseased parts.
  If it should become  necessary to make injections into the womb,
which is not in general very  difficult, we should begin by introducing
a catheter, using the forefinger of one hand for  our guide, as far
as the neck, and into the interior of this organ; in other respects,
we proceed as has been stated for injections of the bladder.
Article XVI.—Enemata.
  The art of giving enemata is usually confided  to nurses and
invalids; often, also, the patients administer them to themselves.  It
is, however, an operation of much delicacy, and one which may be-
come dangerous, if not guarded by proper precautions.  It is neces-
sary, therefore, that the student or surgeon  should  know at least
how to point out its rules and direct its performance.  The syringe
we use to give  a clyster,  is generally of the  capacity of a pint;
if we fill it entirely, the  enema is complete.  It is in this way it
should be given when we  desire to  encourage  the  stools.  If, on
the contrary, we wish to deposite in the rectum emollient or medi-
cated liquids, in the  character of topical applications, or internal 
VARIOUS KINDS OF DRESSENGS.
225
baths, we fill it only one half.  When we wish certain  liquids or
substances to be absorbed, it is not proper to inject more  than a
quarter of the syringe.  These quarter portions of an enema, im-
pregnated with narcotic substances, camphor, cinchona, cubebs, or
balsam of copaiva, form a bulk of sufficiently  small volume not to
distend the intestine, but to permit the patient to retain and absorb
it as if he had taken it by the mouth.  The syphon of the syringe, in
such cases, is, as in the injection syringes, ordinarily conical, or it is
cylindrical and straight where the clyster is to be given by another
person. When we wishvto make the injection go far up, we adapt to

                            (Fig. 142.)
it- a tube of gum-elastic, and the syphon should be curved like the
vagina syringes if we wish the injection to be given by the patients
themselves.  Then the patient  passes  the instrument from before
backward, between his thighs, so as to make its beak enter the anus;
pressing afterwards on the piston, he gently forces the liquid forward
with as much facility as  a nurse placed behind  with a straight
syringe would do it.
  The instruments termed  clysoirs and clyso-pompes, invented in oui
times as substitutes for syringes, are a kind of forcing-pump, (pompes
foulantes—-Fig. 142,) provided with  a  reservoir, and with flexible
                             29 
226
NEW ELEMENTS OF OPERATIVE SURGERY.
tubes, (conduits—Fig. 143,) also with a beak or a syphon that allows
the patient to give himself any kind of injection into the rectum, and
to introduce with facility the different kinds of enemata or clysters.

                             (Fig. 143.)
  To give an enema properly, it is necessary that the pipe of the
syringe or clyso-pompe should, for the extent of about an inch, be
directed a little forward, as if to pass from the perinaeum towards
the umbilicus, in  order that it may thus follow  the course of the
anus;  having reached this depth, which is a little more in man, and
a little less in woman, we first slightly, and afterwards to a greater
extent, incline the point of the syringe backward, as the rectum
follows the curvature of  the sacrum, and, above the  sphincter,
is strongly bent in this direction.   In conforming ourselves to these
rules, we may penetrate without inconvenience, to  two  or three
inches of depth; but, unless we have a flexible pipe, it would be
imprudent to go much further.
  If the syringe has not gone above the line of the sphincters, its point
almost always buts (arc-boute) against the bas-fond of the bladder, or
the posterior wall of the vagina, and the liquid comes out in proportion
to the distance the instrument has gone in, or it stops, and does not en-
ter at all. The same resistance is met with higher up, if the pipe has
not been properly inclined backward, or if it is caught in any way in
the folds of the intestine.  It is then that a serious accident  may
happen. If, in fact, in order to overcome this unlooked for resist-
ance, we push upon the  syringe, there may result from it an abra-
sion, chafing, (eraillure) or even a perforation of the vagina, of the
posterior part of the  intestine, or the  perinaeum.  These kinds of
lacerations  seem to be  possible, also, by  the action  even of the 
VARIOUS KINDS OF DRESSINGS.
227
liquid itself,  forcibly driven into the  syringe which has  been thus
obstructed or imprisoned, (enchevetree.)   We must not, therefore,
suppose that a  danger of this kind is  merely hypothetical; there
have already happened eight instances within my own knowledge,
four of which occurred in the hospitals of Paris, and four in the
city.   The patients in these  cases  experience,  suddenly, a vio-
lent pain, sometimes immediately followed  by syncope, and soon
after by nervous symptoms more or less alarming ; there afterwards
take place vomitings, and all the symptoms of a violent peritonitis,
or extensive inflammation of the  pelvic cellular tissue.  If,  under
these  last mentioned  circumstances, the patients survive, a gan-
grenous suppuration soon takes place about the  rectum, showing
itself near the margin of the anus or perinaeum, and rendering it
necessary to make numerous incisions that again place in jeopardy
the life of the patient.   It is in this way that six of the cases I have
just enumerated perished, among whom was a young lady who had
herself administered the  enema with a clyster pipe.  Of  the two
cases that survived, one has an enormous cavity in the interior  of
the pelvis, which  has  never yet entirely ceased to suppurate; the
latter, a lady, aged about  forty years, and mother of a distinguished
in-door  pupil of  the  hospitals of Paris, did  not  recover until
after having undergone very serious difficulties, and submitted to
nearly a year's course of  treatment.  [Dr. Mott has seen one case
only, in all his  practice,  and that was  in  New York.  The entire
mucous coat of the rectum sloughed off.—T.~\

                   Article XVII.—Douches.
  The douche is a kind of injection which sometimes has  also the
character of an enema: we mean by this word the projection of a
liquid, or gas, upon the body of an individual at a certain distance
from the reservoir.  There are ascending and descending douches.
We give the name of descending douches to those which are  made
from an elevated place, and that of ascending to those that are  made
from below upwards, upon the anus, for example, M'ith the  view of
overcoming certain obstinate constipations, or into the vagina, to act
upon the neck of  the womb.  In the douche, the liquid sometimes
falls in drops, sometimes  in a minute stream, (par filet) at  other
times in a jet, or like a shower of rain, or in  rays  as through a
watering-pot.  In short, these different kinds of douches are made
from a point more or less  elevated or  with  a greater or less degree
of propulsion.   To make  the descending  douches ascending, we
have only to prolong the tube or  canal, which is connected with
the reservoir, and  curve it from below upward in a  bathing tub,
or some other vessel, at some distance  under the perinaeum ; the
cock being open,  then allows the water to yield to  the pressure
which acts upon it, and to be thrown upon the diseased part.
  The vapor douches, chiefly employed in diseases of the skin, are
either dry or wet.   The dry douches are made wdth heated atmo-
spheric  air, but  they are but little used.  The wet douches, which
are made with the vapor  of pure water, sulphurous, aromatic, and 
228
NEW  ELEMENTS OF OPERATIVE SURGERY.
other vapors, are  applied by means of a long pipe, which may be
made to act in any direction upon different parts of the body.   So,
also, is it easy to direct vapor  douches upon the eye, ear, nose,
mouth, or any other region of the body.   We may have  an exact
idea of the manner of applying the douche, by recalling to mind
M'hat firemen do  in extinguishing fires, or gardeners  in sprinkling
public places or gardens.
  Douches resemble, it is true, to a certain  extent, irrigations and
injections ; but they differ from them in  this, that their  object is
to excite  the parts by the repeated shocks of the liquid, so that the
liquids should be  propelled from a  greater height, or with greater
force, as they are  intended to produce  a shock rather than a change
of temperature, or mere washing of the parts; while the effect of
irrigations is to moisten or cool the parts.

                    Article XVIII.—Baths.
  By baths, we generally understand  the substances into the midst
of M'hich we plunge  the whole  body, or  some part of it, so as to
act upon its surface or temperature.  We have thus hot, cool, and
cold baths; baths of water, vapor, sand, or ashes.   A bath is called
general, when we plunge the whole body into it up to the neck.
The duration of  these  baths  continues from half an hour to an
hour, or an hour and a half.
  In foot-baths, the limbs ought to be plunged into the liquid to a
level at least with the ankles or the calves.   Such are called pedi-
luvia, and consist sometimes of  hot water only, which is occasion-
ally made stimulating by adding  thereto a handful of mustard flour,
or salt, with a glass of vinegar,  and they are to be continued from
ten to twenty minutes.  [A far more effective bath of this kind, and
of infinite value in practice as a  powerful counter-irritant, is the
addition to the pediluvium of half a pound  or a pound of cayenne
pepper.—T.]
  The  hand-baths, (manuluves) are prepared precisely in the same
way.
  The  ordinary temperature of a  bath is from 26 to 29 degrees
of Reaumur, (i. e., 90° to 98° Fahrenheit;) some persons bear it
very well to 30 degrees, (100° F.,) and even to 31 degrees, (102°
F.,) while others find it sufficiently hot at 26 degrees, (90° F.)  In
general, a bath becomes exciting, and even rubefacient, (rubefiant,)
beyond 30 degrees, (100° F.,) as it  has the character of a cool bath
from 18 to 25 (72 to  88° F.) degrees,  and a cold bath under 15 de-
grees, (66° F.)
  Liquid, like vapor baths, are distinguished into simple and medi-
cated.   The first  consist of pure water, the others of water con-
taining gelatine, if  we wish to render  them nutritive,  or some
aromatic  ingredient, or sulphur, mercury, the alkalies, &c.  It is
important in giving  a bath, that the patient should  not be in too
small an apartment, that he should not have eaten for the last two
hours,  and that, from the beginning to the end, he be not exposed
to the  slightest current of air.   It is also necessary, if the chamber 
VARIOUS KINDS OF DRESSINGS^               229
be small, that the air penetrate freely into it;  without that, the
rarefaction of the atmosphere  by the aqueous vapor would soon
fatigue the respiration, and might occasion syncope.  It is well to
be enabled to have it in our power, from time to time, to introduce
into the bathing tub, while the  patient is in it, hot or cold water,
that the liquid may be kept at the same temperature from the com-
mencement to the end of the bath.
  Dry baths, such as those that  may be made with sand, ashes, and
bran,  and which were formerly  used in the treatment of dropsies,
and to restore the circulation to parts threatened with gangrene,
are scarcely any longer employed  at  present.   The  only trace of
them  which remains among us, is the satchels, (sachets) or sort of
cushions, analogous to fracture cushions, which, after being  filled
with hot bran, ashes, or sand, some practitioners still place around
limbs in which the principal arteries have been tied.   Though it
may have been right to reject baths of dung and other substances,
whose use has become repugnant because of their filth, it is not so,
perhaps, to have laid  aside dry baths in dropsy, and infiltrations
which do not depend upon the manifest lesion of any viscus.
  In fact, we procure by these dry baths, still better than by insola-
lation, an absorption of the serous fluids, (des liquides blancs) and a
desiccation of parts that are engorged, which we can obtain by no
other  medication, internal or external.

        Article XIX.—Precautions required  in Dressing.

  When we are about to apply  a dressing to any wound whatever,
it is useful to  ask ourselves what are the rules that ought to be fol-
lowed to make it as advantageous as possible.  To say that the sur-
geon ought to place himself in a convenient position, that the part
should be properly cleansed, that the pieces of the dressing should
be laid on gently, applied with  delicacy,  and in a manner to sooth
rather than to fatigue the patient, and that the wound should be
placed in a suitable situation after  the dressing, is to teach nothing
to the pupil, for these  are the suggestions of natural good  sense,
that have no need of being particularized.  But the surgeon ought
to know to what point he should protect M'ounds from the action of
air, cold, or heat;  to what extent they may be cleansed of the blood
or other matters that may cover them ; how  we are to proceed
with the first  dressing, and with those that follow; the advantages
or inconveniences of frequent or procrastinated dressings, of  those
that may be removed,  or of those that are to be immoveable.

                      § I.—Action of Air.

  Many surgeons  in former times were under the persuasion that
wounds should be exposed as  little as possible  to the action of
the external air;  they therefore recommended the patient to be
surrounded with bed-curtains ; to have prepared beforehand all the
pieces and articles  which there might be  any occasion for; and
when  the wound  presented a large surface, to  cover successively 
230
NEW  ELEMENTS OF OPERATIVE SURGERY.
  the different parts  of it with the new dressing, in proportion as
  the old one M'as removed; some went so far as to recommend
  holding different kinds of chafing-dishes, or other means of propa-
  gating heat, around the patient, to protect him from the possi-
  bility of becoming in any way chilled, and to remove all appre-
  hension of change  of temperature during the whole course of the
  dressing.  The action of the air appeared to them dangerous, both
  because of the irritating properties which they imputed to this fluid,
  and of the emanations of which it might be the vehicle.  It is not
  without surprise that I  have seen these ancient errors revived in
  our own days, and sanctioned by the name of Dupuytren.  Atmo-
  spheric air is so far from being injurious by its momentary contact
  with traumatic surfaces, that many surgeons still ask the question,
  if wounds do not heal  much better in the  open air than by the
  most  methodically  adjusted dressings.   It is at least certain that
  animals get well  very rapidly of their wounds, though they remain
  from  the  beginning to  the end in contact with the  atmosphere.
  The  precautions, then,  that are  recommended on this head, are
  utterly useless.  To uncover any wound or ulcer, to cleanse any
  injury whatever, to free it of the portions of the-dressing that en-
  veloped it, cannot, in the whole, require more than a quarter or half
  an hour.  But the atmosphere is incapable, in this space of time, of
  producing, in its character of gas, the least serious accident.  Con-
  sequently, in these matters we should confine ourselves to avoiding
  currents of  air, and sudden reductions  of temperature, (les refroi-
  dissemens  brusques) and throw a piece of linen over the uncovered
.  wound, if from any cause whatever we should be prevented from
  immediately finishing the dressing.
     The despatch recommended by authors could be  of no utility,
  except there should be prevailing in the wards or apartments where
  the patient was, some contagious or miasmatic disease, susceptible
  of being communicated through the suppurating surfaces.  It is,
  however,  not the less true, that, to perform a dressing well, a sur-
  geon  should take care to have  prepared and arranged beforehand,
  in proper order, all the articles which he supposes he shall have
  occasion to  make use of.

         § II.—Treatment of the Wound at the First Dressing.

     The first  dressing of wounds presents different varieties, accord-
  ing as it  is to unite by first intention, or that we dress to obtain
  secondary cicatrization.
     Union by  the First Intention.  In the first case it is  indispensable
  that the blood should be effectually arrested, and all the clots care-
  fully removed ; that no  blood whatever any longer exudes from the
  surface of the wound.   To arrive even with more certainty at this
  result, Parish in America, and also a great number of surgeons in
  England and Germany, and Dupuytren in France, have established
  a precept not to dress recent wounds, but after the lapse of some
  hours; but this method,  which is advantageous in certain instances, 
VARIOUS KINDS OF DRESSINGS.
231
is fraught with so many inconveniences in others, that it cannot be
adopted without much qualification.
  As we are obliged to use adhesive plasters to obtain immediate
union, it is necessary, after having removed the blood by means of
M'ashing, to sponge and carefully wipe the edges of the wound, and
the M'hole cutaneous surface in the neighborhood, with a napkin or
some dry pieces of linen.  We then attend to the ligatures, which,
after one of their threads is cut near the knot, must be brought for-
ward and collected near the lower angle of the wound, or placed
separately in a right line upon the point nearest to the knot.  After
having turned  them back, we fasten them  upon the skin by means
of  a piece of adhesive plaster  placed crosswise.  This is much
better than enclosing them in a small piece of linen by themselves,
or by a ligature compress, or fastening them permanently under
the turns  of a containing bandage.   In this kind of dressing we
proceed thus:  first, the  adhesive straps ; secondly, the perforated
linen ;  afterwards, the lint; then  the  compresses ;  and finally, the
bandage.  [Dr. Mott approves very highly of leaving many M'ounds
exposed for some time, even for the space of an hour or mote, espe-
cially where there is an  oozing of blood, or apprehension of much
hemorrhage.   It is  therefore  better,  also,  in  such  cases, to leave
such wounds undressed  for many hours, and when we do dress
them, to dress  them  loose and M'ith lint, and allow them to sup-
purate, and  not hope for first intention.  Much is thus saved,  by
avoiding consecutive hemorrhage, removal of dressings, &c.—T.]
  Union by the Second Intention.  When we are not to unite imme-
diately, there is no need  of cleansing and of completely washing
out the wound, or of so  carefully drying the skin in the neighbor-
hood.  In the  place  of retaining also  one  of the halves  of each
ligature, we may cut both at  the distance of some lines from the
knot.  This being done, we apply upon the whole wounded surface
small balls of lint, naked if we Mash, to guard against any bloody
exudation, but  upon  a plain  or  perforated piece of linen  spread
with cerate, if the  case  is one of an opposite  nature.  When the
wound  is not very deep, we substitute  for the balls of lint one or
more plumasseaux.   In any case, it must be remembered that the
balls themselves are to  be covered with  plumasseaux. and that,
setting out from this point, the dressing does not differ from the
preceding.  The application of the adhesive plasters and the band-
ages at the first dressing, should  be made in such manner  as not
to interfere with the tumefaction,  which must inevitably take place
in the course of the first  two or three days.

             § III.—Removal of  the First Dressing.

  The removal of the first  dressing, generally creates much  appre-
hension in the  patient.  The  fears of patients on this head, are
explained by recalling to mind, that even up to the commencement
of the present  century,  almost all wounds, stuffed with lint or
sponge and dressed naked, were uncovered on the day after the first 
232           NEW ELEMENTS OF OPERATIVE SURGERY.

dressing, or upon the day following.  Then, in truth, the first dress-
ing was 'rendered excessively painful.   Now, it is not perceptibly
more  painful than the  others.  Not taking  place until after the
lapse  of three or four days, it has been anticipated by the suppura-
tion, and by the  saturation of the. under portions  of  the dressing.
The perforated  linen, which  rests bare  upon the wound, being
spread with cerate, is raised and separated without  the necessity
of the least degree of painful traction;  if there are balls of lint and
sponge, we do not detach them until they have been insulated by
the pus.  This method, already extolled by Magati, is, at the present
time,  that of all good practitioners.  It has, nevertheless, been the
object of some recent attacks, and rejected as injurious by a sur-
geon of the hospitals of Paris, who, returning to the routine of the
ancients  and that of nurses,  recommends that after great opera-
tions  the dressing should be renewed  upon  the second  day.  He
has, without  doubt, inadvertently imagined, that  by this course he
could guard against the purulent discharges, (les fusees purulentes,)
erysipelas, and other  inflammations, whereas it Mould be the best
means of favoring them, for it is only  after the third  or fourth day
generally, that such accidents show themselves.
  This period of three or four days, however, necessarily has many
exceptions.  For example, if the part  Mas in too great pain, and
if the  wound seemed  to cause  too violent a reaction, we should
uncover it in the first twenty-four hours, or at least before the end
of the third  day, taking care,  however, unless  there should be
some  special indications to  the  contrary, to remove only the por-
tions of* the dressing that were either too hard or improperly placed,
and to leave untouched the deepest seated portions. In other cases,
in cold seasons, for example, or in treating regions or tissues where
suppuration goes on  tardily,  and where we wish to obtain a free
and immediate union, (une reunion franchement immediate) we may
wait even to five or six days.   At the  end of this time, we must,
in general, saturate all the dressing  with tepid  water ; but the
bandages, compresses, and sometimes even the lint itself, are then
sometimes so strongly glued together, or indurated  by the blood,
that the water softens them with difficulty.  In this case, Mre must
soak them at least for half an hour beforehand, or detach them piece
by piece, until M'e reach the edges of the perforated linen.  This
being clothed with cerate, alloM's of being separated and removed
with all the pieces it supports, without drawing any upon the wound.

                   § IV.—Hours for Dressing.

  The hour selected for dressing is generally in the morning; this
arises from a practice dictated by the  occupations  of every one,
and from the time that has elapsed since the period at which we
were enabled to make the last dressing to the wound.   When there
is but one dressing in the twenty-four hours, this  practice has the
advantage of giving more tranquillity to the patient for the remain-
der of the day;  but it has the inconvenience of leaving him less at 
VARIOUS KINDS OF DRESSINGS.
233
his ease for the night.   Moreover, we see patients who desire to be
dressed both night and morning.   I would not  say, here, that the
dressing of the morning should be made  after sunrise, and that
of the evening after sunset; for there would result from this, that
in the month of December, for example, the two dressings would
take place at the interval of five or six hours,  while in July they
might be  separated by twelve or fifteen hours.  The best course
in this matter is, to dress the patients towards eight or nine o'clock
in the morning, and from seven to eight in the evening.
  These frequent dressings belong to almost all those of the second-
ary character; they are useful when we are treating wounds that
suppurate abundantly, or are employing certain topical applica-
tions—cataplasms, ointments, and  liniments, for example.  In other
cases they are calculated only to  irritate the wound, and to retard
the process of cicatrization.
  [No healthy wound, Dr. Mott thinks, should be-dressed over once
in twenty-four  hours.   They should be let  to  suppurate freely.
They do much better in their own pus, and they are injured by too
frequent dressing.  A compound fracture is a good illustration of
this sound practical precept.—T.]

      § V.—Dressings at Long Intervals, (Pansements rares.)

  Formerly, many surgeons dressed all wounds once, twice, three,
or four times a day.  Now, we call those frequent and ordinary
dressings, which are repeated at least  once in twenty-four hours,
and delayed dressings, [i. e., at long intervals,]  those which do not
take place every day.  These last  are  divided into two orders.
They merit, in  fact, the name of immoveable when they are only
renewed every  two, three, four, or five days, in  such manner as to
make it necessary to change them a certain number of times during
the course of the cure.
  Permanent dressings should be understood of  those which, when
once applied, remain in place until the wound is cured.  This kind
of dressing, which the Egyptians, Greeks, Arabs, and Spaniards ap-
pear to have often employed, and M'hich M. Blaquiere  revived in
1815, has been  definitively adopted by the elder Larrey.  In fact,
Marechal, on his part, has made a fortunate application  of it at
the Necker hospital, in the treatment of wounds, and the observa-
tions published by M. Sazie, are of a nature to awaken attention
upon this point.  I have already described in what manner we may
best carry out this dressing for fractures.  As to wounds, we proceed
in the same manner as for a simple dressing, but with the precau-
tion not to touch the bandage, if no accident supervenes, until at
the end of ten or twenty days, the epoch at which the union  of the
parts ought to  have been  effected.  M. Larrey, who renders the
dressing perfectly immoveable in  this case, as in the treatment of
fractures, applies it as well to wounds that are  to suppurate, as to
those which he wishes to  unite by the first  intention.   Protecting
the parts from contact with the air, applying to them a  uniform 
234
NEW ELEMENTS OF OPERATIVE SURGERY.
 pressure, and enabling them to escape all traction or inflection, (tout
 tiraillement,  toute inflexion) the bandage, imbued  with the M'hite
 of egg, or  starch, or with dextrine, gives the pus an  opportunity
 of spreading and concreting at a distance from the wound, without
 preventing, says M. Larrey,  the regular progress of  the  cicatri-
 zation.
  For my own part, I do not think, in the instance of wounds, that
 the immoveable or  permanent dressings have all the  advantages
 that M. Larrey attributes to them.  It has always appeared to me
 right to renew, from time to time, the  dressings of wounds in a
 state of suppuration ; nor can I think we can question the advan-
 tage of renewing the dressings in ordinary wounds, provided there
 be  no reason to suppose that there will be a  complete  aggluti-
 nation.
  The immoveable dressing, then, is not in fact preferable to ordi-
 nary dressings',  but for wounds complicated with fracture, or those
 in which it  is  important to prevent the  slightest movement, or
 where we  have reason to  hope  for an absolute  and immediate
 union.
  [Leaving the Dressings on.  We would receive this last remark
 of the author with  some qualifications, especially as  to immediate
 union.  In all those  fractures of the body near the great centres of
 circulation and sensation, Dr. Mott has always impressed upon his
 pupils the importance, wherever it can  safely be done, of leaving
 on the first dressings, for wounds complicated  with fracture or not, for
 many days, or even for  weeks, or as long a time, in fact,  as possible.
 More especially has he  insisted, and does still insist upon this prac-
 tice as a surgical axiom, in all fractures of the cranium, however
 vast or complicated, as  success of the most marked kind has ever
 resulted  to him from this course, even where  several inches in
 extent of scull and considerable portions of brain  have come away,
 directly from the injury, or  in the course of trephining.  Even in
 cases, also, where a  portion  of the longitudinal sinus has been torn
 away or lacerated, he adopts the  same course, as  in these rather
 rare instances no  other addition  is made to the dressing than the
 insertion of a single pledget of lint into the wounded sinus, which
 arrests  the hemorrhage definitively, especially in  the  application
 of the adhesive straps, with a moderate pressure, over the com-
 presses, upon the incisions.  A recent remarkable case of this kind
 occurred here to Dr. Mott, in which the  sinus was wounded in the
 vicinity of  the  occiput, and two circular  perforations  had to be
 made with the trephine in the direction of the sagittal suture, the
under table of the parietal bone being splintered  off so  as to press
 upon the dura mater.  The dressings were left on, full a fortnight,
 and consisted only of the pledget above mentioned, light  compresses
 over the approximated  edges of the wound, and a few  adhesive
plasters crosswise on the scalp, the whole making only  a moderate
pressure.   The plan of Dr.  M. is, to leave the  dressings on until
they are self-separated by the lubricating effect  of the subjacent
bland pus that  constantly besmears and protects, and rapidly pro- 
               BLEEDING, OR SANGUINEOUS  EMISSIONS.            235

motes the already far-advanced or nearly-completed granulations.
At this time, the under portions of the dressing are so imbued with
the partially decomposing exudations that have  soaked into them,
that they become offensive, and  must be  removed.  The danger
of removing the dressings to the brain at an earlier period, is, that
of exciting inflammation in this  organ ; and when the brain has
become once  accommodated to the pressure of the dressing, it is
better to defer the second dressing till the critical period is passed
over, which is generally within a fortnight.   Serious consequences
have arisen from interfering with the dressings  at an  earlier pe-
riod.— 7'.]
TITLE  II.
           ELEMENTARY  OPERATIONS.


  I shall include, under the name of Elementary Operations, all
those which enter into the province of minor  surgery, (la petite
chirurgie.)   I shall consequently explain, in this place, what relates
to the different modes of bleeding, cauterization, drains, (exutoires)
rubefacients, (rubefactions) vaccination, &c.
                         CHAPTER I.

            BLEEDING, OR SANGUINEOUS EMISSIONS.

  Bleeding is understood of every operation, which consists in ab-
stracting blood from  the  human body, wdth the view of relieving
or curing it.  This operation is divided into many kinds, according
as it is practised on venous trunks, arteries, or the capillary system.
It takes the name of bleeding, properly so called, when the extrac-
tion of the blood is made from one vessel only.  In this case, also, we
give it the name of general bleeding.  If we perform it by means
of leeches,  scarifications, or the opening of several  small veins,
it receives more especially the name  of local  bleeding.  General
bleeding is known under the title  of phlebotomy, or simply blood-
letting, when it  is performed on the veins; if an artery is opened,
it is designated by the name of arteriotomy. 
236
NEW ELEMENTS OF OPERATIVE SURGERY.
    Article  I.—Phlebotomy, or  Bleeding properly so called.

  The employment of blood-letting goes back to a period so remote
in the history of nations, that we know nothing precise of its origin.
The negroes of Guinea, the Hindoos, the Chinese, the Scythians, the
inhabitants of the Oceanic isles, (de I'Oceanie) made use of it before
medicine was reduced to the form of a science; every thing proves,
then, that the  history of the hippopotamus, spoken of by Polydore
Virgil, should be considered as a  simple fable.  We may, also, con-
ceive  how the loss  of blood caused by wounds, might have given
man,  at the origin of the world, the idea of taking blood from him
artificially on the occasion of certain maladies.  However that may
be,  phlebotomy is an operation which  may be performed, and M'hich
the Greek and Roman physicians performed, in fact, on most of the
superficial veins of the body.   To believe Oribasus, Antylus had
already laid down rules for bleeding  in the forehead, angle of  the
eyes,  mastoid region, tongue, hand, bend of the  arm, ankles, and
ham.  We may add, that at the present time, bleeding in the dorsal
veins  of the  penis, those of the  scrotum, neck, limbs, and certain
tumors, also deserves particular notice.
(Fig. 144.1
         § I.—Bleeding at the Arm.

   Physicians  who had imagined that blood-letting
might be simply evacuant or depletive when applied in-
differently to this or that vein, derivative, on the contra-
ry, when performed between the diseased organ and
the heart, and revulsive when as far as possible  from
the region to be  relieved, ascribed a great import-
ance  to the veins upon which the operation should be
.practised ; at that  time their choice lay between
bleeding at the arm, neck,  or  foot.   Now, however,
since  those  distinctions  of the  schools  have lost
all their value, blood-letting by the arm is almost
the only kind employed.  Even on the supposition
that we have gone  too far in this  matter, and that
phlebotomy in other regions  has relapsed into un-
merited oblivion, it is  nevertheless always true, that
the theoretic reasons M'hich governed the practice of
the ancient physicians are evidently too futile to re-
quire to be discussed at the present day.

     A. Veins at the  Fold of the Arm—(Fig. 144.)

   In the arm  we perform bleeding upon all the veins
of a certain  size which become prominent  under
the skin.   Thus, the cephalic vein of the thumb, the
salvatella  or  dorsal veins of the  hand, the different
veins upon the body of the forearm, and the cephalic 
BLEEDING, OR SANGUINEOUS EMISSIONS.
237
vein in the deltoid groove, when it appears too difficult to reach
it in the bend of the arm, may be had recourse to.  In this last
region, the veins are so distributed as most usually to present five in
number.
  I. Outside and upon the outer prominence of muscles is found
the cephalic, which receives, in passing from the anterior surface of
the supinator longus, on the side of the biceps, the median cephalic
and the  anterior radial.  This vein, accompanied  (longee) by the
external cutaneous or musculo-cutaneous nerve, from which it is
separated in  the  arm by  the aponeurosis to near the external
condyle, (epicondyle) is situated between the superfical fascia and
the aponeurosis properly so called ; lower down it is also accompa-
nied (cbtoyee) or surrounded by nerves that vary exceedingly as to
their number.  If it is true, as is asserted, that a surgeon of our epoch
says he has never seen nerves in the neighborhood of the cephalic
vein, it  is because he could not have dissected  it but upon one or
two subjects,  in whom, by some  anomaly doubtless,   they  were
wanting.
  II. The basilic, situated on the inner muscular prominence, passes
over the inner condyle (epitrochlee) to gain the groove of the biceps.
The cutaneous nerve enclosed in the same sheath is almost always
situated upon its inner side above the bulge of the muscle.
  III. The median is seen at the  lowerjaart of the region, or near
the apex of the triangular space which separates the two muscular
masses  at the bend of the  arm.   This vein, which comes from the
anterior or palmar region of the fore-arm, and which is  either
inclined to the external or internal side, soon divides into  three
branches, one of which enters deep between the muscles through
the aponeurotic aperture,  to become united M'ith the deep-seated
veins, and the two others, which separate in the manner of the two
branches of a Y, to join the basilic and  cephalic.
   IV. Median-Cephalic.  The external  or cephalic branch  of the
median vein follows the outer inter-muscular groove, is surrounded
with  nervous filaments, and at one or tM'o  inches above its origin
opens into the cephalic vein, properly so called.
   V.  The internal branch or median-basilic crosses very obliquely
the brachial artery, from which it is only separated by the aponeu-
rosis, then crosses  the tendon of  the biceps, reaching the basilic a
little  above the articulation.  In short,  this vein approaches much
nearer to the artery while  in the hollow of the  fore-arm than a lit-
tle above, because of the fibrous bandelette of the biceps, which has
the effect  to separate the  vein from the artery in this  last-named
 place much more than in the former.
   All these veins, though subject to numerous anomalies, sufficient-
 ly resemble in their general grouping the form of a capital M.
   Situated between the sub-cutaneous  superficial fascia and the
 sub-cutaneous deep fascia, they are more or less easy to be dis-
 tinguished, according as the embonpoint of the arm is more or less
 considerable.  This arrangement is the cause, on the other hand,
 why the relative position of the artery or nerves with the veins is 
238           NEW ELEMENTS OF  OPERATIVE SURGERY.

not sensibly changed by the infiltrations or obesity of which the
bend of the  arm may be the seat.
  It results from these anatomical considerations, that bleeding upon
the fore-arm is more easy in the median basilic vein, but at the
same  time  more hazardous, than in the  median  cephalic;  that,
strictly speaking, phlebotomy may be performed upon all the veins
at the bend of the arm; that, if the veins are more projecting and
more distinct in thin than  in fat  person-, they have also the incon-
venience of rolling more easily under the skin, and of being less
fixed ;  that, if in fat persons the vein is therefore difficult to be dis-
tinguished, the  compensation for this is, that it is more steady and
somewhat more separated  from the parts to be avoided; that they
are all  surrounded with nervous filaments, and that, therefore, it
would be  absurd, in this respect, to prefer one to another.

                       B. Preparations.

  To perform bleeding at the arm, we must  procure lancets ; pre-
pare a light, tepid water, cold water, vinegar, or some other volatile
liquid; two bands, (bandes) one about a yard in length, called the
bleeding ligature, the other  nearly three yards long, designed as a
bandage on the limb after  the operation ; a small square compress,
folded  six or eight  times ;#some  compresses or pieces of linen to
wipe with ;  a sheet folded, or a napkin, to protect the clothes of the
patient; finally, a vessel to receive the blood, forceps, scissors, and
a probe in case of need.
  I. Lancets. Without being  able to say at M'hat epoch the lancet
was invented, or who was  its inventor, we at least know that, up
to the time of the daMn of civilization, phlebotomy was performed
with other instruments.  The lancet  of the present day is composed
of a blade and its handle, (chasse)   The frame or handle is made
of two slips  of shell, pearl, or horn, fixed upon the heel of the blade,
which they  embrace by a rivet that  goes through all the three pie-
ces.  These two pieces  of  the handle, M'hich may be made to turn
and move upon one another, and upon either one of which we may
also turn  or arrest the blade, afford every  facility for opening and
cleansing  the instrument.
  The  lancet, properly  so  called, terminates in a point which has
given to it the different  names by which it is known.  If this point
is wide, and, as it were, blunted by  the rapid approximation of its
two edges,  it constitutes the barley-eared  lancet, (lancette a grain
oVorge—Fig. 145.)  When  a little  more  pointed, it makes  the oat-
eared lancet, (lancette a grain d'avoine—Fig. 146.)  When still more
pointed, it becomes the pyramidal or serpent-tongued lancet, (lancette
pyramidale ou a langue de serpent—Fig. 147.)   In fine, if the heel of
the lancet goes back considerably behind the edge of the handle
when opened at a right  angle, it takes the  title of the Spanish lan-
cet.  The  abscess lancet, which was  formerly used, and which some
persons still employ for arteriotomy, did not differ from ordinary
lancets but  by its dimensions, which are  nearly twice their size. A 
               BLEEDING, OR SANGUINEOUS EMISSIONS.            239

case called the lancet-case, (lancetier—Fig.  148,) contains the four
or six lancets we have most frequent occasion for.

 (Fig. 145.)          (Fig. 146.)           (Fig. 147.)              (Fig. 148.)
   II. Hour for bleeding. When we perform phlebotomy for an acute
affection, we bleed indifferently at almost any hour of the day.  If,
on the contrary, it is for mild diseases, or that the bleedings are
precautionary, in fine, such as are not urgent to be performed at
the moment they have been ordered, the morning is generally pre-
ferred.  Moreover, it is proper that the  patient should not  have
eaten at  least for three hours, and that he does  not eat afterwards
for an hour or two.  There  is for bleeding, as  wfe see, a  time of
election and a time of necessity, which the surgeon  should not con-
found.
  III. Position of the Patient. We may bleed patients standing, (de-
bout) sitting, or lying.  We do not bleed them  standing, however,
except with the view of more rapidly producing syncope, this posi-
tion being at the  same time the  least  convenient  for the surgeon
and the  most fatiguing for the patient.  The sitting posture on a
chair, an  arm-chair,  or stool, is that which is  generally adopted
M'hen the patient is  not obliged to keep his bed.  In this position
there is every facility for the assistants and the surgeon; the pa-
tient has no need even of removing his dress ; but there results from
it  a manifest tendency to syncope, and additional  embarrassment
when any accident obliges us to lay the patient on  his back.  Ev-
ery person, therefore, whom  we wish to bleed, should be  placed,
by preference, in his bed, either seated or in a horizontal position.
  Whatever in other respects may be the position that may have
been chosen, it  is necessary to spread a napkin between the upper
part of the arm and the parts of the clothing or of the bed which
might be  soiled by the blood.   We afterwards roll up  the  sleeves
of the patient to near the arm-pit, so as completely to uncover the
veins which  we have just been speaking of. If the  limb should be
found strangulated by the portion  of dress thus  rolled up, it is ne-
cessary to rip it, or take it off.
  IV. The ligature, called the bleeding  bandage, is a   (Fig. 149.)
strip of red flannel an inch wide, and a yard or a yard    ^dE?5-
and a half long, (Fig. 149.)   Being pliant and  suffi-   ^jfi^"
ciently firm, it answers very well  the end we have in   'HBP
view; but without admitting that  it may in  reality
alarm the patient, that it seriously exposes to the transmission of cer-
tain contagious affections, it is just to say,  that one end of an ordi-
 
240          NEW ELEMENTS OF OPERATIVE  SURGERY.

nary bandage may perfectly well take the place of it, and that it
then becomes entirely superfluous.  Whether, however, we make
use of the  bleeding bandage,  a riband, or the ordinary linen ban-
dage, we must proceed in the same manner in applying it.   We
place the hand of the patient upon the side of the chest of the sur-
geon, who fixes it in this spot with the upper part of his own arm.
This bandage, then applied by its middle part upon the forepart of
the biceps, at an inch or two above the vein we M'ish to open, should
make two turns on the lower part of the  arm, and should be tied
by a single bow-knot, the  loop (ansc) of M'hich should rest above.
This band, the purpose of which is to retain the blood in the super-
ficial veins, ought not, however, to be  so  tightened as to prevent
the arterial circulation and arrest the pulsations at the wrist.  It is
sometimes  placed higher up, sometimes lower down, even to half
an inch from the point where the lancet  is to be inserted, accord-
ing as it appears  to distend the veins better in one region than an-
other.   We fasten it  only by a single bow-knot, the two heads of
M'hich hang down and outside the arm, in order to loosen it  M'ith
more facility, if that should become  necessary in the course of the
operation.  When it  is arranged, we bend the patient's arm, and
then place it for a few moments in front of his chest.

                       C. The Operation.

  The surgeon then arranges his instruments. He chooses the lan-
cet of the shape of the barley ear, if  the vein is superficial or volu-
minous, or  he is  apprehensive  that  he shall not properly hit the
moment of elevating the lancet, (ou s'il craint de  ne pas executer
convenablement le  temps d'elevation de  la saignee)  On the contrary,
he uses the oat-eared shape lancet, M'hen the veins are less appa-
rent or deeper, and when he has been much practised in bleeding.
The serpent-tongued  is scarcely ever now employed,  and M'e no
longer use in France the Spanish lancet.   Opened at a right angle,
or at one that is a little obtuse upon  its handle, the lancet is imme-
diately carried up to and placed betM'een his lips by the extremity
of its handle, so that  its  point is turned towards the arm that we
are about to bleed.  Returning to the patient, the surgeon extends
his fore-arm, examines its vessels, makes some friction from below
upward along the course of the veins, assures himself by the aid of
the finger of the position of the artery, and of the tension of the ban-
delette of the biceps, and endeavors to find  if there exists or does not
exist any vascular anomaly in front  of the elboM\   He then  fixes
the hand of the patient betM'een his chest  and the upper part of his
arm, in the hollow of his axilla, that  he may  embrace the patient's
elbow M'ith his hand on this side, placed downwards in a supine
direction, so as conveniently to stretch the integuments in the bend
of the arm.   He may also, by holding his hand in a state of  half-
pronation, fix the vein with  his thumb while  his fingers are spread
over  upon the  elbow.  It is  with  his   left  hand that  he  thus
supports the right arm, whilst it would be with his right hand that 
BLEEDING, OR SANGUINEOUS EMISSIONS.
241
he would fix the left arm, so that we use our right hand to bleed
the right arm and our left hand to bleed the left arm.  On the sup-
position that the surgeon is not ambidexter for this operation, and
that  he would be obliged to  use his  right hand  for both sides, he
should place himself outside, with his back towards the head of the
patient  when he  is to bleed in the  left  arm.  Then carrying  in-
wardly the right hand that  holds the lancet, to bring it from the
chest towards the bend of the arm, while the left hand extends and
fixes the fore-arm, he would  succeed nearly as well as by the other
method.
  I.  The Operative Process,  (manuel opcraloire.)   The arm being
fixed, and the vein to be opened properly chosen, the surgeon takes
the lancet, which he held in his mouth, and embraces it at its heel
between his thumb and his first two fingers half-flexed. Obtaining,
then, by means of his two other fingers, a point d'appui  on the in-
ner part of the elbow, he then, by forcibly flexing his fingers, draws
back the heel of the lancet toM'ards the palm of his hand ; then,  by
a movement of extension, he  quickly carries its point into the ves-
sel by an angle more or less  acute and a puncturing motion, (Fig.
150.)  The absence of resistance, the appearance of a small drop

                            (Fig. 150.)
of blood, and a sensation impossible to describe, soon prove to him
that the anterior wall of the  vein  is passed.  Then elevating his
wrist, he pushes the anterior edge of the lancet towards the oppo-
site side and withdraws it in an upward curvilinear [or oscillatory]
motion, (mouvement d'elevation et de bascule)'  These two motions,
also, are so quick, and so completely involved in each other when
the bleeding is well performed, that it is difficult to distinguish them
                             31 
242
NEW  ELEMENTS OF OPERATIVE SURGERY.
with the eye.  Perhaps, however, it would be more convenient
to seize the lancet as we would a pen, and plunge it in perpendic-
ularly.
  The puncturing movement, which some persons have  recom-
mended to be made horizontally, with the view of avoiding the ar-
tery more completely, and which others  direct to be made almost
perpendicularly, would render the upward movement, to a certain
extent, useless.  When  we use the  barley-eared lancet, the opening
of the vein corresponds almost inevitably t£ the middle of the incis-
ion in the integuments.  With the oat-eared,  or serpent-tongued
lancet, we should, on the contrary, have  too oblique a wound, if the
upward movement was not united  to that of the puncture.
  The lancet being M'ithdrawn, the blood immediately leaps out.
But if we look to performing the operation with all possible neat-
ness, we immediately  apply the thumb upon  the vein below the
puncture, while with the other hand we  shut the blade upon one of
the pieces of its handle, and pass it  into a vessel filled with cold wa-
ter. Up to this time, the face of the patient should have been turned
to the opposite direction, or covered with a bandage.   The assist-
ant approaches, provided with a vessel to receive the blood, and
presents himself in front of the puncture.   The surgeon now, after
having brought the fore-arm forward, ceases to compress the vein,
and releases, so to speak, the blood, which then jets out  in an arc
to a certain distance. If every thing goes on well, he holds the fore-
arm with his right hand, and the lower part of the upper  arm with
his  left  hand, while the patient holds, presses, or turns in his hand,
either a roll of linen, a box,  or lancet-case.  By this  position,  the
surgeon is enabled to preserve the  parallelism between the Mound
of the vein and the wound of the integuments, by increasing or di-
minishing the pronation of the hand of the patient, and by drawing
the skin to the radial  or ulnar side, according to the indication.
He may also, by untying the knot of the bandage with the  left
hand, increase the compression, if the venous circulation does  not
seem to be sufficiently excited, or diminish it, if the blood encoun-
ters too much obstruction in the course of the artery.
  [Bleeding in the Arm. Dr. Mott is in the practice of drawing the
attention of the operator to the importance of tying the arm some-
what higher up than is generally adopted, so that the bandage shall
press upon the swell of the biceps  and give an opportunity for the
median veins to be fully distended.  By  this means, we procure a
more perfect distension of the branches where the puncture is to be
made.   He also is in the habit of  forcing the point of the lancet
(which should neither be too acute nor broad, but of a medium an-
gle on  a long  curve)  into  the vein by  a firm, slow, graduated
pressure, rather than by a sudden sweeping plunge, or puncture, as
nastily practised by some, who may thus divide the  vein through
and through, if not also an abnormal arterial branch concealed be-
low, and thus cause great if not dangerous mischief by extravasation
into the tissues, a false, circumscribed, or diffused aneurism, &c, re-
quiring often amputation. There is no necessity, whatever, of bur- 
BLEEDmG, OR SANGUINEOUS EMISSIONS.
243
ry, if the lancet is sharp and the vein firmly fixed by the thumb of
the left hand, be the integuments ever so thick or tough.   Also,
this cautious  method is eminently important in fat  persons, where
the vein is deep-seated in the adipose tissues, and where Mre must
often grope our way by the touch or feeling only. Here, too, in such
persons, there is this compensating advantage, that the cutis  is
usually thin and delicate, and easily punctured.'  The left hand of
the surgeon should, by long practice in  early life in the dissecting
room, be made as famifcar,  if possible, with the handling of instru-
ments as the  right, for it is, in  the opinion of Dr. M., the true and
safest, and certainly the most professional mode, to use the left in
bleeding the left arm of the patient.  The hand of the patient should
be held, before and after the operation, edgewise; that is, the thumb
fronting upward and the fingers grasping around the upright spoke,
for example,  of the back of a chair which is firmly fixed.  The
grasping fingers may be kept in motion, squeezing, as it were, the
round piece of wood they embrace. The arm should be held slightly
flexed, because it is easiest for the patient, and therefore least likely
to be changed, and it is also the best position for securing a full flow
of blood.—T]
  II. Quantity of blood to be drawn.   We draw in  this way from
three ounces  to three or four pounds of blood, and it is rare that
we wish to take less or more.   An ordinary bleeding is about ten
ounces.  The surgeon, moreover, is to direct whether there is to be
abstracted a greater or less quantity.
  III. Palettes.  The vessel which is to  receive the blood may be
a plate, saucer, wash-basin, dish, &c.; but to ascertain with more
certainty  the quantity  taken, vessels have been contrived which
bear the  name of palettes or poelettes.  As  these vessels, which
contained three ounces in the time of Dionis, have  generally now
a capacity of four, errors  on that account might  occur in prac-
tice, if we did  not  take the precaution to prescribe bleeding  by
ounces rather than by palettes.
                               There  are found  in hospitals  a
                            kind of porringers, containing'about
                            twenty ounces, which are divided by
                            four or five  circular grooves, (Fig.
                             151,) indicating so many palettes of
                            four ounces, so that without chang-
                            ing  the vessel we may know when
there has been drawn either'one, two, three, four, or five  palettes
of blood.                   * '
  IV. Closing the Vein.  To «lose the vein, the surgeon having
untied the ligature, immediately applies  the thumb upon the punc-
ture, or a little below it; replacing the hand of the patient under
his armpit, as at the commencement of the operation, he causes a
vessel to be brought filled with tepid Water ; then wipes the parts
soiled with the blood,  first with a wet, then with a dry linen.
This being done, he takes the small square compress, and quickly
adjusts it  upon  the  puncture in place  of his thumb.  [Dr. Mott
 
244
NEW ELEMENTS OF OPERATIVE SURGERY.
prefers a small pledget  of lint next the wound, and then the com-
press.  The lint is softer and more delicate, and less irritating, and
is more  likely to remain adherent if the bandage should become
displaced.  A strip of adhesive  plaster is preferable to a band-
age.—71.]  I  have always found  it better, in this  case, to  draw
with the  left thumb the  upper lip of the wound a little  outward,
while compressing also the  vein, at the same time that with  the
right hand we apply the compress from below  upward, to force
upMard the lower lip; relaxing then the %st lip, we see it rede-
scend and place itself in contact with the other  lip; from whence
it happens that they have no longer any tendency to separate, and
that immediate reunion  is almost certain.
  Moreover, it is important that  the pressure exercised by the  left
thumb in  such cases should be above the commencement of  the
branch which connects the median veins with the deep-seated veins
in the bend of the arm. Without that, the blood would continue
to flow, and might alarm the young surgeon.
  The thumb, placed on the  square piece  of linen,  maintains  the
compression,  while with the  right hand the surgeon surrounds  the
region wdth a figure of 8, the crosses of which correspond to  the
puncture, and which is  tied  by a  knot outside, or fastened by pins
above the outer condyle.  The forearm, which has been gradually
placed in a state of flexion during the application of the bandage,
is then brought in front of the patient's chest, or a scarf is arranged
to hold it.  It should be kept thus without moving for twenty-four
hours.   At the end  of this time, the  small wound is generally
united, and it is only for extra precaution that we sometimes leave
on the bandage till the  day after.  We  must not, however, forget
that it is from neglecting to  keep the elbow properly at  rest, that
the wound in many persons becomes  inflamed, and the source of
serious accidents.
  [Some surgeons are in the habit of using special bandages,  ex-
pressly M'oven for tying up the  arm with.  Such  are about  an
inch in width, and are  made elastic by the threads  of caoutchouc
interwoven M'ith them.  They are  always fastened by pins, and
their  elasticity completely adapting itself with a  more uniform
pressure to slight movements at the elbow joint, prevents  the turns
of the bandage from slipping or becoming displaced, and renders
the injunction of rigid immobility, which  is often unpleasant and
annoying to  the  patient, not so  imperative.  Dr. J. K. Rogers, of
this city, prefers these bandages.—T.]
  V.  Cleansing the Lancet.  Standing by the side of his patient, the
surgeon now coolly wipes his lancet, and shuts it up.  This instru-
ment should never be cleaned in hot water, which might rust it or in-
jure its temper.  This is a, duty, also, which should not be confided
to any one.  The  lancet being turned upon one of the blades of the
handle, is first wiped- on one of its sides, always from its heel to its
point, and with fine linen.  It is then turned upon the other blade
of the handle, the latter itself having been  previously wiped, that
we may cleanse the other side, and afterwards dry also the second 
               BLEEDING, OR SANGUINEOUS  EMISSIONS.            245

blade of the handle as Mas done with the first.  We succeed full
              as well, also, by pressing the  lancet,  completely
              opened, on fine linen between the thumb and finger,
              provided we take  care  to suspend the pressure
              whenever the point of the instrument, drawn by the
              other hand, arrives betM'een the fingers.
                After this cleansing, the lancet is  replaced in its
              small case of shell, silver,  gold, or silver gilt, known
              under the name  of the lancet-case,  (lancetier) and
              which,  as in this figure,  (Fig. 152,) may be made
              to end below in a kind of scarificator.   It is  true,
              however, that most surgeons at  present dispense
              with this article, and carry their lancets in the folds
              of their instrument-case.

                   D. Difficulties in Bleeding.

  Simple and easy as bleeding in the bend of the arm in appear-
ance is, it is, nevertheless,  sometimes a  delicate  and very  embar-
rassing operation.   Its difficulties depend upon many causes.
  I. Intractability of the Patient.  Children, and even adults, cannot
remain  tranquil from  the moment we bring the  lancet near their
veins, and suddenly jerk back the arm as soon as they feel them-
selves touched by the instrument.   By long habit and much address
we overcome this difficulty, by keeping the eye and instrument
steadily upon the retraction of the limb,  and thus, to a certain ex-
tent, perform the operation while following the movement.   But a
more certain process,  and which I have often succeeded with, con-
sists in  keeping the elbow firmly fixed upon the knee, previously
elevated by means of a stool, or upon the  chair of the patient, while
we hold also his hand and forearm in the  manner mentioned above.
It is then almost impossible for him to change  the  position of his
arm, and the surgeon is wholly at liberty, if he is well assisted,
to open the vein as he wishes.
  II. The Vein  over the Artery.   At other times bleeding presents
difficulties, because the only vein which  is apparent is that which
corresponds to the artery; for example, the median basilic.  In this
case we sometimes succeed by pronating the  hand of the  patient
in order to force the artery a little deeper within the tendon of the
biceps, and separate  the vein from  it, the vein in that case being
immediately raised up by the aponeurosis. If this movement should
not produce a  sufficient separation to inspire confidence, it would
be necessary, in case the vein was large and superficial, to puncture
it by applying the lancet flatwise and horizontally.   Some persons
have devised for this particular case a very sharp-pointed lancet,
which has but one cutting  edge  like that of a bistoury, and which
is to be inserted very obliquely, taking care to keep its back towards
the side of the artery.  But besides that this requires  a  special
instrument for the purpose, we must  be  convinced, from the least
reflection, that  it would not be free from danger.   The only way,
 
246          NEW ELEMENTS OF OPERATIVE SURGERY.

then, in such cases, is to look for another vein, or to have recourse
to the address of a professed bleeder.
   III. The veins are  sometimes  so deep that they cannot be distin-
guished through the skin but with very  great  difficulty.   When
that is  owing to their absolute diminutiveness, we  must seek for
others.   If,  as is so often seen among the women of Turkey, Asia,
and all Africa, the embonpoint of the patient is the cause of the dif-
ficulty, M'e are generally enabled, provided the ligature is properly
tightened, and we carefully press  the  different  points at the bend
of the arm  M'ith the pulp of the  finger, to distinguish one of the
median  veins—for example, the median cephalic—under the form
of a tense elastic cord, and with a blue line which is visible through
the skin.  As in this case the vein is  completely surrounded M'ith
fat, the  surgeon punctures it without  the fear of  its  gliding from
under the  instrument, and proceeds to plunge  in the lancet to a
certain depth, to procure the quantity of bood desired.
  Sometimes, also, the veins are but slightly visible in consequence
of the emotion the patient experiences, and the enfeebled state  (etat
maladif) he finds himself in.  In this case we have recourse to im-
mersion of the limb in hot M'ater, keeping it there for a greater or less
length of time, M'hich, however, has the disadvantage of reddening
the skin, and masking in some degree the track of the veins.  In
other cases we use gentle and repeated frictions  on the forearm, or
make the patient move his fingers, or we leave  the ligature on for
a quarter or half an hour.  If  all this does not succeed, and the
indication of bleeding is  imperative, we search for another vein.
  IV. The blood dont flow or flows badly. Another  difficulty in bleed-
ing is, that  the vein being opened, there is some obstacle  to the
flow of  the blood.  This  depends sometimes upon the ligature
being either too tight or too loosely  applied.  The cause of the diffi-
culty in such cases sufficiently points out its remedy.   Sometimes,
also, it is the dress which  strangles the limb  in the  manner of a
second ligature above the first.  All that is required in that case
to remove the difficulty, is to loosen or divide (debrider) the portion
of dress in question.   A flake of fat sometimes  protrudes into the
incision  in the integuments; it  is to be thrust back with the head
of a probe, or cut off by  the scissors.
  V. Sometimes, also, the incision  is in reality too small; the sur-
geon ought then, without hesitating, to enlarge it forthwith.  With
the oat-eared lancet, we  sometimes make  an opening in the  vein
larger than  at the skin ;  in this case we must  immediately replace
the point of the instrument into the puncture, and divide the tegu-
ments by finishing the upward movement of the operation of bleed-
ing.  On the supposition, also,  that the vein which is opened  may
be too small, we  must immediately proceed to another bleeding.  It
is possible, also, that there may not be a perfect coaptation (paral-
lelisme) between the opening of the skin and that of the vein; we
then successively draw the opening in the integuments in different
directions, until it meets that  in the vessel.  If this conjunction
should appear impossible, we puncture the vein  in another place. 
               BLEEDING,  OR SANGUINEOUS  EMISSIONS.            247

  VI. If the flow of blood  should be impeded by the debility of the
patient,  we should have recourse to frictions upon the track of the
veins, slight  strokes (secousses) or slaps (chocs) upon the front  part
of the forearm, or  make the patient .flex his fingers.  In certain
cases the blood does not run because the  patient is on the point of
fainting, or  is  seized with some cerebral affection, or other condi-
tion, which  arrests or considerably retards  the venous circulation.
Here Mre have  no other resource than to wait for the restoration
of the functions of the heart.
  VII. Patients who  have  been frequently bled, sometimes have
the principal veins in the  bend of the arm  riddled (criblees)  with
cicatrices.  This condition of the parts not  only often conceals the
vessel, but also is attended  M'ith the  disadvantage of flattening it,
diverting it from its natural course, and even  sometimes  of oblite-
rating it.  It M'ould be idle  to suppose that the same process would
answer in all cases to surmount the  difficulties resulting from this
peculiarity.   If the vein is  really obliterated, which  is  generally
indicated by its abrupt disappearance above the cicatrices, we must
puncture farther doM'n.  When the calibre of the vein is preserved,
there is no difficulty in bleeding above.  We may then also easily
puncture below, or with more advantage upon the cicatrices them-
selves, because, from  their being  less moveable, the vein, when
once recognised by the finger, is for the most part easily divided.
   [ Another  serious  and unforeseen  difficulty  might be found
in the  cicatrix.  Thus, Dr. Mott  mentions  a remarkable case,
wherein a prolonged  and painful  neuralgia  at the  bend of the
arm, from bleeding, in a lady, was not relieved until a small  fila-
ment of nerve, that  had been caught as it were, or wedged into
the firm texture of  the cicatrix M'hile the latter was consolidating,
was actually dissected out of its imprisonment.  Where, therefore,
a cicatrix or many of  them exist, and unconnected with any neu-
ralgic pain in the part, there would, a fortiori, be still greater safety
in making the aperture in that point, so far as concerned the possi-
bility of causing the accident we have named.—T.]

                   E.  Accidents from Bleeding.

  Though trifling in appearance, the operation of bleeding is not
the less  exposed to  numerous accidents, such as, dry  bleeding, (la
saignee  blanche) thrombus and ecchymosis, syncope, inflammation
of the neighboring tissues,  lesion of the lymphatics,  puncture of
the fibrous or nervous  tissues, and phlebitis.
  I. Missing the Vein.   We say that a surgeon has made a saignee
blanche,* [literally, white bleeding,] when the puncture he has made
in the arm is not followed by a flow of blood.  This accident may
arise from our  having wished  to puncture a vessel that  was too
deep or  too rolling,  (trap roulant) or  badly supported,  or from the
  * [We think a saignee seche, or dry bleeding, would be more expressive, if sarcasm is
intended upon the blunder or faux pas.— T.] 
248
NEW  ELEMEN1S  OF  OPERATIVE SURGERY.
 skin itself being flabby, or the bend of the arm  badly lighted, or
 from the patient having made an unexpected movement, or, in fine,
 from some one of the difficulties which I have before enumerated.
 Sometimes, however, the blood does not run, though the vein has
 been opened.  I have already remarked above, that syncope,  a
 vivid emotion, or a  lesion of the brain, were ordinarily the cause
 of this last mentioned accident.  When the saignee blanche is owing
 to the vein not having been touched, we must, provided we can
 distinguish the vessel at the bottom of the  puncture, immediately
 have recourse again to the lancet, and  open  it; in the contrary
 case, and should this prove difficult, it is  better to  puncture the
 same vein, or another vein, upon a different point.
  II.  Thrombus.  If there should occur effusion of blood between
 the teguments and vein to such extent, before the bleeding is  over,
 as to cause a  sluggish tumor to be formed, in  shape of a bump,
 (bosselure) of which the small wound represents the apex,  it is
 called a thrombus.  This accident  is owing to the parallelism be-
 twseen the vein and tegument having been disturbed; in some cases
 it prevents us from taking the quantity of blood we desire.  If the
 surgeon notices it in time, he brings the two punctures together as
 exactly as possible ; if that should not be sufficient, and the blood
 should stop running too soon, we should  have to choose between
 dilating the wound with a lancet, and a new puncture, either on
 the same arm or the other;  but, unless we should be perfectly
 sure of succeeding by the  first course, it  would be more advisable
 to adopt the other.   After the  bleeding, whether it has  been  per-
 fectly effected or not, the thrombus acts  like any other effusion of
 blood in the cellular tissue ; that is, it insensibly disappears by ab-
 sorption,  and  need never cause any uneasiness.  We promote its
resolution by covering it with a graduated compress saturated  with
 a resolving liquid, as, for example, a solution of common salt, lead-
water, or brandy.
  III. Ecchymosis means  a livid  or  bluish spot which appears
around the wound, and  sometimes to some distance  above  and
below it, upon the second or third day after the bleeding.   This
has no other  inconvenience than that of leaving, for the space of
from six to twelve days, the appearance of  a bruise in the bend of
the  arm; it is an accident which does not require any treatment.
  IV. Syncope.  Many patients are seized with faintness, (lipothy-
mie) or fall into a complete syncope, before having lost the quantity
of blood we wish to take from them.  Timidity, or  some idiosyn-
crasy and peculiarity of constitution, are often the cause  of this
 accident.
  Syncope is promoted by a  large opening of the vein, and by the
erect position  of the patient; it occurs, also, from the individual
having eaten but a short time before, or  from his  having been
 seriously put out of humor by some unforeseen circumstances.   As
 soon as it happens, we  must place the thumb on the puncture, lay
 the patient in  a horizontal position, and throw cold water or vine-
 gar and water upon his face; if after some minutes he comes to 
                   #
               BLEEDING, OR SANGUINEOUS  EMISSIONS.            249

himself, and we have not yet taken  a sufficient quantity of blood,
we release the  vein in order to continue the bleeding; in the con-
trary case, we remove the ligature to proceed to the dressing of the
wound, and the employment of the different remedies used in syncope.
  V. Lesion of the Lymphatic Vessels.  Some surgeons pretend that
after bleeding there may take place an  exudation of lymph from
the puncture ; that  in fact the puncture itself may remain fistulous.
This, in my opinion, is, if I am not deceived, an imaginary accident,
to whose account probably has been placed some other kind of
wound; but it is not the less true, that bleeding is sometimes  the
cause of disease in the  lymphatics, and of angioleucitis, character-
ized  by certain red  lines which extend from  the puncture towards
the axilla or the hand,  and by the painfulness  (endolorissement) of
the supra-articular and axillary ganglions, and which takes place at
the expiration of some days, as a consequence of bleeding, as well
as from any other wound.
  VI. Puncture of the Nerves.   The  ancient authors attribute  nu-
merous accidents from bleeding, to wounding the nerves in the bend
of the  arm.   It might in fact be possible, in performing this opera-
tion, to puncture the branches of the musculo-cutaneous, the internal
cutaneous, or possibly even the median nerve; but the inflamma-
tions, the gangrene, and  death even, said to have followed this kind
of lesion, must obviously be ascribed to something else: what  has
been written upon puncture of the nerves, has rather  been predi-
cated upon preconceived opinions than  upon well-recorded facts.
At present it is so rare to see accidents after bleeding which cannot
be explained without calling to our aid the puncture of the nerves,
that  no one scarcely any longer speaks of these kinds  of M'ounds.
Nevertheless, if, after a puncture  of the  lancet at the bend of  the
arm, there should supervene violent pains, convulsions, or tetanic
symptoms, as has been  asserted, and without our being enabled to
refer them to some  particular  inflammation, we should cover  the
limb with compresses  saturated with decoction of marsh-mallows,
or with emollients  sprinkled with tincture  of opium, or wet them
two or three times a day with  some narcotic liniment, at the same
time that we should give  internally calming and anti-spasmodic
drinks : the section  of the nerve M'ould not be allowable until after
the trial of these remedies.
  [Dr. Mott has  met with  a number of cases of neuralgia from
puncture of the nerves in bleeding at the bend of the arm.  In the
case  of his, related a few pages above, the neuralgia not only super-
vened  immediately  after bleeding, but was afterwards increased
by the traction upon a filament of the nerve imprisoned in the inci-
sion when cicatrization took place.—71]
  VII.  Puncture of the Tendons.  Formerly they attributed to punc-
ture  of the tendon  of the biceps, or of the  aponeurosis, almost all
the accidents which occasionally follow bleeding ; but besides that
this puncture is difficult in ordinary cases, we know at  the present
time  that it could not produce the  dangerous consequences that  are
imputed to it.   Who, in fact, does  not perceive that the puncture 
250
NEW ELEMENTS OF OPERATIVE SURGERY.
of a tendon or aponeurosis, or that the puncture, or even section
of some of the nervous filaments in the neighborhood of the veins
of the arm, could not of themselves cause the least degree of danger.
[This remark of the author, as is seen by the grave neuralgic symp-
toms which are mentioned above, as occurring in the practice of
Dr. Mott, from implicating a filament of nerve in the bend of the
arm, and requiring the exsection of the filament, must be taken
with some  allowance.—T.~\  All that M'e may say on this head, in
favor of the opinion of the ancients, is that a punctured nerve, apo-
neurosis, or tendon, may give rise to inflammation in  the lamellated
cellular tissue, which is reflected upon or surrounds them, and thus
become the source of serious inflammation.
  VIII.  Inflammation of the Wound. If the lips of the puncture have
been properly brought together, if the limb has remained unmoved,
and the compression has not been too great, the M'ound from bleed-
ing is almost always united at the  expiration of twenty-four hours.
[We have repeatedly seen it in healthy, robust  subjects, and once
even in a delicately formed female of 80 years,  perfectly  united
in the space of four hours, so as to alloM' the bandage  to be removed
with safety.  In one case recently, it  was  effected in three hours
after taking a pint and a half of  blood.—T.]  On the contrary, the
neglect of these precautions, and the employment of  a soiled lan-
cet, expose  the M'ound to the risk of inflammation and suppuration.
  While the edges of the puncture only are red, swollen, and pain-
ful, there is no danger, and the  application of simple  dressings or
emollient cataplasms, and afterwards,  at  the end of two or three
days, a diachylon plaster, suffice  for the cure.
  If, on the contrary, this condition of things is accompanied with
engorgement of the subjacent tissues and a certain degree of tume-
faction, it may, perh aps, be the commencement of a formidable disease.
  IX. Erysipelas.  Bleeding, like  every other species of wound,
sometimes  causes simple  erysipelas, which is recognised by its or-
dinary appearances upon the skin.  Unfortunately,  the erysipelas
it most frequently  occasions is of the phlegmonous kind.   This
rarely occurs before the expiration of two, three, or four days, and
its usual cause is a simple inflammation of the edges of the wound.
The patient then complains of pain, heat, and swelling in the bend
of the  arm ; the  tumefaction, as in every other phlegmonous ery-
sipelas, occupying chiefly the sub-cutaneous tissue,  and extending
itself to a greater or less distance upon the arm or fore-arm.  The
treatment of this erysipelas should be energetic and prompt. If the
affection is yet in the condition of a small phlegmon, emollient  cat-
aplasms and the expulsion of the pus by pressure might, in the be-
ginning, suffice. At a more advanced period, it M'ould be necessary,
while continuing these means, to recur immediately, if there existed
a purulent collection,  to  methodic compression, associated  with
resolvent  fomentations, or even to the application of a number of
leeches.  The employment of numerous incisions would be prefera-
ble only where there existed purulent collections with a separation
of the teguments.   On the supposition that neither compression nor 
               BLEEDING, OR  SANGUINEOUS EMISSIONS.           251

leeches were desirable, we might make trial of strong mercurial
unctions.                                 t
  X.  Phlebitis. In place of puncture of the nerves or tendons, mod-
ern surgeons have introduced inflammation of the veins.   It is cer
tain that  bleeding  may, and often does, in fact, occasion purulent
inflammation of the internal membrane of  the punctured vein, and
that, therefore, it may produce all the consequences of phlebitis and
purulent infection—a species of poisoning that rarely fails to prove
fatal to the patient; but I had said, in the year 1825, (Anat. des Re-
gions, torn, i., art. Pli du Bras) that there had been attributed  to
phlebitis consequences which do  not belong  to  it; that is  to say,
that persons had  characterized with the name of phlebitis  almost
every case of  phlegmonous erysipelas, or of angioleucitis, produced
in consequence of bleeding.  It is important, then, that the surgeon
should endeavor to  avoid this confusion, and that he should learn
to distinguish the three  diseases which I have just named. He will
not err in  noting that angioleucitis, before becoming very severe, al-
ready occupies a very considerable space ; that phlegmonous erysip-
elas is accompanied with extensive,diffused, and, ordinarily, uniform
tumefaction, making the bend of  the arm its centre, or prolonging
itself, in the direction of the axilla, along the groove of the biceps,
in the form of a long caky induration, (plaque longue) more  or less
painful, accompanied with symptoms only of general inflammation ;
while phlebitis is characterized by a dull pain, the sensation of a hard
and knotty cord, and the existence of red patches, (plaques rouges)
irregularly distributed along the course of the veins, and, finally, at
the end of some days, by tremors and symptoms of putrid fever.
  In short, we must  recollect that, in such cases, as in all others,
phlebitis may be external, that is, occupy only the exterior envelopes
of the vein; internal,  having  for  its seat the  internal coat  of the
vessel;  or complicated,  when formed by the union of the two pre-
ceding varieties.
  It is external phlebitis, more especially, which has been confound-
ed with phlebitis properly so called, though it belongs rather to phleg-
monous erysipelas ; and it is especially internal phlebitis which is
dangerous, because  of the pus which it may infuse into the blood.
  The causes  of phlebitis are sometimes impossible to determine ;
it is true, that a dull-edged or dirty lancet, or a repetition of punc-
tures,' and which tear rather  than cut;  also, that a bad  dressing
and improper movements of the patient in  the  first twenty-four
hours—in  fine, that every thing which is capable of disturbing the
union by first intention  of the lips of a wound, are sufficient to ex-
plain its cause in a  great number of cases; but it is also true, that
bleeding,  performed in' the best  manner possible, and a puncture
with the cleanest and best prepared lancets, do not always exempt
us from this terrific  disease.
  No remedy has yet been found for phlebitis, when it is internal
and has already become extended.  In the  beginning, and while it
is yet circumscribed,  we should have recourse to the same treat-
ment as for phlegmonous erysipelas ; that is, either to the free ap- 
252
NEW  ELEMENTS OF OPERATIVE SURGERY.
plication of leeches and emollient cataplasms, a properly adjusted
compression, strong n»ercurial frictions, or temporary (volant) blis-
ters, sufficiently large to extend beyond the limits of the inflamma-
tion.—(See Introduction, supra.)
  XL Wounds of the Artery.  Another accident, M'hich may happen
in performing venesection, is the puncture of the artery.   This oc-
curs either  from some sudden movement of the  patient, or from
some anomaly in the  vessels, or because the humeral artery is too
closely united to the  vein which  it had been thought advisable to
open, or, in fine, from the  aM'kwardness of the surgeon.   As soon
as the artery is opened, the blood  issues out with force, and in suc-
cessive jets, (per solium)  and immediately assumes, in the basin, a
red color, and a lively and frothy appearance. As, hoM'ever, there are
individuals whose blood, as  they  themselves describe it, is full of
life, (vif) and in whom a simple puncture of a vein is succeeded by
that leaping motion, and a flow of blood of a highly red color, we
must not rely exclusively on the appearances mentioned.
  We may ascertain with  certainty if the artery has been wounded,
by compressing  the vein immediately below the puncture with a
certain degree of force.   If the blood is  arrested by this pressure,
there is nothing to fear, the vein only is opened.  If, however, its
jet thereby becomes stronger, it is an additional reason for believ-
ing that there is a wound  of the artery; it could, however, happen
that a communicating branch between the deep-seated and super-
ficial veins might deceive  us.
  All doubts M'ill be removed by shifting the pressure to  the inside
of the arm and above the elbow.   By this mode, in fact, if the artery
is wounded, the  blood will be stopped, change its  character, and
cease to leap out in  curved jets; while  in the  contrary case, the
stream will pursue its ordinary  course.   Moreover,  as it might
happen, also,  that  an abnormal division  of  the  brachial  artery
might be found at some other points than those of its ordinary track,
it would  be  necessary, before pronouncing definitively, to make
pressure in this manner successively upon the inside and the outside,
and on the middle  part of the front and lower part  of the arm; or
better still to make the first compression in the hollow of the axilla
against (contre)  the inner side of the humerus.  It is for want of
taking all these  precautions that some surgeons, alarmed by some
of the symptoms above described,  have thought they had punctured
an artery, when the vein  only had been opened.  It is in this way
I have seen some practitioners lose their self-possession, and aban-
don their  patient, because they had observed that the blood leaped
out in jets, though they had punctured the basilic vein below the
artery; and others become alarmed in the same way, because, not
reflecting that they had made pressure below the deep-seated me-
dian vein, they attributed  to  a wound of the  artery the  continua-
tion of the flow of venous blood.
   Should, however, this accident  happen,  the surgeon ought so to
conduct himself, if he can, as to maintain his self-possession suf-
ficiently not to  betray his fears to the  patient.  We must say to 
               BLEEDING, OR SANGUINEOUS EMISSIONS.            253

the patient that his blood is  highly vitalized or  inflamed—that
this is a  reason why much should be taken from him ;  in tranquil-
lizing him, we must place him in such a position as to permit the
blood to  run until it has nearly caused syncope, if the  constitution
or health of the individual do not present objections.  To arrest the
blood in  such cases, we  must  make upon the  puncture a circum-
scribed and much stronger pressure than for ordinary venesection ;
we therefore form, by means of small graduated compresses, a sort of
pyramid, whose apex should rest on the wounded region, and which
should be fastened by means of a figure of 8 bandage, and afterwards
by a roller extending from the wrist to the armpit.   Formerly this
compression was  effected by neatly enclosing in a piece of paper or
linen, a solid plate, or a sou,  for example, which was then  slipped
between  the  folds of the graduated compress.  We justify these
precautions in the eyes of the patient, by telling him that if his arm
were less securely bound, the  heat and activity of his blood, and the
vivacity of his constitution, might expose him to the danger of hav-
ing the wound reopened.  We  afterwards frame reasons to induce
him to support this dressing from eight to fifteen days, and even to
have it reapplied if there should be danger of its becoming displaced.
  In case the hemorrhage does not reappear, we may  possibly in
this case  effect a  cure  of the wound in  the vessel.  No  one,
however,  at  the  present  time,  admits  that  this wound can  be
cicatrized without obliteration of the calibre of the artery.  It is
nevertheless true, that in two  cases that  were admitted into the
hospital of  La Charite, in  1836, in consequence of puncture of the
brachial artery at the bend of the arm, the cure was accomplished
without the pulse ever having ceased to beat in  any point of the
whole extent  of the forearm.   I may add, that  similar facts have
been noted by a surgeon of London, M'ho in one  case had an oppor-
tunity of proving,  by dissection upon the  dead body, both the actual
cure of the former wound, and the preservation  of the calibre of
the vessel.  It is nevertheless true, that, after the removal of the
bandage, and even in spite of the bandage, and  in the very first
days, there will be found either a primary false  aneurism, or one
by infiltration, or a circumscribed false aneurism, or a varicose ane-
urism, (un aneurisme variqueux) and that from that  moment there
is no longer any other resource than the ligature of .the artery.  (See
Ligature  of Arteries.)   We must, however, take care that we are
not deceived by false appearances.  I have seen after venesection
an infiltration of blood, M'hich, though so large that it occupied the
entire thickness of the bend of the arm, was cured without any bad
consequences following, by the employment of compression and
resolvents,  (resolutifs,)  though  every one supposed  it a primary
false aneurism.  On the other hand, I have seen the  pulsations of
the artery produce a thrombus  so uniform, soft, and regularly ele-
vated as  to lead  to  the  belief of a circumscribed  aneurism.  In
another case there was a purulent collection, accompanied with a
slight degree  of pain, which deceived the surgeon in the same
manner.  [In extensive practice, especially in the vitiated  consti- 
254
NEW ELEMENTS OF OPERATIVE  SURGERY.
tutions of hospital patients, we must not. as the  author justly re-
marks, be surprised to find, after the utmost care as to the edge and
cleanliness of the lancet, and dexterity in the manipulation of it,
that more or less inflammation—rarely,  hoM'ever, phlebitis or the
forms of erysipelas—will ensue.   The inflammation, ordinarily, is
that of the pure  phlegmonous  character from any incised wound,
but it  is  frequently followed by more  or less suppuration in  the
superficial parts  immediately surrounding the wound, M'hich must
be treated, as  in other cases, by poultices, and afterwards incision
into the purulent  sac.—T.]
  I am of opinion therefore that we should, in  every case, treat
this accident by  resolvents  and methodical  compression,  as if it
were really in our power to effect a radical cure, and that M'e must
not resort to the ligature until after having made trial of the other
means from eight to fifteen days, unless, however, there should
supervene some complication of a serious character.
  Bleeding in the Hand.  The veins M'e have recourse to, under
such circumstances, are those on the dorsum  of the hand or of the
forearm.  The rule is, to puncture  that which is the most promi-
nent ; but as  the  veins which return  from  the index  finger and
thumb to form  the cephalic, and those  which come from the index
and middle fingers, and from the little and ring fingers, to form the
salvatella, give rise to two  trunks of considerable size, it is com-
monly upon the  cephalic of the thumb, or upon the  salvatella,
that we perform venesection in the hand.  In this  case it is better,
but not indispensable, to remove  the ligature from  the arm, and
place it  above the wrist.   In fact, the  puncture  of the  cephalic
vein of the thumb, or of the salvatella, is wholly without danger,
if we take care  not to touch the subjacent tendons.   We should
more frequently have recourse  to  this  mode of venesection if the
veins in question  always presented a sufficient degree  of volume,
were equally apparent in all individuals, and that we  always had
it in our power to abstract from them the quantity of blood desired.
Unfortunately, however, this is not always the case, and it is pre-
cisely in persons in whom the veins at the bend of the arm are but
little prominent, that those in the hand also are smallest.
  Bleeding in the Cephalic at the Shoulder.  It is in consequence of
this difficulty that it has been proposed, at the present day, to make
an  incision of an inch in length on the  forepart of the  shoulder, in
order to reach the cephalic between  the deltoid and pectoralis-
major, at the bottom of the deltoid groove.  But besides the objec-
tion, that in this  case the vein is accompanied by the  descending
branch of the  acromial artery, it is situated so deep that it M'ould
be  more easy, and much less dangerous, to  arrive at it by an inci-
sion of the same,kind in the external groove of the biceps, at the
distance of three or four fingers width above the external condyle.

                   § LT.—Bleeding in the Neck.

  Venesection at the neck, employed in the  sixth century by Alex-
ander Trallianus, and afterwards extolled by Paul of iEgina, and 
BLEEDING, OR SANGUINEOUS EMISSIONS.
255
the Arabs, was so much in vogue in the sixteenth century that
Thomas Bartholinus professes to have had recourse to it a hundred
times with success.  Nevertheless, it is rare that it is resorted to
at present.  Without pretending to decide in this place if it be true
that it may have  more influence  upon diseases of the head than
bleeding by the arm, I will nevertheless give a careful description
of it.

           A. The Veiits that may be opened in the Neck.

  The veins of the neck that are selected for this operation are the
external and  anterior jugulars.
  Situated between the platysma myoides and  the  cervical apo-
neurosis, the  external jugular  descends obliquely from the parotid
region, into the supra-clavicular depression, crossing, in a very ob-
lique direction, the outer side of  the sterno-mastoid muscle ;  many
branches of the cervical plexus surround it in its superior half.
Below, where it is farther removed  from nervous filaments,  it
receives many veins from the shoulder before it terminates in the
sub-clavian or internal jugular vein.
  The anterior jugular vein, which  is often wanting, and  which
only attains to a considerable size in persons in whom the upper
half of the external jugular is but little developed, descends from
under the chin and lower jaw, or from the face, where it is united
with the facial, obliquely downwards  and outM'ards, to terminate
in the internal jugular vein, a  little below the thyroid cartilage.
   The anterior jugular might be  punctured, without difficulty or
danger, instead of the external jugular ;  but as  it does not always
furnish the quantity of blood we wish to extract, and as we almost
always have it in our power to use the external jugular itself, it is
scarcely ever thought of when wishing to draw blood from the neck.

                       B. Preparations.

   When we propose to perform venesection upon the jugular, we
must procure a handkerchief or narrow cravat, two small bands, a
square compress, some cards, or a groove  of metal, and the other
articles of  which I have spoken in treating of bleeding at the arm.
We may also, as in this last, place the patient in a chair, but it is
far better to operate upon him in bed.
   I. Compression.   We  commence by making pressure under the
point to be punctured.   This pressure  may be effected in different
Mrays.  The machines invented for this purpose are entirely useless.
The most simple mode is, to place a  graduated compress of some
thickness upon the lower part of the vessel in the supra-clavicular
depression, and to  cover it by the middle of the cravat, or a narrow
band, whose  extremities are attached by means of a  knot under
the axilla of the opposite  side,  (Fig. 153 a) or  held tight  in this
direction by an assistant.  We obtain the same  result  by causing
pressure to be made upon the vein by the thumb of another person,
or by compressing it ourself below the point we wish to puncture, 
256
NEW  ELEMENTS OF OPERATIVE  SURGERY.
while the skin is made tense above by means of the index and middle
fingers.  M. Magistel, who has published a very good treatise upon
bleeding, sometimes effects this compression by means of a porte-
cachet supplied with  a pelote ; but it is evident that the finger of

                            (Fig. 153.)
the operator, or a  cravat, or the extremity of a band, or a riband,
passed from the supra-clavicular region to the holloM' of the oppo-
site axilla, perfectly  accomplish the object in vieM', while they
interfere as little as possible with the operation itself.  If the vein
should not be sufficiently swollen, we should cause the patient  to
move his jaws as in mastication.

                    C. Puncture of the Vein.

  There are, in fact, many reasons for opening the external jugular
in its lower half, rather than in the neighborhood of the parotid re-
gion.   First, it is generally smaller above than below; again, it is
at that part of it near the os hyoides where it is most  surround-
ed with nerves ; nevertheless, we should not puncture it at the ex- 
BLEEDING, OR SANGUINEOUS EMISSIONS.
257
treme lower part, as it might then be difficult to make pressure
below, and the branches of the cervical plexus here again surround
it  at this point.  We make  choice, moreover, of the right or left
side, as in the arm, according to the convenience of the surgeon or
patient, or according to the  size or prominence it presents  upon
one  side  rather than upon  the other.   [A  convenient point is
where the vein is passing over the sterno-cleido-mastoid muscle,
first, because  the vein  can be  rendered more prominent  in this
point; secondly, because you  can here command the hemorrhage
better.—T]
  The patient, having the head and face a little inclined to the op-
posite side, being properly  supported by  alezes,  and with the
shoulder a little depressed, the surgeon, placed on the side of the
bed, stretches the integuments and the vein with the left hand, takes
the lancet in his right, and punctures the vessel with the same pre-
cautions as in bleeding by the arm,  except that he makes a wound
a third larger.  Some authors recommend  not to cross the  vein
from one  side to the other,  for fear,  say  they, of producing a
thrombus  in the deep-seated cellular tissue, and causing there in-
flammation, purulent collections, abscesses, &c. ; but  these fears
are, it appears to me, without any plausible foundation, and I do
not believe  that there would be any cause for alarm, though we
had found that the point of the  lancet had penetrated  even to the
aponeurosis of the neck.
  The question  also has been discussed, as to the direction that
should be  given to the wound.  If made obliquely, from below up-
wards, and from within outwards, this M'ound M'ould divide, nearly at
a right angle,  some of the fibres of the platysma-myoides ; in which
case the puncture easily remains open, and the blood flows  freely.
Made in an opposite  direction, the cut of the lancet would pass be-
tM'een two  bundles  (faisceaux)  of the same  muscle,  and  would
make a M'ound whose edges would have, as it  is said, a great ten-
dency to become approximated.  Without denying that there  may
be truth in the substance of these remarks, I ought, nevertheless, to
say, that  having sometimes opened the external jugular in one di-
rection, and sometimes in the other, I have  never seen that  there
was any great difference in the result.   However, I would not ad-
vise the preliminary incision and use of the bistoury, as spoken of
by M. Magistel.

                      D. Flow of"'Blood.

  As soon as  the vein is opened, and while the pressure is contin-
ued, the surgeon deposites his  lancet in clean  water, and receives
the blood directly into a basin, if it issues out in an arc ; or if, as is
most frequently the case,  the  blood dribbles out slowly, (coule en
bavant) he places under the puncture the extremity of a card, curved
in  the form of a gutter, to conduct the fluid into a basin, or any
other vessel. If, after having begun to run, the blood should appear
to stop, we should cause the patient to have recourse to the move-
                             33 
258           NEW ELEMENTS OF OPERATIVE SURGERY.
                                                           I
ment of mastication, or, at least, we should endeavor to remove the
difficulties which have thus retarded the flow of the blood.
  The  desired quantity of blood being once obtained, we remove
the pressure and then apply the thumb on the puncture, in order to
give time to wash and wipe the parts soiled by the blood.  Without
recurring to adhesive plasters, which endanger erysipelas, or to the
suture, which would be  more painful than the bleeding itself, we
apply, instead  of  the  thumb, a small graduated compress,  as in
bleeding at the arm.   [Nevertheless, there can be no objection to
adhesive plasters, decidedly the mcst to be relied on here, and al-
most in all cases,  for dressing of Mounds, to keep the compresses
firmly and securely attached. Infinitely preferable, we should deem
them, to a folded cravat or kerchief.—T.]
  The best containing bandage in such cases is a cravat, the mid-
dle of which is placed on the sound side of the neck, crossed on the
graduated compress, and its extremities attached under the opposite
axilla.   On the next day, or the day after, the bandage may be re-
moved.  We must take  care not tp make any pressure upon the
air passages.
  E. The accidents to which M'e are exposed in puncturing the ex-
ternal jugular vein, are, as in that of the arm, the missing  of the
vein, Qa saignee blanche) thrombus,  puncture  of the nerves and
lymphatics, and different kinds of inflammation.  Nevertheless, we
have here neither tendon nor large artery to disturb us,  but  it is
one of those veins by opening  into which  many persons think at-
mospheric air may be introduced into the heart and kill the patient.
It  is for that reason it is recommended not to remove the pressure
from it until at the moment when we apply the graduated compress
to  the puncture, and also that we should apply this compress from
below upward, before raising the thumb.
  Phlebitis and phlegmonous erysipelas would be  attended here
with yet more dangers  than in the arm, because of the neighbor-
hood of the chest and heart.

                  § III.—Bleeding in the Foot.

  Like that of the jugular, bleeding in the foot, so frequently in use
even in the last century, is now scarcely  ever employed, notwith-
standing the exertions made by Leroy and Fretau in its favor. It is
rarely any longer resorted to but for some congestive affections of
the head  or uterus.   It  is,  moreover,  designated by an incorrect
name, for the puncture is almost always  made on the veins of the
leg, and not on those of the foot.

                           A. Veins.

   We might, in truth, open, in almost any part of it, the great ve-
nous arcade, which runs  from the roots of the toes to the internal
malleolus, after the manner, in some degree, of the cephalic from
the thumb, and towards the external malleolus after the manner ol
the salvatella; but, if we performed venesection upon this, it would, 
BLEEDING, OR SANGUINEOUS EMISSIONS.
259
 in general, yield but too little blood.  As in the hand, so in the foot,
 we do not bleed there, except where we have no other resource.
   The internal saphena, situated betM'een the integuments and the
 tibia or aponeurosis of the leg, is accompanied, also, from its origin
 to the  knee, by the nerve of the  same name.  It is rare that we
 find it behind the malleolus, but almost always situated at its com-
 mencement, on  the inner or anterior surface of this eminence.
   The external  saphena,  ordinarily of less size than the internal,
 and generally more irregular, is situated  at first nearly between
 the tendo-Achillis and the fibula, ascending from thence towards
 the ham, where it receives, from the upper  and posterior  half
 of the thigh, a  long anastomosing branch before it terminates in
 the popliteal vein.  It is likewise accompanied by its nerve of the
 same name.

                         B.  Operation.

  To bleed in the saphenas, M'e require a ligature and most of the
 other articles already mentioned, but we require, moreover, a suit-
 able vessel  and hot water for a foot-bath.  This venesection is
 more easy in the evening than in the morning, or in persons  that
 have taken  some  exercise  than  in those who  have not left their
 beds during  the day.
  The  patient may be  seated in a chair or an arm-chair, or upon
 the edge of  the bed; this last  position is the most convenient for
 aH.  We  commence by placing the limb we wish to bleed in the
 hot water up to the beginning of the calf, in order to  produce a
 congestion in that  part, and to render the veins more prominent.
 The surgeon then  arranges  his dressings;  at  the  end of some
 minutes he removes the limb  from the bath, examines the veins,
 and applies the ligature.  Between the calf and the knee, or above
 the knee,  this ligature produces  less  effect than at  three or four
 inches above the malleoli.
  After having properly compressed the parts by a double turn of
 the bandage, we fasten  this ligature by a knot, outside if it is the
 internal saphena vein, and inside  if we wish to  open the external
 saphena.   We immediately replace the  foot in hot water; after
 which the surgeon  seats  himself in front upon a stool, provides
 himself with an aleze folded four or eight times, places his lancet
 in his mouth, withdraws the foot of the patient and  fixes it upon
 his knee, carefully wipes it, as well as  the lower part of the leg,
 causes the knee to be held by an assistant, fixes the vein M'ith  the
 thumb of the left hand at the point where it appears most easy to
 open it, and punctures it (Fig. 154) with the right hand if he ope-
 rates on the right leg, as has been said in  speaking of the other
 modes of bleeding, taking care to make  the opening rather large
 than too small.
  Whether this vein be  opened transversely, obliquely, or length-
wise, it nevertheless gives rise, occasionally, to a jet of blood in the
form of an arc at first, while at other times the blood from the very 
260           NEW ELEMENTS OF OPERATIVE  SURGERY.

beginning runs with difficulty.  If it runs in a jet, we receive it
in a vessel, as in bleeding at the arm ;  but if, what is infinitely
more common, it  escapes  dribblingly, (en bavant) we immediately
replace the foot in hot water, so that the puncture may be found
at a short distance below the surface of the liquid.
  That the bleeding may not be arrested  too quickly, we rub the
part from time to time with the finger, or with linen, with the view

                            (Fig. 154.)
of preventing the  formation  of clots within the lips of the punc-
ture.  We cause the patient, moreover, to move his toes.
  In short, we  cannot in  this manner ascertain but very imper-
fectly, and that by means of the greater or less discoloration of the
M'ater or of the linen that we place in it, the quantity of blood
abstracted.
  When we wish to stop  it, we remove the ligature, bring back
the foot td the knee, place the thumb on the puncture, wipe the
limb with care, remove the foot-bath, apply a  small square com-
press, then fasten it  by means of a figure of 8 bandage, which
surrounds the tarsus  or the  instep  by  its anterior  loop, and  the
lower part of the leg by its upper loop ;  the figure of 8 being ter-
minated by one or two turns  and a double knot or pin on the side
opposite to the wound.  It is this bandage which  we designate
under the name of stirrup, (etrier)
  C. Accidents from bleeding in the foot are almost all referable
to a M'ound of the saphena  nerves.  We cannot, in fact, wound
the arteries but in consequence of anomalies difficult to foresee.
  The size of the internal saphenus nerve, and its intimate rela-
tions with the vein, are such  that it is almost impossible to avoid
it.  Though many accidents imputed by Sabatier and others to the 
               BLEEDING, OR SANGUINEOUS EMISSIONS.            261

wounding of this nerve, may be referred  to  inflammation of the
lymphatics, or of the sub-cutaneous cellular  tissue, if not to that
of fhe vein, it is difficult, hoM'ever, not to admit that puncture of
the nerves of the  leg has been sometimes followed by accidents
of a serious character.  The  symptoms, as in the  arm  and neck,
would be pain, convulsions, &c.  For these, also, we must use simi-
lar remedies.  Erysipelas, and all other kinds of inflammation, are
infinitely more easy to control when they  are the  result of this
kind of venesection than of the others.   But an accident which is
peculiar to it, is the puncture  of the periosteum and the breaking
of the lancet.  I do not, however, think that the first of these acci-
dents merits all the  importance which has been ascribed  to it.  As
to the second, it may doubtless happen, but it  is rare.  We should
remedy it immediately, by enlarging the wound, and proceeding to
search for the  point of the instrument with a forceps.  Left in the
tissues, this small foreign body could cause at most only a phlegm-
onous inflammation there, and afterwards  a small  abscess, which
would ultimately cause its separation from the parts.

    § IV.—State of the Blood drawn from the Veins in Bleeding.

  When patients are bled in the arm, the blood being received and
preserved in a vessel, may be examined at leisure, for the space of
twenty-four hours.  At the  moment it  escapes from the vein, we
often hear the patient, or the  persons who surround him, cry out,
that  it  is thick, clear, lively, (vif) or altered, according as the jet is
more or less rapid;  but Mdthout denying that its greater or less de-
gree of coagulability, or plasticity, (plasticite) may  insensibly nar-
row the aperture of the vein and retard the jet from it, the surgeon
ought not, however, to accord any  degree of  importance to these
common expressions.   When the blood is deposited in the vessel, it
takes on a variable aspect, according to the nature of the patient's
disease, and also according to the manner in which it has flown.
Thus, the blood of an  individual perfectly healthy will remain red
and vermilion, while that of a pleuritic patient, or one affected with
rheumatism, will present  a coat of yellowish  fibrine two to three
lines thick; and that  of an individual laboring under typhoid fever
will remain fluid, (diffluent) greenish, or of a variegated black color.
We must  recollect, besides, that, in the same  diseases, this aspect
will not be the same when the blood is drawn by a small orifice as
when it issues through a large one, or when it dribbles out as when
it escapes by a continued jet, or when it  is received into a flat, wide
vessel as M'hen it falls into a narrow and deep palette, [Neverthe-
less, most important deductions in practice are, in  our opinion, to
be made from these appearances of the blood drawn, which are in-
dependent of any contingencies of the shape of the vessel used, &c.
These are, its dark or bright color, and its inspissation or attenua-
tion—in other words, its thick, glutinous,  fibrinous character, in
plethoric, robust  habits and entonic inflammations, causing almost
its immediate  and entire coagulation and consolidation, ima few 
262
NEW ELEMENTS OF OPERATIVE  SURGERY.
minutes, throughout its whole substance; or its limpidity, or fluid,
thin, and watery appearance  in dropsy and  adynamic  fevers; its
coal-black color, tarry consistence, and highly carbonated condition,
where respiration and decarbonization are defective, as  in phlegm-
atic temperaments  and sedentary persons that feed well; also, its
bright, frothy, sparkling, vermilion, arterial color and natural con-
sistence in the sanguine temperament, and when the lungs are large
and expanded, and much exercise is taken.—T.~\

           § V.—Bleeding in certain particular regions.

  Besides the veins of the arm, neck, and foot, the ancients bled,
also, in those of  a great number of other regions—the occipital or
auricular, the frontal, the angular of the  orbit, the nasal, the sub-
lingual, and the  dorsal of the penis, for example ; but  now, and
since the discovery  of  the  general circulation of the blood, we
never scarcely use this mode of venesection, so much lauded by the
Greek physicians, and especially by Marcus Aurelius  Severinus.
Perhaps, in truth, it  has been  rejected in too summary a manner.
For my part, I am not convinced that bleeding in the veins in the
forehead, or in the vena preparata, and in the veins of the mastoid
region, has not some advantages  in inflammations of the scalp,
(cuir chevelu;) nor that  that  of the angular  vein, M'hich is contin-
uous with the ophthalmic in the orbit, is devoid of efficacy ; nor that
the bleeding of the ranine veins in diseases of the  tongue, those of
the scrotum, penis, knee, and, in general, of the veins nearest to the
diseased part, ought  not, in many cases, to be preferred.  M. Jan-
son, in the present day, has extolled these modes of venesection,
and I have often employed them with very favorable results.
  In conclusion, we  perform bleeding of the vena preparata, or of
the forehead, by compressing the vein with the thumb between the
two eyebrows, while we puncture  it on the point where it is most
conspicuous.   The vein of the large angle of the eye, communicating
with those of the orbit and face, would have to be compressed near
the caruncula lachrymalis, and  on the root of the orbitar process,
if we wished to  arrest  the  course of the blood there.  When we
open the  ranine veins, we must  puncture them rather in the direc-
tion of the lower wall of the mouth than of the proper tissue of the
tongue, if we would avoid with certainty the arteries of the same
name. The dorsal veins of the penis, which are ordinarily of suffi-
cient size, should be  compressed posteriorly near the symphisis pu-
bis ; those of the scrotum, and those which run upon the surface,
either of the joints or certain tumors, having no fixed course, should
be  distended and punctured after the  manner of simple varicose
veins.
  In  all  these varieties of  venesection we  must, if we wish  to
draw a certain quantity of blood, expect to be obliged to puncture
several veins  successively, or  the same  vein in many places.   It is
for this reason, doubtless, that almost  all practitioners at present
substitute leeches in the place of this operation. 
BLEEDING, OR SANGUINEOUS EMISSIONS.
263
                   Article II.—Arteriotomy.

  It appears that bleeding by incision of the arteries was  in use
at the time of Hippocrates, Celsus, Galen,  and Aretaeus;  and a
great many surgeons continued still to practise it in  the  fifteenth,
sixteenth, seventeenth, and even eighteenth centuries.  At the pres-
ent day it is almost entirely abandoned ; and I much fear, in .spite of
the reasons urged in its favor by MM. Larrey and Magistel, (Traite
Pratique des Emissions Sanguines, Paris, 1838, p. 44 et  suiv.,) that
arteriotomy will remain in the oblivion into which it has in  reality
fallen.  No one, for example, will venture to return to bleeding by
the radial artery, nor to that of the arteries of the tongue.   Arteri-
otomy, even in the mastoid region itself, will not be reinstated in
favor, and that of the temporal region is the  only one that has any
chance of being preserved.
  The temporal  artery, in truth, is  of sufficient size to furnish a
suitable quantity of blood.  Situated superficially between the skin
and aponeurosis, supported by bones rather than by soft parts, and
separated from  every important organ, it may be opened without
difficulty, and  afterwards compressed with the certainty almost of
effecting its obliteration.   The  objection, however, is the danger
of an aneurism succeeding to the puncture, as has often happened,
and of experiencing difficulty in arresting  the blood, or of finding
the bleeding stop  of itself before  having furnished the desired deple-
tion, and also the chance of obtaining as  good  a result  by  the
simple opening of a vein.  If, however, it should'be thought neces-
sary to  recur to  the opening of the temporal artery, we  must not
open the trunk  of this artery immediately  above the zygomatic
arch in front of the tragus or helix,  but one of its branches on the
side of the forehead, about fifteen lines anterior to the  meatus audi-
torius.  There, in fact, the artery is nearly outside of  the temporal
muscle;  it is prominent  under the skin, its  pulsations are easily
felt, and it rests  almost immediately  upon the bone ;  if its anterior
branch should seem of sufficient size, the operation in fact may be
performed much farther in front, and on a line  with the external
orbitar process.   In  every case we  require  a strong lancet, or a
bistoury, a long narrow band, a graduated compress, and the other
articles necessary in bleeding at the  neck.
  The patient, lying down or seated, ought to have his head held
to the opposite side; with the left hand the surgeon fixes the  artery,
while with the right, armed M'ith the instrument, he divides it; in
order to  render the vessel more conspicuous, the patient, if he is
not in a state of unconsciousness, should be recommended to press
his jaws tight together.  The lancet  is inserted transversely or ob-
liquely, as in venesection.  If, however, the bistoury is used instead
of the  lancet,  it  is equally  important to make it penetrate from
the integuments  to  the  artery, (Fig.  153 b) and also from the
deep-seated  parts to  the  exterior, as when we  puncture, the im-
portant point here being to  cut the vessel completely through in 
264
NEW ELEMENTS OF OPERATIVE  SURGERY.
the place of performing a simple puncture.  As soon as the artery
is opened, the blood ordinarily leaps out with force ; it is received
either directly into a vessel, or by the aid of a card or gutter of tin;
if it stops too soon, we M'ash the puncture with tepid water, in order
to detach the clots from it.  When the bleeding is terminated, the
artery is compressed above and  below with the thumb and index
finger of the left hand; the parts are washed and M'iped ;  the small
square compress is applied, and then compression is made, either
with the packer's knot, (le nceud d'emballeur) which patients gene-
rally support badly, or, what is better, by means of some turns of
the bandage, properly applied.   I do not think that the  suture or
torsion should be used here in the beginning.  The accidents from
opening the temporal  artery are reduced, in fine, to  the possible
formation of an aneurism, or to the puncture of some nervous fila-
ments.  [A small globular,  superficial, purple-colored aneurism,
with a thin cuticular pellicle for its sac, and of the size of a  pea or
hazelnut, may form, it  is true,  immediately after the cicatrix is
completed ; but  it is  generally perfectly cured, and the  artery in
this part effectually obliterated, by M'ell-directed compression, per-
sisted in for several weeks, or even months, in  spite of occasional
rupture of the sac and  hemorrhage, which  may alarm the  young
surgeon. I have not, in any of those cases*found it necessary to
recur to a ligature.—T.]


                 Article III.—Local Bleeding.

  We generally give  the name of local or capillary  bleeding to
that of the  small vessels, when performed as near as possible to
the diseased region.  It is a name, however, but little suitable to it,
for bleedings at the anus for diseases of the abdomen, those at the
epigastrium, and at the parietes of the thorax, for affections of the
stomach and lungs, those at the neck for diseases of the  encephalon,
are full as much general bleedings as those by the arm.
  The name of capillary bleeding is not much of an improvement
in expressing the idea of the practitioner, for there are  local bleed-
ings performed on small veins (veinules) that are too large to retain
the name of capillary.  It must be conceded, then, that the term
local  bleeding, whatever  be its object,  should be applied  to the
opening of vessels too small to  give egress to a large  quantity of
blood.   This  bleeding is effected by means of leeches, the  lancet,
bird-peck punctures, (des mouchetures) or scarifications.

                         § I.—Leeches.

   A. The leech is an animal of the family of hirudo, and  employed
in medicine from almost immemorial time.   The best are the leech
termed medicinal, of a greenish hue, and marked with  six narrow
iron-colored bands,  and the officinal leech, whose color is browner,
and whose longitudinal bands are of a rusty tint. 
BLEEDING, OR SANGUINEOUS EMISSIONS.
265
  B. To apply leeches, the part must be previously washed, and
sometimes even besmeared with sweetened water, milk, or blood.
When the leeches are hungry and sprightly, all these precautions
are unnecessary.  On the contrary, if they do  not incline to bite,
MTe may heat them or dry them by rolling them between folds of
dry linen, so as to excite them gently.  Also, we apply them some-
times singly, or in mass.  In the first case, each one is seized by the
fingers, either naked or between linen, so as not to lose hold of them
until they are well attached.   Some  persons, as M. Magistel and
others, seize them near their posterior extremity with a forceps, and
force them thus to fasten themselves on any part we choose.   The
pupil should know that the leech, by its vermicular movement and
unctuous coat, slips through  the fingers with remarkable facility.
In the  second case, we  make  use of glasses or the hand, holding
the leeches in a piece of linen. The  small liquor glasses [wine-
glasses] are preferred for circumscribed  regions, or when we  do
not wish to apply but a  small  number of leeches* The tumbler,
(le verre de cabaret) on the  contrary, is used, if we have a large
surface, and wish to apply from ten to fifteen leeches.   These ani-
mals, placed in the glass, and having no other exit, are obliged to fall
back upon  the living tissues, (Fig. 155,) and rarely fail to attach

                             (Fig. 155.)
themselves in a very short time.  Sometimes, however, they remain,
as if asleep, near the bottom of the glass, and do not detach them-
selves from it unless we apply some cold substance.  Even though
the leeches bite well under the  glass which covers them, there re-
Bults, nevertheless,  the inconvenience  of the punctures being too
                              34 
266           NEW ELEMENTS OF OPERATIVE SURGERY.

nearly approximated together, if we use a small glass, or, if it is a
large glass, of having them frequently collect, as in a circle, around
its circumference.   But we use, generally, the hand, provided with
a piece of linen, instead of the glass of M'hich I have just spoken.
The  leeches  are  then gathered into a compress, in order to ap-
ply them immediately to the integuments, in  such  manner  as
to keep the linen moderately pressed around all that part of the
skin  which the leeches occoip}', (Fig. 156.)  If this precaution were
not taken, the leeches would soon escape, and would be lost  by
creeping about in all directions. The small cuvette of silver wire, in
form  of an  egg-stand, m hich  some persons  have devised for this
purpose,  is a useless contrivance.  The  fingers, the  forceps, the
glass, and the hollow of the hand,  provided M'ith linen, are accessi-
ble to all and always sufficient.  [When  these usual modes, how-
ever, fail, as they too often do, a glass tube,  M'ith a narrow aper-
ture,  through which the  leech can  merely protrude  his mouth,
(that is,  his pointed extremity,)  while a bulge in this part of the

                             (Fig. 156.)
tube admits of full  distension of his body, will be found useful, es-
pecially in applying leeches in narrow passages, as to the tonsils,
tongue, gums, nares, ear,  anus, vagina,  &c, &c.  In all cases, a
sovereign remedy to excite them is, to dip the glass, before using it,
or placing the leeches in it, into ice-water, and they are soon glad
to get as far as possible from it, and huddle together upon the warm
skin.   Another still more  efficient  mode, especially in  applying
leeches to loose, flabby tissues, (as to the scrotum in orchitis, &c.,)
where it is difficult  to keep them on by  any means, is, to use a cup-
ping-glass, or, better still, the  receiver of an air-pump, and after
exhausting it till considerable congestion is produced, put on the
leeches, and a gentle stroke or two more of  the pump, compelling
the leeches to look to the  blood for  the   supply of oxygen  to
their spiracles, will make them seize greedily hold of the minute
vessels.   A mode to induce  them to  bite,  recommended recent-
ly, is that of placing them in beer or  ale before applying them. 
               BLEEDING, OR SANGUINEOUS EMISSIONS.            267

  It is also unnecessary to apply leeches one by one, but upon cer-
tain regions, or upon some cavity lined with mucous membrane, for
example.  We know when the leech is  attached by his distension
and the suction  movement of his pump, as M'ell as by the pain he
causes.   The time he requires to fill himself varies from half an
hour to an hour and a half.   They increase to three, four, or five
times their bulk.  If the leeches do not  fall off of themselves, we
may easily loosen their hold by sprinkling them with salt, tobacco,
or, better still, with ashes.  To remove them by force,  or by pres-
sure on the skin, would endanger tearing their mouths and leaving
in the tissues some particles of their cupping apparatus, (ventouse.)
Persons who have recommended cutting off the posterior extremity
of the leech, to make the blood run more abundantly, forget that this
operation causes the animal to fall off immediately.   Running a
thread through  his tail, in order to  have better command of his
movements, would incur the risk of preventing him from biting, and
perhaps soon cause his death.
  Each leech draws from two to four gros* of blood.   There flows as
much, also, sometimes from the puncture ; but I do not know what
credit to attach  to the assertion that the leech abstracts two and a
half times his weight of blood.

                     C.  To stop the Bleeding.

  In all cases when the leech has come off, we are in the practice
usually of letting  the puncture flow for half an hour; if, at the ex-
piration of this  time, there is nothing to apprehend, we cover the
part  with  a large emollient  poultice, which thus  absorbs the re-
mainder of the blood; if we do not M'ish the bleeding to be copious,
or if it continues beyond the time required, there are various means
of checking it.  The first of these consists in covering each puncture
with small pieces  of agaric, or in sprinkling them with colophane,
ashes, or spider's web.  Styptics, such as vinegar, eau de Rabel, creo-
sote, or  a very hot  compress, might do equally well, aided by a cer-
tain degree of pressure.
  Sometimes  the  hemorrhage resists  these  first  measures, so
as  to endanger the life  of the  patient,  especially  in infants.
In that  case  we  may  recur  to cauterization with the head  of a
probe, or with  the bird-beaked cautery, (cautere en  bee d'oiseau.)
The crayon of  nitrate of silver has always ansM'ered with me,
in uniting compression  with it.   This crayon,  cut in the form
of a  cone, should be applied by its apex  into the  puncture, and
held there one or two minutes. As the blood immediately tends to
spread the caustic, it is advisable to substitute quickly, in place of
the lapis infernalis, a small hard ball of lint, and small pieces of
agaric,  or very narrow graduated compresses, and to press on these
objects  with the thumb until the blood ceases to flow.   We are yet
more certain to succeed by compressing the  contour of the puncture
[* See the measure of a gros above.] 
268           NEW ELEMENTS OF OPERATIVE SURGERY.

with a ring, while we cauterize as above.  It would not be practi-
cable to apply the suture, or to seize the two sides of the wound and
strangle them between the branches of a forceps, but in a small num-
ber of cases, and they are means still less to be relied on than those
I have just mentioned.  I cannot say that a cupping-glass, applied
upon a part that the leeches have quitted, will avert all the hemor-
rhage, by filling all the punctures with clots, as M. Ridolfo  believes.
For myself, I do not believe this  kind of hemorrhage can  resist
compression, cauterization by nitrate of silver, the employment of
the small ring, or the red hot iron methodically applied.   [The
most efficacious and certain  mode  of putting a total stop to the
exudation of the blood, which is  often  alarming in infants, for
example, in  leeching  the neck for croup,  &c, M'here  pressure
cannot be  made without strangling the air-passages, is to pass
a  fine needleful  of delicate but strong  white  silk  thread, with
a fine sewing-needle, through the  lips  of the  puncture  once or
twice, as in  taking up a stitch, and then fastening the  ligature
with a firm  knot.  It is done  in a moment, and the bleeding is
instantly stopped, creating much surprise to the alarmed friends
and bystanders.  This delicate and easy operation may be  perform-
ed upon all the punctures that continue obstinately to bleed, though
that is not generally the case with more than two or three at  most.
I am  indebted for this ingenious and important suggestion to Dr.
Richard K. Hoffman of this city.  In reference to M. Ridolfo's re-
commendation of the cupping-glass to check the blood, it will be
seen, in our  previous note,  that the effect is and must be, by its
suction, directly  the reverse.  Torsion might sometimes  answer,
were it not for irritating too much  the already inflamed puncture.
It is to be remarked, says Dr. Mott, that  in infants it  is sometimes
next to  impossible  to apply the stitches as  above mentioned, but
that a more easy and quite as effectual a mode is, to  insert a deli-
cate needle across the perforation,  and then  to fasten it there and
draw the aperture together by the figure of 8 twisted suture.—T]


                 D. Preservation of the Leeches.

  When the  leeches have fallen off, it may perhaps  be advisable
to preserve them, to be used  at another time.  There are many
methods employed to effect this, but the best is to throw them on
the hearth,  and to allow  them to creep there on the  hot  ashes.
That is much better than sprinkling them with tobacco or  salt, and
especially than disgorging them by force, by pressing them  with the
fingers from one  extremity to  the other.   When they are entirely
empty they are  cleaned and washed,  and placed in vessels half
filled with water, which  are changed every three, four, five, or six
days.   To  preserve  them in large  quantity, it  suffices to  throw
them into large basins, and not to take them out but at the expira-
tion of some  months.   [It is  stated that  the American leech may
be depended  upon for doing  its duty, if  it  be kept previously in
distilled water.—T.] 
               BLEEDING,  OR SANGUINEOUS EMISSIONS.           269

  Punctures from leeches do not generally require any care;  if they
are not irritated, nor their scabs torn off,  a period of two  to four
days is sufficient for the cure.   They are, however, sometimes the
cause of erysipelas, angioleucitis, and small abscesses.

      E. Regions of the Body where Leeching may be Applied.

  With the exception of the track of the arteries, or of the large sub-
cutaneous veins, as in the  limbs and neck, we may apply leeches
to every part of the body ; we must  also add, that we may, by
avoiding the vessels themselves, apply them without  any inconve-
nience to the limbs.  Thus, we place  them upon the large angle of
the eye, the temple, and the mastoid processes, for  ophthalmias and
cerebral affections; to  the anus, pudenda, and groins, for diseases
of the abdomen and genital organs ; to the epigastrium, for affec-
tions of the stomach; on the entire abdomen, for inflammations of
that cavity; and generally to every part where the blood appears
to have accumulated. At the angle of the eye we  apply them by a
small glass, or place them on one by one.  On the skin of the eye-
lids they occasion  often a  considerable swelling,  which must not
alarm us; upon the inner lining of the lower eyelid it is  also neces-.
sary to apply them in succession, and in such manner that they do
not puncture  too near the ciliary edge of the organ.   In that place
it  is rarely advantageous to employ more  than two or three at a
time.   Moreover, they occasion but little pain there, and fill them-
selves quickly.  It is when we apply  them to the nares, tonsils,
and gums, that we may require the forceps to hold  them, or we may
make them pass through a cone of glass, or a piece of  card rolled
up in the shape of a trumpet.  The card is in my  opinion the best.
The beak of  it, being of sufficient width to allow the mouth of the
                              leech to pass through it, ought not to
                              be so large as to allow  the animal
                              to escape entirely  from it.   Apply-
                              ing thus the apex of  the card to a
                              convenient spot,  the leech is  di-
                              rected  by means of a ring, or by
                              the finger, (Fig. 157,) as by a sort
                              of piston, and we have then no fears
                              that it can escape.   To the anus
                              leeches ordinarily attach  them-
                              selves  very quickly; to prevent
                              their getting into the intestine, it
                              has been recommended, uselessly,
                              as I think, to plug up the anus by
                              means  of a small tent of oiled
                              linen.  To apply them to the neck
                              of the womb we make use  of the
                              speculum,  and  the entire  specu-
                              lum (speculum plein) is preferable.
The instrument being adjusted, the  leeches are placed in  it, and
(Fig. 157.)
 
270           NEW ELEMENTS OF OPERATIVE  SURGERY.

are forced along, or of themselves soon make their way to the os
tincae.

                     F. Leeches Internally.

  If it should happen, as in certain instances it is said to do, that the
leeches have escaped into the rectum, we should destroy them there
by means of injections of salt water or tobacco infusions.  If they
should have got into the oesophagus, or even the stomach, M'e must
in that case also have recourse to salt M'ater.  Tobacco fumes and
vinegar would  be  less  efficacious.  In the larynx or trachea, the
accident  would be more formidable, and we should  be obliged  to
have recourse to tracheotom)'.  [In conclusion, we consider the glass
tubes with a bulge at one extremity, as described in a note above,
preferable to a trumpet of pasteboard, wine-glass,  or any  other
contrivance.
  Consequences of Leech Bites.   Among the  most  formidable  in
appearance, and slightly alluded to by the  author, is the  abun-
dant serous effusion, or sub-cutaneous oedema, which their suction
power, communicated to the capillaries in all loose, flabby textures,
occasions, giving rise to a tumefaction apparently alarming, as (when
applied to the eye) in the whole face, resembling a  sudden attack
of erysipelas, closing up the eyelids, and causing much uneasiness,
from the  dryness, tension, and heat of the stretched dermoid  tissue.
So in the scrotum  and  penis, causing in the latter,  sometimes, an
cedematous inflammation, or even phymosis or incarceration of the
glans, more serious than the original disease for the removal of M'hich
they were  employed.  In all such cases, a mild emollient, cooling
lotion, such as  of pulverized slippery-elm  bark solution strained,
or flax-seed,  and afterwards  a very weak  solution of lead-wa-
ter  or diluted ether  and alcohol combined, as in  true  erysipelas,
are all that is required in  addition to  saline purgatives and absti-
nence.—T.]

   § II.—Bird-Peck Punctures (Mouchetures) and Scarifications.

  Leeches, while they  draw a certain quantity of blood, produce
an irritation which many physicians regard as of much importance
in local bleedings ; and there are many physicians who think that
no other  kind of bleeding  can be substituted for  leeches.  How-
ever that  may be,"  the  bird-peck  puncture and  scarifications,
which also have the effect of irritating the tissues, at the  same
time that they allow a certain quantity of blood to be abstract-
ed, have often been prescribed  in place  of leeches :  they are,
however, two different operations, which  it  is important not  to
confound.'

                  A. The Bird-Peck Puncture.

  The name of mouchetures is given to those simple  prickings per- 
               BLEEDrXG, OR SANGUIVEOUS EMISSIONS.            271

formed on the integuments, with  the view of unloading the parts
of the fluids that may have stagnated, or been infiltrated into those
tissues.   We have recourse to it in cases of serous  infiltration,
whether of the limbs, trunk, scrotum, or penis, in individuals affect-
ed M'ith anasarca, or local cellular dropsy.  We recur to it in some
cases of congestion or sanguineous engorgement of the conjunctiva,  •
nares, tonsils, tongue, inside of the mouth, and even in the treat-
ment of certain kinds of erysipelas.   To perform these punctures,
there is no need of needles, nor any other special instrument; the
ordinary  lancet, directed perpendicularly (Fig. 158) upon the tis-
sues, and drawn back  in  the same  manner,  after having been
quickly plunged into them to the depth of a line or two, always
suffices.  The punctures performed in this M'ay should be numer-
ous and made with rapidity.  The only inconvenience they present
is that  of exposing to the risk of erysipelas, and of thus causing in
debilitated and dropsical patients  (individus anemiques  ou  infiltres)
inflammations which sometimes speedily pass into gangrene. [The
most convenient and speedy M'ay of making these punctures is M'ith
the lancet open, at an acute or right  angle, upon its handle, which
latter is  held lightly  between the thumb and fore-finger, placed
near the extreme point of the handle, so as to have a better lever.
This is the origin of the term bird-peck puncture.—T.]

                            (Fig. 158.)
B. Scarifications.
  I do not mean here the puncturings made directly into the small
veins which are often seen on the surface of diseased regions, or on
certain tumors: this is a kind of local phlebotomy.  The scarifica-
tions, which are actual incisions, and not  simple punctures, consti-
tute one of the most ancient modes of bleeding.  They were in use
at the time of Galen and Oribasus, for we remark in these authors
that Antylus, for  performing them, was in the habit of  using a
scarificator with many blades.  From those remote times scarifica-
tions have never been entirely abandoned.  If, to effect them, we
no longer use a sharp-edged shell,  flints, or stalks of wood, there
are still employed particular kinds of scarificators for the conjunc- 
272
NEW  ELEMENTS OF OPERATIVE SURGERY.
tiva, interior of the nares, or urethra, or for the cutaneous surface.
The German scarificator, (Fig. 159,) the English  scarificator, that
which the manufacturer Charriere (Fig. 160) has  modified, or that
of M. Larrey, (Fig. 161,) are the only ones which  deserve to be re-
(Fig. 159.)                                             (Fig. 160.)
tained.   Moreover, the lancet, bistoury,  or  razor, or  the  fleam
(flamme) of veterinarians, suffice for all cases.
  Scarifications are sometimes intended as a substitute for bleeding
or leeching;  at  other times to subdue certain inflammations.  In
the first case they are made, indifferently almost, with the lancet,
bistoury, or razor, instruments that should be held like an arc, or in
the fifth position, and which ought not to penetrate over half a line
in depth, and should be  drawn rapidly across  the skin  from space
to space, (Fig. 162.)  In the  second case, we  scarcely use other
than the bistoury.  In that case, it is generally advisable to pene-
trate to the sub-cutaneous layer ; for these are true incisions, from
one to two inches in length, which we make at a distance of twelve

                             (Fig. 162.)
to fifteen lines apart, upon regions affected with phlegmonous ery-
sipelas, or infiltrations tending  to gangrene.  In these  cases the
convex bistoury should almost always be preferred.  If we incline
to employ the  razor  for scarifications, it is  advisable to use that
which ends in a rounded extremity.  When we employ the scarifi-
cator, it is first  necessary to make its blades recede into the box by
turning the spring of the instrument.  This being applied upon the
skin, we press upon the button which makes the spring act, and the 
BLEEDING, OR SANGUINEOUS EMISSIONS.
273
blades immediately cut into the skin by moving in the arc of a
quarter-section of a circle.  In this way the twenty scarifications
are made at once, and the operation is over in an instant.  But we
penetrate  always to the same depth, whatever may be the region
M'hich requires to be scarified, and we obtain in this manner punc-
tures  rather than  true  scarifications.  With the razor, lancet, or
bistoury, on the other  hand, we make  incisions as superficial, long,
or deep, and as few or many, as we may desire.   With some prac-
tice, we may execute  them almost as rapidly as with the scarifica-
tor ; and young  surgeons, moreover, find in this exercise an excel-
lent means of familiarizing themselves to the handling of the bis-
toury.
  The use of the scarificator, then, should be reserved for patients
who are exceedingly timid, and for intractable persons, or such as
cannot be reasoned with.
  The scarifications do not require any particular treatment after-
M'ards.  They are small M'ounds which cicatrize immediately, and
which, moreover, could not require any other attentions than those
given to wounds in general.

                    § III.—Cupping-Glasses.

  After the leeches have dropped off, or when we have performed
puncturings or scarifications, we sometimes wish to prolong the
flow of blood by applying a cupping-glass to the wounded part.
  We understand by cupping-glasses, a sort of bell-shaped vessel
in which a vacuum is created, and which is then immediately ap-
plied  upon the skin with the view of producing a congestion, tume-
faction, and elevation of a portion of this tegument.
  Cupping-glasses present  two principal varieties, as to the object
for which they are intended to be employed; that is to say, there
are dry and scarified cuppings.

                       A. Dry Cupping.

  The object of  dry cupping  is solely to irritate certain  regions of
the integuments, and to  draw the fluids to  it by  a greater or less
degree of revulsion.   The cupping-glass
itself was anciently the extremity of the           (Fig-163->
horn of some animal.  At present they
are of different  shapes—some have the
form of small bells  surmounted by a but-
ton, (Fig. 163,) or of a simple gourd.  In
a case of necessity we might use an or-
dinary drinking glass—they are, also, of
various sizes.
   In some  countries, in  Italy and Germany, for example, dry cup-
ping was used in the time of Dionis, under the  title  of hygienic
means, as the massage and electricity are at the present time in
                             35
 
274
NEW  ELEMENTS OF OPERATIVE SURGERY.
France ; but with us there never have been  any grand vaulted
halls  nor stoves,  whither we could repair and  have  ourselves
cupped at pleasure, as in Germany.
  To apply dry cupping, we  must first rarefy the air. or create a
vacuum  in  the vessel in  some way or  other.  We effect this by
various modes; the Germans confine  themselves to dipping the
glass into very hot water,  from whence it  is draM'n out quickly, to
be applied immediately  upon the skin.  A more simple mode con-
sists in keeping the flame  of a spirit lamp for some seconds Mdthin
the cupping-glass, and  then  transferring  this last to  the integu-
ments  as quickly as possible.   This is the  mode of MM. Backler,
Rohmer, and Buchel, M'ho, in importing dry cupping from Germany,
have endeavored to infuse a taste for it in Paris.  This is an easy,
expeditious method, requiring but little address to perform it with
ease.   It is found more  convenient,  however, to  rarefy the  air in
the glass by burning in  it either tow, lint, cotton, or paper, espe-
cially paper manufactured from silk, or we may simply burn alco-
hol.  I do not speak of  the small  candle, the sulphur matches, or
night-lamp, that some introduce  into the cupping-glass upon a bit
of card, because they are bad contrivances.  It is desirable that the
wool or paper used should be slightly impregnated with alcohol or
ether.  In other respects these substances should be very dry, light,
and thin, (rarefiees)  After having placed them at the bottom of the
vessel, we apply the fire to them; or, better yet, if paper is used,
we make it into a peloton of net-work, (a laciniures multiples) and
very porous, which we light M'hile we  hold it in  the  forceps, and
then immediately  place it in the  cupping-glass.  The important
point is to apply this upon the skin before the ignited body is en-
tirely extinguished.  It  must,  however, be on  the point of being
consumed, otherwise it  might burn the  patient in falling upon his
skin.
  The  skin  is immediately expanded and swells while it reddens
under  the  cupping-glass.   We  leave the  glass on  one or two
minutes.  To remove it, M'e  depress the  integuments upon some
point around its circumference by means of the thumb, M'hile with
the other hand we endeavor to make the  glass incline to the op-
posite  direction.  The slightest  opening effected in this manner,
alloM's the air to enter, and the cupping-glass to be detached.   We
afterwards reapply it upon other parts of the skin, as many times
as we judge  proper, or we  have a number of them, which we
place on immediately, before detaching the first.  We thus apply
cupping-glasses to the  breasts,  to arrest  certain uterine hemor-
rhages, to the anus, to reproduce hemorrhoids,  and on different
parts of the body, under the character of a revulsive.

                     B. Scarified Cuppings.

   When  we  employ cupping-glasses  to  draw blood, we  apply
them after the separation of leeches, to prevent the bites of these
worms (annilides) from closing, or upon the punctures or scarifica- 
BLEEDING, OR SANGUINEOUS EMISSIONS.
275
tions, to promote their bleeding.  In the two first cases it suffices
to recall what I have said of dry cuppings and of the  application
of leeches, to understand the whole operation.  As to scarified cup-
pings, properly so called, they are employed most usually in the fol-
lowing manner: the first step consists in rarefying  the  skin as
above ; the glass being removed, M'e rapidly scarify with the lancet,
bistoury, razor, or scarificator, the congested portion of the skin, so
that the small wounds are sometimes  simply parallel, or dispersed
in quincunxes, (quinconces) or crossed like window frames, or made
so as to include small rhombs, (losanges) or sometimes in imitation
of certain fancy figures, &c.
  The  cupping-glass, prepared as in the first case, is reapplied as
quickly as possible, and so on with the others.  The  blood oozes
out  immediately from all the wounds, and escapes into the glass in
greater or less quantity, according as  the vacuum has been more
or less  complete.  When we have taken the necessary quantity of
blood, or the  cupping-glasses produce no  more, we  detach and
empty them; we remove the blood from the skin, then, if M'e judge
proper, reapply them without additional scarifications, taking care,
nevertheless, not to replace the edges  of the glass  too often in the
same groove of the skin, for fear of producing a cauterization.  We
might, in this manner, abstract a  large quantity of blood from the
same place, but  it is  better to increase the  number  of cupping-
glasses.

                 C.  Air-Pump Cupping-Glass.

  This instrument is composed of the ordinary cupping-glass, and
the  body of an air-pump, (pompe aspirante) which is adapted to it
or removed at pleasure, (Fig.  164.) We avoid thus the necessity
of rarefying the air of the cupping-glass by heat; it is sufficient,
in order to create the vacuum,  to apply the glass to the skin and to
set the pump in motion; by opening a cock on its side we allow
the  air to re-enter into the glass, and thus  detach it whenever we
wish.  When  the  scarifications are finished and  the instrument
reapplied, we may draw a large quantity of blood ; we then remove
the  glass and clean  the  parts, then recommence in the same man-
ner, till we have produced the effect desired.
  Other persons, Sarlandiere among others, have transformed  the
air-pump cupping apparatus into an instrument called bdellometre,
(Fig. 165.)  It is a pump cupping-glass, armed with a  scarificator
of five  or six blades;  so that the instrument once  applied, allows
of the vacuum being made, the skin to be scarified, and the bleed-
ing  completed without changing any thing.

                D.  Cupping-Glass of M. Toirac.

  To conclude, there are others, M. Toirac in particular, who, to
make a more  effectual substitute for leeches, have devised small
spindle-formed glasses with narrow apertures, or ordinary cupping- 
276           NEW ELEMENTS OF OPERATIVE SURGERY.

glasses, which by means of a long tube of flexible tissue, or gum-
elastic, communicate with the body of a pump, so that we may apply
them at a great distance, and at the bottom of any cavity whatever.
Thus modified, (Fig. 166,) the air-pump cupping-glass would better
(Fig. 164.)                                         (Fig. 166.)
deserve the title of an artificial leech, than the instrument to which
the English have applied this name.
  Of all the modes of applying the scarified cuppings, or cupping
in general, there are really none to reject but the bdellometre, since,
in one respect, it does not exactly answer the intention of the sur-
geon, and, on the other hand, is too much complicated.
  Local bleedings should not be confounded with general bleeding;
in addition to the fact that they do not abstract blood rapidly, (some
persons having gone so far as to advise to apply leeches only one by
one, that they may thus succeed each other  for the space of twenty,
thirty, and forty-eight hours,)  they also have the effect of creating
a special irritation upon the integuments.  It must not, however, be
forgotten, that by phlebotomy we abstract from the patient venous
blood only, blood consequently which has lost a portion  of its nour-
ishing principles, and which has become charged with a large pro-
portion  of excrementitious matter, (de'tritus;) whilst by leeches,
puncturings,  and scarifications, we draw  also  arterial as well as
venous blood. It has even been thought, erroneously, however, as
I believe, that of equal quantities of blood abstracted, local bleed-
ing debilitates more than general. 
CUTANEOUS IRRITATIONS.
277
                        CHAPTER II.

                CUTANEOUS  IRRITATIONS.

  We create upon the skin irritations that are either temporary or
permanent, under the title of frictions, rubefacients, vesication, and
suppuration.

                     Article I.—Frictions.

  Some practitioners employ, though rarely at the present time, fric-
tions continued for a long time, sometimes on certain articulations,
which it is desirable to render more supple, sometimes along the en-
tire course of the vertebral column, with the view of exciting  mus-
cular action, or of counteracting certain deep-seated affections.
There  are employed for this purpose  the coarser descriptions of
brushes, or portions of rough linen, which are briskly rubbed, and
with some degree of force, upon the parts we desire to irritate.
  The principal precaution  to take in  such cases is, not to rub to
the degree of congesting or reddening the skin, nor to proceed so
far as to abrade it, (a Texulcerer) or make it bleed.


                     Article II.—Massage.*

  The massage, which is much used in Russia, Germany, and many
other countries, under the character of a hygienic  resource, and for
which they have constructed in those countries establishments like
ours in France for bathing, consists in pressure,  traction, and all
sorts of movements that  another person may impress upon the dif-
ferent regions of the body.  The individuals who devote themselves
to this employment, press, pinch, (compriment) and rub with their
hands the  middle portion of" the limbs ; they twist,  draw, bend, and
extend the fingers one after the other;  they act in the same man-
ner upon  the articulations of the wrist, elbow, shoulder, foot, leg,
and thigh, and do this with the view of  rendering  the muscles and
ligaments, in fact, the whole fibro-muscular system, more supple.
As the massage may be made effectually useful, especially if there
be associated with  it a hot  temperature and vapor baths, as  in a
great number  of chronic affections,  particularly in those pains
  * [This may be translated by the word " shampooing," an ancient process in the East,
from which that of massage is undoubtedly derived.—T.] 
278
NEW  ELEMENTS OF OPERATIVE SURGERY.
termed rheumatic, it deserves  to  be retained, and its application
should be under the direction of a surgeon.

                   Article III.—Rubefaction.


  We redden the skin by creating there an artificial and unnatural
redness, analogous to that of an incipient erythema.   The means
employed for this purpose  are  hot water and all substances im-
pregnated with caloric, provided they are held at a  certain dis-
tance from the body, or are not long enough in contact M'ith it
to produce phlyctaenae.  Mustard flour, however, is almost the only
thing now used for this purpose.  We must  take care to have it
pure and fresh, and not mixed with other farinaceous matters, and
that it is made  into cataplasms. Under this form it takes the name
of sinapism.
  Up to within a recent period, sinapisms were made with vinegar
and mustard flour, under the idea  that the vinegar rendered them
more active ; at present we are in the practice of another method.
The progress of chemistry having shown that the volatile oil of mus-
tard was decomposed by the vinegar, and that  hot water  retarded
its disengagement, induced  M. Trousseau to prepare sinapisms with
cold water.  I have  generally used them in this way since 1834,
and it is certain, that in this form they act as M'ell, at least, as with
vinegar.   I have made a comparative trial of the  two kinds, by
putting the vinegar sinapism, for example, on one side of a patient,
and the  water sinapism on the other; but experience has shown
that the sinapism made with water is the most active.
  Nothing, moreover, is more  simple  than the application of the
sinapism.  The mustard flour is mixed with the Mater precisely as
has been said in speaking of naked cataplasms ; the paste is after-
wards spread upon a thick piece of linen, the edges of which are
flattened down in order to make the  cataplasm more perfect.  Ap-
plied sometimes to the plantar, or  to the dorsal surface of the foot,
the legs, or some other region of the body, even to the breasts, with
the vieM' of recalling menstruation, or between the shoulders to
check hemorrhage, the sinapism ought to  remain in its place from
one to three hours, according to the degree of irritation M'e wish to
produce, or according to the sensibility of the  individual.  If we re-
moved it too quickly, it would produce no effect; in leaving it on
too long, it might cause vesication.
   It is well to  add, that with patients in a state of unconsciousness,
as  M'omen in  convulsions or spasms, (eclampsie) and in cases of
dangerous fever, apoplexies, &c, they may appear at first to have
had no  action, though they have, in  fact, produced on the skin a
considerable degree of irritation.  It is to be remarked, that persons
who have remained three, four, and five  days without exhibiting
any appearances upon the place which the sinapism occupied, have,
nevertheless, at the moment M'hen the  senses resumed their natural
functions, been affected not only with rubefaction, but also vesica- 
CUTANEOUS IRRITATIONS.
279
tion, and in some cases even with eschars.  I saw this particularly
in a lady attacked with puerperal convulsions, and whom 1 attend-
ed in consultation M'ith M. Larrey.  [To render the mustard sina-
pism still more active and expeditious, it is often  advantageous to
sprinkle it over with cayenne pepper.—T.]
  When the sinapism is removed, we should cleanse the part with
tepid water, if it should not be requisite to produce an intense de-
gree of rubefaction.  If there should already be too much pain and
redness, we must  cover the part with cerate, or some other emol-
lient substance ; in the contrary case, we may confine ourselves to
cleansing and wiping it M'ith linen.
  In the place of genuine sinapisms, we sometimes  make use of
mustard cataplasms, or baths.  There  are cataplasms of flaxseed
meal, the exposed surface of which is sprinkled with mustard flour
before  applying them on the skin.  As these cataplasms are inca-
pable of causing vesication, and are prescribed only as gentle ex-
citants, they should remain on all night, or all day, and they exact,
moreover, no special precaution.

                   Article IV.—Vesication.

  The practice of vesication has been most extensively employed
in all  times.   It consists  in producing upon the surface  of  the
skin blisters  filled  with  a M'hite or serous fluid.   We  effect this
object  with  a great  variety of substances.   Most  of the acrid
plants, almost all  the ranunculas,  also the  euphorbias, and  the
spurge-laurel, furnish  a material for  obtaining this  result. It is
for this purpose that  bruised  spurge,  (esule) thistle,  (tithymale)
euphorbia, and ranuncula, or the juice  of these  plants, and  the
clematite  and oil  of anacardium, have   often  been  employed.
At  the present time, however, in order to produce vesication, we
scarcely ever use any thing else than ammonia, boiling water, sub-
stances dipped in boiling water, or different  preparations of can-
tharides.
  Ammonia,  when  applied  to the skin,  causes vesication  almost
immediately/   We rarely  use  it,  unless  it  be  indispensable  to
act with great expedition.   We then wet a piece of linen, or a
tent of lint or sponge  with it, and, holding it  in the  forceps, pass
it over the teguments, or keep it there unmoved for the space of a
minute.
   The Pomade  of Gondret, composed of liquid ammonia and lard,
produces most frequently a simple rubefaction, and not a true vesi-
cation.  We  rub it in with the finger, morning and evening, upon
the region M'e wish to irritate, as on the skin of the eyelids, forehead,
and sinciput, for example, in some cases  of amaurosis, until the
epispastic effect, or a  considerable degree of rubefaction,  is ob-
tained.
  Boiling water also produces vesication very rapidly; but as it
is difficult to measure its effects, it has been proposed to employ it
under another form.   Carlisle, an English surgeon, obtained blis- 
280
NEW ELEMENTS OF OPERATIVE  SURGERY.
ters by placing a wet linen, folded twice or four times, upon the
point to  be irritated; and by then  applying  to the linen the num-
mulary cautery (cautere nummulaire) heated  to a  reddish brown:
it is a mode too imperfect to be retained.
  The hammer, used by M. Mayor, is evidently preferable.  With this
instrument, which is found  everywhere, and the flat and somewhat
broad head of which is  dipped in boiling water,  we procure the
same effect as by the process  of Carlisle.  None  of these things,
however, can take the  place  of  the blister, properly so called.
With the preparations of cantharides we are better enabled to give
to the vesication the form  and  extent we desire.   Moreover, the
vesication caused by cantharides is not the only effect that we may
expect from them.
  Blisters  with  Cantharides.   Among  the  insects comprised in
the family of meloe, there  are two species,  the mylabra of chic-
ory and  the  cantharides, which are specially endoMed with vesi-
cating properties.  The  researches of M.  Bretonneau have,  it is
true, shown that the mylabras might, in cases of necessity, replace
cantharides ;  but this latter is too well known, and too easily pro-
cured, to allow of our attempting to substitute other insects in its
place.
  Under  the  character of  blister M'e use various  preparations of
cantharides.   Cantharadine, applied to the  skin by means of paper
or oiled linen, causes vesication with  certainty and great rapidity.
It  is a mode introduced  into  practice by M. Bretonneau, and one
with which I  have myself been equally well satisfied.  Others have
proposed vesicating paper, from which we have only to cut out the
slip, to   be applied to  the surface  of the  teguments; but the
method the most common, and which procures the most certain
results, is the following:  we spread the blistering ointment upon a
piece of  fine  skin or sparadrap, or, better still, on a piece of linen.
After the plaster has been properly  formed, we  sprinkle it over
with finely powdered cantharides.   We then give a margin to the
edges by a small quantity of the gum diachylon,  or fold  over the
edges of the  linen  upon  its border.   The skin having been previ-
ously cleansed, and afterwards rubbed M'ith vinegar, then immedi-
ately receives the blister, which is then  fastened with  strips of
adhesive plaster  and compresses, or with a  compress  and proper
containing bandage.
   In lieu of  blistering ointment, we  may, in a case of necessity,
make use  of leaven, (levain) or any paste whatever, which  may,
in the same  manner, be sprinkled with cantharides.   The  same
result could  also be obtained, if we simply placed the blistering
powder, wet  with vinegar, upon a piece of diachylon plaster.  This
powder,  soaked with oil,  and placed on linen, could equally well be
substituted for the plaster;  but the plaster being more convenient,
in more  common use, and  of  more certain effect, will continue to
have the preference.
   With either of these preparations,  our object is to produce two
results:  1. A more or less active irritation upon the skin;  and 2. A 
CUTANEOUS IRRITATIONS.
281
more or less abundant evacuation of serous fluid.   For the first
purpose, the blisters  are  employed as  revulsives; in the second,
they ought to be regarded as evacuants.   However, whether they
be prescribed for one  or the other of these objects, they are not the
less  divisible into two kinds,  temporary,  (ve'sicatoires volants) or
permanent blisters.  Blisters  are limited to revulsives but in a few-
cases, when, for example, they  are not  used to the extent  of
causing vesication, (des phlyctenes;)  then  their effect is reduced
to a simple rubefaction.   Whenever  they  raise the cuticle,  an
exudation  of fluid takes  place,  and  they  belong  to  the   class
of evacuants.  It is  from not  having  contemplated  their  action
in this point of  view, that the  schools of solidists and  anato-
mists have reduced  blisters to the character of simple external
irritants.   For myself, I  am convinced that blisters may, in re-
gard to  the lymph,  be compared  to  leeches;  and as respects
the  blood,  to cupping : so much so, that I would  willingly es-
tablish in  therapeutics serous or lymphatic,  as well  as sangui-
neous  emissions ;  lymphatizing,  (lymphees)  as well  as bleeding,
(saignees)

                    § I.—Temporary Blisters.

   Most practitioners understand by a temporary blister, (vesicatoire
volant) one that is not left sufficiently long  upon the skin to elevate
the cuticle, or one that is shifted from one region to another. Others
say  that the temporary blister should be kept on till the epidermis
is separated, and  that, having cut  the bladder on  its dependent
part, we should take  care not to remove  the cuticle, and  should
dress the surface with dry linen.   I admit that we may consider a
temporary blister under this point of view, but I generally employ
them in another way.  With me  the temporary blister differs from
the permanent only in this, that we do not  excite suppuration from
it after the removal  of the plaster.  Thus,  vesication being pro-
duced, I  empty the bladder by simple  punctures with the lancet
or a pin ;  I also often remove  the whole of the separated cuticle.
But  in place of beet (poiree) leaves, or* an exciting ointment, I cover
the surface with blotting-paper, (papier brouillard) or simple linen,
besmeared with cerate.   Used in this manner, the temporary blis-
ter appears to me to  constitute a mode altogether peculiar, which
I have frequently used in the last  ten years  for the purpose of
lymphatic  emissions.   The  temporary blisters, also, which I use for
this  object, differ altogether in size from that of ordinary blisters;
to point out their dimensions in  one word, it  is sufficient to say,
that the plaster should extend from half an inch to an inch beyond
the limits of the swollen  or inflamed part.  Under this form tem-
porary blisters may be applied with advantage over the entire cra-
nium, in concussions (commotions) of the brain;  upon the whole
circumference of the  neck, in certain cases of angina; upon one-
half of the thorax in pleurisy, or pericarditis; on the entire epi
gastrium, in a great  number of affections  of the stomach; on a
                              36 
282          NEW ELEMENTS OF OPERATIVE SURGERY.

large portion of  the  abdomen, in a  crowd of acute or chronic
affections of the hypogastrium; on the entire of the great articulations
in arthropathies of the soft parts ; on a limb affected with phleg-
monous erysipelas, angioleucitis, or phlebitis ; on the  greater part
of the inflammations  of the lymphatic glands ;  and on a great
number of phlegmonous inflammations.  [The great difficulty in
these vesicatoires volants, as they are called,  is, that after  even
the smallest sized phlyctrenae, or clusters  of  minute vesications
only, are once produced—and they may be  in  two hours  in  a
young, and in three or four in an adult person—it is next to impos-
sible to prevent the irritation in most cases from going on to sup-
puration.—71.]

                   §  II.—Permanent Blisters.

  Blisters that are to remain on, are also evacuants, but no longer
in the manner of the temporary blisters which  I have just spoken
of.   Designed to keep up on some part of the skin a  slight degree
of suppuration, they also have the advantage of abstracting  from
the blood any deleterious ingredient; but they do not  produce such
abundant evacuations that they can be compared to sanguineous
emissions.  Moreover, they are applied almost  always at a consid-
erable distance from the disease, and only in the character of revul-
sives.  However  this  may be, those two kinds of blisters require
the same kind of  processes in their application.  It is only in rela-
tion  to the  subsequent dressings that they differ.   When once ap-
plied, as has been said  above, the plaster, taffeta, paper, or  epi-
spastic linen, is secured by means of the containing bandage best
adapted to the form of the region to be  covered ; the blisters are
afterwards dressed in the two following ways.

                    A.  Temporary Blisters.

  Upon the supposition that we wish to preserve the epidermis, we
must,  after having  punctured  and  emptied  the  bladder, place
over the part a piece of linen, or dry paper, and secure it by a roller
or circular bandage.  As the exudation continues from the irritated
surface for some days, the portions of the dressing imbibe it, become
hardened, and are sometimes difficult to detach  ; it is, consequently,
better to besmear the paper or linen with a thin covering of emol-
lient ointment or  cerate.  In cases where we might apprehend too
much exudation, the perforated and cerated linen might be substi-
tuted for blotting paper.   We place the gateaux of lint and the
compresses over this, and then support  the whole  by means of a
bandage, as in any other simple  dressing.   If  M'e wish to remove
the  cuticle, and the sometimes very thick layer of plastic lymph
which is found under it, we separate it at first on one of the points
of the circumference of the phlyctaenae, and afterwards detach the
remainder of it, either by tearing it away, or cutting it off with the 
CUTANEOUS IRRITATIONS.
283
scissors.  The skin, being put in contact with the atmosphere by
this operation, is greatly irritated, and ordinarily becomes the seat
of very acute pain.   It is, therefore, advisable, when we look more
to the evacuant than the revulsive effect of the blister, or when we
have to deal with nervous and timid subjects, to substitute a large
emollient poultice at every other dressing.  The cuticle is detached
without pain  at the removal of the first or second poultice, and
without its being necessary to cut or tear it.
  After this first dressing, the temporary blister should be covered
every morning with paper or linen spread with cerate, and not with
leaves of succulent plants, (plante grasse.)   Treated thus, it dries,
ordinarily, in from three to six days.   We must, however, recollect,
that its circumference, or a margin (liseret) of unseparated cuticle,
constantly remains  ; that this margin, I repeat, often remains irri-
tated, and tends to  suppurate in the manner of a tourniolle.  We
put a limit to  this  slight difficulty, which might serve as the point
of departure for an erysipelas, by taking care cautiously to detach
from the margins of the blister the smallest particles of separated
cuticle.

               B.  The blister, which is to remain on,

always requires that the cuticle should be removed, that we should
dress  them  for a day or two with simple greasy substances, a beet
leaf besmeared with butter, for example, and afterwards proceed
in good season to the use of stimulating ointments.
  These ointments, known under the names of epispastic ointment,
ointment of garou,  and savin, are used  to spread  upon the linen
which we directly apply  to the denuded  integuments.   Sometimes
we  use a beet leaf, or that of the cabbage, or ivy, or a piece of taf-
feta spread with gum, or blotting paper, or simple linen.   With
taffeta and the leaves of succulent plants we generally obtain a
more  abundant and bland suppuration. But the paper and linen are
more  convenient for use.
  Permanent blisters should ordinarily be of the breadth of a five-
franc piece.  As they are to be kept on  for a certain number of
months, it is important to circumscribe them with precision, and to
prevent as much as possible their spreading and slipping.   We ef-
fect this object by a very simple precaution : a piece of linen, pierced
with a circular hole and  spread with cerate, is first placed so as to
leave uncovered that extent of skin only where we  desire to estab-
lish suppuration; the plaster spread with  stimulating ointment is
then applied over this aperture ; there remains  nothing more than
to place over the whole a compress folded double,  and the neces-
sary containing bandage.
  Unless there should be  acute pains, or too abundant a suppura-
tion, the blister, in  mild seasons, should only be dressed once in
every twenty-four hours.   Uncovering it morning and evening, as
most  patients wish, would only tend, by irritating the surface, to
vitiate the secretion of pus. 
284           NEW ELEMENTS OF OPERATIVE SURGERY.

  Blisters to the legs, thighs, or head, are supported  and dressed in
the same manner as those to the trunk, by means of the ordinary
containing bandages.  It  is the same with blisters to the  nape of'
the neck and the mastoid region.  It  is the blister to the arm only
that requires a  particular bandage.   In this region the first ban-
dage we use is a roller;  but M'e  must be particular to begin it at
the loM'est part near the elbow, and to extend it to the border of the
axilla, taking care not to make it so tight as to interfere with the
circulation below, but to give  it sufficient  firmness, hoMever, to
keep the other portions of the dressing protected from all displace-
ment.
  We must here add, that there is found in commerce, and at the
bandage-makers, different kinds of bracelets and pieces, which ena-
ble the patients themselves to perform this dressing M'ith the great-
est degree of ease.  Finally, the permanent evacuant (exutoire) blis-
ters should generally be  placed on the inside the calf, towards the
middle of the inner side of the thighs, on the outer and middle part
of the arm, and  on the middle of the  posterior region of the neck,
seeing that they are more easy to keep on and to dress in those re-
gions than anywhere else, at the same  time that they are, in those
parts, in the neighborhood, also, of a good deal of cellular tissue and
numerous lymphatic vessels.
  Notwithstanding the employment of blistering ointments, it often
happens that the blister tends to dry up.  Independently of the con-
stitution of the patient, this result may  happen from the ointment
not being sufficiently irritating, or, in fact, from its being too much
so.   In the first place, we must change  it, or increase its strength,
while, in the other, it is to  be  weakened by diluting it  with lard.
Above all, it is here important to quiet the irritation,  and to remove,
by the aid of emollient poultices, or taffeta-plaster spread with ce-
rate, the white layer deposited  on the blistered surface. We sub-
due the excess of irritation, the erythemas, and the tendency to
erysipelas, in the neighborhood of every blister, by lotions  of lead-
water, compresses soaked in elder (sureau)  Mater, or by poultices
of flaxseed.  Moreover, M'e must recollect that the temporary blis-
ter, and  even that M'hich has suppurated but from fifteen to twenty
days, produces very little change upon the mucous net-work of the
skin, and leaves scarcely any trace after its cicatrization; whilst,
in the course of a considerable  length of time, blisters may produce
fungosities and ulcerations which it  is not  always easy to cure, or
which, at least, after their cure, leave indelible marks upon the in-
teguments.

                Article V.—Drains, (Exutoires)

   The word exutoire is applied to a suppuration artificially kept up
on a circumscribed space upon the surface of the body; under this
character the permanent blister is a drain.  The same may be said
of issues, or cauteries, and the  seton. 
CUTANEOUS IRRITATIONS.
285
                          § I.—Issues.

  Cauteries, or issues, (fonlicules) are small superficial ulcers, es-
tablished with the view of preventing, moderating, or curing  cer-
tain  diseases.   Like  the  blister, and drains in general, the issue
is, at the same time, revulsive and^ evacuant. Like the blister, also,
we employ it in tM'o  different ways : 1. On certain tumors, in the
neighborhood of certain articular swellings, on the sides of the spine
in some cases of diseases of the spinal marrow or vertebrae, and on
different points of the thorax for various affections of the chest.  In
these respects,  issues may, to a certain degree, be compared to
the temporary blister, since we apply them as near as possible to
the disease, and, in general, suppress them soon, preferring rather
to shift them  upon different points, than to keep them  always on
the same.
   2.   In the  character of derivatives,  or revulsives,  issues have
some analogy with the permanent blister, since M'e ordinarily place
them on regions remote from the disease, and we sometimes keep
them in the same place for many years, and in some patients during
even their M'hole lives.   On the sides of the perinaeum, along the
spine, and on the articulations, upon different kinds of tumors,  and
the contour of the parietes of the thorax, cauteries, or issues, should
be dressed by means of bandages  adapted to 'the form of each of
those regions.
   The permanent issue,  being  scarcely ever applied but to  the
cranium, and upon the nape, arm, thigh, or leg, requires, on this
account, to be  regulated by some general rules.
   Thus, for the head,  we generally apply it upon  the anterior  fon-
tanelle.
   In the nape, I prefer placing it in the sub-occipital fossa, that is,
in the kind of depression bordered on each side by the splenii mus-
cles, above by the occipital bone, below by the spinous  process of
the axis, and corresponding to the posterior occipito-atloidean liga-
ment, than to place it, as is generally directed, near the middle of
the posterior region of the neck.  In the place that  I indicate, the
issue is nourished by a  considerable  quantity of cellular tissue,
continuous, in  some degree, with  the external surface of the dura
mater,  and in  the near  neighborhood of important  vessels  and
nerves.   It is, therefore, a region  very favorable to the action of
drains, M'hen we desire to act upon affections of the brain or eyes.
   In the arm, the cautery should be applied in the depression bound-
ed above by the insertion of the deltoid, in front by the biceps  and
brachialis-anticus muscle, and behind by the triceps muscle, inas-
much as the cellular  tissue at this point  is sufficiently abundant to
supply a good suppuration, and that the muscles cannot effect any
disturbance or change in the artificial ulceration.
   The cautery to the thigh should be placed at three or four fingers'
breadth above the inner condyle of the femur, in  the hollow which
separates the vastus  internus from the adductor magnus,  or inter-
nal border of the ham. 
286           NEW ELEMENTS OF OPERATIVE  SURGERY.

  In the leg, it must be placed under the garter, (jarretiere)  three
fingers' width below the inner condyle of the tibia, and in the hol-
low  bounded behind by the gastrocnemius internus, above by the
tendons of the pes anserinus,* and in front by the inner edge of the
tibia.
  In fine, cauteries should be applied opposite to muscular intersti-
ces, and on points that are the most abundantly supplied M'ith fatty
cellular tissue.
  Whatever may be the  locality  M'here the issue is established,
we should, nevertheless, recollect that surgery possesses many meth-
ods by which this operation is effected.   The three methods still in
use at present, are incision, blistering, and caustic.
  Issues ofy- Incision. The most ready means  we possess for es-
tablishing an issue, consists in making a small incision into the in-
teguments, and  keeping it from closing by placing a foreign body
in it.  For that purpose,  the  surgeon makes a fold of the skin by
means of the thumb and fore-finger of the  left hand ; he then di-
vides this fold, by puncture or incision, to the extent of from four to
six lines, and in  such manner as to  traverse the M'hole thickness of
the cutis. Or M'e may limit ourselves to  stretching the integuments
with one hand, whilst we divide them by a puncture M'ith the other,
holding the bistoury in the manner of a  writing pen.   The convex
bistoury, held like an arc, or in any other manner, would not offer
the same advantages.   The  incision having been made, we place
in it a small  and very hard ball of  lint of a pea shape, in order to
change it into an ulcer;  a perforated piece of linen, a layer (gateau)
of lint, and  compress, and then a suitable bandage,  complete the
operation. The dressing should not be removed but at the end of
three or four days, that is, at the period when the suppuration ap-
pears to have become  established;  M'e then insert an issue-pea
(pois a cautere)  in the place of the ball  of lint,  and the  same dres-
sing is afterwards renewed daily.
  Issues by Blistering.   When a blister, which we desire should
be kept open, constantly tends to dry up, it sometimes happens that
the patient or surgeon may wish to change it into an issue.  In such
cases, we should cover the whole surface of the blister with a piece
of linen spread M'ith cerate, and provided with a small hole in its
centre ; after having arranged this linen in its place, the opening
is filled up with a pea, which should rest bare on the  suppurating
surface ; we then apply to this pea a compress several  times folded,
and a suitable bandage ; thus pressed, the pea gradually excavates
a hole in the skin, and ultimately excites a suppuration there, more
or less abundant, while the linen, spread with cerate, and renewed
every morning, rapidly dries up the remainder of the suppurating
surface.
  This kind of cautery is decidedly bad.   The skin, not being divi-
ded, and only depressed, tends  continually to rise upward, so that,

  * [Patte d'oie, or  pes anserinus, is a phrase applied to the tendons of the sartorius,
the gracilis, and the semi-tendinosus, near their insertions  into the upper part of the inner
surface of the tibia.—7.] 
CUTANEOUS IRRITATIONS.
287
without a sufficiently strong pressure, carefully watched, the issue
would disappear from one day to the next.  It  should  not  be pre-
ferred, therefore, except in patients who  are exceedingly timid or
unreasonable.
  In timid persons, who have  an extreme dread of every kind of
pain, we establish sometimes a small blister, by means of ammo-
nia, boiling water, or cantharides, in order that we may proceed, at
the end of some days, or almost immediately, in the manner I have
just pointed out.  But M'e have the  same objections to make to this
kind of  issue as to that which precedes it.
  Issue with Caustic. The caustic most generally used for making is-
sues is potash prepared by alcohol.  We begin by placing on the skin
a piece  of sparadrap or diachylon plaster, of the diameter of from
twelve to fifteen lines, and pierced in its centre with an aperture of
one to two lines in width.   It is  this aperture which  must corre-
spond exactly to the point upon the skin that we wish  to ulcerate;
we then place in this opening  a small particle of very dry potash,
of the size of a large pin's head, or a grain of hemp-seed ; a second
piece of diachylon plaster, as large again as the first, is applied over
this; the whole is covered with a compress  three or four times
folded, and then we  apply a suitable containing bandage.  Some
time after the potash liquefies, by combining with the tissues ; a pain
somewhat  acute  is  then  soon experienced by the patient, but it
rarely continues over four to eight hours.   At  the end of six hours
the caustic has generally produced its effect;  what then remains
of it is changed and almost entirely neutralized. We might, therefore,
without danger, defer removing the dressing until at the expiration
of twenty-four hours.   In the fear, however, that the  potash, now
become liquid, might spread itself to a greater distance than is
proper, we are in the practice of removing it  from the skin at  the
end of from six to eight hours.   This unavoidable liquefaction of
the caustic, in fact, requires that we should calculate  upon it, and
apply to the skin  a particle of potash only one half or one fourth
the size of the eschar that we wish to produce.  Thus, for an issue
of from four to six lines, we use a piece of potash of the diameter
of from one to tM'o lines.
   Employed in this way, the caustic  produces an eschar which in-
cludes the entire  thickness of the skin,  and requires from ten to
twenty  days to become detached.  When the  eliminatory inflam-
mation  has expelled it, we place a pea in the ulcer and the issue is
established.  If we  wish  to proceed more expeditiously, we may,
on the very first days, make a crucial incision upon the eschar, (le
pointescarrifle) raise the four angles of the division, and adjust the
pea immediately.  If, as sometimes happens, the eschar should con-
tinue to dry up gradually, and to favor cicatrization in the tissue be-
neath, it will be necessary to dress it with some irritating ointment,
as, for example, basilican or epispastic ointment.   In the contrary
case, that is, when it is surrounded  with a florid (sanguine) inflam-
mation, we  must  have  recourse to emollients in general, and par-
ticularly to  flaxseed poultices.   If  every thing goes on  regularly, 
288           NEW ELEMENTS OF OPERATIVE SURGERY.

and we neither wish to hasten nor retard the separation of the es-
char, we may limit  ourselves to dressing it every morning with
linen spread M'ith cerate.
  Once established, the issue may be kept running by the ordinary
pea, that of the iris  root, (pois d'iris) or  of wax, or  the different
kinds of medicinal peas.
  Those M'ho are interested in  the manufacture have,  naturally,
maintained that such or such a  description of pea offers more ad-
vantages than any others ;  but practice demonstrates that it is a
matter of very little moment whether we use this or that kind.  If
the issue is to have more than four to six lines of diameter, as is seen
in issues employed as counter-irritants, it is often advisable to place
in it, at the same time, tM'o, three, or four peas. [The common gar-
den pea Dr. Mott considers as good as any thing.—T.]
  The  derivative issue is, however,  kept open  very well by the
presence of only one  of these peas.  The issue peas, perforated and
attached by a thread, have the advantage of being more easily re-
tained  in the ulcer, and of allowing of their removal Mdthout diffi-
culty.  They are, also, so much the more preferable, because vege-
table peas, increasing in size under the action of the humidity of the
parts, sometimes become confined within the  ulcer; and wax peas,
or the  different sorts  of medicinal peas, permit themselves to be
partially covered over, during the interval between the dressings,
by the  contraction of the small purulent cavity.
  The  dressing of issues is also  a very simple affair; after having
M'ashed and cleansed the ulcer, we place the pea in it, taking care
to raise up its thread and fasten  it outside by a small  slip of adhe-
sive plaster, (diachylon.)  We then place  over this either an ivy,
cabbage, or beet leaf, which has been previously wilted at the fire,
(ramollie par la chaleur)  and had the ridges upon it removed, or a
small plaster of diachylon, or  taffetas, (taffetas  gomme;) linen,
spread with cerate, would not sufficiently promote the suppuration,
and plasters of the mother ointment (onguent de la mere) have the
disadvantage of soiling the skin too much.  A compress, many times
folded,  is placed over the whole, and the rest of the dressing  is, in
every respect, similar  to that for a blister.  An issue in the sub-
occipital fossa, concealed by a plaster,  and then  by the  hair, may
be very neatly adjusted with the aid of  the upper edge of the cra-
vat ; but it is better  to support it by means of a plaster, or a band,
the two extremities of  which are attached to the  front part of the
head, or brought back  upon the nape, and then  around the neck.
For the arm, the issue bandage is exactly  similar  to that for a blis-
ter.  For the thigh, or  leg, we use only a simple circular bandage;
we may add, that the issue, also, should not be dressed but once in
twenty-four hours, unless there  is too abundant a suppuration, or
some special indications.

                    \ II.—Seton, (Fig.  167.)

   In surgery, the word seton signifies three things: 1.  A linen band
which  we pass through certain cavities, where we wish to promote 
CUTANEOUS IRRITATIONS.
289
suppuration, or retain the principal openings ;  2. A drain, formed
by a kind of sub-cutaneous fistula, which is kept up artificially by
the presence of a skein (meche) of linen, (linge) or cotton ;  3. The
operation which is performed to establish this drain.

                             (Fig. 167.)
  As  a drain,  the seton has some analogy with the issue.  In the
place  of effecting a purulent exudation upon the surface of the skin,
it exerts its action on the sub-cutaneous cellular tissue.   So also is
it more powerful and effective than the blister, properly so called,
and even than the simple, issue in deep-seated affections.
  The seton may be applied upon all the regions of the body—on
the head, face, or neck ; on the chest, for diseases of this cavity ; on
the hypochondrium, in affections of the liver ; above  the  pubis, in
some affections of the bladder ; to the perinamm, for diseases of the
prostate ; on the joints, affected M'ith white swellings ;  everywhere,
in fact, where  it may be useful to establish  an irritation and a de-
rivative suppuration.  Nevertheless, we rarely employ a seton as a
drain, except on the back  part of the neck.   Thus, also, many au-
thors speak only of the seton to the nape.
  To  perform this operation upon the  nape, we  must have—1. A
straight bistoury, an abscess lancet, or the instrument known under
the  name of the seton needle;  2.  An eyed  probe,  (stylet-aiguille)
threaded with  a narrow strip of band, or  a  skein of cotton; 3. A
perforated piece of linen, besmeared with cerate, a gateau of lint,
a long compress, and a band of two to three  yards in length; 4. A
napkin, (aUze) hot water, and sponge. 
290           m;\v elements of operative surgery.

  The patient, being  seated  on a chair, or lying down upon his
side, inclines his  head forM'ard.  The napkin  is  placed on  his
shoulders, in order to attach its two upper  angles to the forepart of
the chest.  The surgeon then makes a longitudinal fold in the mid-
dle of the nape, gives one of the extremities of this fold  to an as-
sistant, holds the other fast himself with the fore-finger and thumb
of his left hand, M'hilst with the right hand, holding the cutting in-
strument, he quickly passes through its base.  If he uses the straight
bistoury, he may, if necessary, direct its cutting edge, in that case,
downwards or  upwards, from left to  right, or from right to left;
but I find it  more convenient to hold it like a writing pen, and to
carry it from right to left, with the back turned either upwards or
downwards.  In this manner, the bistoury, having traversed the tis-
sues horizontally in the line of its upper or loM'er border, easily al-
Iom's of the first incision being enlarged, either in advancing or in
coming out again, (en ressortant) if we take care to elevate its han-
dle a little as  soon as its point has transfixed the cutaneous fold.
Before withdrawing it, we cause the probe, threaded with its skein,
to slide in upon one of the sides of its blade; we  may  also pass
this probe from the handle towards the  point, or from the point
towards the  handle of the bistoury.  As soon as its button has
passed beyond  the double incision, we remove the cutting instru-
ment, in  order to take the probe, which  we  draw with one hand,
while with the other we support and direct the skein.
   The large or abscess lancet,  which Mas formerly much employed,
and which is scarcely any longer used at present, has the advan-
tage of making a wound in entering and  one  in passing out of per-
fectly equal dimensions, and perhaps, also, of causing a little less
pain ; but, by means of a gentle oscillating movement, (leger mouve-
ment  de bascule)  the bistoury easily gives the same result as the
lancet; and as it allows of our making an  incision sometimes nar-
row and at other times wide, according to the desire of the surgeon,
and as, in taking care, when we withdraw it,  to press with its back
against the tissues, it causes no more  suffering after the incision is
made, it is very natural that  the abscess lancet should have been
generally laid aside.
   The  seton needle, a kind of abscess lancet, a little curved on its
flat part, very  thick, and also  with a transverse  eye near its heel,
In order to receive the skein, has the  advantage of easily piercing
through the parts, and, at  the same time,  of drawing along after it
the skein or band which is to  remain in the wound.
   The only objection that can be urged against this needle, the in-
vention of Boyer, is that of not  being indispensable, and of not giv-
ing to the incisions, as the bistoury does, sometimes a greater and
 sometimes a less diameter.  [The seton needle is used and prefer-
 red by Dr. Mott, who, when he has none at hand, has recourse to
 an ordinary lancet and eyed probe.—71.]
   Meanwhile, the skein, once passed through, should be detached
 from its  conductor.  As it had had  its  shorter extremity doubled,
 upon its longer one, and  been  besmeared with butter or cerate, it 
CUTANEOUS IRRITATIONS.
291
suffices to undouble it to have an opportunity of detaching, also, the
needle and probe from  it.  The wounds and all the parts soiled
with blood are now wiped;  then the perforated linen is adjusted ;
we fold the short head of the skein over this and a little to the upper
side;  to this succeeds the layer (plumasseau) of lint and the com-
press.  This being done, M'e must roll up, (pelotonner) or fold upon
"tself a sufficient number of times, the long portion of the seton skein,
in order to raise it, in the  form of a pacquet, upon the exterior fold
of the compress, to the  point where it would be least liable to be-
come soiled.   The band  serves to fasten the whole by means of
some circulars. In the neck, as everywhere else, we ought to pierce
only through  the skin  and  the sub-cutaneous fascia.   If  the en-
veloping aponeuroses were comprised in the incision, it would run
the risk  of wounding  the  muscles,  arteries, and  nerves, or, at
least, of producing deep-seated suppurations.   The two  wounds
of the seton  should be  separated at least an inch apart, and even
an inch and a half when we have no fear of exciting too abundant
a suppuration.  It is, moreover, easy, in measuring the fold of the
skin, to know very nearly what will be the  length of the  perfora-
tion, since the skin of this fold, when once left to resume its place,
will be one half wider.  In the place of  a  narrow  linen band,
we employ, in some cases, a roll of cotton thread ; M'e have thus a
less irritating skein,  one generally easier to move, and much ex-
tolled by Dupuytren.   But for that reason alone, that this skein is
less irritating, (plus douce) it is far from being suitable in all cases.
At any rate, we should be wrong in conceding to the one any very
superior efficacy over  the other.  We do not generally dress the
seton for the first time till at the end of three or four days; that  is
to say, at  the period when the suppuration shall have been estab-
lished, the same as with wounds in any other operation.
   Subsequent dressings. The bandage being  removed, we take care
to separate the two portions of the seton both from the compress and
from the layer of lint, and from the perforated linen, which are de-
tached with care ; we remove or cleanse off, with a sponge dipped
in hot M'ater, the matters  or incrustations in the neighborhood ; we
moisten, in the same manner, the  middle portion of the skein, (le
cdte du plein de la meche) if it  is hardened  by its contact M'ith the
blood or pus.  We besmear this portion of the skein, to the extent
of four to five inches, with cerate or some other ointment; we then
seize its free  extremity and draM'  it to the other side, in order to
bring the  fresh  and newly anointed part  into the wound.  The
soiled end of the skein is immediately removed by a cut of the scis-
sors, and the  surgeon has nothing farther  than to proceed to the
dressing, as in the first instance.   These dressings are afterwards
renewed every day, or even more frequently, the same as in treat-
ing an issue or a blister.  The  skein first applied will answer for a
longer or shorter time, according as it  has  greater or  less length.
When it is nearly exhausted, it is  unnecessary to  recur to instru-
ments to introduce a new one.   All M'e have to do is to attach the
latter through a slit in the old one, which thus answers the purpose 
292           NEW ELEMENTS OF OPERATIVE SURGERY.

of a probe or needle for the new one.   Nevertheless, we might
stitch their ends together with a needle.  The skein (meche) of
cotton would require that the filaments of the extremity of the old
one should be intertM ined with those of the extremity of the  new
one, and that they should be fastened together by some circular
turns  of thread.  It is unnecessary to add, that this union should be
freely anointed with cerate and smoothed down  regularly M'ith the
fingers in both cases, before forcing the new skein to follow the old
one through the  opening.   If, however, either by accident or inad-
vertence, we should have entirely  withdrawn the exhausted skein,
the probe would easily suffice* for introducing the new one.  It is
to be remarked, that this last method causes, in reality, much less
pain than the others, and that, if it is not employed, it is because
of the fear M'hich patients  have of it, from the idea they attach in
their minds to every  thing which  bears  the  name of an instru-
ment.
  When the seton is applied to children, or intractable persons, we
guard ourselves against any displacement of the skein, by taking
care to tie the two ends into a knot to make a large circle of it,
which should be folded and collected together into a pacquet upon
the most elevated part of the bandage.

                 § III.—Accidents from Drains.

  Blisters, issues, and setons, are liable to  various accidents. They
often cause, for example, simple erysipelas, and this  accident be-
longs  more particularly to blisters than to the other drains.   Often,
also, these  artificial ulcerations produce either angioleucitis, prop-
erly so called, and  all its consequences, or engorgement and inflam-
mation of the lymphatic ganglions in the neighborhood.  It is  also
possible, and this is to be remarked more particularly of the seton,
that drains might produce phlegmonous  engorgements, and even
true abscesses.   We may indeed suppose  that they may become a
point  of departure for purulent infections,  either by phlebitis or re-
sorption; but this last accident must necessarily be very rare.  One
of the most common results  is the affection  of the lymphatic  sys-
tem.  If all practitioners were aware how many patients there are
M'ho have kernels  in the neck  and under  the jaws, and are after-
wards labelled with the title  of scrofulous subjects, merely in  con-
sequence of drains they have worn, for a longer or  shorter time
previous, either on the nape or cranium, we  should see fewer of
those emunctories established permanently in patients who cannot,
in reality, derive any advantage from them.   In fact,  the different
diseases of which I have just spoken are liable to the same dangers,
and require the same kind of treatment, when caused by drains as
when originating from any other source.   On the supposition  that
the accident has yet but just commenced, or presents itself under a
mild form, it is  possible that we may arrest it by means of simple
emollient compresses, or mild topical applications, even though the
drain be continued.   In the  contrary case, unless there shall be 
CUTANEOUS IRRITATIONS.
293
urgent necessity of keeping up the artificial ulceration, we  should
remove from it every foreign substance and source of irritation.
  Drains also cause irritation when they are not attended to with
all the care which is required to keep them clean.   In such cases,
by means of better-arranged dressings, they soon resume their nat-
ural course.  When a drain is  covered with fungous growths, or
cellular granulations too prominent, we repress their surface by
powdered alum, or nitrate of silver.  If the blister tends to spread
too much, or more on one side than another, we can easily circum-
scribe it by leaving a single aperture only open in the cerated linen,
or blotting paper, intended to cover all the rest of the surface.
  The issue, which also  sometimes tends to eat in, or to become
displaced by progressive ulcerations, either owing to the weight of
the peas, or in consequence of pressure improperly applied, cannot
be restrained in its natural limits but by pressure in a contrary di-
rection, and by a carefully adjusted dressing.  We prevent the track
of the seton from cutting itself through, and its incisions from be-
coming extended in a vertical direction, by taking  care to fold the
skein, at every dressing, in such manner that, by placing it rather
towards the  occiput than in the direction of  the shoulders, it shall
exercise no  traction upon the wound.   If the seton, from lack of
irritation, should no longer incline to suppurate, we may re-excite
it by substituting for the cerate, with which the skein is besmeared,
either basilican, balsam of Arcaeus, or any other drawing (epispastic)
ointment; so, also, if it should happen to excite the parts too much,
we should cover it morning and evening, for some days, with emol-
lient cataplasms.

                  § IV.—Suppression of Drains.

   Patients who wear a drain for a long time are generally fearful
of drying them up.  Regarding this artificial ulceration as an emunc-
tory intended to  draw off the noxious humors of the body, they gen-
erally imagine  that, if suppressed, the  matters which had issued
from them would ultimately  produce some serious affection.  Phy-
sicians are divided on this question into two  classes.  Some, indeed,
treat the  fears of common  people, relative to the suppression of
drains, as chimerical, and class among the tales of old women every
thing that our ancestors have said on this subject.  Others concede
that  there may be  sometimes danger in too suddenly arresting an
old drain, but they explain it on the  principle of  the influence of
habit, by saying that the sudden disappearance of such an irritation
may well cause disturbance in some of the functions.  It is a sub-
 ject which has been, in my opinion, treated of too lightly.  Modern
researches on the  condition of the humors and the state of the
blood in  certain patients, authorize us in believing that an issue,
 seton, or blister,  might, in truth,  abstract from the natural fluids
 some elements or principles that it would not be well to leave there;
that these emunctories might, in fact, have, to a certain extent, the
property of purifying the humors, as was believed in ages past. From 
294           NEW ELEMENTS OF OPERATIVE SURGERY.

whence, therefore, it is reasonable that, when M'e wish to suppress a
drain that has existed for some time, we should do it  only by de-
grees, or, in fact, temporarily substitute another for it, and reinforce
our hygienic precautions, by administering  internally some  tisan
and  depurative  drinks, such  as the decoction  of dock, burdock,
chicory, and the  juice of herbs, together with purgatives.
                         CHAPTER III.

                     CAUTERIZATION.

  In surgery, we give the name of cauterization  to an operation
M'hich has the effect to destroy the vitality and organization of the
tissues to a certain depth.  We obtain this result by two kinds of
agents: 1.  By certain chemical substances which, on that account,
take the name of potential cauteries; 2.  By inert  bodies  charged
with caloric, and which are known  in this  state under the title of
actual cauteries.

                Article I.—Potential  Cauteries.

  We use  potential cauteries, or chemical caustics, to  change the
surface  of certain wounds and ulcers, to destroy tumors, or estab-
lish artificial ulcers or issues.   It  is  thus we daily put into use the
nitrate of silver and nitrate of mercury, caustic potash, butter of
antimony, Vienna powder, the paste  of Frere Come, or that of zinc,
and many of the concentrated acids.   All these substances cause,
for their first effect, the formation of an eschar ; but, as they do not
all act  in  the  same manner, nor with the  same energy, there are
some of them that are much used, and others that are scarcely ever
employed.

            § I.—Nitrate of Silver, or Lapis Infernalis.

   The caustic most used is, unquestionably, the nitrate of silver.  I
do not speak of  its employment here under  the form of solution or
ointment, but solely as nitrate of silver liquefied  or crystallized. It
is in this solid state that it is used to touch strictures in the urethra,
the interior of the nasal canal, the pustules of small pox, the vesicles
of zona, and other cutaneous eruptions ; the SM'ardy  (couenneuses) in-
flammations in the  interior of the mouth and pharynx, erysipelas,
cysts that we M'ish to inflame, the interior of certain abscesses, the
track of certain fistulas, and the  surface of wounds and ulcers in
general.  When the lapis infernalis is to  be applied to an ulcer,
with the view of repressing its cellulo-vascular surface, the surgeon
should use it gently by rubbing a  little upon all the exuberant veg 
CAUTERIZATION.                     295
etations, with the precaution, however, of leaving untouched about
a line's breadth of the outer pellicle which  generally occupies the
periphery of the wound.  The ulcerous surface whitens thus in a
few moments, and is converted into a thin inorganic lamella, which
is detached and falls off in the space of twenty-four or forty-eight
hours, and allows of our repeating the same operation at the expi-
ration of this time, if all the prominences upon the wound have not
been sufficiently reduced.
  In abscesses, cysts, and  fistulas, we  apply the nitrate of silver
crayon to the interior of the  cavity, so  as to touch with a certain
degree of force  the whole extent of its walls.  In the mouth and
pharynx we proceed as in  wounds;  it is the same in certain cases
of fungous or purulent ophthalmias,  with certain degenerations in
the neck of the uterus, certain varieties of eczema, erysipelas, &c.
If, on the other hand, it is proposed to cauterize ulcers of the cornea,
or cutaneous vesicles  or pustules, it is important to have a straight
crayon, sometimes slender, or cut  into a shelving edge, or tapered
into a  point, and to appply it rather quickly upon  the point to be
touched and to withdraw it as soon as possible.  Around the nails,
where we often find the  tourniolle, or that purulent condition known
under the name of onglade, the crayon  of nitrate of silver, shaped
in a wedge form, should be inserted as  deeply as possible between
the cutaneous fold and  the horny plate.  We  proceed in the same
manner in cauterizing the inner side of the gum when  there should
take place between it and the teeth any diphtheritic (diphtheritique)
inflammation, or actual ulcerations.
   The pupil ought not to forget that the nitrate of silver blackens
the skin; that the skin, thus spotted, retains from six to ten days
the appearance of being stained with ink ;  that it is the same with
linen we use for wiping it; and that if, after having used it, we do
not take care  to dry it well,  it will liquefy and be decomposed in
the case.  It is,  in fact, owing to this very property  that nitrate
of silver has of causing black spots upon linen and the skin, that it
is sometimes used  to mark  the places where we wish to use the
bistoury, and to note the changes M'hich are effected in the size or
length of certain parts.
   In conclusion,  the  nitrate  of silver,  which rather  modifies  the
surface of the tissues  than  really cauterizes them, and which is
incapable at most  of producing a deep eschar, has the advantage
of being exceedingly convenient for  handling, and of favoring the
cleansing and  desiccation of surfaces at  the same  time that it
represses or destroys (mortifie) them.

      § II.—Nitrate of Mercury, (Nitrate Acide de Mercure)

   The most valuable caustic after the nitrate of silver, is unques-
tionably the nitrate of mercury with  excess of acid.  I have myself
used it for a  great many  years, with marked advantages, in an
infinity of diseases, in all kinds of ulceration resulting from syphilis,
for example, in many varieties of scrofulous ulcers,  in scorbutic 
296
NEW  ELEMENTS OF OPERATIVE  SURGERY.
ulcers, ulcerations of the neck of the womb, and for all  growths,
(plaques) whether ulcerous or incrusted, or with vegetations of the
integuments, which threaten to take on, or have already assumed, a
cancerous aspect.  This  caustic, being liquid, is enclosed in a vial,
which must be stopped M'ith emery, since it rapidly acts upon cork,
or any other vegetable substance.  We dip into this liquid a  small
pencil of lint, fine linen, or sponge, firmly attached to the extremity
of a rod of wood or whalebone, then gently touch M'ith it the sur-
face to be cleansed, taking care to protect the  neighboring tissues
by means of linen,  lint, or a piece  of diachylon plaster.  If  we
have under treatment ulcerations whose  surface alone has need
of being modified, we only touch  the parts lightly with the pencil
moistened with the nitrate.  We proceed in the same manner, also,
at the bottom of fistulas, and of openings and different  kinds of
burrowings of parts, (decollement.)   It is only in cases  of cutane-
ous exuberance,  and of parts that are actually to be destroyed, that
we should bear on  with a certain degree of force.   We might also
here replace the  .pencil or sponge by a glass  tube, which  is easily
charged with a drop of caustic, and which would conduct it  with-
out difficulty to the diseased part.
  Moreover, if we wish to make use of the same pencil again,  we
must stir it briskly  in water  immediately after  using  it, in  order
to clean  it and  separate from it every remaining particle of  the
acid. The eschar that the nitrate of mercury makes does not gen-
erally disappear  so soon on wounds,  but sooner on the skin, than
that from the nitrate of silver.  The applications, also, of the former
should only take place every four or five days, while we may repeat
those of the latter  every second day.  After cauterization with  the
nitrate of silver,  we dress either with the perforated linen and lint,
or with cataplasms, as in simple cases.  The nitrate of mercury
allows us to proceed in  the same M'ay when  the cauterization is
superficial  and of  little extent;  but in the contrary case it may be
necessary to  cover the part  either with compresses or emollient
cataplasms, at least during the first  twelve  to twenty-four hours.
Like the nitrate  of silver, the nitrate  of mercury employed in this
manner, it is said,  does not appear to be susceptible of  absorption.
This last fact, however,  is not placed entirely beyond dispute. I
have seen some accidents,  M'hich seem unquestionably  to prove
that the nitrate  of mercury, to a certain extent, passes sometimes
from the cauterized surface into the mass of the circulation. I have
seen, for example,  two or three women who had undergone only a
gentle application  of this caustic upon the neck of the uterus, and
who, on the day  after, or the day after that, were seized with a pro-
fuse mercurial salivation.  I have observed the same thing in another
woman, in whom I had very slightly cauterized a simple cutaneous
ulceration  a little above the right knee.  I have even seen acci-
dents much more serious supervene after the employment of nitrate
acid of mercury, but I would not venture to  affirm that they were
really the effect  of this caustic, rather than of some of those coinci-
dences that so often surprise us in practice.  It is enough, however, 
CAUTERIZATION.
297
to show that we should not use this nitrate but with caution, and
that we should closely watch its effects.

                     § III.—Other Caustics.

   A. Butter of antimony,  nitric, sulphuric, and hydrochloric acids,
and ammonia, are attended with such difficulties in their employ-
ment, that we generally substitute  for them the potash, or some one
of the compositions of which I am  about to speak.  Having shown
the mode of applying caustic potash to the skin when treating of
cauteries and issues, I do not think it necessary to recur to it here.
If we desired  to make use of butter of antimony, or the concen-
trated acids, as is still sometimes  done to circumscribe malignant
(charbonneuses)  affections, the malignant pustule, or hospital gan-
grene, M'e should moisten a pencil of linen or lint with them, or
conduct them through a glass tube, as has been described in speak-
ing of the nitrate of mercury.
   B. The paste of Frere Come, which is  composed of arsenic,  old
burnt shoes, and spider's web, like the powder of Rousselot, and all
arsenical compounds, for a long time in vogue, has the advantage
of cauterizing only within the limits that we trace for it, though it
does so to a sufficient depth, and of allowing, also, the cicatrix to be
formed under the eschar; but it  has the inconvenience of being
susceptible of partial absorption, and of  hazarding, therefore, the
poisoning of the patient.  I shall  return to it in speaking of the
destruction of tumors.
   C. Vienna Paste.   There has been in use for some time a paste
composed of five  parts of potash and six  parts of lime, triturated,
and reduced to a paste by adding thereto a small  quantity of alco-
hol. This composition, known under the  name of Vienna caustic,
applied in the manner of caustic potash, produces its effect in less
than a quarter of an  hour, and appears to cause, perceptibly, less
pain than the caustic potash or concentrated acids.  It may, there-
fore, be used for making issues.
   D. Zinc  Paste.   PvL Canquoin has introduced into practice a
paste, which, when prepared, presents in some  degree  a resem-
blance to the color, elasticity, and consistence of caoutchouc.  This
paste, which may be preserved for  a great length of time, and car-
ried in the pocket like taffeta, [court-plaster—vid. English Taffetas,
supra,]  is composed of chloride of zinc, meal, and a little water.
The inventor recommends the addition of a small  proportion of the
butter of antimony;  but I  have made some with the hydrochlorate
of zinc, flour, and a  small quantity of water, which appears to be
endowed with all the properties of the paste of M. Canquoin.
  To apply it, it should be cut into pieces of greater or less size
and thickness—to produce eschars, from two lines even to an inch
in thickness—destroying the  tissues as if they were separated by
a cutting instrument; with this provision, however, that we should
have previously removed the cuticle from the skin, for without that
the zinc paste has absolutely no action.   It is. however, a caustic
                              38 
298
NEW ELEMENTS OF OPERATIVE SURGERV.
which has scarcely any use but for cancerous affections, and of
which I shall speak M'hen treating of the extirpation of tumors.
  [Caustics.  Sir Benjamin Brodie, in some late practical remarks
on caustics, says, when you wish to keep open the edges of an ori-
fice to a  sinus, &c, lest matter should form  M'ithin, it is better to
use caustic  potash than nitrate  of silver, as he has seen the latter
close it.   In the bite of a dog, as in the hand,  where you cannot lie
sure of completely excising the complex tissues, melt the alkali in
a platinum«cup, and dip in a blunt-pointed probe, M'hich latter, be-
coming thus incrusted with the caustic, may be made with cer-
tainty to penetrate beyond  the  deepest part that the saliva of the
dog has reached.   The alkali is equally efficient in destroying the
bottom  of a diseased  lymphatic gland that has suppurated.  For
warts on  the penis or pudenda, nitric acid is  often better than the
nitrate of silver, which is in those cases too  weak.  Or the nitric
acid,  3j.,  may be used in combination with  3 ij. of muriated tinc-
ture of iron.  And for  these warts  a good escharotic, also, is pow-
dered savine and aerugo aeris sprinkled upon them, as it causes
sloughing.  To avoid destroying the surrounding skin, have along
with you  some vinegar when you  use the alkali, and bicarbonate
of potash when you use chloride of zinc, and so with  other caus-
tics.  Little vascular spots in children's faces, formed from a large-
sized vessel M'ith several branches, may be treated  thus.  Touch
the principal vessel M'ith some  nitric  acid in  a glass pen, or insert
into a puncture in the  vessel a fine point of potassa-fusa, and you
destroy the vessel, and by a little vinegar outside  prevent the skin
being injured.  You thus  obliterate the vessel without leaving a
scar,  tie recommends, also, nitric  acid to small mulberry-colored
superficial congenital  naevi (agglomeration or meshes of blood-
vessels) on the skin, but the insertion of red-hot needles, (not named
by Sir B. Brodie,) we may remark, have superseded every thing
by their admirable efficiency in completely and harmlessly eradi-
cating the worst description of these naevi, even in infants of a few
months  old.  In  sub-cutaneous  and  purple-colored naevi, Sir B.
Brodie recommends caustic as far preferable to ligature. Puncture
them, he says, with a finely-pointed lancet, and introduce a probe
which has been  dipped into fused nitrate  of silver.   Sloughing
ensues, and then obliteration of  the vessels.   If the tumor is large,
repeat the  application.   You  save the skin by  using a narrow
instrument for dividing it.   Use olive oil in the vicinity, to prevent
excoriation from the nitrate of silver.  But in these naevi, also, Dr.
Mott has  used  the red-hot needles with the happiest results.  Sir
B. Brodie  recommends, also, for  certain purposes, pastes containing
mercurial compounds;  but as a general rule, we think all mercu-
rial applications are to be avoided where other caustics will answer
equally well or better.—(Vide Medical Times,  1840; Medical Ga-
zette,  1841.)  Dr. Roe, of New York, greatly  extols the use of con-
centrated nitric acid,  as for the formation of a large eschar upon
the proecordia  in  chronic inveterate affections of the digestive or-
gans, &c.—T.'j 
CAUTERIZATION.
299
                Article II.—Actual Cauteries.

  If all substances charged with  caloric,  and which when  ap-
plied to the tissues would  produce an eschar, merited the title of
actual cautery, boiling water, inflammable oils, and the different sub-
stances employed for making moxas, would take this name, as well
as metals heated red-hot in the fire ; but usage has  decided other-
M'ise, and obliges me to reserve the title of actual cautery for instru-
ments of iron, steel, brass, &c, which, after surcharging them with
more or less caloric, are used for the purpose of destroying the tissues.
  I must, however, speak of the moxa before examining metallic
cauterization, properly so called.

                          § I.—Moxa.

  Much employed  in China and  Egypt for many ages past, the
moxa rarely entered into the practice of European surgeons until
at the close of the  last century.  Its form  and nature, since then,
have been  singularly  varied.   That which is most  frequently used,
is made of cotton, strongly pressed in the form of a cylinder in a
piece of linen or old compress.
  To form it we take a piece of carded cotton, which is  rolled up
and shaped into  a cylinder, and then enveloped in linen, which is
tightly wrapped around it, so as to give to it the consistence of a
peloton of wool.  We  fasten the whole by means of a thread, which
is bound around the cylinder from one end to the other, or sewn by
a close stitch along one of its sides.  We divide the cylinder thus
constructed into pieces of from eight to ten lines in thickness, the
diameter of which varies from three lines to an inch.
  Instead of enclosing the cotton  in linen, some persons find it
more convenient to besmear it with a solution of gum.   But  the
moxas made in this  manner  are  generally too soft.  In order to
render the  cotton more combustible, others impregnate it previously
with a concentrated solution of nitrate of potash. This last modifica-
tion is  worthy of being preserved.
  To apply the moxa, we seize it with a dressing forceps, or with
the porte-moxa, (Fig. 168, a) a kind of ring with three feet placed
at the end of a long handle, or by adjusting it in an aperture in a
piece of pasteboard ;  it is applied bare by one of its extremities to
the part we wish to cauterize.  We then apply the fire, unless we
should have preferred to ignite its free extremity before applying it.
To keep up the combustion, we are obliged to blow it.  For this pur-
pose we do not use the mouth, because of the smoke and sparks which
M'ould be thrown on the face, and the fatigue which would neces-
sarily result from it, but the tube constructed by M. Larrey,  (Fig.
168, b) or a simple bellows.  The  surgeon, provided with forceps,
holds the moxa in onehand, and with the other fixes the mouth of the
bellows, or the point  of the tube,  in order to be enabled to regu-
late it  conveniently, while  an assistant puts the instrument  into 
300
NEW ELEMENTS OF OPERATIVE SURGERY.
action.  If the current of air should fall constantly upon the same
point of the moxa, the burn would be made in an irregular man-
ner.  We must proceed, therefore, in such way that the beak of the


                            (Fig. 168.)
bellows corresponds successively to  all the points on the burning
surface.
  When the fire reaches to about three lines from the skin, it be-
gins to occasion a little pain.  This pain afterwards becomes more
and more acute, until the eschar is formed;  that is, until the cylin-
der of cotton is entirely burnt.  At the moment when the fire comes
in contact with the  teguments,  there  is heard  a snapping noise,
(petillement) or a species of crackling, (craquement) altogether pe-
culiar, and caused by the skin becoming crisped and  split, (se fen-
dille.)   It  is proper, during  this operation, that the neighborhood
of the parts should  be covered  by linen, to protect them from the
sparks and particles of fire scattered about by the action  of the
bellows.
  The pain which results from the application of the moxa, gene-
rally less acute than the patients expect from it, does not cause 
CAUTERIZATION.
301
 them to cry out, until the burning approximates  the  layer of the
 moxa next to the skin.
   If it be desirable to apply several moxas to the  same region, we
 proceed with the second, and then with the third, in-the manner al-
 ready described.
   We obtain by this operation a blackish colored eschar, a little
 crisped, and which penetrates to greater  or less  depth, according
 to the thickness of the moxa and the time it has taken to burn.  Or-
 dinarily, however, it includes only a part of the thickness of the in-
 teguments, and does not reach, but  with few exceptions, or by acci-
 dent, to the aponeuroses  or tendons.   As it is necessary that  the
 eschar should fall off from the effect of the inflammation, it is cov-
 ered, if not during the first days, at least at the moment when the
 separation  commences,  either with a  plaster of  diachylon, or of
 mother ointment, (onguent de la mere) or some other unctuous ma-
 terial.  When it is  once detached, the moxa resembles  an ulcer,
 which it would be very easy to convert, and which is, in fact, some-
 times converted, into an issue.
   Under the title of simple moxa, we dress this solution of conti-
 nuity like a wound or simple ulcer  ; the cicatrization  is generally
 effected between the fifteenth and thirtieth days; the eschar falls
 from the eighth  to  the fifteenth;  which makes  from three to six
 weeks for the whole duration of the moxa.
   In place  of proceeding thus, several surgeons have proposed to
 ignite a piece of camphor, or phosphorus, and to  let it burn upon
 the skin; but, in this way, M'e obtain eschars either too superficial
 or too deep, too narrow or too wide, and the pain is still more acute
 than in the preceding.  [Dr. Mott,  however, prefers camphor when
 a powerful effect is not wanted, as it is the cleanest substance of
 this class, and the quickest in its action.]  Others, and particularly
 M. Jacobson, make  use of small cylinders of linen previously  im-
 pregnated with chromate of potash, and which thus burn Mdthout
 the necessity of blowing.  I have  made  use  of the moxas of M.
 Jacobson, and have had every reason to approve of them.  Never-
 theless, the others are so easy to make, that it would be difficult to
 dispense with them.
   The down of the mugwort,  (armoise) proposed by Sarlandiere, in
 example of the Chinese, has equally failed of coming into general
 use.   The same may be said of the pith of the turnsol,, extolled
 by Percy, and the moxas that Regnault kept separate from the skin
 by a circular piece (disc) of linen, of greater or less thickness.  The
 ordinary moxa is still the only one, at the present time, which offers
 security and all the facilities of application desirable.
   I will add, moreover, that  the efficacy of moxas, in the opinion
 of practitioners, has singularly diminished within the last ten years.
 In fact, it is nothing but a burning which  could easily be replaced
 by the red-hot iron, or the hammer dipped in boiling water.  In
 conclusion, they  can only be  useful  when we M'ish to irritate ac-
• tively some region in the neighborhood of the disease, and upon
 points that  are exceedingly circumscribed. 
302
NEW ELEMENTS OF OPERATIVE  SURGERY.
  We apply the moxa to the temple, to the  mastoid process, and
below or around the articulations, upon the course of the bones, and
along the spine.   We may,  also, apply it anyM'here  else, taking
care to avoid the course of the nerves, arteries, veins, and tendons,
and all the organs which it would be dangerous to burn.
  [Lime Moxa.—Dr. Osborne, of Dublin, has availed himself of the
high temperature  produced by lime in the  act of slaking, for the
purpose of a moxa.  About an inch depth of the powder is placed
on the skin, inside a porte-moxa, or a strip of card bent so as to form
the section of a hollow cylinder.  Some  M'ater is  dropped on and
mixed with it.  In about two minutes, the mixture swells and be-
comes dry, producing a high degree of heat, amounting, according
to some experiments, to 500° F.   Dr. Osborne deems it the best of
all moxas, from its being very capable of being  made equal in
power to the potential cautery by increasing  the bulk of lime, also
from its convenience, and its emitting no sparks or smoke.  When
less lime than the quantity above mentioned is  used, and M'hen left
on but a short time, a thick crust is formed, as after the application
of acetic acid, which crust separates in proportion as the new skin
is perfected underneath.  When the quantity of lime is large, and
kept on M'hile the heat continues, a complete destruction of the skin
ensues, and thus deeper issues may be made, and in shorter time
than by the  usual escharotics.  He  ingeniously  determines its
strength beforehand, by ascertaining to what depth it will coagu-
late the albumen of an egg when  applied on the shell.  Dr. Osborne
says its advantages consist in producing a contraction and change
in the action of the vessels beneath, with great excitement of the
absorbents, enabling them to  return to a state of health after the
failure of other means, as noticed by Larrey, and as is familiarly
known in the practice of veterinary surgeons.  In a case of ulcer-
ations in the upper part of the rectum and in the sigmoid flexure,
with purulent and bloody discharges, this moxa, applied over the
latter externally, effected a complete cure before the ulcer of the
moxa (about the size of a crown) had filled  up.   Similar success
followed in a case of softening of the tubercles, and in  another of
purulent infiltration after pneumonia; also, it  was used with benefit
in two cases of severe hip-joint disease, in one  of which the joint
had become destroyed, and was extensively enlarged.   Lime from
the lime-kiln, if fresh, answers well for ordinary purposes.   The
cheapness of this  moxa is another  recommendation.   The  ulcer
made, it must be recollected,  is alM'ays twice the diameter of the
lime applied.—Dublin Journal of Med. Science, January, 1842.—T.]

               § II.—Metallic  Cauteries,  (Fig.  169.)

   The actual cautery, properly so called, is understood  of metallic
rods of various forms, and which are heated to different degrees be-
fore being applied to the skin.  We may make use of rods of gold,
silver, or platina, instead of steel.  M.  Gondret, indeed, pretends
that copper acts four or five times more quickly, and, consequently, 
CAUTERIZATION.
303
causes less pain, than iron or steel; but the infusibility and capaci-
ty for caloric of these last are so well known, and they are so easy
to be obtained, that all surgeons continue to prefer them.
  We have cauteries of a reed shape, (en roseau—a) a sort of cylin-
(Fig. 169.)
!\
J    3
^
jk  "^   s
drical rods that may be applied to the deepest passages ; the olive-
shaped, (en olive—b) which serve for burning the interior of certain
cavities and cysts, and the bottom of small excavations.  The coni-
cal (c) cautery  is more particularly designed to penetrate  through
a certain quantity of tissues.   The hastile or cultelaire cautery is a
species of shield, (rondache—d) or sapeur's hatchet, designed for
making burnt lines (des rates de feu) upon the integuments.  When
we wish to cauterize flatwise and upon a large surface, we employ
the nummulary (nummulaire) cautery, (e.)  That which Percy has
described under the name of the annular cautery is not used; but
we sometimes  employ the bird-beaked,  (bee  d'oiseau—f) and the
haricot (g) cautery.
  All these cauteries, which are sometimes straight and sometimes
curved, terminate in a rod which is furnished with a handle at the
time of  being used.  The tail of the cauteries, moreover, is so ar-
ranged,  that the same handle  (h) may be applied, to all.  For that
purpose, it is only necessary to turn a small screw, placed on the
side of this handle, to enable us to fasten or withdraw the cautery.
When we desire to apply these instruments, we place  them upon
a  chafing-dish  in the midst of burning  charcoals, which are kept
in a state of active combustion by the bellows ; the degree of heat 
 304           NEW ELEMENTS  OF OPERATIVE SURGERY.

 we wish to obtain is determined by the color the metal assumes in
 becoming  heated.  Thus, the gray is the loM'est  degree chosen;
 and the dark red, the cherry red, the yellow red, and the white red,
 follow in succession.   It  is necessary to recollect,  that the pain in
 this operation is in an inverse ratio to the degree  of heat em-
 ployed.
   The cauterization by the hot iron takes the name of inherent cau-
 terization,  (cauterisation inherente) when we disorganize the tissues
 by a continued application of the  metal upon the diseased  part;
 ten  to  fifteen seconds ordinarily suffice, in this case, to obtain an
 eschar, if the cautery is heated  to  a white heat.   On the supposi-
 tion that Mre wish to go deeply, it would be better to change the
 cautery when it sinks to a dull red heat.   In  all cases we ought to
 act quickly, and not leave the  cautery in its place till the cooling
 is completed, if M'e do not wish  it to adhere to the eschar and en-
 danger some laceration.  In order to protect the neighboring parts,
 we cover them, generally, with some interposing substances, either
 linen,  felt, or pasteboard, M'hich  we take care to wet with saline
 liquids, unless we apply the cautery through  a canula of metal,  or
 wood, covered with wet linen.  The result is, in every respect, sim-
 ilar to that of a burn in the fourth degree, and  exacts the  same
 precautions for the treatment.
   Cross (transcurrent) Cauterization. The ancients, who frequently
 used transcurrent cauterization, employed it, as the veterinary sur-
 geons do at present, to trace lines and different figures upon the
 diseased regions, and especially about the articulations.  It is the
 hatchet cautery which is used for this  purpose; heated to white-
Tiess, it should be passed  by its cutting edge upon the region to be
 cauterized, so as to burn  about half the thickness of the skin.  We
 thus make a certain number of grooves, which should not approach
 nearer than half an inch, and  may be made  parallel,  though it
 is sometimes better  to arrange them in the shape of fern-leaves,
 (enfeuilles de fougere.)   The consequences of this  kind of cauteri-
 zation are  very similar to those of moxa.
   Objective Cauterization. We mean by this last epithet something
 analogous  to insolation.  In fact, the objective cauterization is made
 by means of burning charcoal, or a metallic body heated to a red
 heat, and which is held at a certain distance from the part.  Eulo-
 gized by Fabre in the last century, objective cauterization, which
 I  have sometimes thought it advisable to make trial of, is rarely
 any longer advised at present, and appears to me  to merit the dis-
 use into M'hich it has fallen.
   We  see, by these few  details, that the actual cautery which is
 employed in venomous or poisoned wounds, to arrest certain hemor-
 rhages, to  prevent hydrophobia, to limit and destroy the malignant
 pustule and carbuncle, (le charbon) cancerous growths, and vari-
 ous tumors, requires the reed or olive-shaped, the conical, bird-beaked,
 haricot, or nummulary cautery, when we desire inherent cauteriza-
 tion ;  that the hatchet cautery is, in  fact, for cross-cauterization
 only, and that pieces of metal would suit much better for objective 
VACCINATION.
305
cauterization.   Every thing shows, that if the ancients, especially
Sevennus, made a singular abuse of the actual  cautery, modern
surgeons have neglected its employment too much, and that  they
do not attend sufficiently to the reasons urged by Percy in favor of
this therapeutic means.   We must, however, acknowledge  that
the actual  cautery runs the risk of never recovering its ancient
popularity,  either because art  now  possesses means which,  to a
certain degree, take the place of it, or that it inspires  a great
degree of dread in most patients, because, before using it, we have
to be very sure that we can demonstrate its efficacy.
  After the employment of the actual cautery, the treatment is the
same as after the application of moxas.
                        CHAPTER VI.

                      VACCINATION.

  The small-pox, a disease so often formidable, and always loath-
some, has found in the vaccine virus an almost constant preventive.
To maintain to-day that the vaccine does not destroy the principle
of the small-pox, would be absurd; it would scarcely be less so, to
persist in saying that no vaccinated individual can be attacked
with small-pox.   I have not in this place to consider how far it is
useful to revaccinate  those who have  been vaccinated in their
youth; nor can the subject of the necessity or inutility, at the pres-
ent  day, of retaking the vaccine fluid at its  natural  source in the
cow-pock, now occupy my attention; but vaccination, of itself, is
of a utility too indisputable to permit me to dispense with pointing
out to pupils the manner of performing it.
  There are in vaccination three principal circumstances: the ope-
ration, the development of the vaccine, and its preservation.

                    Article I.—Operation.

  We may vaccinate in many different ways.   Some have thought
that after having made friction on the part with a  piece of linen,
to the  point of excoriating the cuticle,  it would be sufficient, in
order  to attain the  end proposed, to apply upon the surface thus
prepared  another piece of linen impregnated with  the vaccine.
Others, after  the example of Osiander,  have advised to destroy
the  cutis by means of a  blister.   There were others, also, who
made  a slight incision into the integuments, and  insinuated be-
tween the lips of the  small wound a thread imbued with vaccine;
but  they have  now, everywhere, substituted  for these three pro-
cesses the simple puncture.
                             39 
306           NEW ELEMENTS OF OPERATIVE SURGERY.

  To effect this, we  use either the vaccine-needle  (Fig. 170) or
an ordinary lancet, M'hose point is slightly charged M'ith the pre-
ventive fluid.  Holding the instrument in the right hand, after the
manner of a writing  pen, or as for bleeding, the  surgeon inserts it
very obliquely (Fig. 171) between the epidermis  and the rete mu-


                                     (Fig. 171.)
cosum, to about one line in depth, so as to cause at most only a very
small drop of blood.  Before withdrawing the lancet  it is well to
move it a little within the puncture, then to wipe its two sides, one
after the other, upon the surface of the little  M'ound.   We proceed
in this way on four to six different points, and the operation is ter-
minated.  This is done with so much rapidity and so little pain,
that infants asleep are not awakened by it, and the most intractable
have scarcely time to cry.  The skin should afterwards remain ex-
posed to the air from five to six minutes, in order to give time for
each puncture to  dry.  It is sufficient, after that, to cover the part
with a piece  of fine linen, and to dress the infant as usual.
  The number of vaccine  punctures is altogether arbitrary.  We
are in the habit of making six ; some, however, make but four, and
every thing shows that it would be sufficient, in truth, if we had
only one good one; but  it is better, in reality, to have too many
than too few, seeing that they rarely all  take.
  The region of the body has little in reality to do with the success
of the vaccine;  we could succeed in vaccinating the  foot, leg,
thigh, breech, abdomen, chest, head, and neck, quite as well as on
the thoracic members; but we prefer the arm, as the most conve-
nient for all the circumstances  of the operation.  It is generally on
the middle third of the humerus that the vaccine is applied, taking
care  to  make three punctures on each  side; one on the outer
side of the deltoid, the other opposite the  insertion of  this muscle, 
VACCINATION.
307
(Fig. 172.)
d
and the third  under it, (Fig. 172, a.)   In this way they are sep-
arated an  inch  at least from one  another,  are  easy to  M'atch,
and protected  from all friction.  Instead
of placing them in this manner, some sur-
geons prefer arranging them in a triangle,
one in front, the other behind, and the third
below on the point of the deltoid,  and this
with  the  view of  keeping their cicatri-
ces afterwards more  easily covered.  In
either mode it is  necessary that the  child
should be undressed, and that  his limb be
entirely free.  Embracing it below  with
the left hand, the surgeon  stretches the
outer surface  of  it, while with the  right
hand he performs the punctures spoken of
above.
  The age which suits best for vaccina-
tion, is that of the last six months of the
first year, and throughout the whole second
year.  It is not that in a more advanced
age children have less to hope from the
vaccine; but as  in waiting they are ex-
posed to the occurrence of the small-pox,
it is very natural that many families prefer
having them vaccinated  as  soon as pos-
sible, that is to  say, in the first months
after the birth.  Experience seems to have
proved, moreover, that at the second month,
and even in the first weeks, this operation
is as effective  as at a later period.   It re-
sults from this, that in  seasons of  epidem-
ics infants should be vaccinated at a very early period, while if the
small-pox is nowhere  prevailing, we may M-ait  till the middle or
end of the first year.
Article II.—Progress of the Vaccine.
  The wounds of the vaccine  are not ordinarily the seat of much
action, and remain in the  state of a simple puncture, (a) or of a
prurigo pimple, (papule de prurigo) to  the  end of the  third  day.
This lapse of time is known under the name of the period of incu-
bation.
  At the moment even of the operation the punctures are surrounded
with a large areola  of some lines, and of  a pale rosy color, and
then a little tumefaction, which all disappear at the end of a quar-
terqr half an hour.
  Off the fourth day, the small wound seems to rest on a hard base,
and its  apex strikingly assumes the appearance of the bite of an
insect. 
308
NEW ELEMENTS OF OPERATIVE  SURGERY.
  On the fifth day, the whole presents a conical vesicle, whose apex
begins to be depressed.  Quite a severe itching sometimes accom-
panies this first stage.
  On the sixth day, the base of the vesicle is enlarged and its apex
is depressed.   But it is not until on the  seventh  day that we see
formed around it a  slight  swelling, this latter also having at its
circumference a narrow inflamed areola.
  On the seventh day, (b) the vaccine pock is still more depressed,
and of a  fawn color, and is surrounded with a silver-colored ridge,
(bourrelet) evidently distended by a fluid.
  This ridge (bourrelet—c) increases sensibly on the eighth day, and
is  surrounded with a rose-colored zone and with a tumefaction,
which, on the ninth day, is extended from one puncture to another,
if they have not been separated more than  an inch apart.
  It is not till on the ninth day (d) that the vesicle is the most de-
veloped,  and that its apex begins to assume the  form of a small
dark-colored crust.
  On the tenth day, the vaccine pock, more flattened, less shining,
and manifestly enlarged, rests upon  a general tumefaction exten-
sively developed. Then the whole outer side of the arm is swollen,
as if from clusters of furuncles, (furoncles rapproches.)  It is ac-
companied with heat, and the patient  complains of a severe itch-
ing.  Then, also, the child sometimes  becomes fretful  (maussade)
and difficult to manage ; he feels restless, and has a slight fever
and chills, accompanied with paleness  of the visage, and swellings
in the axillary glands.
  On the eleventh day, (e) the pock is hard, flattened, and destitute
of fluid;  it assumes a pearl-gray or  dirty yellow color, and be-
comes covered with a dark-colored eschar.
  The stage of inflammation is thus terminated.  Now comes the
stage of  desiccation.  On the twelfth day, (/,) we observe a scab,
which  occupies the epidermis, a  remnant  of turbid liquid, and an
areola, which is paler, harder, and of less  extent, than the day be-
fore.
  On the day after, and on the succeeding days, the engorgement
which  surrounds each pock diminishes more and more, and the li-
quid of the pustule becomes puriform.
   Counting from the fifteenth day, the  vaccine scab, changing from
a fawn to a dark red color, now assumes  a more or less deep-brown
hue, and stands out more and  more from  the  surface of the skin.
This scab, sometimes raised up by pus, and accompanied with des-
quamation of the neighboring cuticle, falls  from the twenty-fifth to
the thirtieth day, leaving a dotted (pointillee) cicatrix, easily recog-
nised, and which never disappears.

             Article III.—Anomalies of the Vaccine.

   Vaccination does not always proceed with as much regularity as
 I  have just  described; there are cases where the inflammatory
 stage is  formed at the end of twenty-four or forty-eight hours, while 
vaccination.
309
in other cases it will not be manifested before the expiration of a
month, and in consequence of a  second vaccination.  It appears,
also, that this stage may last from three weeks to a month, instead
of being restricted between the third  and twelfth days.  History
also makes mention of persons so repugnant to the vaccine, that it
has required eight  to ten  successive operations before the virus
would take.  It  is also said, that, in certain cases, the vaccine has
produced only some general symptoms, leaving, however, the sys-
tem protected against the small-pox.
  False Vaccination. In place of a genuine vaccination, which is
the only one that is protective, we sometimes obtain only a spuri-
ous one.  This  false  vaccination takes place  in  individuals who
have had the small-pox, or who had already been vaccinated.  In
other cases, it arises from having used a dull-pointed or rusty  lan-
cet ;  or because  the vaccine was bad, too old, or decomposed—in a
word, because the fluid was spurious, or that the operation has been
badly performed.  In such cases there is generally no stage of in-
cubation, and the suppuration is found in the vesicle on the third
or fourth day.   The  stage of  desquamation,  on  the  contrary, is
longer, and the cicatrix has none  of that dotted appearance which
makes  it easy to distinguish from every other mark on the skin.
Sometimes, also, the scab falls on the  fifth day, and is reproduced
and detached anew, as with ulcers in general.  [In reference to the
pointillee, or dotted appearance  of the cicatrix,  it is well to  add,
that  its shining, smooth, glossy appearance, and white or pearly
white color, and  its  circular or ovate form, and its usually slight and
sometimes greater depression below the general surface of the  sur-
rounding skin, and  also the pellicle-like thinness of the new cuti-
cle  covering this depression or cicatrix, so transparent as some-
times to permit the minute veins  to be seen beneath it, are all
characteristic marks  of the genuine vaccine, not to  be over-
looked.— T.]

   Article IV.—Preservation and Transmission of the Vaccine.

  Previous to the sixth day, it would be next  to  impossible to ob-
tain from the vaccine vesicle the  least particle of liquid, and thus
to make use of it  for vaccinating another child.  The seventh, eighth,
and ninth day, the end of the sixth, and the beginning of the tenth,
only, allow us to  obtain any that will prove efficacious.  Later than
this, the scabs being pulverulent or moistened, the pus which they
contain, M'ould rather  produce  a false than true vaccination.  I
should also add, that, from  experiments made  at  Tours from 1816
to 1820, on a great  number of patients, the preservative property
of the vaccine is at its maximum of intensity at the end of the
sixth to the commencement of the eighth  day.   We extract  and
pieserve this liquid in various ways.

              § I.— Vaccination from Arm  to Arm.

  If the child to  be  vaccinated is near that which is to furnish the 
310
NEW  ELEMENTS OF OPERATIVE SURGERY.
 vaccine, we make  a few punctures on  the swollen border  (le
 bourrelet peripherique) of the pustule;  with the point of the lan-
 cet, or a needle, we  take a small drop of this liquid to transfer it
 immediately, as has  been said, to  the arm of the other child.  Af-
 ter having  made two punctures with the first drop, we  return to
 take a second, then a third ; we might even, for greater certainty,
 supply the lancet anew at each puncture.


                               §11.

,  , If it should become necessary to transport the vaccine to some
 distance, we should open the border of the pock, as in the preceding
 case, and then charge with the fluid the points of several lancets,
 which should be immediately shut up in their handles, from which
 latter they are kept  separate by means of a  small piece of paper.
 We thus arrive at the child to be vaccinated without any  fear that
 the vaccine may have become decomposed, provided it is applied
 before the end of the first or second day.

                              § III.

   But it is often required to preserve the vaccine for a much longer
 time, or to transmit  it to great distances ;  many means have been
 devised for this purpose.  One of the oldest,  and which M'as em-
 ployed by Jenner, consisted of two small  square plates of crystal
 glass, (g)  one  of which  was hollowed  out in the middle into a
 slight depression, (cupule.)  It  is in this cavity that the vaccine is
 deposited, after which the plates are placed  together, and the bor-
 ders then luted with glue or sealing-wax. This process has the  in-
 convenience of requiring much more vaccine than it is sometimes
 possible to obtain.  In other respects, it is  exceedingly convenient
 and  useful.  Many  persons have substituted  the employment  of
 simple plates of glass, (h,)  the  middle part of  which is applied to
 the vaccine pustule to receive its liquid, and then the two luted to-
 gether, as with the others.  In adopting this  mode, it is impossible
 to avoid losing a very considerable quantity of the liquid, or to pre-
 vent its desiccation.
   The threads that  were formerly used, as well as the pieces of
 linen, to imbibe the vaccine fluid, are no longer employed, since the
 incision and friction  have been abandoned.

                   § IV.—Bretonneau.'s Method.

   The most valuable  mode  known at  present, is  that which we
 OM'e to M. Bretonneau.   This physician  has proposed glass tubes,
 of from fifteen to eighteen lines in length.  Spindle-shaped, (fusi-
 formes—i) capillary, and drawn out at the lamp of the enameller,
 they are applied like a writing-pen by their  point, inclined at the
 same time more or  less  downward, to * each drop of liquid; they 
VACCINATtON.
311
thus become filled by capillary attraction.   Presented afterwards
successively to  the flame of a candle, the extremities  of the tube
are melted, shut and converted into a small  bulb, (boule) which for
greater  security may be enveloped in wax.  The  tubes thus pre-
pared and put  aside in the hollow of a quill or some other case,
after the manner of needles, preserve the vaccine in a liquid state,
and in all its energy, to an indefinite period.
  To avoid breaking M'hen they are to be transmitted to a great
distance, we place them in cases or small boxes filled with bran,
sawdust, or charcoal.   It is  M'ithin  my knowledge, that  vaccine
sent in this manner to America, has produced at the expiration of
three years as many  vesicles as punctures.
  More recently, M. Fiard has had tubes constructed, one of the
extremities  of  which resembles the bulb  of a thermometer, (j.)
Held in the palm of  the hand this bulb becomes heated, creates to
a certain degree a vacuum, and as it cools  compels the vaccine to
be forced into it.   But the tube of M. Fiard is too large, and seems
too difficult  to fill, or would require, at least, too great a quantity
of vaccine, to suppose that they could be  substituted for those of
M.  Bretonneau, which  latter are now in general use.
  In whatever  manner, however, the vaccine has  been collected,
we must make  use of it as if it had been taken from  arm to arm.
If it has been  preserved in  the  mode of  Jenner, we unglue the
plates of the crystal, move them upon each other, in order to sepa-
rate them, and  dip the point of the instrument into a drop of the
liquid.  If we have  used the plates of glass, it is  necessary, after
having  separated them, to moisten a little,  by means of the finger,
wet with tepid water  or saliva, the dried vaccine matter, before
charging the lancet with it.  By the method of M. Bretonneau, we
begin by breaking the two small heads of the tube ; we then adjust
the largest of the two extremities into the glass tube of a blow-pipe,
which latter should be two or three times longer than the vaccine
tube, or M'e insert it  merely into a stalk of straw.   Raised to the
mouth, the extremity of the blow-pipe, thus arranged, serves to force
the vaccine upon the point of the lancet, (Fig.  173,) M'hich is held
in one  hand, while  the other directs the tube, and  prevents  it
from  moving.   In this manner a tube which contains less  than a
drop of vaccine, may suffice for six and sometimes even a dozen
punctures.
  Though the taking away the  fluid from all  the vesicles of the
child  may have no effect in destroying the efficacy of the opera-
tion upon it, it  is, however, as M'ell to leave at least  one of them
untouched.  It  must  be also confessed, that this  abstraction renders
the progress and changes of the vaccine evidently much more irri-
tating, without  being of any advantage to the person M'ho submits
to it.   The  quantity of the vaccine fluid, also,  is in relation with
the development of" the pock from M'hich we take  it, and not with
the constitution or health of the  child that furnishes it.
  [Mides of Preserving; also, the Test of Purity.  Dr. Mott thinks
the best M-ay of preserving and transmitting the virus is upon small 
NEW ELEMENTS OF OPERATIVE  SURGERY.
(Fig. 173.)
flattened ivory points, about an inch or an inch and a half in length,
charged with the virus, and placed in small vials carefully sealed
with wax.  It is the neatest and most convenient.   Points of quills
are the common mode in this country.  The dried scab, shut up in
sealed vials, is a most excellent mode of transmission. When used it
is powdered, and, moistened with saliva or water into a little paste,
is a most efficacious mode, and may for a long time retain its virtues.
Again, scarifications, and those crossed, and all of them restricted to
a small space, is, in Dr. Mott's judgment, a much better mode of
communicating than puncture or any other  plan, unless when it is
from  arm to arm, where  puncture is preferable.   Next to Jenner,
Brice, of England, comes in for much praise, as having introduced
a great improvement in vaccination,  and M'hich improvement is
the only true  Test  of the constitutional effect of the vaccine dis-
ease.  It is this: on the fourth or fifth  day, on puncturing the mar-
gin of the pock, there will be obtained on the point of the lancet a
particle of lymph,  which, upon being inserted upon the same or
the other arm, or any part of the body, will take effect, and go on
and reach maturity pari passu with  the pock from which it is pro-
cured, thus proving the constitutional effect of the vaccination. 
PERFORATION  OF THE EAR.
313
In this curious pathological phenomenon, the stage to which the
primary vesicle has advanced, imparts a proportionate maturity to
the one which is reproduced by it, and they proceed on together,
the original and its type and test.—T.~\
                        CHAPTER  V.

            PERFORATION OF  THE  EAR.

  The rings and jewels which women usually wear in their ears,
and M'hich many men also formerly wore, cannot be inserted with-
out a small operation, known under the name of the perforation of
the lobe (lobule) of the ear.
  Whether it is  performed when young, or not decided upon until
after puberty, the  operation is so simple, that the persons upon
whom it is performed are scarcely sensible of it, if the proper pre-
cautions are observed.  It consists in  quickly perforating the lobe
of the ear, in its middle portion, through and through, at three to
four lines above its lower extremity.   We begin with benumbing
the part by rubbing it, M'ith a certain degree of force, between the
thumb and fore-finger.   We now press the base  of a cork against
its posterior surface, and then  effect the perforation with the other
hand by means of a particular  kind of instrument: This instrument
may be a kind of punch, (emporte■-piece) or a needle armed with a
canula, that is to say, a very small hydrocele trochar.  The punch,
perforating the lobe, separates  a  small fragment of it, which it car-
ries with it into the cork, (Fig. 174.)  As soon as it has  completely
perforated the part, and that M'e have  disengaged it from the cork,
we remove from its cavity, by means of a pin, the fragment of tissue
which it has cut, in order to attach to  the punch the extremity of
a leaden wire, M'hich is drawn  through the perforation by means of
the puneh, M'hich thus serves the purpose of a larding-pin, (lardoire.)
When the trochar is preferred,  which is in fact more convenient,
we force  it in the same manner to a  certain depth into the cork.
After having withdrawn its punch we introduce the leaden wire
into its canula, which latter is  immediately withdrawn, and the
operation is finished.
  In place of a leaden wire, whose ends must be united and twisted
to prevent  displacement,  some  persons make use  of a skein of
thread or cotton, and sometimes, also,  of the ring itself, so as to
make  the operation complete at once.   But as  these foreign bodies
are to act at first in the manner of a  seton, their object being to
force the wound to convert itself into a fistula or passage, by means
af the cicatrization on the surface of its cavity, the lead, for those
                              40 
314
NEW ELEMENTS OF OPERATIVE  SURGERY.
reasons, is in reality the one to be preferred.  When the interior of
the perforation has undergone this cutaneous transformation, that
is, at the end of fifteen, twenty, or thirty days, sometimes  more,
rarely less, we may substitute the ring itself for  the temporary con-
trivance of which I have just spoken.
  This small operation, relating to a homogeneous tissue, M'hich
includes  neither vessels, large  nerves, nor muscles, nor tendons,
does not endanger  any serious wound ; thus, therefore, is it daily
performed by jewellers, and even by common  people.  It is well to
know, however, that, like  any  other puncture, it  may cause an
erysipelas, or even a  phlegmonous inflammation, in the lobe  of

                            (Fig. 174.)
the ear.  I have frequently seen small abscesses form around the
aperture, and it not unfrequently happens that the puncture ulce-
rates and cuts its way out by means of the seton.  In this respect
the punch, effecting a loss of substance, offers some advantage over
the trochar.  It is because of the tendency of the wire to cut the
parts, that  it is  better to puncture a little higher up, rather than
lower down.  In order to avoid all inflammation and  suppuration,
it is better to move the temporary ring, generally every day, taking
care to besmear it with a little ointment or fatty substance.  It is
proper to know, also, that if by chance the seton should cut through
from the perforation before the definitive formation of the fistula,
the hole would shut up very quickly, and that  it would then be
necessary to recommence upon another point, or to repass a new
seton through the first wound by  means of a  blunt probe.  On
the supposition that inflammation or purulent collections should
manifest themselves about the foreign body, it would be better to
withdraw it, to reapply it at a later period, than to persist in keep-
ins it in its olace.
60 
OPERATIONS  ON THE TEETH.
315
                        CHAPTER VI.

      OPERATIONS THAT ARE PERFORMED ON THE TEETH.


 "Like all other parts of the human body, the teeth require various
special operations, which consist—
  1.  In favoring their egress ;
  2.  In giving them a proper direction ;
  3.  In maintaining them in a state of proper cleanliness ;
  4.  In filing them to arrest the progress of caries ;
  5.  In filling them ;
  6.  In cauterizing them ;
  7.  In effecting their extraction.
  For this chapter I  have not wished to rely upon my own proper
experience ; I have desired my friend, Dr. Toirac, one of the most
skilful and capable dentists of the capital, to  prepare  it for me.
The  reader, therefore, must  expect to  find here the doctrines and
precepts of this distinguished practitioner, rather than mine.

Article I.—Incision of the Gum to favor the  Egress of the Teeth.

  If the  acute pains and convulsions, which  the infant  sometimes
experiences in pushing  forth its first teeth, depend  upon the  resist-
ance of the gum,  the incision of this part is indicated. This opera-
tion, which is effected with a lancet or bistoury, does not succeed
well, except it is performed sufficiently deep, and so that the divis-
ion (debridement)  is complete.  The incision for the incisor and ca-
nine  teeth should be  simple, and for the  molar, crucial.
  The last or wisdom tooth, in the lower jaw, may also require the
use of a cutting instrument: this is when it appears to be arrested,
in part, by a  thick border (bourrelet) of gum.  This border inflames
and ulcerates, and causes sometimes intolerable pains, which ex-
tend to the  ears, to the parotid and sub-maxillary glands, and to
the neck, and, by sympathy,  to the teeth of the upper jaw. A
simple deep  incision, and, better yet, an excision in  form of  a V,
with its apex forward, suffices in  most  of the cases ; we take the
precaution of introducing under the loosened  portion of  the gum a
small dossil of cotton or lint, to retard the  too prompt cicatrization
of the M'ound.  If it  should be judged  proper to make a complete
removal of the flap, (lambeau) a bistoury, or good pair of scissors,
and a dissecting forceps, would suffice.  If we  should desire to ef-
fect the same result by cauterization, the small curved cauteries,
heated to whiteness,  should be preferred to the potential cauteries,
which are ordinarily insufficient. 
316
NEW ELEMENTS OF OPERATIVE SURGERY.
             Article II.—Straightening the Teeth.

  Nature, which makes every sacrifice for the arrangement of the
first teeth, has often need of the  assistance of art for  that of the
second dentition.   If the dental arches are well developed ; if the
arch of the  palate is  Made and rounded;  if, at the age of five or
six  years, the milk teeth  are separated, leaving  certain intervals
between them, it is to be presumed that those which are to suc-
ceed them will be placed regularly upon the alveolar border.  But
if, on the contrary, the curve  which the jaws  make is narrow and
protrudes forward ; if the milk teeth are small and wedged togeth-
er ; if,  in fine, the  vault of the palate is contracted  and elevated
into a cone,  these signs of an unfavorable aspect announce an ir-
regular dentition, which it will be essential to watch.
  As a general rule, it is  important not to remove the milk teeth
too soon, that is, before nature has indicated by their looseness the
presence of those that are to succeed them. This method is injuri-
ous, because the jaws, by contracting themselves, cause the alveo-
lar  border to be diminished, by which means osseous  cicatrices are
formed, which render the egress of the second tooth more difficult.
There are, however, cases where  the premature extraction of the
first teeth, as well  as the sacrifice of one or tM'o of the second den-
tition, are necessary ;  but it  is easy, from what we have just said,
to foresee the moment for this a long time in advance.
  When the dentition has not been properly directed, or that it has
been impossible to effect a regular arrangement of it;  when some
are out of the arc  that they  ought to form, and some  are snags,*
(sur-dents) or cross each other, or are of unequal length, we must
recur to the different mechanical expedients  used for  such cases,
and which  consist of threads of  silk or metal, plates  of different
forms,  inclined planes, &c. The  younger  the subject is, the more
promptly will the means we employ succeed.
  When a  tooth projects too much,  supposing that it is, in this
case, a large or small incisor, it can be brought into the circle by
passing a cord of the  proper  size  on the outer surface of its neck;
we then conduct this cord so that it may pass on the  posterior face
of the  neighboring teeth ; afterwards it is  brought forward  by
passing it between the canine and first bicuspid, and finally tied
upon one of them.   If we wish to bring the same  tooth forward, in
the case that it should be found too far back, instead  of placing the
cord on  its  anterior face, we should pass it behind, and we should
in the  same way make our points d'appui upon the canine teeth, or
upon those more remote.
  If the teeth that we would wish to bring forward should be found
imprisoned by those of the lower jaw, as sometimes happens to in-
dividuals with prominent chins, it is easy to be conceived that the
action  of the threads would be almost nothing, since the movement,
* [Sometimes called wolves' teeth.—T.] 
operations on  the teeth.                317
which we should have the intention of producing on the teeth above,
would be neutralized by the obstacles which would be constantly
opposed to it by the teeth below.  It would be necessary, then, to
dispense  with the cords, and have recourse to the inclined plane.
With the cords and the inclined plane, which are used together or
separately, we  may effect all the results desired for restoring and
adjusting the  position  of the teeth.  [A very efficient  and easy
mode, which  I  have practised, when one of the large incisors, for
example, of the second dentition in the upper jaw, has emerged
only one half from the gum, and, as often happens in such cases,
takes an abrupt direction backwards, or within the mouth, is this :
Cut out a portion of the gum in front, of the shape of a narrow per-
pendicular A inverted, of the length, say, of the part of the tooth
that has emerged, and the two branches of which  should,  at their
base, be at the distance from each other of about one half or two
thirds the breadth of the tooth.  This excision is very conveniently
made on the  superior half of  the anterior surface of the tooth
which  is yet covered by  the gum, and causes little  or no pain,
while the effect of it is perfect in unbridling the tooth, and, in a
few weeks, enabling it to resume, by the pressure of the gum be-
hind, which now has no antagonist  force, its proper position in the
arc. When the tooth is entirely protruded, no traces are to be seen
of the excision.—T.]
Article III.—Cleaning the Teeth, (Fig. 175.)


                  (Fig. 175.)
I
u       u
a
£Q^

t
  When the daily use made of the brush does not prevent the teeth
from becoming covered with tartar, we should have recourse, from
time to time, to  the  employment of an instrument.   Before com-
mencing the operation, we should have at hand a glass of tepid 
318
NEW  ELEMENTS OF OPERATIVE SURGERY.
water, if it is in winter, a wash-basin for the person operated upon
to spit in, and a napkin to wipe the instruments.
  The patient  being placed on a suitable seat, so that his head is
supported behind, and  the operator, having at hand all the instru-
ments M'hich he considers necessary, places  himself on  the right;
then taking the simple scraper, (grattoir—a) in the manner of a
writing-pen, the mouth being  slightly open, he uncovers the teeth
of the lower jaw, and keeps the lip depressed by means of the fore-
finger, while M'ith the thumb he supports the tooth upon which he
is acting with the instrument,  the  point of which he forces below
the tartar, in order .to break it into fragments, which must be  dis-
placed from below upwards, in order not to wound the gum; he
proceeds thus with each tooth, until he finds no more foreign mat-
ters to remove.   The same instrument, by having the point almost
square, is more  convenient for scraping the small and large molars,
and is attended with less risk of M'ounding the cheek, which is kept
aside by the  fore-finger.  Then taking the curved scraper, (b) he
effects the removal  of the tartar  which is found on the opposite
side of the same teeth: for this purpose, the  operator places him-
self sometimes  in front and sometimes behind the patient, accord-
ing to his convenience, taking care to guide  his instrument so as not
to wound the gum.   All  the  tartar discoverable having been re-
           moved, he introduces between the teeth the extremity
  (Fig. 176.)  0f ^g biac[e 0f the instrument,  (c) in order to complete
           the  cleaning.   In order to be certain that no more re-
           mains, he makes use of the small mirror, (Fig. 176,)
           which is  so placed  in the mouth as to enable him to ex-
           amine each tooth successively.
             The teeth of the lower jaw being entirely cleaned,
           he then  proceeds to those of the  upper jaw ; this  row
           of teeth  is, in general, less covered with tartar than
           the preceding.  To clean them, the surgeon passes his
           arm around the head  of the patient ; with the fore-
finger he  raises  the upper lip, while the  middle  finger, placed
on the free border of the tooth he is cleaning, supports it, especially
if it is loose ; as with the incisors and canine teeth below, he must
here use the scraper a and the scraper b.  The instrument Fig. c.
serves to scrape the  inner side of all the teeth.
  There are other details that we pass over in silence,  and which
good sense, address, and practice know how to employ M'hen the
occasion requires—such as supplying the mouth, from time to time,
with water, to remove the foreign bodies that have become de-
tached, or the  blood in persons whose gums are swollen, soft, and
bleeding.
   We sometimes meet on the crown of the teeth with deep spots,
which are very difficult to remove with the instrument; they then
require the use of an acid, more or less diluted (etendu) with water,
 
OPERATIONS ON  THE TEETH.
319
which is gently applied with  the end of a match, (allumette) and
which we must immediately wipe off, that it may not extend to the
neighboring teeth ;  we use, also, for this purpose a piece of pum-
ice-stone, shaped in  form of a  cone  ; the extremity of it is  dipped
in water before using it.  It is very seldom,  however, that we have
to recur to these means, which are  not  to be used but with much
circumspection, for fear we should destroy too much of the enamel
portion of the tooth.


                Article IV.—Filing the Teeth.

  The  file (d)  is chiefly employed to level those teeth which have
too much length, to  separate them when they are too much crowd-
ed,  to remove the caries that attacks them, and to free them of ine-
qualities of every description ; internal diseases and fractures pro-
duce, occasionally, a roughness which would wound the cheek, lips,
or tongue, if the file were not used to destroy it.
  The  small flat files, cut sometimes  on one side, sometimes on
both, serve to  separate the teeth.  They are  usually held in the
hand; it is only when we wish to separate the large molars  that
we have  recourse  to a file-handle, (porte-lime)  The round and
half-round files are only used  when we wish to file the teeth to a
level with  the gum, when their crown  is nearly destroyed, or we
wish to fit in an artificial tooth. The triangular file, which is called
also tire-point, serves to file down the teeth which rise above each
other.   It is  made  to act  flatwise on one of its sides, or one of its
angles ; we thus make a  groove of greater or less depth, in order
to obtain a hold for the clench (mors) of a  pair of cutting-pincers,
to remove  by a single stroke the portion of the tooth which is in
excess.
  The  manner of handling the file is simple ;  it requires, however,
some address and  delicacy  on the part of  the person that uses it,
especially when it  is applied  to the teeth in front.   As a general
rule, M'hile we  are  removing  the diseased  part, we must manage
the external table of the tooth in such a way as to  prevent it from
having a  disagreeable appearance.   The incisors and canines are
those that most frequently require  attention to this precept;  it is
also necessary that  the file should be placed obliquely from before
behind,  so  that it may cut much more behind than in front.  We
must take  care to  leave  at the neck a small projection, (talon)
which resists the approximation of the teeth.  This precept might
be neglected, if the  space  between the teeth which have been sep-
arated should be thought too great.  As to  the lateral teeth, it  is
sufficient to separate them more or less, according to the progress
the  disease has made.
  Operative Process.  Whatever may be the object we have in view
in filing a tooth, the patient should be  conveniently seated.  The
operator, placed on the right, holds the file between the thumb and
fore-finger of the right hand.  He dips it in hot water, if it is in 
320           NEW ELEMENTS OF OPERATIVE SURGERY.

winter, and passes the left arm, as in cleaning the teeth, around
the neck of the patient; then raising the lip with the middle finger
of the same hand, he files the tooth steadily, (sans secousse) and
without employing force.  If the file sticks, (s'engage) he stops,
draws it out, and dips it in hot M'ater, in order to remove the matters
it has become covered with.  Teeth, properly filed, should not  ap-
pear to have been touched; it is proper, also, in order to complete
the operation, to round off the angles and the sharp edge which the
instrument leaves.  In this manner we cause all the roughnesses
to disappear, and try to give to the tooth its original form.


                 Article V.—Filling the Teeth.

  We give this name to the operation by which we introduce lead
into the cavities which the teeth present, in consequence of caries or
particular alterations of the enamel.  They formerly used for this
purpose only sheet-lead in very thin laminae, (enfeuille  tres mince;)
since  that, recourse has been had to tin, which oxydizes less; to
gold, silver, or platina leaf; finally, to the metal of Darcet, render-
ed more fusible by the addition of a sixteenth or twentieth of mer-
cury ; by means of the  actual cautery, we melt this last composi-
tion in the  cavity we  wish to obliterate.
  The operation of filling is one of the most simple  and easy.
Nevertheless, it should not be done without taking into consideration
certain conditions, which relate as much to the choice of the metal
to be employed as to some particular cases where we must abstain
from practising it. Gold, silver, and platina are employed, by prefe-
rence, to fill (obturer) the cavities which may present themselves
in the incisor, canine, and all the other teeth, which, by their posi-
tion, are seen between the lips. The other metals may be reserved
indiscriminately for the other teeth, [excepting all mercurial alloys,
amalgams, &c, which cannot be too strongly condemned and pro-
scribed, as  producing  the most disastrous consequences, salivation,
destruction of parts, &c.—T.]
   Operative Process.  The patient being seated, and the head sup-
ported against the back of an arm-chair, it is necessary, first of all,
to remove carefully, by means of a rasp, (rugine) or a small probe,
whatever there is of foreign matter in  the dental cavity.   We
gently scrape the  walls of this cavity; then  pass into it, succes-
sively a number of times,,small balls of  cotton, and continue this
operation till the cleaning is complete ; we satisfy ourselves, also,
that there  is no ichorous exudation going on through the canal of
the tooth; for, in checking it by the filling, we  should  bring on
pains and abscesses, the  pus of which might  extend sometimes to
remote parts, giving rise to fistulas, the cure of which could not be
effected without taking out the  filling, or, perhaps, extracting the
tooth.   If the dental pulp should be exposed, it would be necessary
to endeavor to destroy it by the processes we have pointed out, for, 
OPERATIONS  ON THE TEETH.
321
unless that is done, the operation would be impracticable, or would
produce insufferable pain.
  Every thing  having been  done properly, the operator rolls be-
tween his fingers, without compressing it, a small ball of the me-
tallic leaf which he wishes to use, and the size of which is nearly
three times larger than the cavity he wishes to fill; he places it on
the opening, and forces it gently, at first, in  the centre ; he then
successively brings  together  the  surrounding  parts, until they are
all  introduced.   If the metal should bulge out too  much, or inter-
fere with the shutting of the jaM's,  we should take  care to remove
the excess with a scraper.   Then making use of the blunt extrem-
ity of a probe, (/,) we should polish the metal and burnish it, so as
to leave no roughness.
  When we desire to make use of the fusible filling, (du plomb fon-
dant) we proceed, at first, as M'ith the ordinary filling: we clean,
then scrape, the cavity of the tooth; then, passing  cotton  several
times into it, to  free it from moisture, insert a small piece of fusible
metal, and then apply to it  the extremity of a probe, (e,) heated
at a fire, or  by a lamp  or candle.  When we perceive that the
composition is melted, we press  it with the finger to make it take
the exact form of the cavity, then  level with a scraper the parts
which are found in excess.
  At different epochs, and also in our own times, they have greatly
extolled various kinds of paste, as capable of replacing the different
metals we have mentioned ; but they are far from effecting in an
advantageous manner the results that have been attributed to them;
and  experience unfortunately daily proves, that those  self-styled
discoveries, up  to  the present  moment, have  turned only to the
profit of charlatanism.

            Article VI.—Cauterization of the Teeth.


  The object of cauterizing the teeth is to destroy the  sensibility
which exists in  them. Hot iron and caustics of different kinds are,
by turns, used for this purpose The preference should be accorded
to the hot iron, M'hich acts with more celerity and certainty, though
it may often prove insufficient.
  The cases in which we may resort to cauterization are—1. When
we  have filed a tooth, to relieve the sensation which is produced
upon the part we have operated upon by water, cold air, and sub-
stances of a greater or less degree of acidity ;  2. When a tooth has
experienced a shock which has broken a portion of it, or when the
teeth have been much worn down by mastication ; 3. When caries
has made sufficient progress to lay the dental pulp bare.
  This operation is performed by small  cauteries, made of different
forms and thicknesses, according to the place where we wish to
apply them.   The flame of a candle, or of a small spirit lamp, or-
dinarily  suffices for heating them.  We apply them carefully to
the part  we wish to cauterize, taking care,  if it is a tooth which
                           41 
322            NEW ELEMENTS  OF  OPERATIVE SURGERY.

has been filed, to touch only the part laid bare, (partie eburnee)
and avoiding any action on the enamelled portion.
  When Me have  to  destroy the dental pulp, M'hich is done with
sufficient facility on the teeth that have but one root, as in the in-
cisors and the Canine teeth, we make use of a small pin, or a needle
heated to a white heat, which is held by a forceps, or, better still,
by a needle-holder, (porte-pointe;)  [that is, a handle, into which a
needle, or any thing similar, may be firmly fixed.—T.]   The point
of this instrument  is quickly introduced into the  opening which
communicates M'ith the pulp, taking care to enlarge it, if the pas-
sage is too small.
  If we  wish to use potential cauteries, which  are applied more
especially to the molar teeth, because of the number of their roots,
we must begin by carefully cleansing off the caries by means of
the scoop and by rinsing the  mouth with tepid water.  We  then
take a small ball of cotton, slightly moistened, upon which we scrape
a small  quantity of lunar  caustic, and then introduce  it into the
dental cavity.  Creosote, chloride of zinc, the  nitric and hydrochlo-
ric acids, the  essential oil of  cloves, cinnamon, and mint, are also
used upon a small ball of cotton, which is  reneM'ed once or twice
in twenty-four hours; this dressing is  to be repeated until the in-
sensibility is complete, which will then allow us to proceed to the
filling, of which we have already spoken.
  Destruction of the pulp by bruising it, (par le broiement) We have
given this name to an operation  by which the  dental pulp is de-
stroyed  without having recourse  to cauterization; this operation,
which is attended  with considerable pain, consists in introducing
into the dental canal a hog's bristle, or very small probe, M'hich is
moved about by turning it  around between the thumb  and index
finger.   It is a means  which succeeds very well, but is more pain-
ful than  cauterization.


 Article VII.—Of Extraction of the Teeth, and the Instruments
                 THAT ARE USED IN THIS OPERATION.

                 There are few operations in surgery for which
               more instruments have been invented than  for ex-
               tracting teeth.  Of all those that have been con-
               trived,  there are  a very small number that have
               been retained in practice.   I Mali describe those
               only that enter  into this list, and  which are suffi-
               cient for all the operations.

                      § I.—The Key of Garengeot, (Fig. 177.)

                  Without  entering into a description  of  all the
 [    o    ")   modifications  which this key has undergone since
                its invention, I will remark, that the most  secure
 and commodious  form appears to me to be the following:  The
(Fig. 177.)
 
OPERATIONS ON  THE TEETH.
323
keybit (panneton) is of a medium length, and  it may take its point
d'appui  at  a convenient distance from the tooth to be extracted.
When it is too long, the alveolar process is readily broken; when
it is too short, we may fracture  the tooth.  Upon this keybit are
two  notches for receiving the bifurcated heel of the hook, the di-
visions of which adapt themselves to it, and are fastened by means
of the pin, which has at  the end some threads of a screw to prevent
its falling out.  The  advantage of this arrangement is, to give us
the poM'er of applying the hook close up to the termination of the
keybit, for the extraction of the last molar teeth. We may easily
change  the  hook to  either side, and make use of different sized
hooks, according as they may be required.   The curve in the stem
(tige) of the turnkey, where it joins the keybit, is also essential, that
we may not be incommoded by the teeth in front when we are op-
erating at the bottom of the mouth.  The handle, which is removea-
ble, may, by that means, be  adapted to other instruments.  Sepa-
rated from  the stem, it may also be better  adjusted to the pocket-
case.
  Operative Process.  After having carefully examined the  tooth we
wish to extract, and  adjusted the hook to the key, and wrapped
around  the keybit a  small piece of bandage,  or the corner of a
napkin, we firmly grasp the handle of  the  instrument in the right
hand, the stem passing between the fore and middle finger.  The
patient having his head supported against the back of an arm-chair,
and holding the mouth sufficiently open, enables the surgeon to in-
troduce the stem of the key, which he guides with the fore-finger
of the left hand to the tooth he wishes to extract; the same finger
serves to push aside the cheek or the  tongue, as the case may be,
and to adjust the keybit in a proper manner upon the gum; in ap-
plying the finger afterM'ards upon the hook, it holds this last firmly
fixed upon the neck of the tooth, as near as possible to the edge of
the alveolar process.  This being done, we give to the instrument
a twisting  movement, tending to turn  the tooth in the direction of
the keybit; this movement should be made gently and without any
violence, in order that we may give to the surrounding parts the
opportunity of yielding to the elasticity which is proper to them,
and that M'e may wound them as little  as possible.   As soon as we
perceive that  the tooth is completely loosened, (luxee) we give to
the instrument an  upward movement,  and thus effectually extract
it, or we finish its extraction by seizing it with a straight or curved
forceps, according  as we operate above or  below, especially if we
find that a  small portion of the alveolar process has been carried
off with the tooth, or the gum is  adherent to it to  a considerable
extent.  It  is  then proper to make use  of a curved bistoury, or
scissors, to disengage it completely.  In  all cases, we should en-
deavor to avoid this inconvenience, by properly separating the gum
from the tooth before the operation.
   In operating with the key, it is  almost always the practice to
grasp the tooth from M'ithin outwards ; but there are cases where
it is indispensable to act in  an opposite direction.  They are—I. 
324
NEW ELEMENTS OF OPERATIVE SURGERY.
When the croM'n of the tooth presents a manifest inclination in the
direction towards the tongue : in thus forcing the tooth to move in
the arc of the circle that  it naturally describes, we run much less
risk of breaking it; 2. When the crown of the  tooth, undermined
by caries, offers on its inner side no point d'appui to sustain the
hook ;  3.  When the gum, in fine, on the side of the  cheek, is the
seat of an active inflammation, or an abscess.

§ II.—The Straight Tooth Forceps (Davier droit) and Straight Pincers.

  These  two instruments, which are always confounded together,
differ from each  other  in this, that in the  davier  the  clipping
branches are  arched in the direction of their articulation; its upper
branch is longer by a line or two than the other, and goes beyond
it, M'hich gives them a resemblance to a parrot's bill.   It is neces-
sary to have  acquired a certain degree of tact  in the use of it, or
we incur  the risk  of breaking  the tooth that we wish to  extract,
should the latter offer any considerable degree of resistance.
  The straight pincers,  (Fig.  178,)
has the clipping branches separated    ™-178)   <Fis-179>   (Fie-,8°)
laterally.   It is used like the davier,
to remove the front teeth when they
are not too much decayed, and when
they offer a hold sufficiently firm to
resist a certain degree  of pressure.
The Z shaped pincers (Fig. 179) of
Dr. Toirac is one  of the  most conve-
nient for reaching the bottom of the 0
mouth in  operating upon the teeth
of the upper jaw.
   The Operative Process.   The  pa-
tient being placed  as above, with
his mouth open, we raise the upper
lip M'ith the fore-finger of the left hand, the thumb  being placed
upon  the  border of the teeth ; the instrument  being held in the
right hand, we grasp between the bite of the pincers  the tooth we
M'ish to extract as  high  as possible under the gum; this being
done, M'e make half rotatory movements, and on loosening the teoth
we draw it towards us in the direction of the external border of the
alveolar  process.

     §111.—The Curved Davier (Fig. 180) and  Curved Pincers.

   There is the same difference between these two instruments as
between the straight davier and  straight pincers.  The  pincers
should have the preference, and it  is advantageous to have them
of different sizes.   They are particularly useful in removing teeth
that have not much solidity, and the milk teeth, from  both jaws.
   We seize the tooth, without giving to it the twisting movement,
as in using the straight pincers, and endeavor to detach it gently 
OPERATIONS ON  THE TEETH.
325
forwards, drawing it at the same time towards  us, or out of the
socket.

              § IV.—The Elevator, or Carp-Tongue.

  The instrument thus named is composed of a stem,  which is
adapted like the key to a handle, and the bent extremity of which
is terminated  by  a quadrangular  flattened and truncated pyramid.
This is one of the  most valuable of instruments, and which no other
can  supersede, for the  extraction of the last  molars, or wisdom
teeth.
  Operative Process.  The patient being seated, with the head firmly
supported upon a resisting body, we grasp the handle of the instru-
ment with the whole hand, the fore-finger and the thumb being sepa-
rated upon the stem, and holding it firmly;  the operator  stations
himself on the right, if it  is a tooth on the right side, and on the
left, if the tooth belong to the left side.  He then introduces the point
of the elevator flatwise between the tooth he wishes to extract and
the next molar, which serves as a point d'appui; then, by an oscil-
lating movement,  drawing towards himself and downward, he pries
out the tooth, pushing it upM'ard and at the same time backM'ard.
It is proper to  remark, that during the operation  it is advisable to
place the fore-finger, wrapped in linen, on the inner side of the
crown of the  tooth we wish to extract, in order to arrest the point
of the instrument, which might slip and wound  the base of the
tongue at the  moment when the  tooth, forced with too much vio-
lence, should suddenly give way.   It is necessary, also, in  order to
facilitate the operation, to loosen the tooth laterally by means of a
bistoury or gum-lancet, (dechaussoir) and its posterior part with the
myrtle-leaved  curved gum-lancet; this form of instrument is very
convenient in  such cases.

              § Y.—The Dog's-Foot, (Pied de Biche)

  This name  is generally given to a steel instrument terminating
in one end  in a  pear-shaped  handle, and in the  other in a slight
bifurcation in  form  of a forked foot.   The most convenient Fi„ ]81)
and effectual dog's-foot for removing all the roots of a tooth,  "^
is the following, (Fig. 181.)   We are indebted  for it to Dr.  ff
Toirac, and it  may be applied to all the points of the mouth.
Consisting of steel moderately  tempered, it  represents a Z,
the terminating branch of which  should not be over half a
line in length.
  Operative  Process.  The handle of the dog's-foot being
wrapped in a napkin, we grasp its stem with the whole hand;
then, supporting its smaller extremity upon the root we wish
to extract, we  push it forcibly from below upward  when we
are operating on the lower jaw, and from above downward   j
when on the upper jaw.   The operator places himself upon  ^
the side upon  which he operates.  As in the preceding case, we
• 
326
NEW ELEMENTS OF OPERATIVE SURGERY.
must pass the  finger,  wrapped  in  linen, upon  the  side opposed
to the action of the instrument, for fear of wounding the cheek if
it should too suddenly slip.

   Article VIII.—The Straight and  Curved Cutting Pincers.

  These instruments may be, to a certain degree, replaced by the
straight and  curved pincers  of which we have  spoken, with this
difference, however, that their cutting branches,  when  approxi-
mated, have the form of a ring, in order that the crown of the tooth
that we cut may be embraced by it.  We employ them to remove
fragments of teeth that wound the tongue, crowns of teeth in great
part destroyed by caries, or when we wish to preserve  some roots
of teeth to aid mastication, or to insert there the pivot of an arti-
ficial tooth.

                Article  IX.—General Remarks.

  The surgeon, when called upon to operate upon the mouth of a
child, ought to have instruments much smaller than those  which
are in common use for adults.
  It is necessary that he should know, also, that in daily practice we
sometimes meet M'ith teeth and roots that present difficulties in ex-
traction impossible to be overcome by ordinary instruments; and
that  it is  then better to abstain  from vainly attempting a painful
operation, which may lead  to serious consequences, such as contu-
sions, wounds of the gum, fracture of the tooth, or of a portion of the
alveolar arch, nervous  symptoms difficult to subdue, or even to a
general disturbance of the whole  system, as in  timid  females,
especially during the period  of utero-gestation,  lactation,  or the
menstrual flux. 
DIVISIONS.
327
TITLE  III.
GENERAL  OR  COMMON  OPERATIONS.
  Those operations that are performed after the same rules,upon cer-
tain  regions of the body, have appeared to me to merit the title of
common or general operations; only, as there are those among them
which form, to a certain degree, the point  of departure for others, I
will subdivide this grand class into two families, the one for simple,
the other for complex operations.
  The greatest number of operations are composed of several differ-
ent stages, which are often in themselves so many distinct operations*
Everywhere, in fact, in operative surgery, we find incisions, dilata-
tions, extractions, and reunions,  alone, or in various ways asso-
ciated. To dilate and to extract being the province of some opera-
tions in particular, and each time requiring, so to  speak, different
instruments or processes, nevertheless constitute two indications,
whose  examination  in this place Mould be superfluous ; but as
there are few operations that do not commence with a division and
terminate with a  reunion, it appears proper to  say a few words at
first of diaeresis and synthesis.
          PART  FIRST.

SIMPLE  OR ELEMENTARY OPERATIONS.
                        CHAPTER I.

                          DIVISIONS.

               Section I.—Cutting Instruments.

  Leaving out of consideration the laceration (dechirure) and tear-
ing (I'arrachement) of parts, and ruptures, which are also divisions,
diaeresis has no other agents than the bistoury, scissors, and some
particular instruments. 
328
NEW ELEMENTS OF OPERATIVE SURGERY.
          Article I.—Manner  of  holding the  Bistoury.

  In itself the bistoury is a complete arsenal to surgery.  If it were
absolutely necessary, it could supply the place  of all other cutting
instruments; for that  reason, the  surgeon should study, before all
other things, to  use it scientifically.   There  are three principal
ways of holding it:  1.  As a table or carving knife ;  2. As a pen in
writing; 3. As a drill-bow, (archet.)  As each of these three modes
also have several modifications, I shall briefly point them out, giv-
ing to each the title of position.

§ I.—First Position—the Bistoury held as a knife, the edge  down-
                             ward.

  In  this  position, which is the most  common, the handle of the
instrument, enclosed in the palm of the hand, and supported by
the ring and little  fingers, is grasped between the thumb  and
middle finger at the point of junction of the handle with the blade,
while the fore-finger rests on the back of the blade.  Thus held, it
offers all the  firmness and security desirable ;  Ave may thus  move
it in any manner, and  give to  it any particular direction we may
wish.  If it should be necessary to employ much force, to cut into
solid  tissue, excise large flaps, or vast and very hard tumors, or to
pare off certain dense  excrescences, nothing would  be easier than
to bring the fore and middle fingers back and in front of the others
upon the open border of the handle, and thus  to grasp it with the
full hand.

  § II.—Second  Position—the Bistoury held as a  knife, with the edge
                           upwards.

  In place of being directed towards the tissues, as in the preceding
position, the edge  of  the bistoury should sometimes be turned
in an opposite direction. It is the belly, then, of the handle, and not
its back, which presses^ against the palm of the hand, and the thumb
and fore-finger which grasp its sides, while the  middle finger passes
under it as well as the ring and little finger.  Thus turned upwards
and in  the direction of the back of the  hand, this position is pre-
ferred for some  incisions  from within outward that require more
force than grace in their motions.

§ HI.—Third Position—the Bistoury held as a pen, the edge downward,
                         the point forward.

   Emerging from the back of  the hand, the handle of the bistoury
in this third position, as in the  first, is also held between  the thumb
and the first two fingers.  The remaining fingers are left free to find
some point d'appui near the part to be divided. 
DIVISIONS.
329
§ IV.—Fourth Position—the Bistoury held like a writing-pen, with the
                        point backward.

  In the fourth position, the middle finger, advancing more or less
upon one of the sides of the blade, turns, in the act of flexion, the
point  of the  bistoury towards the operator, or his wrist, in such
manner that  its edge looks towards the palm of the hand, from
which it is separated by a triangular space of greater or less extent,
and having its base backward ; the greater part of the delicate in-
cisions made  in dissections require the third  position, the  fourth
being more suitable to puncturing and to incisions from deep-seated
parts to the surface.

§ V.—Fifth Position—the Bistoury held as a pen, the edge upwards.

  To  dissect, or to cut from us, and to enlarge certain deep-seated
openings, we are often obliged to change the relations of the edge of
the bistoury,  to direct it in the plane of the dorsal surface  of the
fingers, and to place its back on the palmar surface ; apart from this
circumstance, which obliges the fore-finger to be substituted for the
middle finger, it is held with the point  either directed forward or
inclined  towards  the wrist,  as in the third or  fourth  position,
according as the fingers  are  extended or flexed, and as it may be
desirable to make a continued incision, or merely to divide attach-
ments.

       § VI.—Sixth Position—the Bistoury held as a drill-bow.

  The sixth position holds, in some measure, the middle  place  be-
tween the first and second. As in one, the handle of the instrument
rests in the interior of the hand, and as in the other, it is held only
by the ends of the fingers; it differs from both, however, in this, that,
in respect to the  axis of the  arm, the bistoury is  situated upon a
horizontal plane, and the pulp of the  extended fingers supports it
on  one side, while the thumb is applied to the other.  The three
varieties of this position  are  easily distinguished.   In the first, the
edge of the bistoury is turned downward ; in the second,  which re-
sembles the second position, it is turned upM'ard;  and in the third,
it is directed from right to left, except that, in place of holding its
handle by the flat faces, the fingers and the thumb, being directed
upon  the edges of the handle grasp it by its back  and belly.  The
first of these modifications, allowing us  to cut  with great delicacy,
is particularly useful in cases of scarifications in phlegmonous ery-
sipelas, where we have decided to operate by incisions,  and also
 for the opening of large sub-cutaneous abscesses.   We rarely have
 recourse to the second, but to divide small lamellae while guiding the
 bistoury upon the groove of  a director.  The utility of the third,
also, is confined to a small number of cases, M'here, from the fear
of wounding some subjacent  organ, we believe it advisable to di-
                               42 
330
new elements of operative surgery.
vide horizontally, by successive laminae, as in the manner of planing,
(en dedolant) the tissues which  present  themselves, as  is done in
front of certain arteries, for example, or in the  operation for stran-
gulated hernia.

          Article II.—Manner of holding  the  Scissors.

  The manner of holding the scissors being familiar to every one,
I have no necessity of describing it.  I shall confine myself to re-
marking, that, in place of the fore or middle finger, it is the ring, or
even the little finger, and the thumb, which are  to hold the rings of
the instrument.  The first two fingers being placed forwards, either
upon the  handles, or on one of their sides,  increase their force and
give more precision to their movements.
  The use of scalpels, (des couteaux) and of particular kinds of bis-
touries, will not be described until we come to the operations which
require them.
                     Section II.—Incisions.

  All incisions are referable to two fundamental methods: Some
are made from the skin toward deep-seated organs, and are named
from without inwards; the others, on the contrary, are  made from
the deep-seated  organs  towards the exterior, and are named from
within outwards.  The preference to be given to the first, or to the
second, depends upon a thousand circumstances, M'hich will be suc-
cessively explained in the sequel, and in great part recapitulated
under the head of opening of abscesses.
  Whatever may be the method determined upon, the incision is
performed—1. ToM'ards the operator, (contre soi) M'hen the bistoury
is brought from the commencement of the  incision towards the op-
erator ; 2. From the operator, (devant soi) when the case is directly
the reverse ; 3.  From left to right, (de gauche a droite) when, with
the right hand, we direct the handle or point of the bistoury, either
directly crosswise,  or  obliquely backwards  and outwards, while
flexing the fingers, wrist, or forearm, that  M'ere previously extend-
ed ; 4.  From right to left,  (droite a gauche) if, under the same con-
ditions, Me perform with the left  hand, or even with the right, in
holding the bistoury in a particular manner.
  The direction from left to right, being altogether natural,  is,
therefore, that which one takes most willingly  ; so that the others,
which might indeed be considered as exceptions, are  not, at any
rate, so often indispensable.
   The single or simple incision is that which is made in one direc-
tion, and  which may be made with a single stroke of the bistoury:
almost(always straight, and sometimes curved or semi-lunar, it is
that which, in combining itself under a thousand forms, gives place
to  the complex and multiplied incisions, whose shape, formerly so
varied, is reduced now to  that of a V, an  arcade <~v, or a half cir-
 cle o, a T, a cross +, an ellipse <0> an oval A, a crescent f?^
 an L, and a star Q. 
divisions.
331
                  Article I.—Simple Incisions.

                        § I.—Direction.

  Unless there is a special indication, the straight incision should
be parallel—1.  To the great diameter of the part; 2. To the direc-
tion  of  the* arteries, large veins,  or principal nerves;  3. To the
course of the fleshy fibres and muscular masses, or that of the ten-
dons ; 4. To the  natural folds  of  the integuments;  or, 5. To the
great axis of the tumor.
  Upon the dorsal or plantar surfaces,  or on the sides of the foot,
around the knee, in front, behind, and outside of the thigh, we make
them, in general, correspond with the axis of the limb, because the
vessels,  nerves,  muscles, and tendons,  take nearly this  direction;
behind the malleoli, we make them a little concave in front, be-
cause in this place the  same  parts are obliged to make a slight
curve to reach the sole of the foot; on  the inner part of the thigh
they would be  oblique, and in the direction of the sartorius, the
saphena vein, or the femoral artery ; in the  fold of the groin, we
only make them in the direction of this groove when they have not
to penetrate  below the sub-cutaneous  cellular tissue ;  the impor-
tance of the vessels is paramount here to every thing else.  On the
breech,  the muscles serve as guides, as they do also on the sides of
the abdomen, while in front, and behind this cavity, it is  the axis
of the body; the  chest is exactly in the same case, except  towards
the hollow of the axilla, M'here it is better to follow the axis of the
trunk than the fibres of the serratus anticus.  The hand  requires
that we should have regard to the wrinkles on its palmar face, and
the bend of the  arm to the arrangement of its veins, muscles, or
arteries, rather than to the direction of  the limb ;  in the neck, the
incision should be in relation with the  muscles, vessels, or axis of
the part; but it is rarely advisable to make them crosswise, except
in the bottom of the supra-clavicular fossa; on  the cranium, they
follow the radius of the  sphere on which they are made, and will
be thus  found parallel  to the muscles and the principal arteries; on
the eyelids, they will be in the form of an arc, because of the mus-
cles, wrinkles, and arteries ; it is the same nearly on the lips; they
will be straight on the nose, and oblique, in this or that direction, on
all the other regions of the  face, according as they shall fall on
such or such a wrinkle, or on the course of the vessels or muscles ;
in the ear, in fine, it is the projections of the organ which  will de-
termine  their direction.  The nature and the locality, superficial or
deep-seated, and the form of the diseased part, can alone cause any
deviation from these rules.
  Stretching the Skin.  There are many ways of stretching the skin,
when we wish to make a simple incision—1. With the ulnar bor-
der of the left hand, the thumb acting in an  opposite  direction ;
2. By grasping the part underneath with the whole hand ;  3. With
the extremities of the  four fingers  placed on the  same line, and in 
332
NEW ELEMENTS OF OPERATIVE SURGERY.
the direction which the bistoury is to take ; 4. By taking up a fold
of the integuments ;  5.  By drawing the tissues apart by means of
assistants, in order to have both hands free ; 6. By drawing upon
one side, while an assistant draM's the integuments in the other di-
rection.                                                   •
  Where we make tension with the thumb and little finger, it is  ne-
cessary that the part  should be held firmly; and the tension is rare-
ly equal on  all the  points, unless we join with them the action of
the fore-finger, and  even  that  of the two  other fingers.  The
grasping the organ itself (empoigner Vorgane) is a mode that is  not
applicable but to the limbs and to some tumors that are exceedingly
salient, or very much isolated.
  With the  ends of the fingers only the skin is held  firmly secure,
and the nails furnish a point d'appui for the instrument, but  the
tension is incomplete  and acts only on one side.   The taking up of
a fold of the integuments suits but in a very small number of cases,
and is not always practicable.   The hands of the assistants, or of an
assistant,  are  never as secure as  that of the operator,  and can
scarcely ever be called into requisition, except  in incising around
or upon the surface  of tumors or  voluminous masses.   The first
mode, then,  is the best, and  it is for the surgeon to determine under
what circumstances he  should  have recourse to the others.  The
important part of it is, that the  tension should  be  alike on both
sides.  Otherwise, the wound in the integuments would,  after the
operation, be no  longer in correspondence with the division of the
deep-seated parts.

               § II.—Incision from without inwards.

  If we wish to cut from without inwards, the bistoury may be held
in the first, third, or sixth position, according to the degree of force
to be employed, the situation of the disease, and the extent we  in-
tend to give to the wound.  The convex bistoury, which,  all other
things being equal, cuts better  and causes less pain, has the incon-
venience of leaving, more readily than the others, a queue* (trainee)
at the  extremities of the incision, and of not being adapted to those
more  minute dissections that go below the depth of the cutis, nor
to those which are made on  excavated  parts, and which require
that the instrument should act especially on its point.  The straight
bistoury, though it is less rapid in its action in the beginning, is in-
comparably more convenient  afterwards, and could, if necessary,
be substituted in all cases for the preceding.
  In the first position, the convex bistoury is applied, by the  most
salient  point on  its blade, to the middle of the space stretched by
the thumb  and fore-finger, then drawn from left to right to  the
place where the  incision is to terminate, so as to divide the whole
thickness of the cutis in the first cut, and more deeply still, if there

  * [Meaning the small superficial cut—a sort of queue or tail—which,  from the shape
of the bistoury at its point, it almost unavoidably makes in entering and leaving the in-
cision.—2Yj 
DIVISIONS.
333
exists underneath  no important organ to  avoid.  In order that it
may leave as little of a queue as possible, we take care to make it
with firmness in the beginning, and to elevate the wrist in finishing
it.  In holding it  in the  third  position, it will cut more with its:
point than with the  swell of the blade, and will run less risk of
wounding the subjacent parts and of  leaving long queues ; but it
will lose some of its facility (legerete)  of movement and other ad-
vantages. In the sixth position it cuts  after the manner of a razor,
and divides with equal ease the most delicate and soft tissues and
those that are the thickest and most tense, (tendues;) only that it
is not firm, and seems like cutting  in the air.
  The straight bistoury, held in the first position, and applied as in
the preceding case, and making the cut and withdrawn in the same
manner, acts  especially upon its point, penetrates to  much less
depth, but in a more uniform manner, and leaves scarcely any
queue.  In the third position, it is necessary to  plunge in its point
by  puncture by raising the  handle a little, and then gradually de-
pressing its heel as we draw the  instrument, and to terminate by
elevating the wrist, so that the point may be placed almost perpen-
dicularly ;  in conclusion,  if used in this M'ay, the instrument com-
mences by an  oscillating movement from above downwards, and
finishes by an oscillatory  movement from  below upwards. Being
satisfied by experience that the queue of the incisions is a matter
of no great inconvenience, I think it immaterial, in commencing and
terminating them, whether it be by puncture or by drawing with the
straight bistoury.  In this position, the little finger, fixed to the right
of the incision, serves as a support to the rest of the hand, and gives
every security to the steps of the operation;  lastly, in the sixth, the
action of the instrument  is, in every respect, similar to that of the
preceding, and held in the same manner, with this difference, that it
does not penetrate as well nor as  quickly.

             § HI.—The incision from  within  outwards.

   To cut from within outwards, we operate  either with  or without
a director, or M'ith the bistoury or the  scissors, and sometimes on a
part that has not been operated upon ; at other times through an-
other division.
                              §IV.
   Without a director, and when there is no  previous opening, the in-
cision is made  either from or  towards the operator, and with the
straight bistoury.
   From the operator, (devanl soi) the instrument, held in  the second
 position, is introduced by puncture ; after which the wrist is quickly
elevated, that the bistoury may divide the tissues, from  its heel to
its point, and be converted into a lever of  the second kind ; or we
raise the point by depressing the handle, so as to pass through the
skin a second time by puncture, and terminate by bringing the bis-
toury back to us, with the cutting edge upward, so as to divide the
tissue (la bride) by making it act as a  lever of the third kind. 
334
NEW ELEMENTS OF OPERATIVE SURGERY.
   Towards the operator, (centre soi) we hold it, with the ring finger
fixed on the side of its blade, at such distance from the  point as
may limit its progression.  We then introduce it by puncture ; when
it has entered far enough, M'e quickly elevate it perpendicularly, in
the manner of a lever of the second kind,  by draM'ing  its heel
towards us, as if to convert the fourth position into the third, in such
manner, in fact, that, by extending the fingers, its point when with-
drawn is  found entirely free, and directed forward like the point
of a pen, in place  of being turned towards the upper part of the
wrist, as it was in entering.

                              §V.
  On a director, when there exists a previous opening, we guide the
instrument into it,  either from or towards us;  without a  director,
when the thing appears easy; and in the contrary case,  flatwise
upon the fore-finger, or upon a grooved sound if the finger is too
large ; we afterwards proceed as above.  The sound is held in the
left hand, like a swing, or lever of the first kind, to which the index
finger placed below forms the fulcrum, the thumb fixed on  its han-
dle the power, and the tissue to be divided, which its point  tends to
raise, the resistance; to glide upon  it with facility, the  bistoury
must be  guided in the second, fourth, or sixth position, with  the
edge upward.   The grooves which  have no terminating  crest,
present no obstacle to the point of the instrument, which may thus
emerge from within outM'ard, traversing through the tissues; M'ith
this  crest,  it is necessary, on the contrary, to raise the  bistoury
up, as  a  lever  of the second kind.  The  narroM'er the bistoury is,
the better it advances ; the convex bistoury does not answer in such
cases, because its extremity is too M'ide, and that its point, by being
thrown too much backward, buts (arc-boute) readily against  the
groove of the director.  However little convex the back of the bis-
toury may be, it tends, in escaping, to leave some lamellae betM'een
its point and the director.
  After having arranged the director, we may  also proceed in
another manner, viz : endeavor to feel its point through the skin,
for example, then, M'ith a cut of the  bistoury, to lay it  bare by a
small transverse incision, as in making a counter-opening; the point
of the instrument,  placed  in the  groove of the director,  is then
glided along towards the handle of the sound, or from right to left;
or, what is as well, without taking the trouble  to make a previous
incision, the bistoury being  held  in the fourth position, we fix by
puncture the point of the bistoury on  the  director near its  beak, to
make it glide quickly as we bring it towards us.
  With scissors, it  Mould be necessary to slide  one branch of it
along the finger or director, leaving the other outside, and cutting
from us, and as quickly as possible, all that we  wish to divide.

             § VI.—With a Fold of the Integuments.
  In timid and  intractable  patients, if the skin is very flexible, or
it is  not desirable to go deeper than  that tissue, it is sometimes 
DIVISIONS.
335
necessary to take up a fold of it before cutting it.  This fold, whose
thickness varies, according as we wish" to give greater or less ex-
tent to the  wound, ought to be held on one  side  by the assistant,
placed in front, and on the other by the operator.  We then divide
it on its free part, down to its base,  as  in incisions from without
inward, or  in the opposite direction, that is to say, by puncturing it
and cutting through it, from its  adherent border toM'ards  the free
border, as M'ith incisions from within outward.  The pressure made
upon the integuments blunts their sensibility, and consequently ren-
ders the pain less acute ; moreover, as the bistoury only perforates
through the parts, in the manner  of an arrow, the  operator runs no
risk of failing, or of being  embarrassed by the movements of the
patient;  only that we  are not so sure in this, as in folloM'ing the
other method, of giving the incision  the precise  extent and neatness
requisite.

         §  VII.—Raising Layer after Layer, (en dedolant)

  The incision in a horizontal direction, or en dedolant, is that which
is least frequently had recourse to, and only  when we  wish to sep-
arate, layer after layer, on  the  same point, the  different tissues
which cover an organ which it is important to  avoid;  the bistoury
is held in the sixth position, the edge sidewise  ; the left hand, pro-
vided with a good forceps, raises  up each layer of the tissue, while
the right hand divides the detached layer by carrying  the bistoury
under  the  point  of the forceps.  Almost exclusively reserved for*
the operation of hernia, this kind  of excision, hoM'ever, is  some-
times met with in  other operations, those, for example, for aneu-
risms.

                 Article II.—Compound  Incisions.

  Complex incisions being only a combination  of  simple incisions,
are necessarily subject  to  the  same rules  of practice, and may be
made from without inward, or from  within  outward,  and with or
without a director.

                              §1.

  The V incision is composed of two  straight  incisions, which,
though  setting out from the same  point, terminate at  so much the
greater distance from each other, in proportion to the greater length
we desire  to  give to the triangular flap which they include.   Its
point, unless  there are particular counter-indications, should  be
turned towards the  most depending part, and we commence  the
incision by its base.  The reason for this  rule,  which at first sight
seems little in accordance with the object in view, is, nevertheless,
easy to comprehend: if the bistoury was placed in the upper ex-
tremity of  the first incision, in order to commence the second, the
instrument, before dividing it, would roll up, displace, and wrinkle 
336
NEW  ELEMENTS OF OPERATIVE  SURGERV.
its border, which is necessarily badly supported, and would cause
more pain than usual, and make  an irregular and  contused inci-
sion ; the convex bistoury would, in addition, have the inconveni-
ence of leaving a  queue beyond  the external  border of the first
wound, or of not separating the second from it at its angle but very
imperfectly.   In commencing by the base of the flap, nothing of
this kind happens.   The skin is not more difficult to extend for the
second incision than for the first.  The bistoury itself, in some de-
gree, stretches it in approaching the apex of the triangle, which it
isolates and completes without  the least difficulty, should the sur-
geon understand the proper manner of elevating the wrist as 'he
finishes the incision.
  To detach the flap thus limited, it is  seized by its point with the
forceps, for which it is well to substitute the fore-finger and thumb
as  soon  as that is  practicable.  The right hand, armed with the
straight or convex bistoury, held in the third position if we wish to
cut  towards  us, or by flexion  of  the fingers;  in the fifth, on the
contrary, if we M'ish to cut from us, or by extension of the fingers,
dissects it from below upward, or from its apex towards its base,
taking care to raise with it  as  thick a layer of cellular tissue  as
possible.  Formerly the incision in V was confined to the trephining
.of the temporal bone ;  at present it is not necessarily limited to any
part, but is used in the removal of certain tumors, and in the ope-
ration for some disarticulations.

                              §11.

   The  oval-shaped  incision,  which will be considered under the
head of amputations, differs from the V incision in being continued
from one branch to the other, as  it passes  around the base of the
flap, which is thus  completely detached; it is, in fact, constituted
of  the V incision and .that of the semicircle.

                   § III.—The  Crucial  Incision.

   The crucial incision, as its name imports, results from tM'o simple
 incisions, which cross each  other at right  angles.   It is only the
 second of these incisions which requires to be described. We com-
 mence it on the left side of the division, with the same precautions
 as for every other straight incision; but in the place of carrying it
 to the other  side without stopping, we terminate it by raising the
 wrist at the moment when we reach the wound, whose left lip only
 we must confine ourselves to cutting.  To complete it, the operator
 must change his position, unless  he  prefers changing the bistoury
 to the other hand, and does on the right what he has just finished
 doing on the left; in a word, it is  an incision  of two stages,  (en
 deux temps)  whose two halves meet, and have  their point of
 junction in  the first wound, which prevents  the instrument from
 rolling  up  and folding  under its edge the second lip of the primi-
 tive incision, as it would almost  inevitably do in passing from left 
DIVISIONS.
337
to right, to finish with a single stroke.  The dissection of the four
triangles M'hich result  from  this double  section,  being only the
repetition, four times renewed, of that described in speaking of the
V incision, requires no other details.

                              §IV.

  The T incision differs from the  crucial incision only in one point:
it is,  that, in  place of  passing from the  two sides, its transverse
branch rests upon the straight primitive incision.  It is thus reduced
to two stages,  instead of comprising three, as the  crucial incision
does.   In other respects, the same steps are to be taken in the  di-
vision of the tissues, in  the dissection of the  flaps,  and even in the
manner of holding the bistoury, in both cases.  One being a simple
modification -of the other, the crucial incision and the T incision are
indicated wherever the straight incision  is not sufficient to lay open
the parts which we wish to isolate or remove ; the relative value
of either is to be determined by the size  of the body to be detached,
and the crucial incision is not, in  reali'y, necessary, unless the T
incision, with its two flaps, does not give the surgeon all the facility
and freedom required for going through with the operation.
  The bistoury, carried  flatM'ise between  the teguments and such
tissues as are to be  avoided, then turned again to cut from within
outwards, or conducted  upon a grooved sound, would convert  the
straight, simple incision into a complex one, as effectually as if it
was directed upon the  integuments from  without  inwards.  This
method, in fact, is sometimes followed or preferred.

                              §V.

  The elliptical incision, which becomes almost indispensable when-
ever it is believed  necessary  to remove  with a tumor a certain
portion of its coverings, is  composed of two curvilinear incisions,
with the concavities looking toM'ards each other.  The marking out
of its direction with ink is  an  absurdity which  has no other incon-
venience than  its inutility, except, however,  in certain rare cases,
where the  least deviation  of  the bistoury might  incur the risk  of
serious consequences.  It is then that the hand of an assistant be-
comes useful in stretching the  skin upon one side, while the surgeon
draws upon the other.   The rule  requires that the most depending
incision should be made first, that the blood which it causes to flow
may, in no respect, interfere with the execution of the other. It is
made  by cutting toM'ards us from  left to right, and in such manner
that an assistant may raise the tumor, M'hile the operator, with his
left hand, stretches the integuments below.  The reverse of this is
practised for the second : here the surgeon himself ordinarily per-
forms the part  of drawing upon or depressing, with the ends of his
fingers, the mass to be excised or extracted, while  his assistant
stretches the skin above, taking care that  this tension shall act  at
the same time in the transverse and longitudinal directions, in such
                              43 
338
NEW ELEMENTS OF OPERATIVE  SURGERY.
manner, that the instrument, placed upon the left or upper extrem-
ity of the loM'er incision, may  effect an incision as neat in its com-
mencement as in the middle part of its track, and, also, that it may
not roll up the skin in terminating. We should not forget, moreover,
that  this upper incision, acting upon a depressed part, has need only
of a slight curvature for the course of the knife, to render it quite
concave when the parts are left to themselves.

              § VI.—The Crescent-Shaped Incision.

  Some persons, in these latter times,  have supposed that a double-
curved  incision, with  the  convexities  concentric,  might, in cer-
tain  cases,  be substituted advantageously  for the elliptic  incision.
The  semi-lunar flap  M'hich  it  circumscribes leaves a wound Math
loss  of  substance, the convex border of which is  easy to dissect
and to reverse  upon its  base, so as to  enable it  afterwards to be
brought back into the concavity of  the other, and upon the bot-
tom of the  solution of continuity.   Perhaps, in fact, M'e  should em-
ploy it for the extirpation of those massive tumors where M'e have
it in our power to preserve almost  all of the skin, and M'here a
straight incision would not expose them sufficiently. It  would pro-
cure the same advantages  as the elliptical incision, without inter-
fering so much with  immediate union.  The dissection of the inner
lip of a simple semi-lunar  or arched  incision, M'hen Mre do not
wish to make any excision of the skin, may be  considered in the
same point of  view, relatively to the V, T, and  crucial incisions,
which  latter, in such  cases, it would frequently render  unneces-
sary.
  I will add, that, in detaching by dissection the lips of any incision
whatever from the subjacent parts, to the extent of one or many
inches, according to the nature or situation of the wound,  we may
cover over  a very  considerable  loss of substance; and that the
integuments thus detached become elongated, and thus allow of our
bringing into immediate contact the edges of a  great  number of
M'ounds that we would have scarcely supposed susceptible of it.

                    § VII.—The L Incision.

  Employed in laying bare some large arteries, the  carotid and
subclavian among others, the  L incision has no need of being de-
scribed in this place.

         Article  III.—Incisions Applicable to Deposites.

  We may say boldly, that the bistoury is pre-eminently the reme-
dy for abscesses, whether they be hot or cold, diffused  or circum-
scribed, massive or diminutive. The pain is nothing in comparison
with the dangers that  it  prevents, and I cannot easily understand
how its use has been so often dispensed with, unless it be that the
fluctuation which results from phlegmonous inflammations remains 
DIVISIONS.
339
obscure.   A heroic remedy as it is, in sub-cutaneous inflammations
themselves, supposing that it opens no abscess, what harm can re-
sult  from  its application?—a  wound  altogether  simple, which
disgorges the tissues and is never an obstacle to the termination of
the principal disease, the progress of which, on the contrary, it al-
most  always favors.   When  we  have been witness to the havoc
insidiously made by the presence of pus, infiltrated  or effused into
the midst of the  organs by the  resorption of this fluid, or its bur-
rowing along the cellular tracks and tissues, it is truly impossible
to hesitate between such dangers and the fear of an unnecessary
incision.
   All kinds of straight incisions  are applicable to abscesses, whose
treatment, however, I do not intend to speak of here.  The large
lancet, called the abscess lancet, formerly employed for this purpose,
has completely fallen into disuse since the last half century.   The
ordinary  lancet, sometimes still  used in its  stead, does not suffice
but for a small number of cases, when, for example, the skin is
very thin and the abscess very superficial  or small; and even in
these  the bistoury would still be  constantly preferred to it, M'ere it
not that  we sometimes meet  with persons who,  though terrified
with the  mere name of bistoury, will  submit readily to the punc-
ture of a  lancet.

         § I.—Opening of Abscesses from  within outwards.

  There is  no circumscribed abscess that cannot be opened from
within outwards.   The operation  is rapid and bnr  little painful;
the instrument enters by puncture  ; its point plunje.s into  the inte-
rior of the  abscess, and its edge, raised from the heel toM'ards the
point, stretches the cutaneous M-all in proportion as it divides it, in
place  of causing its depression.  In this case, the  straight bistoury
is the  only one which is proper ;  it is only held in the fifth position
when  we wish to cut  from us at the bottom of certain cavities—
among others, for  certain abscesses in the mouth.   In the second
position, on the  contrary, it is in very general use ; in holding it
thus, we have all the  power and freedom required;  it  easily cuts
from us, and as obliquely as we may desire, and nothing is more
simple, in order to convert it into a lever of the second kind, than
to  elevate the wrist at the moment of terminating the  incision.
The fourth position  is  yet more  convenient : the  point  d'appui,
which it  allows us to have with the last fingers, is an advantage
which the second does not offer in the same degree.   The puncture
is made towards us; the hand and the fingers being flexed, it is suffi-
cient,  if we bring them to their natural direction by drawing upon
the handle of the bistoury, to assimilate it to a lever  of the second
kind, as in the preceding, to cut  from the heel towards the point,
and to divide the entire wall of the abscess, throughout its whole
extent, with great force and celerity. It is the position in which there is
least danger from the  inconsiderate movements and intractableness
of the patient; and I have for a long time been in the habit of em- 
340
NEW  ELEMENTS OF OPERATIVE SURGERY.
ploying no other, except when there is some special counter-indica-
tion.  The puncture  having been made, the rest of the incision is
completed, as it M'ere, spontaneously.  If it were necessary, this
posidon would not hinder us any more than the second from piercing
entirely through a hard and superficial abscess, as it  is proper
sometimes to do in furuncles, or carbuncles, and some other promi-
nent abscesses with thin walls, upon the limbs.   The  best bistoury
in such cases, as in the opening of abscesses in general, when from
mdthin outwards,  is  the bistoury M'ith a straight blade, regularly
tapering,  and with a  keen edge ; we hold it more or less  obliquely,
according as the deep wall of the abscess is  more or less remote
from the surface ; if it should touch, or plunge into the first with its
point,  the inconvenience, in  ordinary  cases, would  scarcely be
thought, worthy of arresting the attention; but the danger M'ould
be so great, when the abscess  lies in front of a large artery, or an
important viscus, that the very idea of it is frightful. For  prudence'
sake, then, if not  from necessity, as soon as from feeling no resist-
ance, or in any other manner, we are  assured that it has entered
the abscess, we should  cause it  to pass much more in  a parallel
line than in  one  perpendicular to the  axis of the limb or the dis-
eased part, and not  prolong the  incision but in raising  up  the in-
strument.
   In this  mode of incision, the stretching of the parts with the left
hand, M'hile the right hand is directing the bistoury, though  useful,
is not always indispensable.  If the abscess is vast and superficial,
or situated t-r a great distance  from every delicate  part, we may
even dispense with  taking any point  d'appui for the fingers, and
look only to the movements of our hand, as if  we were  cutting in
the air.   However familiar one may be with the habit of handling
instruments, one of the fingers, detached as it were from the others,
and placed on  the corresponding side  of the blade, gives us confi-
dence,'puts us  on our guard against the danger of  plunging the
point of the instrument to too great  a  depth, and in  most cases is
the only  precaution required.

          § II.—Opening of Abscesses from without inward.

   Abscesses  en nappe, or diffused abscesses, those that  are deep-
  seated and those that are formed about the joints, upon the track
  of vessels, and upon the surface of organs which it would be dan-
  gerous to come in contact M'ith or to penetrate, render it desirable
  that in  most cases the  opening should  be  made   from Mdthout
  inward.  The first require large incisions, either M'ith the straight
  bistoury  in the first or third  position, or with  the convex bistoury
  held in  the same manner.  With the straight bistoury, in the first
  position, we incise by applying the whole length of the cutting edge
  (en plein)  on the skin,  as for deep scarifications, and we draw it
  rapidly while passing from the heel to the point; in  the  third posi-
  tion, its  point is first plunged by puncture into  the abscess; the in-
  cision is afterwards continued by depressing its heel and the  rest 
INCISIONS.
341
of  its blade ;  the bistoury thus again becomes a lever of the sec-
ond kind, but acting from  above downward, in  the manner of a
straw-cutter, (coupe-paille)   With the convex bistoury, held in the
first position, we cut quickly and deep;  it generally suits better
than any other for such occasions, since it is admirably adapted by
its form for the  numerous incisions that we are sometimes  obliged
to make, at certain distances from each other, upon different points
of a purulent collection.
  Deep-seated abscesses are naturally divided into two orders:  1.
Those which, being covered over with a thick and dense layer, re-
pose on no region (foyer) which it  is  important to avoid ; 2. Those
whose depth prevents our ascertaining their precise positions, or
which it  is not  prudent to approach but by degrees.  There is no
objection to  operating  upon the first by puncture  M'ith the straight
bistoury  held in the third position, as  for  those on the  eminences
of the hand, for example, the palmar face of  the fingers, the
outer  side of the limbs, the breech, cranium, and posterior region
of the trunk.   The incision by puncture does not do for the sec-
ond : if we  open them with the straight bistoury, it is necessary
to carry it  from  without  inward with  the  right hand,  which
holds  it in the first or third position, and to divide, layer by layer,
all the parts which conceal the abscess, making use of our left fore-
finger, applied  from time to time to  the  bottom  of the wound, in
order that M'e may ascertain to a  certainty the fluctuation or pre-
sumed depth of the  abscess.  It is thus that M'e proceed  for ab-
scesses under the aponeuroses, between the crural muscles  and the
femur, in the hollow of the ham, about the humerus, in the thick-
ness of the  walls of the abdomen or chest, and on the forepart of
the neck.
  If we  did not observe the  same  caution in the neighborhood
of the articulations, we should run  the risk of  opening into the
synovial membrane, and of exposing the  surfaces  of the bone to
the contact  of  the atmosphere, while the  incisions, layer by layer,
do not deprive  us of the option of reaching there  ultimately, when
we may deem it indispensable so to do. If the abscess is extensive,
and the integuments are sufficiently thin, the convex bistoury makes
a neater incision, and causes less pain.  When its situation is less
clearly defined, we have recourse to the straight bistoury, which is
better adapted  to delicate dissections.
   We should proceed upon the  same principles  in the vicinity of
an artery, aneurism, or hernia, and near the pleura or peritoneum,
because we  are then sure of not  going beyond  the anterior wall
of the abscess before encountering the pus, and can stop when wc
think it  advisable, also identify the pulsations of the vessels, and
ascertain with  the finger on what tissue we are acting; while in
the incisions by puncture, and from within  outward, nothing can
protect us against the dangers  from  the  bistoury when we have
once  begun. Who does not know that the instrument has been
often  plunged into  an aneurism, a large and healthy artery, the 
342           NEW ELEMENTS OF OPERATIVE SURGERY.
intestine of the hernial sac, &c, even by celebrated  practitioners,
from having neglected to attend to these rules ?
  [Surgeons  cannot, says Dr. Mott, be too careful how they pro-
ceed under the circumstances above specified with so much ability
and precision by the author of this inestimable  work.  All prudent
surgeons had better look on before they take a step where the life
of the  patient may possibly be hazarded.  It is a golden  rule,
M'here there  is any doubt,  to  give the patient the benefit of it by
M'ithholding all unnecessary  interference.   If surgeons were  to
proceed in this way under all such circumstances, Ave  should not
have to lament the mistakes which ignorance of relative  anatomy,
and rashness of conduct, have in all countries too often occasioned,
and by which a severe and just reproach has been cast on our no-
ble profession.—T.]
  One of the principal objections to these  incisions from without
inward, is their pressing upon the abscess in opening it;  and that
the abscess is  no sooner opened  a few  lines, than this pressure
drives out  the pus, depresses  the walls, and makes it almost abso-
lutely impossible to continue  the incision  M'ith the same stroke.
That, however, should  be understood only of slow or gradual
incisions.   Those which can be made  rapidly  with  the entire
edge  (le plein) of a straight  bistoury, or, better  still, with a con-
vex bistoury,  held in  the  first or sixth  position, as in  deposites
of a vast extent situated  immediately under  the skin,  have not
the same inconvenience, and are, in reality, the  least painful of
all.
   With a Director.  To enlarge  the opening of  an abscess, the
finger or a grooved sound serves as a conductor to the instrument,
and  the bistoury or the scissors are guided, as has been said in
speaking of incisions from  without inward, by  means of a director,
after a previous opening in the skin.

          § III.—Opening Abscesses by Complex Incisions.

   It is thus, also, that the operator should proceed, if, in place of a
simple incision, he should wish to open the abscess by the V, T, or
crucial incision.   Such modifications, more  often useful than most
practitioners seem willing  to admit them to  be, are of great benefit
in sub-cutaneous  abscesses  with diseased condition of  the  skin.
The first opening being made from the left and upward, for example,
and the sound effecting a  separation to  the right, a second open-
ing is made in this direction, and the abscess, thus  disclosed to view,
presents a V incision.   When the cul-de-sac is upon one side, we
immediately make a T incision, and in those  collections in which
we wish to lay the bottom entirely bare,  the crucial incision is also
used.   From  whence  it follows,  that, with the  exception of the
elliptical or semi-lunar incisions, all the different kinds of divisions
may be called to our aid in the treatment of  purulent collections,
but that the simple incision  is, nevertheless,  almost the only one
required for them. 
INCISIONS.
343
  Article IV.—Incisions applicable to the Dissection of Tumors
                          and Cysts.

  The contrary of M'hat takes place for  abscesses is observed in
relation to cysts and tumors ; for these the complex incision is most
generally indicated.  When  all the  skin, however,  is to be pre-
served, the simple incision is often quite sufficient. Rolling, or very
moveable tumors, covered M'ith a pliant and sound skin, do  not
always require an incision M'ith  many branches.   The testicle, the
breast, and various degenerated  ganglions, have often  been  ex-
tracted through a straight and simple incision,  though  they had
acquired considerable development.


                    § I.—Form of the Incision.


  A.  The straight incision, forming a single slit, (boutonniere) should
exceed, by half an  inch or an inch, or even more, in  its two ex-
tremities, the limits of the tumor, and should go through the  entire
thickness of the adipose tissue.   There  are, then, many modes of
continuing the operation : to seize M'ith a forceps, or the first fingers
of the left hand, each lip of the wound,  and to  dissect them one
after  the other, and from within outM'ards, with the right  hand,
while  an assistant draws the tumor in an opposite direction M'ith
his fingers, or with a hook or an erigne, is one of the modes most
frequently adopted.  Others prefer, when the pliableness (souplesse)
of the parts allows  of it, to press with the thumb and first fingers
of one hand through the skin,  as deep as possible upon the sides of
the mass to be extirpated, as if to expel it through the wound,
M'hile with the other hand they cut  perpendicularly the adhesions
of the cellular tissue, in proportion as the edges of the incision re-
cede outwardly or  retract backwards.   If the tumor is  pendent.
M'e arrive at the same result by embracing it underneath with the
palmar face of the entire hand spread out.  By this last method
the pain is  generally less, and the  operation is at the same time
quick,  easy, and  secure, but, unfortunately, it is not applicable
everywhere.   Some find it more convenient  to hold the tumor
themselves, and to cause the lips of the incision to be  kept  apart
by an assistant, while they dissect and isolate it.  It is thus, in fact,
that it is proper to proceed in all cases, as soon as the anterior face
of the tumor is free.  In  adopting another course to separate it from
the deep-seated tissues, the surgeon Mould run the risk of  going too
deep, or of not removing all the diseased parts; in this matter he
can depend only on the  evidence of  his fingers, which have, also,
the inappreciable  advantage  of being enabled to perceive the ar-
terial pulsations, if they should present themselves there,  and with
the action of the other hand of regulating their movements without
difficulty, as also the tractions M'hich they exercise. 
344
NEW ELEMENTS OF OPERATIVE SURGERV.
                       B. The V Incision.

  It would be an error to suppose that the elliptical and crescentic
incisions were the only ones which allow of our taking away a
portion of the substance of the cutaneous tissue ; the V incision has
frequently  fulfilled the same indications.  In cutting many  V's,
or triangular flaps, connected at  their base, and upon the contour
of very large sized tumors, we remove with the disease a stellated
piece of integument, which does not afterwards prevent us from
covering the entire wounded surface with the preserved  triangles.
Delpech and M. Clot have had recourse to something similar in the
removal of enormous (elcphantiasiques) tumors that they have de-
scribed, and I have proceeded in the same manner for the removal
of bloody (hematiques) masses on the fore part of the knee, and with
tumors of all kinds.

                C. The T and Crucial Incisions,

Which are only used when the skin which we do not wish to trench
upon  is not sufficiently pliable to allow a straight incision, to lay
bare the tumor in a proper manner, are  also indicated in certain
cases in conjunction  with the elliptical or M'ith the crescent-shaped
incision; for example,  M'hen the base of a  cyst  is  extended too
much beyond the flap of integuments which we have just circum-
scribed, or when it appears difficult  to dissect alternately each lip
of the wound, or that we do not M'ish to have the flaps too large.
The T and crucial incisions, in fine, resolve themselves into a trans-
verse incision, on one of the edges of the wound for the T incision,
or on both successively for the crucial incision.

                  § II.—Dissection of the Flaps.

  Whatever may be their form and extent, these different incisions
give rise to flaps which it is necessary to dissect off from their apex
to their base.   This is generally the  most delicate part of the ope-
ration, and is not performed exactly after the same rules for all
kinds of tumors.

                     A.  Concrete Tumors.

  In all cases of lipoma, or any other  solid mass  destitute of ma-
lignancy, the edge of the bistoury should be more inclined towards
the tumor or the deep-seated parts than towards the skin, since the
more  thickness we give to the flap by the preservation of the cellu-
lar or adipose tissue that lines its  inner surface, the more highly
organized (vivace) is it, and the more disposed to  reagglutinate it-
self (se recoller) to the subjacent tissues.  If the contrary mode
should be adopted, the instrument  would leave  nothing but  the
mere  skin, and might perforate it and render its preservation or re- 
INCISIONS.
345
union impossible ;  while, though M'e should even go too far on the
inner side, we do not see, in truth, what evil would result from it.

                          B.  Cancers.

  Carcinomatous  tumors require a little more attention  ; the skin
undoubtedly should not be too much attenuated, but it is important
at the same time not to turn over (renverser) with it any portion of
morbid tissue.

                      C.  Cysts, (Kystes.)

  The dissection of encysted tumors, and of sacs  full of liquid or
semi-fluid matters, which we wish to remove Mdthout opening the
cysts, or to extirpate entire, demand still greater care ; the walls
of the cyst  are  sometimes  so  thin  that  the  least deviation of
the bistoury iiiM'ards divides them ;  the sac is immediately  voided ;
the tissues cease  to be capable of distension, and the  operation
which, Mdthout this accident, M'ould have been easy and one of the
most simple, becomes one of the most laborious and, in a great num-
ber of cases, even impossible  to complete.   It is  necessary, then,
while we endeavor to preserve as much as possible of cellular tis-
sue when we are dissecting out a cyst, that M'e should turn the
edge of the knife a little more towards the integuments than in the
direction of the tumor, as often as the walls of the sac to be  avoided
are so superficial,  or appear so thin as to be easily perforated.
  It is also proper to remark, that  certain cysts do not demand so
many precautions, and that we may confine ourselves to slitting up
their M'hole  anterior M'all by a  simple incision, or a T  or crucial
incision,  as if we were opening an abscess; deep-seated and adhe-
rent hydatid tumors, whose interior  we wish to cauterize, or whose
entire cavity we would desire to place  in  contact with the air, to
cause them to suppurate,  also  come under this  exception.  We
shall see, farther on, that it may be the same with encysted tumors
of the cranium, &c.

                      D. Abdominal Cysts,

Collections of fluids in the neighborhood of the  splanchnic  cav-
ities, and the adhesions of which M'ith the adjoining serous mem-
branes do not appear to be definitively established, (bien assurees)
very often justify a mode of incision much eulogized by  some per-
sons in  these latter times.  It is  a simple incision, straight or
curved, and layer  for layer, with a  straight rather than a convex
bistoury held in the first or in the third position, and directed from
Mdthout inwards.   If the cyst is in the abdomen, we cut  gradually
to the  peritoneum, which we lay open  to the tumor, in the event
of its non-adhesion, but leave untouched, if it appears to be merged
into the wall of the greatly attenuated morbid sac.  The operation
is there arrested for the moment; a  roll of lint is placed lengthM'ise
                              44 
346
NEW ELEMENTS OF OPERATIVE  SURGERY.
in the M'ound to keep its lips apart, and renewed, for the space of
several days, as often as there shall be need of it.  Protected from
the  pressure of the divided tissues, the cyst has a tendency to pro-
trude into the  incision, approaches the outer surface, and finally
often bursts by opening spontaneously, sometimes on the morrow,
more frequently after the  lapse of some days.  If it was left free,
this  preliminary incision would  cause an adhesive  inflammation,
which would not be long in reuniting the anterior wall to the layers
M'hich cover  it, and  then we might perform a puncture, or an in-
cision, without the least danger of causing an effusion into the  belly.

                    Section III.—Punctures

  Whenever a surgeon plunges the point of an  instrument M'ith a
single stroke through the tissues, he performs a puncture, (ponction.)
Punctures from within outwards are almost all made M'ith the bis-
toury and suture needles, or M'ith instruments having springs ; the
others, that is, those  that are made from without  inwards, are per-
formed sometimes with a straight bistoury or a lancet, as has been
seen in the preceding articles; sometimes wiih a needle, or with par-
ticular instruments, the trochar, &c.; M'ith a straight or round needle,
or one  furnished with an eye near its heel, like a sewing-needle, as
in certain sutures; with a longer needle, surmounted by a he<id, a
handle, or a ring, as in acupuncture ;  with a needle having a cutting
point on  one or both its sides, or straight or curved, when we wish
to explore certain tumors and collections of a doubtful  nature, as
many practitioners have recommended since Hey, and as has been
still more recently done by M. Pacini (Discors. del Dott. Pacini, etc.,
1836, broch. in 8vo) in a M'ork expressly Madtten upon this subject;
with needles with cutting edges, and of the shape of arcs of a circle,
and furnished with an eye for thread, as, for example, in most su-
tures;  with, different kinds of trochars, when  we wish to convey a
canula to the bottom of some reservoir or cyst, to draw off its liquid
only, and not to leave behind a cicatrizing wound, properly so called.

                    Article I.—Acupuncture.

  By acupuncture is understood a puncture  which traverses the
tissues without breaking the continuity of their  fibres.  The nee-
dle to be used for performing acupuncture should have the form of
a regular cone, and  in  general be exceedingly fine.  This needle,
being  three or four  inches  in length, and terminating in a  small
many-sided  handle,  or by a ring, should  always  be  surmounted
by  a metallic eye when we wish to change  the  acupuncture into
electro-puncture.  We insert it while rolling it betM'een the fingers
of one hand, M'hich hold it  like a writing-pen, and  press it gently
upon the skin,  which latter  the other hand  is  employed in keeping
stretched.  Some persons make it enter by making taps upon its
head with a small hammer; for myself, I prefer,  when the rotation
does not suffice, to press perpendicularly upon its upper extremity
with the fore-finger, while  the thumb and  other fingers hold the 
INCISIONS.
347
needle in the manner already described.  Thus conducted, its point,
separating and not dividing the organic fibres, may traverse the
arteries, even the heart itself, and the most  important organs, as I
have  myself often made it do, (Journal Hebdom. Univ., 1831, t. ii.,
p. 57,) without giving rise to any effusion of liquid, and without
leaving the least trace of its  passage.   In pushing it more rapidly
by a simple effort of pressure, as some persons among us do it, there
is in general a little more pain produced, but prudence forbids that
M'e should apply it upon these principles along the track of the
great vessels.
   Electro-puncture is performed like acupuncture, only that  it  is
not always  necessary to insert the needle as deep, and that, being
once  in its place, it should be put in  communication M'ith a gal-
vanic pile, or a Leyden jar. by means of some  description  of con-
ductor, whatever that may be.

               Article II.—Exploring Punctures.

   2.  The needle preferred for ordinary punctures is  more easy to
guide, and should not be as fine as  the acupuncture needle. Though
the round needle may have been  advised for opening a passage to
gas pent  up in a strangulated intesline, it is, nevertheless, to the
spear-shaped needle, (aiguille en fer de lance) with  a straight  or
curved point, that we always have recourse as an explorative means
in such cases.   A tumor shows itself in a complex  region of the
body: we are not sure that it contains a liquid, or do not know if
this liquid is blood, pus, or serum, or whether the tumor is an
abscess, cyst, or aneurism.  Puncture Md..h  an appropriate needle
immediately removes all doubts.   If there is fluid within the mass,
it causes  some drops to issue from it, and enables us to determine
its nature ; the small M'ound  it makes immediately closes,  even in
the case of an arterial cyst, and  the  surgeon  then makes up his
mind with a full knowledge of the cause. Its insertion is regulated
by the same rules as that of the  bistoury introduced by puncture,
that is to say, that the right hand  seizes it sometimes as a writing-
pen, and sometimes as a knife, by its handle or head, in order to push
it in,  M'hile the left hand stretches the parts. As it is a little wider at
the point than at the  stem, the liquid passes  along this last, and
enables us to make up our judgment before  M'ithdrawing it, and to
determine also the moment of its  entrance into the cavity.  I have
no need of adding, that, in order to  have only a simple puncture,
we should, in withdrawing it, bring it back with care through the
same track which has opened  a passage for it.
   The spear-shaped  needle, which I  make use of  for exploring
punctures, is nothing else than a straight cataract-needle, like that
which was in use before the time of Scarpa.  With this needle
we distinguish Mdthout difficulty the different kinds of deposites of
every solid tumor; but it is not  always sufficient to indicate the
nature of the matters contained  in a cyst.  Unless, in fact, the
matter is very fluid, nothing issues  out by the  puncture, and the 
348           NEW ELEMENTS  of operative surgery.

surgeon may remain in a state of uncertainty.  If there is neither
a large-sized artery nor an aneurism to fear, we then substitute for
it the point  of a lancet, or  of  a bistoury  M'ith a straight keen
blade.
  In place of holding  the lancet as in bleeding, I hold it as a wri-
ting-pen, and insert it in the  manner of a needle.  The  bistoury
should be inserted in the same manner.   If there still remains any
doubt, we may glide in a fine probe upon one of the sides of the
instrument, in order to dilate  a little the lips of the wound.  If we
should desire to avoid  all parallelism between the puncture of the
skin and that of the subjacent tissues,  it would ansM'er to penetrate
very obliquely into the tumor, or, after having  forcibly drawn its
coverings in one direction only at the moment of puncture, to allow
them to return to their position.

     Article III.—Puncture  with Trochars. (Trois-Quarts.*)

  The use of the trochar is  especially distinguished from that of
the needle, lancet, or bistoury, by the canula which the instrument
carries  M'ith it, and  which becomes  the conducting-tube of  the
fluids we wish to evacuate.  Whether its point be flattened, like
that of  a lancet, or pyramidal,  with  three cutting edges, and the
rest  of  the shaft smooth, as  it  generally is, it  requires a certain
force to make it enter; from this results the necessity of embracing
the trochar with the full grasp of the hand.  We place its handle
between the thenar  and hypothenar  eminences,  or  betM'een  the
hollow of the palm and the  last  tM'o fingers flexed.  The thumb and
middle finger, a little  more advanced, hold it near its termination,
whilst the fore-finger,  extended, holds  the instrument  at a greater
or less distance from the point, in order to limit the depth  to which
it is to penetrate.  In a case of necessity we might, for greater
security, detach the middle finger from it, and select a point d'appui
for this finger upon one side  of the place that is to be punctured.
In general I  prefer holding the  handle with my full hand, and of
limiting the entrance by the nail of the thumb, which I keep fixed
at a proper  distance  from the  point.   When  it has entered, the
thumb and fore-finger of the left hand adjust its canula, the spoon-
beak (bee de cuiller)  being directed  downward,  while  the right
hand draws upon the  handle,  and removes the  punch.  The sac is
emptied, and the liquid received in a vessel.  To remove  the tube,
it is sufficient to draw a little briskly upon its head, while the fin-
gers, which till this moment have held it, are applied upon the sides
of the puncture,  in order to hold back the skin, or the walls of the
cavity,  by giving them a point d'appui.
   This instrument, called trocart, or trois-quarts, presents  also nu
merous varieties, relative to  its calibre, length, or form.   In punc-
  * [The word trochar, though undoubtedly a corruption of the French trois-quarts, has
obtained such universal currency that it would be next to impossible to attempt, with the
author, the restitution of its primitive orthography.—T.] 
REUNION.
349
tures  in general, it is sufficient  to have two of them; one small,
called the hydrocele trochar, for tumors of moderate size containing
liquids of great tenuity ; the other almost as large as a goose-quill,
called the paracentesis trochar, for large tumors or liquids of some
degree of  consistence.
  The groove which is upon the  canula of some trochars, and the
openings with which some authors prefer to have them perforated
in their loM'er third, allow, in the first arrangement, the bistoury to
be introduced upon it, if it should be necessary to incise the sac, and
in the other, the liquids to run into it from all the sides of the cavity
at once; but  as they at the same time permit certain matters to
infiltrate themselves between the canula and the tissues, which it
distends, it is better to dispense M'ith them.
  The employment of the trochar demands certain precautions.  It
is important, first,  that the extremity of the canula should  not reach
entirely to the base of the pyramid of the punch, that it does not form
any elevation or border, and that its other end remains firmly clasped
to the handle at the time of the puncture.  It is afterwards neces-
sary to bear in  mind, that a button-headed probe  is required to
clear it out and remove from it the flakes or other solid substances
which might interrupt the flow of the liquid during the operation.
I will add, that  if  the opposite walls of  the cyst are not separated
but by a few lines, the  instrument, tending inevitably to approxi-
mate them more while entering, may perforate  through them at
one stroke, and lead to  serious  accidents.  The error being once
committed, we remedy it by removing the punch  from the canula,
and  then  withdraw  that also by a gentle rotatory movement.   At
the moment when the deeper wall of the  sac is  disengaged from
it, it naturally falls into  the  cyst, and the liquid immediately runs
out.   We then push it back again a little, and nothing is easier
than  to adjust it afterwards  as we wish.   It is necessary, in fact.
to obtain  previously as exact an idea as possible of the  thickness
of the walls of the  cavity.   I shall return to all these subjects in
speaking of operations, and particularly of hydrocele.
                        CHAPTER  II.

                          REUNION.

  The  reunion of divided parts is obtained by the position of the
patient, or of the wound, and by means of bandages and plasters,
and especially by the suture.

                     Article I.—Sutures.

  The  approximation of the lips of a wound by means of threads
or metallic pins, (tiges metalliques) being  the only one among the 
350
NEW ELEMENTS OF OPERATIVE SURGERY.
means of union that is entitled to the appellation of a bloody ope-
ration, is the only one which I shall at present examine.  The suture,
evidently borrowed from  the art of the tailor, formerly enjoyed a
reputation which, to judge by the practice of most operators at  the
present day, could scarcely be credited.  Since the time of Pibrac,
who has censured it so much, and who, in a memoir in other respects
but little  conclusive, wished, to  a certain  extent, to reject it from
the domain  of surgery, the suture has been constantly losing its
former importance  in  the eyes  of practitioners; so that it  is no
longer in fact recommended in classical works but for a small num-
ber of cases.  The  partisans for and against it have  both exceeded
the limits of truth.  If the suture does not  merit the praises M'hich
were formerly bestowed upon it, it  merits still less, perhaps,  the
disuse into which it has in our days fallen.   The only well-founded
objections lhat can  be urged against it, are that of augmenting  the
pain, and prolonging the operation ; but it is only necessary to have
been witness to what  takes place in hare-lip, staphyloraphy, rhino-
plasty, genoplasty, cheiloplasty, and enteroraphy, to be' convinced
that these inconveniences  have been much exaggerated.  In those
kinds of unions, neither the pain  nor the inflammation are the  ob-
jections ; and  the practitioner would be too fortunate if  he had
no other difficulties to overcome or combat.  As to  the  greater
duration of the operation, who would venture  to  make a serious
objection  on that account, if the  suture had the advantages that
were attributed to it before the time of Pibrac and Louis 1
  To speak emphatically,  it is requisite that we should remark, that
the suture is not in reality dangerous, as the  ancient Academy of Sur-
gery pretended, but only that it is useless in an infinity of circum-
stances, and scarcely  ever indispensable.  It is only indicated in
wounds in which we  desire  immediate union; there are,  also, in
these kinds  of lesion  a great number of cases in which it might
be dispensed with,  without inconvenience, as there are also others
where it is totally impracticable.   Preferable to all kinds of  band-
ages or plasters, where we wish to keep in coaptation large flaps,
moveable or badly supported integuments, membranous  or very
delicate organs, it would  give but little assistance  in M'ounds with
firm lips (levres fixes)  abundantly supplied with cellular tissue, and
which penetrate to the thick muscles of the limbs or  trunk, and  the
edges of which follow only the movements of the subjacent parts.
  With the suture no pressure is  necessary ; we may dress lightly,
(mollement) and afterwards  dispense with any traction upon  the
teguments in the neighborhood : the coaptation, which  runs no risk
of being  displaced, is effected through the whole  thickness of  the
bleeding borders.   With adhesive straps, or bandages, we produce
more or less irritation upon the skin ; the contact is rarely perfect;
and should the cutaneous tissue be somewhat flabby and detached,
the lips of the wound constantly tend to roll up inwards, and do  not
touch but upon that part of their line which is nearest approximated
to the epidermis; the least effort, the least imprudence  causes them
to be displaced, and all the  regions of the body do not permit of 
REUNION.
351
their application ;  we do not see, in fact, how, in case of strangula-
tion, it would be at all  more difficult  to  relax  or  divide a stitch
of the suture  than an adhesive strap or piece of linen.  Without,
therefore, conceding as  much favor to this remedy as Delpech, M.
Gensoul, and the greater part of our surgeons in the principal towns
in the south of France do, M'hose views M. Serre (Traite de la Re-
union Immediate,  etc., Paris, 1830) has so correctly embodied, I
think, with this last author, that it deserves to be reinstated to a cer-
tain degree of consideration in  surgery.
  Of all the sutures that have been described, science has scarcely
retained any other than the interrupted (entrecoupee) suture,  or that
with separate  stitches; the whip-seamed,  (a surjet) or glover's, (du
pelletier;)  the zig-zag, or  suture  with alternate side-stitches, (d
points passes;) the noose, [or loop,] (a anse)  or Le Dran's ; the
tM'isted, (entortillee ;) and the  quilled (emplumee ou enchevillee) su-
ture.

                   § I.—The Interrupted Suture.

  To apply the suture with separate stitches, we procure as much
thread, simple, doubled, tripled, or quadrupled, and  well waxed, as
we intend to use in the  different stitches ; also, a  certain number
of needles.
  The needles that were still in use in the last century, and which
were curved and flattened in their anterior half only, and straight,
round, or a little depressed laterally, and pierced in the same direc-
tion with a long eye behind, are entirely abandoned at present; for
these, we now everywhere prefer needles  that are curved into a
regular arc of a circle,  of the  same width and thickness from one
end to the other to within a few lines of  their point, and having a
square opening made in  the posterior part transversely through their
thickness.   These last,  generally adopted since  the time of  Boyer,
(Mem. de la Soc. Med. D'Emul., t. iii, p. 79,) are, notwithstanding,
very inconvenient.  The arc which they form renders their passage
through the tissues difficult; and, being almost  as thin  at the heel
as at the point they are apt to break. I am more  disposed  to make
use of spear-shaped (enfer de lance) needles, with cylindrical stem
and lateral eye, (ckas lateral)  and which, like the ancient needles,
are but slightly, or not  at all, curved in their posterior  half.  The
others are indispensable only  for  sutures that we are obliged to
make at the bottom of certain  cavities or excavations, and the ad-
vantages that  Boyer attributes  to them have not appeared to me to
be confirmed by experience.  A needle, attached to each extremity
of the thread, is required only when we wish to pass both of them
through the internal or cellular surface of the wound ; otherwise,
one is sufficient for each stitch.  Other things being  equal, it is bet-
ter  to  perforate one of  the edges of the wound from without in-
wards, and the other from within outwards ; the  operation, con-
ducted in this manner, is more prompt and less painful;  the  instru-
ment  draws less upon the  skin from without inwards than in the 
352
NEW  ELEMENTS OF OPERATIVE SURGERY.
opposite direction, and is not attended with the inconvenience of
changing  the  needle or hand in passing from one lip to the other.
We should begin upon the straight or upper lip of the wound.  The
surgeon pinches this lip by placing his left thumb (the hand being
turned in pronation) on  its inner side, and the fore-finger of the
same hand upon its outer part; then he raises the lip and reverses
it  slightly  outM'ards.   Having seized the  needle, armed with its
thread, M'ith his right hand, placing his thumb in its concavity, and
the fore-finger and middle finger, and even sometimes the ring fin
ger, upon its convexity, where the needle is rather large, in order
to convert it into  a lever of the third kind, he inserts the point  of it
into the skin at two, three, or four lines from the division, pushes it
in will a circular movement, and brings it out of the wound where
the left thumb guides its progress and direction.  After having re-
laxed his hold on the heel, as soon as it is sufficiently advanced, the
operator seizes its point, by  placing his thumb upon its convexity,
and  continues to draw upon it, bringing the thread with it by a
movement  of supination; he then takes it as he did at first, and
proceeds immediately  to  the second  step of the operation, M'hich
differs from the first only in  this, that the needle should perforate
the second lip of the wound by beginning upon its deep-seated  bor-
der, (sa face profonde)  [M'ithin the wound.—T.,] and that, instead
of the fore-finger, we place the thumb  upon the skin, in order to
hold it firm.
  The other stitches are but  the repetition of the first; and when
many are to be inserted, we  usually begin with that on the right,
or the lowest one.
  The rule  M'hich  directs the first stitch to be  placed  upon the
middle of the wound, is not applicable but to a very small number
of cases.  It is suitable only after the removal of certain tumors,
and for wounds with  flabby flaps, (lambeaux fiasques) or simple
wounds with very moveable teguments ;  otherwise, it is almost al-
ways better to begin on one of the extremities, or one of the angles
of the division.   The more the stitches are approximated, the more
they favor immediate union,  and the less distant are we obliged to
make them from the line of the wound; it is also important, in
most anaplasties, to leave only two  or three lines between them.
As a general rule, the more they are approximated the better the op-
eration succeeds.  It is the same, also, with all other kinds of sutures.
  If any reasons should incline us to use the ancient method,  and
place a needle on each end of the thread, the upper or straight
border of the wound, being raised up as before, should be perforated
the first, from its adherent [or internal] surface to its free [i. e., its
outer] surface, while the right hand should be turned in supination,
in order to place the thumb on the concavity of the needle, which is
pressed by a movement of pronation ; the perforation of the other
border should be made with the second needle, exactly as in the  first
method.
   When we have to act upon tissues that are exceedingly resisting,
we avoid  M'ounding the fingers, and acquire a greater  degree of 
REUNION.
353
force, by covering the whole heel of the needle with a thick piece of
linen. In such a case, it is advisable, also, in order to obtain a point
d'appui, to place the two points of a forceps, slightly opened, under
each side of the bleeding surface, where the point of the needle
is about to penetrate.
  Instead of using separate threads, we may also,  as I have often
done, and have seen M. Dieffenbach  do, insert all the stitches of a
suture with the  same thread.  The first stitch is immediately tied
into a knot, and the thread cut near  the knot.  We proceed in the
same manner, and Mdthout stopping to insert the other stitches, un-
less it should be necessary to change  the needle.  The preparations
for the operation, and the operation itself, are both thereby some-
what expedited.
  Another mode, which I have found  very successful upon the  eye-
lids and anus, and especially upon the vagina, consists in inserting
v\dth the same needle,  and with one thread only,  all the stitches,
and without tying or cutting any of  them.   For that purpose we
have a very long thread, and at each insertion of the needle leave
outside a loop (an.se) of several inches in  length;  afterwards, by
dividing all the loops, the surgeon obtains as many distinct liga-
tures, M'hich he has only to tie separately.       •
  De La Faye, who used this kind of suture, first  placed the lips
of the wound in contact, or caused them to  be held so by an assist-
ant, so that he might perforate them with one and the same plunge
of the needle.
  These, however, are only slight and unimportant varieties of a
process, which each one may modify according  to  his own views,
or the special indications he wishes to fulfil.
  To terminate, the operator cleanses the parts, seizes each  liga-
ture by its two extremities,  adjusts  the coaptation, and  ties the
different threads, one after the other,  upon the least dependent side
of the  wound, where he fastens them by a  bow-knot.  In placing
them even upon the track of the wound, we have, nevertheless, the
advantage of exerting a more uniform degree of tension and com-
pression upon each  side.  I generally adopt  this, and find it does
well.  The  placing of a little  lint between them and the M'ound,
so that  they may not press naked upon the skin, as some persons
have recommended, is a practice which would only be justified by
the  necessity of loosening the suture the next or second day after
its application.  In all other cases  they should remain in their place
without any thing intervening.  A layer (gateau) of lint, or a per-
forated piece of  linen, spread with cerate, and  then dry lint, and
compresses, and a few turns of bandage over them, serve to support
them, when covering the parts with  simple compresses, wet with
cold water, or even  leaving the suture open to the  free air, might
not seem to be sufficient. It is well, also, in  some cases, to aid their
action by adhesive straps of diachylon.
  If  nothing of particular moment should supervene, we  do  not
take  away the threads until the third, fourth, or even the fifth day;
if the tissues, placed in contact, should be thick and very dense, it
                              45 
354           NEW ELEMENTS OF OPERATIVE SURGERY.

might even be advantageous not to remove the suture until at the
end of six, ten, or tM'elve days ; and it can only be by inadvertence
that some have advised to leave it on for a month, for ulceration is
far from requiring as long a time as that for cutting through the
parts.  To remove them, we divide them M'ith  the scissors at the
loM'er extremity of the  loop; the right hand afterwards seizes the
knot, or upper extremity, either with the fingers or M'ith a forceps,
and gently removes them one after the other, M'hile M'ith some of
the fingers of the left hand,  or with another open forceps, M'e sup-
port the skin and corresponding lip of the wound.

             § II.—The Loop Suture, (Suture a Anse)

   Le Dran proposed, especially for enteroraphy, after having intro-
duced the threads M'ith the  straight  needle, as in the interrupted
suture, to unite all their  extremities in one group, and to leave them
collected  in this manner outside without tying them.  His object
was, to have it in  his power to separate them at a later period, and
to withdraw them one after the other, without being obliged to di-
vide any thing.  The evil of this process of Le Dran consists in the
puckering (plissement)  of the sutured part, a puckering which re-
sults from the tendency to approximation of  the stitches (anses) of
the suture, caused by the tail-shaped cord M'hich groups them out-
side the wound.  The plan, in consequence, has not been retained,
except in cases  M'here a single thread suffices, or when, after hav-
ing inserted  several, we  may retain them separately  outside, as is
still done  for certain intestinal sutures.  I will recur to this again.

    § III.—The  Continuous Whip (a suijet) [or Glover's] Suture.

   The glover's (du pelletier)  suture, so called, is that which is gen-
erally employed after the opening of dead bodies and in veterinary
surgery.   Not less frequentl}" employed in human surgery formerly,
it is at present, and improperly, as it seems to me, almost entirely
excluded  from it.   Wounds of considerable length, or that  involve
hollow organs, are not less conveniently adapted to it in the living
than in the dead; and the strangulation, which it is accused of so
easily producing, is  so  much the less a reason for  rejecting it, that
it does not follow this any more frequently than it does the others.
   The whip suture, moreover, is so well known in  the glover's and
tailor's art, that its name alone is sufficient to describe it; we begin
it like the interrupted suture, except that a straight needle is more
suitable than a crooked one. and that,  in place of perforating the
lips of the division one after another, M'e endeavor to bring them
face to face, and to include them in the same fold, in order to pierce
them at one puncture, (du meme trait.)  The assistant then stretches
and keeps extended the tM'o extremities of this fold; the surgeon
pinches it above with the thumb and fore-finger of the  left hand
turned in pronation, carries the needle to the straight or upper lip,
a little above and at a suitable distance.from the wound, pierces 
REUNION.
355
 the fold, draM's the thread through, and causes the assistant to hold
 its extremity, or ties a knot in it to hold it, brings back the needle
 obliquely crosswise over the wound to the same part of the skin, at
 three, four, or five lines from the first puncture, and continues on in
 this manner, so that the last stitch passes a little beyond the other
 extremity of the fold, and that the M'hole suture represents a certain
 number  of  spiral turns; if it  does not appear  to  be sufficiently
 tightened, we draw upon the two ends before fastening them; in
 the contrary case, we widen (Staler) a little the fold of the wound.
 In order that  it  should be well done, it is necessary that the two
 lips of the wound, without  being strangulated, should touch each
 other throughout their whole  surface, and that the  fold  should be
 perfectly effaced.  We finally terminate the suture by making each
 of its extremities pass, as in a running knot, around the spiral turn
 next to it. When we wish to remove it, we cut, with the aid of the
 scissors,  each oblique bridle that it  forms, then draM' out all its
 stitches  separately; or we confine  ourselves to untying  its  upper
 extremity, in order to disengage successively the different turns of
 the spiral, and draw the thread out entire by its loM'er end.
   When we cannot include the two sides of the wound in the same
 puncture of the needle, each stitch of the glover's suture should be
 made precisely as in the interrupted suture, from which, in reality,
 it differs, as is seen, but very little.

 § IV.—The  Zigzag Suture, that is, with alternate Side-Stitches, or as
         in  Basting, (Suture d Points Passes ou en Faufil.)

   This suture, the suggestion of M'hich  is attributed to Bertrandi,
 and which  De Courcelles had already spoken of, (Man.  des Oper.
 les Plus  Ordin. de la Chir., 1756,) is in  a continuous thread, like
 the preceding, and also commences and terminates like that; but,
 in place of  passing  spirally in front of the M'ound, to go from one
 side to the other, the thread perforates its fold each time, first from
 right to left, then  from  left  to  right, and so on to the end, so as, in
 reality, to form zigzags, which leave the anterior edges of the
.wound free and uncovered.  Consequently, the  needle perforates
 the tissues by beginning on the right border; dranvn back through
 the left border, it perforates them anew, but  in an opposite direc-
 tion and  a little above, to come out again upon the right border ; it
 is returned through this last at some lines above ; drawn out again
 upon  the other,  it is reinserted a little  farther on, as at first; in
 such manner that it creeps along, as it were, (marche  en serpentant)
 and not  in spirals, (amlages)  like the glover's suture.  Some sur-
 geons attach  to it the  advantage  of not tearing out or cutting-
 through as easily, because of the lateral  stitches which  it every-
 where makes between two punctures, and of not strangulating like
 the other by passing over the  wound.   M. Champion also thinks
 that it favors, more  than the glover's suture, the adhesion of the
 wound with the neighboring parts, as, for example, of a divided in-
 testine with  the peritoneum of  the abdominal walls.   In admitting 
356
NEW  ELEMENTS OF OPERATIVE SURGERY.
that this may be so, M'e must alloM', at least, on the other hand, that
it has the inconvenience of drawing unequally upon the two halves
of the division, and of not supporting its anterior surface.   Though
slightly improved by Lombard, (Plaies Recentes An. VIII. p. 19,) and
imitated by Be'clard, M'ho proposed that we should make use of two
threads of different Colors, and by M. Champion, who, with the same
object, had confined himself to making a knot at the two extremi-
ties of one of these threads, the zigzag (a points passes)  suture is
scarcely ever  used, and  may nearly always be replaced  without
any danger by the interrupted or by the glover's suture.

         § V.—The Twisted Suture, (Suture Entortillee.)

  One of the sutures the most frequently employed, is that which is
made by means of  threads (cordonnets)  passed in  various ways
(diversement) around metallic pins, (tiges metalliques) which are left
remaining  in  the  thickness of the  tissues.  Needles of iron, steel,
gold, silver, lead,  copper, brass, &c, straight, curved, thick, fine,
long, short, round, and flat, have been employed for this purpose ;
but it  has  resulted in this, that ordinary pins, which are  found
everywhere, and which, in truth, answer the purpose full as well
as metal of the most precious  kind, or that which  has been the
most laboriously M'rought, have now been almost universally substi-
tuted for them.   They are  prepared by sharpening and flattening
their points in any way we choose, as upon some  vessel of free-
stone, or a  fixed piece of stone,  and in covering them with cerate
or tallow.  If they are fine, or if the parts they are to perforate
have but little density, even these slight preparations are not  re-
quired.  If the wound occupies a moveable part, the  lips or eyelids,
for example, and is vertical, the pin that  is to be  applied first is
that which is  nearest to the free border of the organ ; the others
follow afterwards in succession.  When the two extremities of the
wound hold firm, (se tiennent) or we wish to fasten cutaneous
flaps, the placing of the needles is no longer subjected to the same
rules.  The operator then begins at the  middle,  point,  sides, or
base of the parts he wishes to bring into coaptation, according to
the difficulties he  supposes he has to overcome.  Under this point
of view, he must be left to his own particular judgment.  The right
lip of the wound being  held by the fingers of the left hand, as in
the interrupted suture, or with the forceps, erigne, or any other ap-
propriate instrument, he  inserts the needle or pin from Mdthout  in-
M'ards, makes  it appear at the interior of the wound, and continues
to force it toM'ards the  other lip, which he seizes  in its turn and
perforates  from within outwards, so that  the  needle comes out on
the skin at the same distance ;  the needle is then immediately em-
braced by  a turn of thread, which passes under its head and point,
at the same time that it crosses the forepart of the wound and tends
to force its two halves against  each other ; an assistant holds fast
jthe tM-o ends  of the thread and  keeps them a little tense, while  the
surgeon proceeds to the application of the other pins.  As soon as 
REUNION.
357
they are all placed, we occupy ourselves with arranging them and
surrounding  them  with threads.  The middle part of a long liga-
ture is placed on the  last pin, then passed and crossed many times
in figure of 8 on its two extremities, conducted by a figure of X to
the  next needle, and  crossed in the same manner on  the head and
point of that, before going to the third to return upon the second
and first by additional figures of X. We terminate with a knot, or
by rolling  its two ends into a cord, which is turned back under the
head of the metallic pin. In  order that the needles may not wound
the  teguments, a small piece of lint or adhesive plaster is placed
under each one of their extremities; there  is nothing then to do but
to cover them with a suitable dressing, if  it  should be judged ne-
cessary to  use any.
  Their removal is made at  the same periods as those of any other
suture.  We begin by removing the pin which supports the least
traction, in order not to take away the others until the day after,
or the day after that, should  the  reunion not be found  sufficiently
firm.  Should we have any apprehensions on this subject, it is bet-
ter to take away the  needles only at first, and to leave on for a day
or two the pacquet of thread, which, adhering to the  parts and be-
coming more or less hard, does the office of adhesive plasters ; there
is no objection, moreover, to our substituting some strips of adhe-
sive plaster for  two or three  days in the place of each needle that
has been removed. It is necessary, also, that the straight lip of the
wound should be carefully supported by the fingers of the left hand,
or, better still, by the extremities of a dissecting forceps, while with
the  other hand, or  with another forceps, we draw on the  head of
the  pins in  a straight  line, turning them around  upon their own
axis by small  movements of rotation.   The  punctures that they
leave in the place  exude and suppurate for a day or two, and cica-
trize like every other wound of the same nature.

               § VI.—Quilled (Enchevillee) Suture.

  The infibulation which is still practised  by some of the orientals,
and which for a long time has been in no other way employed in Eu-
rope except to  protect  the female  of some animals,  the horse, for
example, from the furious passions of the males, is a kind of quilled
suture, in fact a grillage ; but in the place  of metallic rods, used on
the  mare for the particular purpose for which they  are intended,
this suture in the  human species  is made with threads, and two
small lateral stems,  which  should be more solid.   It is  applied
like the interrupted  suture,  but with  double threads, leaving  a
loop at their free ends.   When they are all adjusted, we insert in
a parallel direction with the wound, and into each of the  loops, a
stem (tige) of wood, a piece  of hollow quill, or the  end of  a sound
or of a gum-elastic bougie, a roll of adhesive plaster, a small me-
tallic rod, or any cylindrical  body whatever of suitable length and
thickness; the loops at the other extremity of the threads are then
opened,  that a  similar  stem may be inserted in them, and upon 
358
NEW ELEMENTS OF OPERATIVE SURGERY.
whieh they are successively tied into a knot, after having effected
the coaptation of the borders which are to be united, without making
too great a constrictive force, but in such manner, nevertheless, as
not to leave a void between the two sides of the wound.
  The quilled suture,  though rarely indispensable, has, neverthe-
less, the advantage of making an equal pressure upon all the points
which the  threads tend to approximate, of being more solid than
any other,  of not  tearing out  the  parts  as easily, and  of  being
specially adapted  to straight, long, and deep M'ounds of the M'alls
of the abdomen and those of the limbs.  Ravaton, who used it also
in transverse wounds, fastened it upon plasters cut and rolled into
cylinders.  These small rolls have the advant age of moulding them-
selves easily  and without  any effort to all the irregularities of  the
wound.  In order  to have the loops  as small as possible, Ravaton
proposes, moreover, that all the threads should perforate  each of
the cylinders, instead of surrounding them entire.  Thus modified,
the quilled  suture is applicable to all wounds of any considerable
length, or those whose  union cannot be maintained without the  aid
of a certain degree of resisting power. It is used frequently in place
of numerously multiplied stitches, and is the only one that tends to
approximate  the parts from  the bottom towards the surface.  This
last advantage is attended with an inconvenience which it is proper
to recollect, namely, a  perceptible gaping open, often, of  the cuta-
neous edges  of the wound.  This, however, is remedied either by
means of adhesive  plasters, or by passing afterwards under the cylin-
ders a certain number of threads, M'hich are each tied in a knot as
in the interrupted suture.   The only objection, then, that can be
urged against this  suture, is  that of exacting a little more care and
time than the continuous suture, and of never, in fact, being in any
case imperatively  required.  It will be spoken of again, under the
head of Suture to the Perinceum.

              § VII.—General Remarks on Sutures.

  In  every kind  of suture whatever,  we  must  avoid multiply-
ing their stitches,  or separating them too  far apart.  The inter-
val to be left between them,  should vary also  according to  the
greater or less degree of resistance to be overcome, and according
as the wound is more  or less distended, or the walls to be held up
more  or  less flabby or difficult to be supported.  Stitches at  the
distance  of half an inch  apart ordinarily  suffice for the quilled
suture, and for some cases of the twisted suture; in other cases,
on the contrary, they are required to be  at the distance of three
lines  or more apart, while  an inch is sufficient in some circum-
stances ; but this  is only to be learned from  particular examples,
which cannot properly be given in this place.  If the  lips of  the
wound do not gape1 between  the stitches, and if these latter  are
sufficiently tightened to put the living surfaces into contact, but  not
so much  so as to interfere M'ith the inflammatory engorgement of
the parts ;  if they extend to the distance of a line from the angles 
       OPERATIONS  FOR  DISEASES OF THE CUT1CULAR SURFACE.     359

of the division, unless M'here it is requisite to leave open at the
lower part an issue for  the matters; if they enter and come out at
an equal distance  from the line of the wound? if they are left in
but a short time  where  the  tissues  are exceedingly vascular or
easily cut through, (secables) as in infants and upon the face;  and
that the contrary is observed in the opposite conditions; then  will
the suture be well made.   The suture, moreover, is  an  operation
which necessarily admits of but very few general rules.  It is when
treating of anaplasty, wounds of the intestines, lacerations of the
pudenda, &c., that we shall be fully enabled to appreciate them.
        PART SECOND.

COMPLEX OPERATIONS.
                       SECTION  FIRST.

OPERATIONS WHICH ARE PERFORMED  FOR  DISEASES OF  THE
         CUTICULAR SURFACE OF THE  INTEGUMENTS.

Article I.—Operations  rewired for Warts, Corns,  and Diseases
                         of the Nail.

                         § I.—Warts.

  The name of warts is  applied to small tumors, sometimes nar-
row and salient, sometimes flat and of considerable breadth, M'hich
are formed upon the surface of the skin, and principally upon the
back of the hand.  They are indolent vegetations of the epidermic
layers and of the sanguineous tissue of the skin.   A great number
of methods have been proposed for  their removal, but there are
none of them that generally succeed, and  the  best thing, when
these warts are very numerous, is to do nothing  at all  M'ith them.
No infirmity has given birth to a greater number of secret or whim-
sical remedies.   I  know a distinguished functionary of the realm,
who firmly believes himself in possession of one of these secrets.
He has related to me with the utmost  degree of sincerity, that by
means of a thread of red silk, each knot of which should be made
to pass around and touch the base of the M'art  before being tied,
and which thread he afterwards deposites and leaves to putrefy in
a mass of dung, warts can be constantly cured !  Without attach-
ing any value to such absurd notions, the surgeon may make trial 
360
NEW ELEMENTS OF OPERATIVE SURGERY.
at least of certain remedies, that are in reality efficacious, when
the w arts are few in number, and the patient desires to be relieved
of them.
  If the tumor is salient and pedunculated, we  may strangulate it
with a thread, and thus detach it by a ligature.
  In that case, it would be still better to seize it with a forceps, and
excise it with one stroke'of the  scissors, taking care to touch the
small wound immediately after  with the nitrate of silver.
  [This mode, peculiarly adapted to and called for in syphilitic pe-
dunculous vegetations on  the  glans, or praeputium  penis, is made
more effectual, and a second sprouting of the warts, not an unusual
thing,  prevented,  by  drawing  them outwardly with the  forceps
applied to their middle, and with such force that the root or base
as it were is elevated above the plane of the skin, by which means
the curved scissors, placed flatwise and close to  the skin, is enabled
to clip  them off entirely below as it Mere their  base, leaving no
small roots or attachments behind.   The  only inconvenience, and
that is in the eye of the  patient only, is that there is in this mode
of extirpating them a small hemi-spheroidal depression or pit gen-
erally left in the skin.  In this method the  nitrate  of silver or other
escharotic is not  requisite, and the Marts never  or rarely return,
which, however, they are very  apt  to do  where they are  clipped
off, as they usually are, in  a line  only with their base, Mdthout
drawing them  out, so that the  scissors  may pass as it were under
their roots, as above directed in this note.—T.]
  If the wart has neither pedicle nor neck, it is treated in another
manner : that is, sucked with the lips  and then bitten off with one
bite of the teeth, as was done in the time of Galen ;  burning it with
a tooth cautery, or removing it layer by layer with  a scraper, are
objectionable methods, in place of which M'e should always sub-
stitute extirpation and free cauterization.
  Extirpation, hoM'ever, which  consists  in removing by one stroke
of the bistoury or scissors, applied  flatwise, the whole tumor, and
the effect  of M'hich is afterwards rendered more  sure by touching
the surface with nitrate of silver, is not a perfect guarantee against
a return.  To take off with the Mart an elliptic piece  (plaque) of
the skin would be infinitely more sure.  [Vide  note a few lines
above.]   With persons who dread the application of a  cutting
instrument, we  should  have recourse to cauterization.  The  end
of a feather or a glass tube serves to conduct  to the tumor a
small drop of nitric acid, which we must take care  not to allow to
spread upon the neighboring tissues.  This cauterization, which is to
be repeated for several days in succession,  acts better and succeeds
more constantly than  cauterization with the nitrate of silver.  In
fine, simple incision, aided by cauterization with the nitrate of sil-
ver, is the mode most frequently employed.
   [Muriate of Am.nonia. Rubbing frequently, says Dr. Mott, with a
piece of this, carried in the pocket, v.dll often cure them. Also, butter
of antimony, applied with a camel's-hair pencil.  So with muriated
tincture of iron, and Aso tincture of iodine.  But every other mode 
        OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.    361

should now be discarded, he says, for the effectual and certain cure
by means of the actual cautery, especially, as in the treatment of
naevi, by perforating the wart, perpendicularly and horizontally, in
two or three places, with  a red-hot pin,  though a great degree of
heat is not necessary.—T.~\

                    § II.—Corns upon the Feet.

  The operations practised for corns  on the feet, and which are
alike varied, are almost  all of them performed by charlatans or
corn-doctors, (pe'dicures)   The  pain, however, which results from
this disease is often  so very severe, and causes sometimes accidents
of so  serious a nature, as  to require the aid of surgery.   Corns are
a production in the shape of a nail, (clou) whose point depresses
the skin, and are composed of epidermic substance, and not of con-
crete mucus, as  some persons appear to suppose.  Removing them
layer by layer with a bistoury gives temporary relief, but does not
effect a radical cure.  There is no other mode to destroy them ef-
fectually, if an instrument is to be used, than by extirpation.  The
method M'hich I adopt with most advantage is very simple.  With
the point of a straight bistoury I separate a portion of the circum-
ference of the corn, then  seize hold of this detached portion of its
border with a dissecting forceps ;  then, continuing to separate it, I
take  care to hold  the point of the bistoury constantly in contact
M'ith  the  surface of the living tissues.  Proceeding by small cuts,
and gently, I thus, in the space of one  or two minutes, and without
causing the  least pain or a single drop of blood, succeed without
difficulty in removing the thickest kind of corns.  It is for this ope-
ration that corn-doctors have devised the instruments called quad-
rilles, furets, and navettes,  and which they use with lenses, (loupes)
or bottles filled with water, to concentrate the light upon the part
they are dissecting.
  The corn thus unrooted  (deracine)  will, nevertheless, grow out
again in most cases, if the friction of the toes continues as before.
It is only by cauterizing the cavity it occupied, or filling it M'ith ad-
hesive plaster, that we  can sometimes prevent it from growing
again.  This, after  all, is but  a  small  operation, which patients
may practise upon themselves, and M'hich they have only to repeat
every month to relieve the suffering produced by corns.
  In taking the precaution to soften the corns, either by means of
plasters, or by immersing  them for a greater or less length of time
in hot water, they are more  easily separated, and in some cases
they  are detached  by rubbing them, or simply pulling  upon them
with the fingers.  It is in this way that certain plasters  or  oint-
ments have acquired a kind of reputation in the practice of corn-
doctors and among common people.
  Cauterization, also, is frequently employed for the same purpose.
It is performed either by  applying to the centre of the corn the ig-
nited  extremity of a piece of wood, or  a drop of melted  sulphur, or
a small roll of spider's web, which is ignited on the part, or sulphu-
                              46 
362
NEW ELEMENTS OF OPERATIVE SURGERY.
ric or nitric acid. I have seen a person even, who had the singular
idea of perforating M'ith a red-hot pin a corn which he  had on the
back of the phalangeal articulation of the fourth finger, (doigt an-
nulare.)   The corn,  in fact, mortified, but produced  an eschar,
whieh exposed the joint, and led to the necessity of amputating the
finger.
  The treatment of corns by caustics is, in every respect, not only
less certain, but more dangerous, especially in the neighborhood of
the joints, than their extirpation, when well performed.
  [The application of a strip of adhesive plaster, firmly embracing
the toe, after the effectual extirpation of the corn by the knife, is
not only an  excellent preventive of the  friction which has often
caused the corn, but also, by  its compression, prevents the new
groM'th, and is thus frequently an effectual cure.  This remark ap-
plfes, also, to the treatment of some  obstinate warts removed by
caustic from the fingers.  A general idea prevails in the  Morld, that
stockings of cotton thread, from the naturally in rating  properties
of that tissue, are a preventive of corns.   Shoes moderately tight
are certainly preferable to those that arc  loose, and which by fric-
tion  chafe  the skin and  produce corns.   Corns become  of a more
serious character when involved M'ith tumefaction of the toe joints,
which has been  produced by painful gouty ailecdons. Keeping the
feet  and toes thoroughly  clean by daily ablutions in cold Mater,
winter and summer, is one of the best hygeian preventives.—T.]

                 § III.—Callosities, (Durillons.)

  Epidermic tumors,  in place of presenting themselves under the
form of a nail, are sometimes seen under the aspect of scales, of
greater or less  thickness, upon the surface of the  parts.  These
plates, (plaques) which are most frequently seen on the outer or
dorsal surface of the  little toe,  and upon the corresponding surface
of the head  and posterior extremity of the fifth metatarsal bone,
and within the metatarso-phalangeal articulation of the great toe,
&c, take the vulgar name of onions (ognon) when they are large
and shelly, and of callosity (durillon) only when they are of little
extent and of the character of a homogeneous'mass.
  Produced by the unequal compression and friction of the shoes, (des
chaussures) these different kinds of callosities, liks corns, cannot be
prevented  or radically cured but by the   removal   of  the causes
that produce them.   They are, however,  temporarily cured by ex-
cision.  For  these, however, the bistoury  must be applied flaHvise,
(en de'dolan4) and the removal of the epidermis layer by  layer is the
mode to be preferred. Their destruction by the file, puniice-slone,
(pierre-ponce) or shagreen-skin, (la peau  de chagrin)  is never as
complete  and prompt as by the cutting instrument.  It is important,
also, to know that, like corns, they very often lie upon a sort of mu-
cous bursa, (bourse muqueuse) which we must take care not to open,
should they exist on the back of an articulation.  I will add, that
under the heel, where there is found a  mucous bursa of this de- 
        OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.     363

scription, corns and callosities often inflame to such a degree as to
produce suppuration, and that their cure in such cases requires that
they should be  completely excised.   I have seen some in the sole
of the foot, and under the metatarso-phalangeal articulations, M'hich
had undergone  such transformation that it became necessary, also,
to remove  the entire thickness of the skin upon which they were
situated.

                   § IV.—Diseases of the Nail.

  The nail, or the parts which surround it, are subject to a certain
number of diseases, almost all of M'hich derive their remedies from
operative surgery.

                   A.  Runround, (Tournioles.)

  The suppuration knoM'n  under the name of  mal d'aventure, or
tourniole, and which presents itself under  the form of a purulent
phlyctaena upon the contour of the nail, almost always, if left to it-
self, causes the destruction of this substance.
  We may, however,  prevent this  disease in two ways—1. By
opening the phlyctaena as soon as possible, then removing the whole
separated portion of the cuticle, and afterwards dressing the denu-
ded  surface,  either with lint covered with cerate, or M'ith simple
emollient  cataplasms.   In  order  that this first means should suc-
ceed, it is necessary that the disease should not have yet penetrated
between the nail and the cutaneous fold M'hich covers its borders
or root; 2. The progress of the disease is arrested, also, by cauteri-
zation ; it  is also necessary that  this cauterization should be per-
formed properly.  The most convenient way in such  cases is by a
pencil of nitrate of silver, sharpened into the form of a chisel (ciseau)
or wedge.  If we take care to make it penetrate between the nail
and the cutaneous border  down to the  bottom  of  the purulent
groove, so that all the  morbid points may be effectually touched, it
is rare that the disease continues, or that  the adhesions of the un-
der (profonde)  surface of the nail are destroyed.  It  is a mode of
operating in M'hich I have always been successful.
  The fungosities  and vegetations M'hich are sometimes seen on
the epidermic margin (filet) which  surrounds the nail, and which
are a very  common result of the tourniole, require the same treat-
ment, and also  are  not effectually eradicated until they have been
well cauterized.  [Dr. Mott has seen these fungoid growths under
the root of the nail burst through  it, and occasionally he has had to
make an opening through the nail to let out the  blood. A poultice
mixed with wood ashes is  then an excellent  application  to com-
plete the cure.—71.]

         B. Nail Imbedded in the Flesh, (Ongle Incame)  .

  The disease known under the name of the imbedded nail, (ongle
incarne) narrowed nail, (ongle retreci) the nail entered  into the 
364           NEW ELEMENTS OF OPERATIVE  SURGERV.

flesh, (ongle rentre dans les chairs)  the onglade, and onyxis, and
which the ancients describe  under  the name of pterigion, is un-
doubtedly, of all diseases of the nails, the one M'hich  has most at-
tracted the attention of surgeons.  To understand perfectly what I
shall say of the operations it has suggested, we must bear in mind
that the nail is  a horny  plate, the concave  surface of which is
continuous with the papillary surface of the cutis, and the sides of
which near its root are surrounded and covered, to the extent of
two lines, by a fold of the integuments. The lunula, (lunule) or small
white spot which is seen at the root, corresponds to a part upon its
concave surface which is but slightly adherent to the rete mucosum
underneath.  The ridge (filet) M'hich is around it  is a simple fold
of the epidermis, and it  is almost always at the expense of this that
are formed those ravellings of the skin (eraillures) known under the
name of hang-nails, (envies.)
   The portion of the integument which covers the root of the nail,
and which, according to some surgeons, is considered its matrix,
does not, in reality, adhere to it but to the extent of a line or a line
and a half in front; farther in the nail is terminated by a thin root,
free and slightly irregular, so that it is  more especially by its con-
cave surface, and  by a  small part of the convex surface of its root,
that it is nourished or reproduced.
   What I have just said of the tourniole applies sufficiently well to
phlyctaenae, and the fungous groM'ths of the tegumentary fold of the
root of the nail.
   The nail of the  large toe often appears as if it had penetrated by
one of its edges, or even by both its  edges, into the  thickness of the
flesh ; it is for this condition of things, M'hich is very unpleasant, as
well as exceedingly difficult to remedy, that an infinity of surgical
means have been  devised.   The processes, in fact,  for this purpose
are  so  numerous  that  it would be easy to name almost a hundred
of them, which requires that they should be treated of under differ-
ent heads, if we wish to examine the principal portion of them with
advantage.
   All these processes have'for their  object—1.  To destroy a portion
or the whole of the nail; 2. To get  rid of the  fungosities (fongosi-
tes)  [fungous groM-ths] which surround the nail;  3.  To narrow or
raise the  plate which M'ounds the  flesh.
                    I.  Destruction of the Nail.
   Surgeons who  have  advised the  destruction of the nail for the
cure of onyxes are divided into three classes.  Some, in fact, confine
themselves to excising  the portion of it  which seems to have perfo-
rated into the tissues, whilst others  recommend destroying by cau-
terization that part of it  which is  covered behind by the integu-
ments, and others again, that we  should tear it out by force, either
by one of its halves or entire.

          a. Destruction of the Imbedded Part of the Nail.

   1  Paul of iEgina, (Lib. vi. cap. 85,)  or Dalechamps, (Chirurgie 
       OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.     365

Frangaise, edit, de Rouen, p. 538,) had already recommended cutting
off the imbedded edge, after having raised it with a probe.
  2. Fabricius ab Aquapendente (Opera  Chirurg., Francfort, 1620,
p. 402) recommends that M'e should keep  the edge of the nail raised
by a piece of lint, and  that it should then be cut off down to its
root, and the detached portion removed with the forceps, and that
we should do this every day, until  there  is no more of it left con-
cealed in the flesh.
  3. Dionis made use of  a  kind of knife, cut the nail lengthwise,
and took away with the forceps the portion to be removed ; some-
times, also, he used  scissors to cut it from before backwards, and
applied to the wound lint wet with lime-water, or a minium plas-
ter, (Operations, edit, de Lafaye, t. ii., p. 781.)
  4. A process, which resembles very much that of Fabricius, has
been published as new by M. Somme, (Archiv. Generates de Medec,
t. i., p. 485.)   It consists in removing the imbedded portion of the
nail, and then sprinkling the fungous growths (fongosites)  and the
adjoining groove  M'ith powdered alum.
  5. M. Blaquiere has modified the process of Dionis in this M'ay:
Before dividing the nail, he thins (amincit) it by scraping it with a
knife or a piece of glass ; after having slit it  down to its root, he
tears out the diseased third of it by turning it  over upon itself by
means of a forceps ; then dresses the M'ound M'ith lint wet with al-
cohol, myrrh, and aloes ; and takes care  to insinuate some threads
of lint under the new nail in proportion  as it grows out, (Jour, du
Diet, des Sciences Med., t. xviii., p. 208.)
   6.  M. Begin, (Jardon, These, No. 101,  Paris,  1836,) who, like M.
Blaquiere, thins  the nail before  excising  it, does  not  afterwards
make use of lint  to raise it up, nor of alcohol to give  tone to the
parts.
                     b. Tearing out the Nail.

   Other processes, more rapid, but which belong to the same class,
consist in quickly removing a  portion of the imbedded nail.
   7.  M.  Baudens, for example, removes  from behind forward, and
by a single stroke, with the cutting heel of a very strong bistoury,
both  the diseased border of the flesh and the entire portion of the
nail which it covers.  Among the  processes of tearing out the  nail,
we have that of  M. Larrey, Boyer, Dupuytren, and Neret.
   The process of Boyer differs from the tearing out, properly  so
called, in this, that, in order to prevent the return, this surgeon es-
tablished, after the operation, a point of  compression upon the ma-
trix of the nail, by means of a small ball of lint and some turns of
bandage.
   8.  Process of M. Larrey. After having removed the inverted half
of the nail from the diseased part, M. Larrey made use of the hot
iron to destroy the  fungous growths  in  the neighborhood  and the
whole surface of the wound.
   9.  Process of Pelletan, (Jardon, This., No. 101, Paris, 1836,) or of
 Dupuytren. Dupuytren proceeded in two different modes for tear- 
366
NEW ELEMENTS OF OPERATIVE SURGERY.
ing out the nail: if the disease M'as simple, and occupied but one
portion of the toe, he confined himself merely to tearing it out, and
adopted the following mode :  The diseased toe being  held  in a
proper manner by the thumb  and fore-finger, M'hile an assistant
presses his hand upon the dorsum of the foot, the surgeon immediate-
ly inserts from before  backwards one of the blades of a narrow-
bladed and very keen-edged pair of scissors between the nail and
the dorsum of the phalanx M'hich supports it.  The instrument should
penetrate  in this manner to at least  two lines beyond the visible
portion of the nail, M'hich is then divided with a single cut by ap-
proximating the blades of the scissors.   A strong dissecting forceps
now answers for seizing one  of the  halves  of the  divided  nail,
which is turned over, drawn  out, and speedily detached from its
median portion to the free border, and  from before backwards, and
the same  immediately afterwards  done for the other half.  The
operation is thus composed of three stages—the first for the divis-
ion, the two others for the successive  removal  of the two portions
of the nail.  The entire operation  is  so rapid, also, as not to con-
sume more than half a minute.
  If the disease should have  been of long standing, and of great
obstinacy, Dupuytren preceded the operation, of M'hich I have just
been  speaking, by a semi-lunar incision, with  its convexity back-
ward, the  object of this incision being to lay bare the root of the
nail from behind forwards, and to destroy its matrix completely.
   10. Process of M. Neret.  In lieu of scissors, M. Neret proposes
to employ the ordinary spatula.  The following  is the way in which
he proceeds, (Archiv. Gen.  de Med.,  3e serie, t. ii., p. 202:) After
having placed the toe as in the usual manner for this operation, M.
Neret, grasping  his  spatula with the entire hand, glides its blade,
the concave part of which faces doMnwards, under the free border
of the nail, and then  forces it on rapidly from before backwards to
beyond the root to be detached. Then turning the instrument upon
its axis, he raises the nail from one of its borders, then from the
other at its median part, so as to make it spring off, (faire sauter)
as it M'ere, with one stroke.   If, after  having detached  it from its
middle part, and then upon its outer border, the spatula should not
separate it completely, M. Neret seizes it with a pair of stout for-
ceps, and removes it as in the ordinary process.
   [Dr. Mott says the scissors  ought  to be  made M'ith great care,
with very short, stout blades—one thick, the other thin and sharp.
It is,  at best,  he thinks, a cruel operation, and one in which he
always feels some apprehension cf lockjaw.—T.~\
   11.  Appreciation.  These processes, then, are comprised under two
divisions, which it is important not to confound ;  the one, M'hich pro-
poses only the destruction of the part of the nail that is imbedded; the
other, which has for its object the removal, also, of a part or of the
whole of its root.  Whether in the first case we follow the process
of Paul of iEgina, that of Fabricius, Dionis, Somme, Blaquiere, or
Begin, is a matter of little importance ; they are such slight modi-
fications of the same method, as not to require specific classifica- 
        OPERATIONS FOR DISEASES tOF  THE CUTICULAR SURFACE.     367

tion.  Their disadvantage  is, that  they rarely secure  the  patient
against a return of the disease, and that  they permit  the  portion
of the nail which has been  destroyed to grow out again soon after,
and again to become a source of irritation to the parts.
  As  to the tearing out of the third or the half of the imbedded
nail, whether we effect this as Ambrose Pare  did and as M. Bona-
fond proposes, (Epidaure, t. i., p. 135,) by removing the nail  and
the fie sh from behind forward with the  bistoury; or whether in the
manner of Dionis, Boyer, Dupuytren, Delpech, and Larrey, we  first
slit it from before backward, and afterwards remove it with a for-
ceps, can in neither case be a matter of any importance ;  I see in
these, trivial modifications only of the same process; except that the
operation  is quicker by the simple excision than by  the  process
of tearing the nail out, properly so called.  This operative process,
a little more painful perhaps than the preceding, is, however, more
expeditious, and  more generally followed by  a radical cure.  By
destroying at once both the portion of the nail which  is imbedded
and also its  root, we  run  infinitely less  risk  of a return of the
disease.
  But we. relieve in this manner only one of  the sides of the im-
bedded  nail.   The process of Dupuytren,  or that of M. Neret, has
certainly the advantage of destroying at once the whole of the
nail, and of putting the parts in a better condition to shrink and
resume their normal state.
  The slit of the nail being the same in both cases, is a reason why
the whole amount of the suffering is not perceptibly greater for the
complete than for the partial removal.   In addition to this, I gen-
erally prefer the entire  evulsion (avulsion)  to  that  of one of the
halves of the nail.  Moreover, I do  not believe it to be a matter of
great importance to effect this evulsion (arrachement) rather with
the spatula of M. Neret than the scissors of  Dupuytren;  neither
has it seemed to me, if we take care to prolong to a sufficient dis-
tance backward  the antero-posterior slit, that it would be really
advantageous to  cut posteriorly the small semi-lunar  flap of  Du-
puytren.  As the reproduction of the disease is caused much more
by the back of the  tissue that covers the phalanx than by the pre-
tended matrix of the nail, this small flap does not give a better
security against a return than the pure and  simple evulsion.

              c.  Destruction of the Nail by Caustics.
  Under the belief that the  nail  vegetates exclusively  from be-
hind forward, many surgeons have proposed to  destroy only the root
of it.
   12. Circumscribing  the whole  imbedded edge in a perforated
strip of diachylon plaster, (une fenetre  de diachylon) M. Wander-
bach  (Journal de Med. Militaire, t. xxviii.) applied  three grains of
caustic potash upon the tissues, in such manner as to  effect, after
the third  application of this remedy, the destruction  of both the
fungous flesh and the  corresponding portion of nail, with  its root
included. 
368           NEW ELEMENTS  OF  OPERATIVE SURGERY.

   13. Another military surgeon, M.  Kremer,  (Meme Journal, t.
xxviii.,) says he has  succeeded by spreading a layer of potash on
all that portion of the nail which is attached to the skin, and thus
causing it to 'all off entire.
   14. This last process has been modified  by  M. Troy, (Bulletin
Med. de Bordeaux, 1833, p. 199;  Gazette Med., 1834, p. 773,) by not
applying the potash except on the matrix  of the  nail, but not on
the fungous growths.
   Some prefer the actual cautery to chemical caustics.
   15. M. Labat, for example, (Annal. de la Med. Phys., 1835,) cau-
terizes by means of a plate of red-hot iron, in the direction of an
arc of  a circle, at four lines behind the border where the  nail ap-
pears to issue from the  skin.
   16. M. Pointier  proposes that in this process  we should only
cauterize  the portion of the  matrix that gives birth  to  the  im-
bedded border of  the  nail,  (Donzel.  These,  Strasbourg, 26 Mai.
1836.)
   17. M. Scoutetten carries the point of a straight bistoury to two
lines behind the nail  upon the diseased side, makes  in that place
a longitudinal incision whose lips  he keeps apart, and  at the bottom
of which he fixes a small ball of lint, in order to insert in this place,
on the  succeeding day, a layer of caustic potash.   The root of the
nail by this  means mortifies, and all that remains is to wait till it
falls  out.
   18. This process, which M. Donzel  lauds, (in his  Thesis  cited.)
M. Ganderax (Donzel, These) proposes to modify as follows:
   19. This last surgeon gives  less extent to the incision, and substi-
tutes nitric acid for the potash, and makes two or three applications
of it daily, until the  nail softens and falls into a  state of slough,
(putrilage)
  20. Finally, M.  Donzel himself, reviving  the plan of M. Troy,
proposes  that we should dispense with the incision, and confine
ourselves to an  application of caustic paste upon the point to be
destroyed, the same as  if we intended to establish an issue in the
part.
  21. Combining the process of M. Scoutetten with  that  of M.
Troy, M. Gairal makes  a longitudinal incision six  lines in extent,
then, at the posterior extremity of this last, a transverse  incision
upon the root of the nail to be destroyed, and  in  this last places
the caustic potash, (Bulletin Clinique, t. i., p.  108.)

                        d. Appreciation.
   It  is easy to perceive  that these different processes of cauteriza-
tion  tend to the same result as those of extirpation.  Their ultimate
effect  is  the same, but  we cannot deny that their action  is more
tardy and their  efficacy less  positive.   The  only advantage they
seem to offer, is that  of causing  less dread  to the patient, and of
being attende,d in reality with a little less pain.   They should not,
therefore, have the preference but in cases where, after the destruc-
tion  has been decided upon, it is found impossible to have recourse to 
        OPERATIONS  FOR  DISEASES OF" THE CUTICULAR SURFACE.    369

the cutting instrument.   As to the choice to be made of methods so
much resembling each other, I  am of opinion that we should more
particularly give the preference to those of MM. Troy and Donzel,
that of M. Kremer, or  even that of MM.  Frebeau and Ganderax,
(Donzel, These, Strasbourg, 1836, p. 41,) which, besides being some-
what more simple,  are full as efficacious as those of MM. Wander-
bach, Labat, Pointier, Scoutetten, and Gairal.

              II. Destruction of the Fungosities only.

   22. In the endeavor to cure the onglade without attacking the nail,
many surgeons have supposed  that they could effect this object by
acting on the soft parts only.   To this method must be referred a
process of Albucasis, (liber ii., cap. 89-91,) who,  as Fabricius after-
wards did, advises to raise the  edge of the nail with a probe, and
to excise and afterwards cauterize the flesh; that of Ambrose Pare,
(CEuvres Completes, in-fol., p. 465,) who limited  himself to cutting
off completely, and with one stroke, the flesh lapping over (recour-
bee sur) upon the nail, and who says he has often succeeded by
adopting this  mode: the process of M. Brachet  and of M. Gantret
differ but little from that of Pare.
   23. Like Pare, M. Brachet confines himself to  the excision of the
flesh.  Holding his bistoury like a writing-pen, he  introduces its
point between the  nail and the raised border of soft parts, which
he cuts through from  above beloM', and separates first  at its back
part; then, seizing  with the forceps the flap which  has been  thus
cut, he terminates  its section  forward  by a second stroke of the
bistoury.  This process, M. Gantret (Donzel,  These, Strasbourg,
1836) says he has  often employed  with success, and M. Lisfranc
(Malgaigne, Man. de Med. Op.,  2e edit., p. 98) believes he has made
an improvement upon it, in  proposing to detach  the flap first by its
anterior part, in place of commencing by the root of the nail, as
M. Brachet does.
   The method of excising the fleshy growths by  the cutting instru-
ment, being fully as painful as  the  processes  which consist in re-
moving at once both the nail  and  the  fungosities which cover it,
does not,  in  reality, deserve a  preference over these last.  It  has
also been attempted to substitute for this the  destruction of the
parts by caustics.
   24. M.  Levrat, of Lyons, who appears to have been the  first
who urged the advantages of this mode, applies caustic potash to
the fungous growths only, and  through a perforation in  a  piece of
diapalm or diachylon plaster.  After the eschar  is detached, he in-
serts between the flesh and nail a piece of prepared sponge, which
gives an opportunity for the  cicatrix to be properly formed.  It  is  a
modification which M. Brachet has himself adopted, and which M.
Sene (Journal Gen.  de Med., 2e  serie, t. xxxii.—Bulletin  de Thira-
peutique, t. ii., p. 378) thinks he has simplified by substituting for
the plaster and caustic of M. Levrat some filaments of lint satu-
rated with potash, and which he insinuates into  the bottom of the 
370
NEW ELEMENTS OF OPERATIVE SURGERY.
wound which separates the flesh from the edge of the imbedded
nail.
  25. Another surgeon, whose same is indicated  only by his ini-
tials, (Bulletin de Therapeutique, t. iv., p. 303,) has also suggested
that it would be advantageous to make use of the Vienna caustic
in lieu of potash, Finally, it is proposed by M. Moreau (Gaz. Med.
de Paris, J 836, p. 830) to introduce burnt  alum under the edge of
the  diseased nail, instead of caustics.
  Appreciation.  It is evident that the processes of MM. Levrat, Se-
ne,  and A. T., differ scarcely  from that of M. Wanderbach, since
the  cauterization of the  flesh is  almost always complicated with
that of the edge of the corresponding nail, and reciprocally. Being,
therefore, more  uncertain, they ought  not to  be retained but for
simple cases, or for patients who have an excessive dread of every
kind of operation.

  III. Readjustment (Redressement) and Reduction (Retrecissement)
                         of the Nail.

  26. Many  practitioners, observing that cauterization succeeded
but imperfectly, and deterred  also by the  pain of extirpation, have
supposed that, by reducing or readjusting the nail, we should effect
the  removal of the disease.  A process of this kind was already in
favor in the seventeenth century.  Dionis, who describes it, (Cours
D'Operat., edit, de Lafaye, t. ii., p. 281,) says it consists in scraping
the  nail every month upon its middle with a piece of glass, and of
thinning it (I'amincir) until it yields to pressure.
  27. M. Biessi (Gaz. Med. de Paris, 1834, pp. 773, 774) has sup-
posed that he has invented a new process by uniting to the attenu-
ating process, spoken of by Dionis, that of cauterization with nitrate
of silver.
  28. I have myself made trial, once with success, and twice with-
out any advantageous results, of a process suggested by M. Moreau,
of Tours, and which consists in  passing the point of a small silver
spoon, (la queue d'une cuillere d'argent) heated to 60 or 70 degrees,
(Reaumur,)  [i. e. 170° to 190°  Fahrenheit,] along  the  back of the
nail, while the imbedded  border is raised  up  with the point of a
horn.  With the view of forcing the nail to withdraw itself from
the flesh, M. Guillemot (Journal  de Med. Milit., 1814, t. i., p. 264)
has supposed that it would be sufficient to cut its opposite  angle
from the middle of  the free border to  one-third of its  length upon
the  adherent border.  Next  we have  M. Faye,  (These, No. 164,
Paris,  1822,) who, after having cut out a V upon the  middle and
anterior part of the nail, passes a waxed thread  through the two
sides of the  notch, which he tightens by means of a small garrot, as
if he was operating for the union of a hare-lip.
  [This  is certainly an ingenious suggestion,  and would  seem to
derive force from the efficacy of the V incision in the gum, which
I found so successful in liberating an inverted incisor.  (See the
chapter on teeth, above.)—T7.] 
        OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.    371

   In  these four processes, the surgeon endeavors to readjust the
 nail by acting on its middle part, and in some degree without acting
 upon its edges.  None of them have appeared to me to be very
 efficacious; but if we  had to give the preference to any one  of
 them, it would be that of M. Moreau or of M. Faye which I would
 recommend.
   29. In another series are  arranged  the processes M'hich consist,
 like that  of J. Fabricius, in insinuating some soft body under the
 edge of the nail.   MM. Hervey and others (Archiv. Gen. de Med.,
 t. xxi., p. 142) make use of pieces of lint precisely after the man-
 ner of Fabricius ab Aquapendente.   I might say the same of M.
 Tavernier, (Bullet, de Ther., t. ii., p. 197,) who also uses a tent of lint,
 but gradually enlarged in size as it glides more and more deeply
 under the imbedded border of the nail; and  of M. Moulinie, (Bul-
 let. Med. de Bordeaux, 1833, p. 199,) who prefers introducing in the
 same manner small balls of the same substance ; of an anonymous
 author,  (Bullet, de Ther., t. ix., p. 158,)  who introduces carded cot-
 ton, in place of lint, between the flesh and nail;  in fine, of M. Bon-
 net, (Bullet,  de Ther., t. vi., p. 339,) who substitutes, for all these,
 some pieces of prepared sponge.  By this process, M'e at the same
 time depress the flesh and raise the border of the nail.  It is cer-
 tainly one of the most mild  remedies  that can be imagined; it is,
 however, unfortunate that it fails the oftenest, and is almost always
 ineffectual when the fungosities have extended to a very consider-
 able distance  upon the side  of the root of the nail.,  We are still
 compelled, therefore, the same now as  formerly,  to look for a more
 effective poM-er for disengaging the imbedded nail from the flesh
 which covers it.
   30. Desault,  (QZuvr. Chir., t. ii., p. 529,) M'ho  was fully sensible
 of the difficulty, proposed to glide under the edge of the imbedded
 nail a small plate of tin, about an inch and a half long, and three
 to four lines in width, which  he then bent back upon the swollen
 flesh from the dorsal towards the  plantar surface of  the  toe, and
 fastened in this  position by some turns of bandage.   It is this pro-
 cess which Boyer and Richerand have modified by substituting  a
 piece  of sheet-lead for the strip of tin used by Desault; but be-
 sides the fact that these plates are easily displaced, tend to cut the
 flesh, and rarely attain the object we have in view, they also have
 the inconvenience of sometimes occasioning very severe pain.
  MM. Dudan, Vesigne, Grabowsky, and Labarraque, in their desire
 to improve the many imperfect  processes in use, have constructed
 a kind of clasps, (agrafes) or hooks, (crochets) which act on the
 borders of the nail without necessarily  pressing upon the flesh.
  31.  The instrument of M.  Vesigne,  modified and  improved by
 M. Grabowsky, (These de Paris, Juillet, 1838,) is composed of two
plates, which are united by a hinge  on  the middle of the nail, and
terminate in a hook on each side.   After having adjusted the
hooks under the edges of the  nail, we  elevate them by gradually
tightening the  clasp by means of a screw.   This  clasp,  besides
being liable to be displaced, acts at the  same time on both sides of 
372
NEW ELEMENTS OF OPERATIVE  SURGERY.
the nail, though there be but one  side only which is diseased, and
also makes an irritating pressure on the back of  the toe; it is, be-
sides, so complicated as to require the aid of a mechanic.
  32. The apparatus of M. Labarraque (These, No. 101, Paris, 1837)
is infinitely more simple.  I have often used it with success.  The
plate of tin which composes it, and which is similar to that of De-
sault, being terminated in a narrow hook at one of its extremities,
and having on its anterior part, at the distance of three lines, a
small notch upon its edges, allows of our attaching to this part,  by
means of some turns of thread, the end of a narrow and long strip
of adhesive  plaster.  To apply it, we attach the hook, and make
it glide as far  in  as  possible between the nail  and flesh;  after-
wards, drawing the strip of adhesive plaster in an opposite direc-
tion, we make a turn  with it around the toe.  The circulars of this
little  bandage,  in  passing upon the free portion of the tin plate,
cause  it to act  (la font basculer) from  above  downM'ard, after
the manner of a lever of the first kind; we  thus raise, with all the
force desirable, the edge of  the nail.  Two similar plates would be
necessary if the nail  was imbedded on both sides.  In taking care
to renew the dressing every three or  four days,  and  at the same
time to depress the fungosities with small rolls of lint, we generally
obtain, by means of this contrivance, a complete  cure in the space
of fifteen days  to a month.

                      IV. General Remarks.

  In  glancing  at  the  three methods of which I  have spoken, and
upon the  numerous processes which are arranged under them, we
are struck with the analogy they present in their point of depar-
ture.   Directing their remedies against the exuberant flesh, or the
edge  of the depressed nail,  surgeons sometimes  endeavored to de-
stroy or repress the fungosities, and sometimes to remove or raise
the imbedded portion of the nail.  There is a  disputed question
upon this point, since, according  to  some, the  nail, being more
incurvated,  narrower, and  more projecting upon its  sides than
usual, in  reality penetrates into  the  tissues,  and irritates them;
whilst,  according to  others, it is  the tegumentary  parts,  which,
crowding, (refoulees)  and coming up from the plantar to the dorsal
surface of the foot, drive in the nail, and thus lap over upon it.  It
would seem, in fact, in adopting  the ideas of  the first, that all
the efforts of art should be directed against the nail, while, to  be
in accordance with the principles of the other party, we should oc-
cupy ourselves with the soft  parts. The fact is, that the origin of the
disease in this matter, furnishes no means for determining the nature
of the treatment to be employed against it.
   Whether as  cause  or as  effect,  the border of the nail and the
fungosities unite together to constitute the disease. In the end the
nail becomes the annoyance, (Fepine;) this difficulty being removed,
the others almost always disappear.  If we remove the flesh without
touching  the  nail, the cure is  scarcely ever more than palliative; 
       OPERATIONS FOR DISEASES  OF THE CUTICULAR SURFACE.    373

from whence it finally results, that the imbedded nail  should  be
treated in the following manner.  We begin by advising easy shoes.
If the disease is slight and recent, we treat it by  lint, cotton, or
sponge, inserted between the flesh and the edge of the nail.   Should
there be fungosities, we repress  them with alum, nitrate of silver,
or even with caustic potash, when they  are  of considerable  size.
We should continue in this  manner until the  nail is effectually
raised and the soft parts sufficiently restored.  If there are fungosi-
ties at the root of the nail, as well as around it, we proceed as in
the previous case, except in giving the preference to the nitrate of
mercury as a caustic.  When the affection is of very long continu-
ance, and that these means have been tried without relief, we have
only to choose  between the readjustment and the evulsion of the
nail.  The readjustment by M.  Labarraque's process is the most
convenient and the most  certain of all; it should, therefore,  be
preferred: but  as it exacts delicate and repeated dressings,  it is
scarcely suitable, except for those who have it in their power to
remain at rest, and to nurse themselves for several weeks at home ;
so much  the  more  prompt would the return of the disease be, if
these  precautions were not persevered in for at least a month or
two beyond the apparent cure of the evil.  With laboring  people,
therefore, and  in general with  the class of poor, it will often  be
preferable to proceed at  once to the evulsion of the nail,  which,
moreover, is  always  left as a last resource,  after all other  means
fail.  This operation, which many authors treat of as one that is
excessively painful, and which is generally qualified with the epi-
thet of horrible, causes in  reality much less  suffering  than  that of
extracting a tooth.   A very considerable proportion of the patients
whom I have operated upon by this process, have borne it without
uttering the least cry, and  have  told me that they suffered but in a
moderate degree, though many of them were very young subjects,
timid women and men of every age.
  In using scissors with pointed strong blades, we  cut, in fact, in
an instant, from the free border  of the nail to beyond its root,  ope-
rating too upon fibrous tissues that have  in reality but little sensi-
bility.  The evulsion, properly so called, of the two halves of the
nail, being also effected with great celerity,  only wounds, in  fact,
as a simple source of irritation, (element irritable)  the cutaneous
duplicature which surrounds its sides and root.  All  this, therefore,
can be no more painful than would  be  the rapid  tearing off of
a small portion of skin.   After the evulsion of the nail and the
cauterization of the fungosities, the dressings are unimportant, and
the patient may resume his labors at the expiration of some days.
It is evident, if the cutaneous groove, or pretended matrix of the
nail, should be ulcerated, or  in  a state  of suppuration, or  should
present fungous excrescences of a bad aspect, it would be necessary
to cauterize it deeply with nitrate of mercury, the Vienna paste, or
the caustic potash.
  The proof, in fact, that the tearing out  of the nail is less painful
than has been said, is that in cases where the root of this plate only 
374
NEW ELEMENTS OF OPERATIVE SURGERY.
is separated by disease, as we often see it in the fingers, the surgeon
passes a branch of the forceps under it, and with a  single stroke
from behind forM'ard, detaches it without the patient making any
serious complaint.
  The wound that results from  it, should be  treated  like  every
other fungous M'ound; only that  the physical  cause which occa-
sioned it having  disappeared, it  frequently happens  that  it tends
immediately to improve of itself.
  [Imbedded Nail. In reference to the contrivances of various kinds
of metallic or other substances inserted under the imbedded edge
of the nail, as those of tin, lead, &c., and to which the author gives
the preference over other means that have been suggested to effect
a cure without coming to the more serious operation of an evulsion
of a part or of the whole nail, it  is to be remarked, that the parts,
especially in old cases, are often  so  extremely sensitive that none
of these  contrivances can be applied.  That  of M. Labarraque
seems  the  most efficient, but there  are few, it would  seem, who
could long  endure so hard and irritating a material as  a tin plate
in such a  position.  We have generally found, in ordinary cases,
that a long, narrow, doubled compress of linen, inserted in the same
manner,  and  the scraping  of the nail down through  the entire
length of its  middle part, to as thin a state as it will  bear,  and ex-
tending this attenuating process as near as possible to  the imbedded
edge, and preserving the anterior  corner of the nail rather long, as
an effectual point of resistance or lever upon  the pledget, will gen-
erally effect a cure, and with the aid of slight cauterizations, soon
repress the fungous growths that had covered it.  In addition to
this, another contrivance of a very ingenious and efficient  nature,
which may be had recourse  to where other means  fail,  consists
in perforating the anterior projecting  angle or corner, and also
the middle portion of the  border of the imbedded edge,  but not
too near the edge, with one, two, three or more circular openings
made in the proper place and at suitable distances; then insert
ing, successively and  cautiously, through each of these apertures
one end of a very narrow, strong, tape-like strip of adhesive plas-
ter, which  is to be there fastened by a knot placed outside of, and
resting upon  the imbedded border.   Finally, carrying  each strip
obliquely, that is, posteriorly  and upward, across the body of the
nail,  previously thinned down through all its  middle  part, each
one is to rest, the same as on a pivot, upon a  small, narrow, gradu-
ated compress, placed lengthwise on that attenuated part of the
nail, and the free extremity of the strip to be  then passed to the
opposite side of the toe, and between that and  the next toe, to the
plantar surface of the neighboring metatarso-phalangeal articula-
tions, where it is  to be kept firmly and steadily fastened by means
of one or two broad strips of adhesive  plaster, over the outer sur-
face of the layers of which the narrow strips may be reversed for
greater security, while the broad strips are rendered more immovea-
ble by making them pass round and embrace the whole foot.  These
narrow strips may thus be regulated, and  made to act with such 
        OPERATIONS  FOR  DISEASES OF THE CUTICULAR SURFACE.    375

force as we please, and as so many levers or ropes, the resistance
to be overcome being the imbedded border of the nail, and the com-
presses the pulleys.  The force of the levers may be increased with
their length, and their power acts  steadily and effectually till the
imbedded nail is ultimately completely raised up into its proper po-
sition,  when it is to be  kept there by a narrow, thick, and suitable
compress, until it entirely recovers its  natural condition.  By this
very plain and easy process, there is constant relief being adminis-
tered to the patient, and Mdthout the slightest pain, and we have
none of the pressure,  hardness, and annoyance of the metallic
hinged clasps, &c.  Conjointly associated with these narrow strips,
and co-operating with  them, we may attach the extremities  of
others, of considerably greater width, to the fungous growth itself,
and as near the  nail as possible.  The  other  extremities of these
strips being then passed on the outside of the toef supposing it to  be
the great  toe, and the outside  of its nail which is affected, and fast-
ened to its plantar surface, or extended  also to that of the foot, are
fixed the same as, or with the others, and thus present, so far as these
last plasters are firmly adherent to the skin of the fungous growth,
an antagonist force to that acting upon  the nail, but admirably co-
operating with it to separate  the two diseased portions from each
other.   In all cases,  we  must not forget to  scrape and thin the
middle of the nail, but not its imbedded edge, for the strength and
greater thickness of that is an  advantage, to prevent the perfora-
tions tearing out.   Leaving the angle on the anterior edge, it is a
still more powerful purchase  if much projecting.   The graduated
compress may be made adherent by diachylon.—T.]

     §  IV.—Exostosis, with Sub- Ungual Fungosities of the Toes.

   The last  phalanx of  the great toe sometimes presents upon  its
dorsal  surface an exostosis, which lifts up  the nail and separates
it, and which, once established, rarely  fails to take on a fungous
character, and to give rise to a very  abundant suppuration. Though
ordinarily situated  under the free border of the nail, this exostosis,
which  Dupuytren (Lecons Orales, t. iii., p. 58) was the first to inves-
tigate  with  care, shows itself also, sometimes, towards  the middle,
or nearer  still to the root of the phalanx.  But it is not the great toe
alone which may be the seat  of it; I have met with it  also on the
neighboring toes, and even on  some of the fingers.  In its first stage,
it is characterized only by dull pains ; which  are  sometimes quite
severe  if  it is placed under  the  middle part of the  nail.  At a
later period, it  is  recognised by its fungous, red,  and  purulent
character  ;  it  is  then that it might be mistaken for  the disease
known under  the name of onglade, or the  imbedded  nail; often,
also, it presents  itself under the form of a fibrous  mass covered
with rugosities,  and  united at  its root  with the dorsum of the
phalanx.
  This affection can be cured only  by the aid of a surgical opera-
tion.  Dupuytren was in the  habit of proceeding first to the total 
376
NEW ELEMENTS OF OPERATIVE SURGERY.
evulsion of the nail, and of afterwards excising the fungous exosto-
sis, even down to the body of the phalanx.   In a young student of
medicine, I was obliged to unite cauterization by the hot iron to
those two first stages of the operation.  For the large toe, that is
the remedy to be preferred.  We proceed afterwards  as has been
said above in treating  of onyxis, M'ith this difference, that it is not
in this case indispensable to destroy entirely the matrix  or root
of the nail.  The nail being once removed, the surgeon destroys the
exostosis with the bistoury, using it as we do a knife in cutting a
pen.  The actual cautery is immediately applied to the wound in
the same manner as for arresting hemorrhage.
  If the disease should exist in one of the four last toes, we could
proceed in another way;  the nail and the last phalanx to these not
having any real importance, might be readily sacrificed without any
inconvenience. The disease would be radically and promptly cured,
by performing amputation of this phalanx at its articulation with
the second.   Then, four or five days would suffice for a complete
cure, while in the simple  excision we require near a month.  The
disarticulation, moreover, is infinitely more  simple and less painful
than the operation proposed by Dupuytren.   I have  already per-
formed it  several times, and have had  every reason to be satisfied
with it.
  [Dr. Mott has seen the nail of the great toe degenerated to such
degree as to  increase by morbid growth to the length of an inch,
and  of proportionate thickness, resembling a horn.  It bled when
cut,  though it was entirely free from pain or inflammation. —T.] 
MORBID CICATRICES.
377
                   SECTION  SECOND.

 OPERATIONS WHICH MAY BE REQUIRED FOR DEFORMITIES.

  The operations which are to be described in the present chapter,
naturally divide themselves into several groups, though they all
belong to the same class.  I shall  form them into  five families,
M'hich will relate : 1. To the deformities from alteration of the skin;
2.  To those from alteration of the  sub-cutaneous tissue ;  3. To
those  from alterations in the tendons or muscles; 4. To those from
alteration of the ligaments ; 5. To deformities from alterations in
the articulations or the bones.
                         CHAPTER  I.

        MORBID CICATRICES, (CICATRICES VICIEUSES.)

  Cicatrices and tegumentary bridles  require the intervention of
operative surgery, either from the pain they occasion, or from their
interfering with the functions of certain parts.  To estimate the
inconveniences of certain bridles and morbid  cicatrices, we must
also, before all other things, consider their mechanism.

               Article I.—Anatomy of Cicatrices.

  When solutions of continuity close  wichout suppuration,  there
usually results a pliant cicatrix, which pjarcely differs in its physi-
cal characters  from the rest of  the tegumentary tissue.  When a
wound or ulcer has not been enabled to cicatrize, except by the aid
of a new substance, or by second intention, we see formed, on the
contrary, instead of natural integument, a dense, elastic, retractile
tissue, which constantly tends  to  approximate  the neighboring
parts to its centre, and which Delpech long since described in our
days under the name of inodular  tissue, (tissu inodulaire.)  But these
cicatrices, which are  principally remarked  as  the consequence of
burns, sometimes give rise to very considerable  deformities.  I have
seen them turn the  toes back upon the dorsum of the metatarsus,
or towards the  sole  of the foot, and even to the  outside or inside of
this part.  On the instep they bring the tarsus upM'ard, fix it on the
forepart of the leg, and produce  one of the varieties of the pied-bot
(club-foot)  anterior  or talus.  When  inward or outward towards
the malleoli, they cause the deviations of the foot known as varus 
378
NEW ELEMENTS OF OPERATIVE  SURGERY.
or valgus.  I have seen a patient who thus had the foot thrown to
the outside, from the effect of a long cicatrix upon the entire outei
surface of the leg.  In the popliteal space they cause an unavoida
ble retraction of the calf towards  the posterior part of the thigh,
I have seen the two thighs  glued (collees) by this deformity to the
walls of the lower belly. A young girl, whom I treated at the hos-
pital of La Charite, had cicatrices of this kind which extended from
the lower part of the chest down  to the knee,  and which forcibly
drew the right  thigh outwardly toM'ards the hip.   In a woman, to
whom I was  called by M. Morisse, they formed  upon  the entire hy-
pogastrium, that is, from one spine of the ilium to the other, bridles
so solid and so extended that they strangled  the womb towards the
middle of its length, and became the cause of an unnatural labor.  At
the anus and vulva, and in the vagina  and urethra,  the modular
cicatrices form obstacles, of which I shall have occasion to speak
in treating of the operations that are performed on these organs.
  We see similar bridles on the side, (aitflanc) so that the last rib
is sometimes brought down upon the crest of the ilium.  The tho-
racic extremity is still  more frequently  affected by them than the
pelvic ; nothing  is more common, in fact, than  to see one or many
fingers made to deviate (decies) by this cause, either !owards the
palmar or dorsal surface of the hand.   The entire metacarpus, or
the wrist, may also be turned either backward or forwards, inward
or outM'ard, by the action of a similar cause.   It is very common,
also, to see  the  forearm drawn towards the arm from the  flexion
caused by the new tissues.   The arm, also, is very often glued (col-
li)  to the chest by  cicatrices upon its inner surface, or by bri-
dles in the hollow of the axilla.  In the neck, the  cicatrices of
which I speak may depress the chin to near the sternum, or incline
the head towards one of the shoulders.   The lips, eyelids, and ears,
also deviate under the influence of inodular tissues into  every pos-
sible direction.  These morbid cicatrices, which are, also, sometimes
attended with the inconvenience of gluing together the fingers and
the toes, and the upper portions of the thighs, and of narrowing or
shutting up most of the natural openings, claim, therefore, every at-
tention from the operative surgeon.

                    Article II.—Treatment.

   Notwithstanding the  variety  and multiplicity of  forms  which
morbid cicatrices assume, the operations which are performed to
remedy them are reduced  to  a very small number.  We confine
ourselves, in fact, to the destruction of these inequalities, or the
projecting portion of them, to incising  them transversely on many
points, or to extirpating them in whole or in part.

                        § I.—Excision.

   If the inodular tissue  causes no other inconvenience than the in-
equalities it produces upon the surface of the skin, or the morbid 
MORBID CICATRICES.
379
sensibility and pains which it sometimes occasions, we may confine
ourselves to its simple excision, or even to its cauterization.  These
small operations must not be performed out of mere complaisance,
that is, when the cicatrix, causing in reality no inconvenience, pre-
sents itself simply under the  form of a seam or small eminence
on  some other part than the face, hands,  and feet.  We  should
then, also, forewarn the patient that  a remedy of  this kind will
probably render the surface more  regular and uniform, but  that it
will not  remove from the part its unnatural color, nor its appear-
ance of deformity.  The cauterization with the nitrate of silver,
nitrate of mercury, or nitric acid, will suffice, in fact, to destroy
simple cutaneous  prominences or seams; but the cutting  instru-
ment is evidently preferable. We then shave off with a keen-edged
bistoury all  the  exuberance of the cicatrix; after having dressed
the  wound  for  some days Math the  perforated linen and lint, we
proceed, if the diseased part admits of it, to the application of strips
of adhesive  plaster.   Upon the supposition that the adhesive plas-
ters are  not applicable,  we must take care to repress the vegeta-
tions of the  wound frequently with nitrate of silver.
  If the  cicatrix should  form a painful nucleus, (noyau doloureux)
as often happens when the extremities of some nerves  are  found
confined  in it,* the cauterization would not answer.  In the place of
shaving  it down, we should hook an erigne into the central part,
and completely excise  its M'hole substance.  Violent  pains have
thus been made to disappear which  had endured for many years,
and which had all the characters of true neuralgia.  It is, however,
evident, that this  species of  operation is  not applicable to  retrac-
tions nor to deviations of the organs, and  that it cannot be em-
ployed except for the removal of simple  and bona fide projections
and excrescences of inodular cicatrices.

                         § II.—Incision.

   Up to a late period, we possessed only one kind of operation for re-
storing to their natural direction parts that were distorted under the
influence of morbid cicatrices. This operation consisted in dividing
through the cicatrix transversely from space to space, either partially
or totally; afterwards we gradually and imperceptibly adjusted the
retracted part, either by the aid of bandages  or machines.  Care
was then taken to force the wounds of the operation to cicatrize by
the second intention, and to keep their lips wide apart.   It was ne-
cessary, also, to make every effort, even after the cure, to resist the
tendency of the organs to resume their unnatural position, and to
cauterize the wounds frequently during  the  course of the treat-
ment.
   If the  cicatrix was long and very prominent, some surgeons pre-
ferred cutting through its base with a double-edged knife, in order
to shave it  off from one extremity to the  other,  and thus cut it out

     * [See a case of this kind from bleeding, supra, as notieed by Dr. Mott.—T.] 
380          NEW ELEMENTS of operative  surgery.

entire.  They afterwards incised the borders of the wound as in
the preceding case, and proceeded in the same manner for the rest
of the treatment.   Though of easy and rapid execution, this last
process has the inconvenience of sometimes causing  very severe
pains, from the commencement to the termination of the cure, and
of producing, moreover, like  the simple  incision, scars and  ner-
vous symptoms, and sometimes even a deep-seated gangrene; also,
of leaving in its train protuberances and  inequalities of great de-
formity, and finally, of not succeeding except in a very small num-
ber of cases.   It is certain, in fact, that, in spite of the  best-adjust-
ed bandages  and dressings, the new cicatrices resulting from this
mode of proceeding often resist all the efforts of the surgeon, and
ultimately bring back the parts to the position M'hich they were in
before the operation.   It was  going too far, however, to say that
the transverse incisions of the cicatrices had ahvays failed. Science
now possesses a very considerable number of authentic  facts which
demonstrate its efficacy. I have seen a young man, whose forearm
was thus detached from the  anterior surface  of the arm, have it
completely extended out in the  space of six weeks.  The motions
of this limb  at  the end of two years  had lost none of their free-
dom.   Similar observations have been published by M.  Hourmann
(Clinique  des Hbpitaux, etc., t. i., No. 16,  p. 4)  and by  M. Berard,
jeune, (Jour, des Connaiss. Med.  Chir., t. ii.,  p. 202.)  The adhesioc
of the arm to the side of the chest, and the retraction of the fingers,
have  sometimes yielded completely to the simple incision.  In the
young girl whom I have spoken of above, and who had such enor-
mous ridges  upon her  side and  upon the external surface of the
thigh, the transverse incisions  effected a partial restoration of the
limb.   Besides, when the cicatrices are wide, or numerous, or very
irregular, the incision is almost the only remedy M'e can oppose to
them.  It is  a method, therefore, which should be preserved, and
one which some modern surgeons have unjustly proscribed.

                       § III.—Extirpation.

   Having shown, as a principle, that every  cicatrix, by the forma-
tion of a new substance, destroys the pliancy (souplesse) of the tissues,
and  tends to retract incessantly upon its middle portion, Delpech
deduced therefrom this conclusion, that the incision is  rather inju-
rious than useful when its object is to remove the inodular bridles.
In lieu of the ancient  method, therefore, he proposed to Substitute
the extirpation, in fact, of the whole cicatrix.  After having raised
the indurated layer by incisions, which were made upon the sound
tissues, he carefully approximated the borders  of the wound, and
directed all  his efforts  to obtaining immediate union ; by  this
means Delpech obtained a linear, pliant, moveable, distensible  cica-
trix, similar to natural integuments, and which  could in no respect
interfere with the movements of the affected region.
   There is no doubt that it would be preferable to act in this man-
ner when the cicatrix  is narrow, and is situated upon a bulky part 
SUB-CUTANEOUS  BRIDLES.
381
of the body.  Upon the dorsum of the foot, and upon the leg, thigh,
hand, forearm, and trunk, and even upon some regions of the face,
an inodular cicatrix, which  should  not  exceed six  to ten lines  in
breadth, might in this way be extirpated with advantage. Though
the wound should have several inches  length, and that we  should
be obliged to detach (decoller) each side of it to the extent of some
lines, there would still be room to hope for immediate reunion, either
by the suture, or by means of uniting bandages or straps of adhe-
sive plaster; but it is evident that, for the fingers and toes, and for
the eyelids and nose, as for all cases where the cicatrix is large and
very irregular, the method of Delpech  would expose  to more in-
conveniences than the old  operation,  and  would  offer no better
chances of success.
                        CHAPTER II.

                SUB-CUTANEOUS BRIDLES.

  I separate here the abnormal bridles from cicatrices, properly so
called, because these latter belong almost  exclusively to the cuta-
neous tissue, while the former are very often situated in the cellu-
lar or the fibrous tissue.  There are, in  fact, four varieties of bri-
dles capable of producing deformities—the tegumentary, sub-cutane-
ous, aponeurotic, and ligamentous bridles.  But I shall  here speak
only of sub-cutaneous  bridles,  those  which  belong to the skin,
blending themselves with the morbid cicatrices of which we have
just spoken ;  those of the ligaments, aponeuroses, and tendons, be-
longing to another chapter.

         Article I.—Anatomy of Sub-Cutaneous Bridles.

  Sub-cutaneous bridles are a fibrous transformation of the fascia
superficialis.   An attentive examination  of the cellulo-adipose tis-
sue shows, that  lamella? and filaments  of considerable density pass
in the natural state in a more or less oblique direction from the in-
teguments to the aponeurosis.  These  lamellae, which, in fact, are
only the origin or termination of certain  muscular or aponeurotic
fibres,  preserve  in the  normal state a  pliancy and distensibility
which cause them to be constantly confounded  with the cellular
tissue, properly so called.  Under the influence of certain causes,
and by a process which is still but little understood, they become,
on the other hand, indurated, hypertrophied, and retracted, so as to
constitute inelastic bridles, which forcibly draw together the movea-
ble parts  which serve for their insertion.  They are a species of
tendons or abnormal  aponeurotic partitions which are formed under
the skin at the expense of the fascia superficialis.   Though these 
382           NEW  ELEMENTS OF OPERATIVE SURGERY.

indurations and fibrous transformations of the cellular tissue may
take place on most of the regions of the body, upon the  internal
surface of the enveloping aponeuroses, in the centre of the limbs,
as M'ell as in the sub-cutaneous tissue, and that they are seen some-
times in the substance of certain organs, as in the mammae, lungs,
and bladder, for example; it is, nevertheless,  upon the palmar sur-
face of the hand that MTe most frequently notice them.   These bri-
dles differ  from morbid  cicatrices in this, that it is  not necessary
that they should have been preceded by any solution of continuity
or wound, and that  the skin remains moveable upon their surface,
the same as upon the aponeuroses and tendons.  Supervening with-
out inflammation, pain, or any previous recognisable pathological
phenomena, they disturb only  by the deformity which is sometimes
occasioned by them.

                    Article II.—Treatment.

   No local application, no general medication, can relieve a patient
of sub-cutaneous bridles; we  must either do  nothing, or have re-
course to the bistoury.   Bandages, forced extensions, and the most
ingenious apparatus, are powerless in such cases.  Generally con-
founded with retraction of the tendons, these bridles had, until later
times, been usually ranged by most surgeons among  incurable dis-
eases. Since their  independence of the tendons has been perfectly
established, we have become  rid of this doctrine, and new opera-
tions have been proposed for their cure.
   Two general methods present themselves under this head: the
object of the  one  is  to divide  the bridle on one or many points.
while the other requires its extirpation.

               § I.—Section of the Abnormal Bridle.

   When the bridles, of which I have just been speaking, show them-
selves under the skin in the form of the cord of an arc, so as to
cause retraction of  certain moveable parts, we are, as it were, com-
pelled, in spite of ourselves, to divide  them upon their most pro-
jecting points.   Three different methods have been proposed to
fulfil this indication.

                   A.  Process of Dupuytren.

   Dupuytren, who  was one  of the first to draw attention (L. Mau-
det, These, No.  141, Paris, 1832)  to the nature of sub-cutaneous bri-
dles, maintains, that the best way to relieve the patient of  them is
to cut through both the skin and the abnormal fibrous cord, some-
times on one point  only, and sometimes on many, until the readjust-
ment of the retracted part may be ultimately effected with ease and
without pain. This process, which was several times practised at the
Hotel-Dieu, of Paris, appears to have almost constantly succeeded.
When we wish to  make trial of it, the instrument  should divide 
SUB-CUTANEOUS  BRIDLES.
383
with care both the principal bridle and the small accessory bridles
M'hich are almost always found in the neighborhood.   Dupuytren
felt himself sometimes obliged, also, to dissect the lips of the wound
a little  on either side, and to glide the bistoury underneath to de-
stroy  the remaining retracted  cords.  The process of  Dupuytren
involves a serious inconvenience.  From the necessity of dividing
the skin freely, it  may happen that  the extremities of the incised
bridle will become  incorporated with the lips of the tegumentary
M'ound,  and that the inodular cicatrix, which might result from this,
tends almost unavoidably to re-establish the deformity.  It is, there-
fore, quite natural that  surgeons have sought another mode of pro-
ceeding.

                   B.  Process  of M. Goyrand.

  Wishing to avoid the necessity of suppuration  and cicatrization
of the external wound by second intention, M. Goyrand (Memoires
de VAcad. Roy ale de Med.,  Paris, 1834, t. iii., p. 589) proceeded in
the following manner :  He commences by dividing the integuments
in a direction  parallel with, and to the extent of the whole length
of, the abnormal bridle; in this manner the cord to be divided is
laid bare, and shows itself to the eye of the surgeon under the form
of a fibrous partition.   Then separating the lips of  the wound, the
operator cuts  through  the bridle transversely, as Dupuytren did,
from  space to space, or on a single point, if one incision alone should
seem sufficient.  Then reuniting the lips of the external division,
he obtains a perfect cure by first intention ; the skin, preserving its
pliancy, in no  respect interferes with the movements (glissements)
of the divided bridle,  or the mobility of the part which was previ-
ously retracted.
  This process has the inconvenience of not permitting as complete
a division, as  that of Dupuytren, of the  lamellae or fibrous cords
which might exist in the neighborhood of the principal bridle.   As
a general rule, however, it should be preferred to his.  I have used
both,  and can affirm that that of M. Goyrand answers in most cases.

                   C.  Process of A. Cooper.

  A process more simple still, and which M.  A. Cooper (On Dislo-
cations,  &c, Goyrand; Gaz. Med. de  Paris, 1835, p. 485) long
since  recommended, consists in inserting by puncture on one  side
of the bridle the point of a straight bistoury.  The instrument, held
flatwise, is then glided along to the opposite side, grazing by the in-
ternal surface of the skin; after having turned its cutting edge down-
wards, the section of the abnormal cord is  made transversely and
from the skin toM'ards the aponeuroses.  The operation, thus reduced
to a simple puncture of the integuments, produces no pain, and is
followed by no flow  of blood.   Were it not that  the  process of
puncture is sometimes rendered impracticable by the adhesions or
want  of mobility in the parts, it certainly would be preferred in all 
384
NEW ELEMENTS OF OPERATIVE SURGERY.
cases.  It would not answer to practise  in  this manner several
punctures and several sections in  place of one, except where the
bridle was of a certain length.
  In conclusion, the three processes which I have described should
be retained in practice. The section by simple puncture of the skin
will have the preference, as often as the pliability and mobility of
the tissues will allow of its being performed.  If the insertion of
the instrument between the bridle and the  integuments  should ap-
pear to be attended with too much difficulty, the process of M.
Goyrand ought to be substituted for that of M. Cooper. In fine, we
should return  to the  process of Dupuytren in cases where the bri-
dle is irregular, and of great width, and has intimate adhesions with
the tegumentary tissue.

                 § II.—Extirpation of the Bridle.

  Setting out  from the doctrine established by Delpech, and after-
wards by M.  Earle, (Abernethey, Lecons, &c, p. 97,) in regard to
the properties of the inodular tissue, I had thought it would be bet-
ter to slit the skin  longitudinally, and then extirpate the bridle,
rather than to make  a simple section of it  in the manner of Du-
puytren.   I performed an operation of this kind at the hospital of
La Pitie, in the  beginning of the  year 1833.  I hoped, by acting
thus, to be enabled to close the wound immediately, and instantly
to restore to the retracted parts their natural mobility ; but although
this operation  was followed by success, and that it included the first
steps in the process of M. Goyrand, I have  since perceived that the
extirpation had not in reality any advantages over the simple sec-
tion, and that it constituted, in  truth, a longer, more painful, and
more  complicated operation.  I do  not think, therefore, that there
is any use in retaining it, except where the bridle should have un-
dergone an actual degeneration,  (veritable degenerescence)
  It is useless to add, that after these operations, and whatever
may be the process which has been adopted, the cure would not be
obtained, if bandages, apparatus, and suitable dressings, did not
come to its aid.   It is  necessary, in fact, to do all  in our power to
effect the union of the wound of the integuments without suppura-
tion, and that  the retracted part may resume its natural direction
and be maintained in  it, without effort, violence, or fatigue to the
organs, until the cicatrization is complete.  The suture, adhesive
straps of diachylon, and uniting bandages, to which are joined the
perforated linen and lint, refrigerants, emollients, or antiphlogistics,
for the period of four or five days, and according to the nature of
the case, are therefore indicated. We make use, at the same time, of
such dressings as will maintain the part, whose adhesions and re-
traction we have destroyed, in that state  of  elongation which we
wish  it ultimately to have. 
SUB-CUTANEOUS BRIDLES.                  385
Article III.—Operations according to the  Region in which  the
                      Bridle  is situated.

                        § I.—The Hand.

  The finger^ and toes are  subject to three kinds of deformities
from bridles, or abnormal  cicatrices.  They are sometimes com-
pletely or but partially united at their sides, at other times simply
retracted into a flexed position,  like segments of a circle, or drawn
backward, or forward, or sidewise.  Though the toes are not stran-
gers to these three varieties of  deformity, the fingers, nevertheless,
are their favorite locality.

             A.  Adhesions of the Fingers at their sides.

  When the fingers are  completely blended together at their two
sides, and that the bones which compose this part of the  skeleton
seem, so to speak, to touch each other, there is but little  prospect
of our succeeding in our attempt to separate them.  It is  not  that
we find any difficulty in  making the  bistoury pass betM'een them
from before backward, or from  behind forward, or to separate them
from each other, but the  little strip of skin M'hich in these cases is
left upon the palmar and dorsal surfaces, not being in all instances
sufficient to keep up the  circulation, almost always has a tendency
to become  gangrenous.  The  wound on the side of each  finger
vegetates, assumes a fungous aspect, and, moreover, does not cica-
trize but M'ith extreme difficulty, in addition to which, a  new ag-
glutination  of the parts rarely  fails to take place.
   A young girl of fifteen years of age, vehom  I had thus  operated
upon for an adhesion of the  three last fingers of the right hand, was
seized with a gangrene  which included the whole of the last pha-
lanx and the anterior half of the middle phalanx of the ring finger.
Some  portions  also of the  skin mortified upon the two other fin-
gers, and  the  cure, which was protracted to a  long time, left
the patient  with as great a deformity at least, though of another
nature, as the one which I had  wished to remove.  It is true that a
roller bandage, with strips of adhesive plaster  of diachylon, and a
dressing wet with cold water, which I had  applied to prevent all
excess of inflammation,  concurred, perhaps, in  bringing about this
unfortunate  result.  I should not, therefore, venture to recommend
but with caution the destruction  of morbid adhesions when found
so  extensive and complete.  The want of integuments on the en-
tire  side of the  fingers is in these cases a cause of failure, which
no means that I am acquainted with has the power to remedy.  We
are not, however, to believe that the complete  union  of these ap-
pendages is absolutely and  always irremediable.  An observation
of Dessaix (Gazette Salutaire, annee 1761, No.  22) proves  the con-
trary.   A newly-born child had the  hands transformed into  two
fleshy  masses, the  entire extremity of which was  covered  trans- 
386           NEM' ELEMENTS OF OPERATIVE SURGERY.

versnly by one single nail.   Without  paying any particulai atten-
tion  to the number  of  the  bones. Dessaix  divided  each of these
masses into four parts instead of five, and thus made as many fingers
of each of them.  The child  succeeded in being enabled to write
and  to work, though the metacarpo-phalangeal  articulation M'as
the only one  which existed, and that the bones of the metacarpus _
did not appear to have any particular continuity of connection M'ith
the fingers.   The author adds, that the operation was of short du-
ration, caused no reaction, and required a month to heal up all the
wounds.
  This fact, at most only probable, is as we see very extraordinary;
but Dessaix relates it with details so  circumstantial, that, it is diffi-
cult to call it in question.
  On the contrary, should the adherent fingers retain their mobility,
and  appear tq have a  tegumentary  membrane between them, re-
calling to mind, in fact, the idea of web-footed (palmipedes) animals,
there is room to hope for their relief.  Under such circumstances,
however, M'e  should deceive ourselves strangely, if we believed  the
thing easy.  The destruction of the bridle in these cases is the least
difficult part  of the operation.  After having perforated this bridle
by a puncture near its root, we  divide it from behind forward, or
from before backward, holding the bistoury perpendicularly,  while
an assistant  stretches  apart the  fingers that are to be  separated.
We  might equally well make use  of a scissors, if the partition
should have only a slight degree  of  thickness.  This  section per-
formed, we should, if no obstacle were interposed, perceive the two
sides of the wound reunite  again imperceptibly,  from the root to
the pulp of the fingers.  Even it is  found that pledgets of lint, plates
of lead, strips  of plaster, and bandages of every sort, placed as
foreign bodies between the  two separated fingers, often contend in
vain against  the tendency to a new agglutination.
  Surgeons are so well convinced of this difficulty, that many of
them have come to the  conclusion to  proscribe the operation itself,
and others have advised to associate with it a certain process of
anaplasty.  M. Krimer,  (Journal de Graefe et Walther, t. xiii., p. 602,)
among  others, has proposed to bring forward, between the roots
of the two fingers,  a flap  of tegument  detached from the back
of the hand, in  order to unite it to  the palmar teguments, and to
construct, out of all of these, a perfect commissure.   This process,
which is attributed to Zeller by M. Chelius, (Trad de Pigne, t. ii., p.
 13,)  and which  would, moreover, considerably increase the danger
and pain of the operation, is not in my opinion necessary.  I should
prefer to proceed as follows: I commence by introducing three pre-
paratory ligatures (ligatures d'attente)  in the part the most remote (la
plus reculee)  from the intra-digital partition, one at the middle, and
one  on each side.   Having divided, and either by puncture from
 behind forward, or from before backward, the abnormal partition,
 to within two or three lines of the points traversed by the ligatures,
 I seize hold of each of these successively, in order to make of them
 a simple suture of three stitches.  I obtain by this an almost imme- 
SUB-CUTANEOUS BRIDLES.
387
diate  coaptation of the  lips of the wound throughout the whole
extent of the commissure.  The reunion on this point being effected,
makes the separate cicatrization afterwards of each of the fingers
a very easy matter.  I would also recommend  to  avoid  carefully
all compression and application of refrigerants upon the wounds
which result from- this operation,  at  least during the first week.
Moreover, it should not  be performed if  the articulations of the
fingers should appear to be anchylosed and incapable  of recovering
their natural mobility.   I may add, that during the whole  course of
the treatment, from beginning to end, the  fingers newly separated
should be frequently flexed or extended, so as to render  them lim-
ber (a les assouplir) by degrees.

  B. Retraction (renversement) of the Fingers by a Morbid Cicatrix.

  I have often seen all the four fingers, entire, retracted by cica-
trices from ancient burns, or from  lesions which had  taken place
during the  period  of intra-uterine life ; I have more frequently
from such causes seen the retraction of only one or of some of the
fingers, either backward,  towards the  sides, or forward.
  When the infirmity is of very old date, or when it is complicated
with a profound alteration of the articulations;  when, in a word,
it is evident that, though the bridles of the cicatrix were destroyed,
the finger would  not recover its former mobility, the  disease can
only disappear^ with the amputation of the finger itself. It is, there-
fore, only in cases where the articulations appear to have preserved
both their form and a part of their natural mobility, or where both
the extensor and flexor tendons appear to have been only slightly
(mediocrement) altered, that it is allowable to undertake one of the
operations which I have  spoken of above.  In that case, we may
also take into consideration the section from space to  space of the
bridle which keeps the finger in a faulty direction.   A number of
incisions, and going to but little depth, ought to be preferred in such
cases  to a single one penetrating to a considerable depth below the
thickness of the skin.  The extirpation of the cicatrix by the method
of Delpech, would  answer only for very narrow bridles,  and is in
reality but rarely applicable to deformities of the fingers.
  If the retraction should be baclcwards, the fingers should, in such
cases, be afterwards held  in a state of sufficiently strong flexion, and
should not be allowed to  deviate  from this direction, except at in-
tervals, until the cicatrization is  completed. The cicatrices on their
palmar surface, on the contrary, would require that they should be
kept properly extended by fixing them to a palette of M'ood or of
pasteboard placed on their dorsal surface.   It is easy, however, to
understand the variety of palettes, plates, and  splints, which  M'e,
may have occasion for in such cases.

      C. Deviation of the Fingers by Sub-Cutaneous Bridles.
 . An  unnatural flexion of the fingers  may arise from  a solution of
continuity, a paralysis of their extensor tendons or muscles, 
388
NEW  ELEMENTS OF OPERATIVE SURGERY.
an anchylosis, a deviation, certain tumors on their articulations or
phalanges, the retraction, shortening, or some alteration of their flexor
tendons, or actual diseases either of their nerves or  vessels, or of
the teguments of their palmar region ; but I design only to speak
in this article of the flexion which depends upon sub-cutaneous  bri-
dles, intending farther on to examine other  kinds of deviation to
M'hich they are liable.
  Previous to the observations  published in the name of  Dupuy-
tren in 1S31 by M. Paillard, (Jour. Univers. et Hebd., t. v., p. 349, et
t. vi., pp. G7, 364,) in 1832 by M. Lemoine Maudet, (These, No. 141,
Paris, 1832,) by MM. Buet and Briere, (Legons Oral, de  Dupuytren,
t. L, p. 1—25  et 516—531,)  by M. Vidal de Cassis, (Gaz. Med de
Paris, 1832, t. i., p. 53, in 8°,) and M. Avignon, (These. No. 16, Paris,
1832.) and M'hich have been resumed by M.  Goyrand, (Mem. de
VAcad. Royalede Med., t. iii., p. 549, et Gaz. Med. de Paris, 1835, p.
481,)  the  cause which  I have here adverted to had scarcely been
thought of. All authors confounded it M'ith the  contraction  (erispa-
ture)  of the tendons, and regarded it, moreover,  as  an incurable
disease.  The observations  of Dupuytren have incontestably  de-
monstrated that the tendons are generally unconnected with  this
retraction; but they have not so clearly proved, as  this surgeon
believes, that the retraction of the fingers depends upon an indura-
tion or a shortening of some of the bundles of the palmar aponeu-
rosis.  These bridles, which present themselves under the form of
projecting cords under the skin, extend almost always over a great
portion of the  length of the  finger ; they occupy especially its me-
dian line, and  prolong themselves at least upon the palmar surface
of the first phalanx, very often, also, upon the second,  and some-
times even upon the third.   But  anatomy teaches that the  palmar
aponeurosis, properly so called, terminates at and fixes itself to the
root  and sides of each  finger, becoming blended either with the
sheath of the flexor tendons, or with the ligaments of the articula-
tion.  Again, the aponeurosis of the  hand does not  extend itself
either to the thenar eminence, or to the root of the thumb.  An ob-
servation, noted in the practice of Dupuytren himself, (Gaz. Med. de
Paris, 1833, p. 112.) makes  mention of an individual M'ho  had all
the fingers contracted, (crispes)  and the palmar surface of M'hose
thumb presented one of these bridles in the fullest state  of develop-
ment.  Having myself proved by dissection, and upon a living person,
that the palmar aponeurosis sometimes remained untouched after the
incision or extirpation of these bridles, I announced, in the beginning
of the year 1833, (Anat.  Chir. t. ii., p. 75,2e ed., 1833,) that the abnor-
mal bridle, of which Dupuytren had spoken, was not always formed
by the aponeurosis; that in one  patient it appeared to me to be
nothing more than the fibrous transformation of the sub-cutaneous
tissue ; and that I should not have been surprised to find that it was
often  so.  The researches of M. Goyrand have fully justified this
prediction.  I will add, as I have elsewhere done, {Gaz. Med., 1835,
p. 511, et Anat. Chir., 3e edit., 1837, t. ii., p. 487,) that the opinions
of Dupuytren, of M. Goyrand, and of M. Sanson, (Mem. de VAcad. 
SUB-CUTANEOUS BRIDLES.
389
Royale de Med., t. iii., p. 592,) would, likt mine, be inexact, if we
were  to adopt one of them, and, after the manner of the ancients,
substitute it absolutely to the exclusion of the others.  If it is false
to believe, as M. Mellet still asserts, (Man. Prat. d'Orthop., 1835, p.
246,) that the retraction of the fingers more frequently arises from
a contraction of the flexor tendons, it would be also so to maintain
that this cause never exists ;  in the  same way as in rejecting  the
doctrine of Dupuytren as  too exclusive, M'e should be wrong not to
admit it for some cases.
  In fine, the retraction of the fingers arises most frequently from
the fibrous transformation of one or more of the lamellae of the sub-
cutaneous or superficial fascia. In reality caused, in certain cases,
by a contraction (crispalion) of the palmar aponeurosis, it also some-
times depends upon a degeneration of the skin itself, or upon some
cicatrix of this tissue, (membrane)   It is well,  also, to add, that the
fibrous sub-cutaneous degeneration, M'hich causes the retraction of
the fingers, does not always  assume the  appearance of a cord, or
simple bridle.   In one of the patients of Dupuytren,  it was per-
ceived that there were transverse fibrous radiations, at the same
time that others ran obliquely and some with the axis of the hand.  I
have myself seen a man of fifty-seven years of age, and otherwise
enjoying the most perfect health, in whom the retraction of the fin-
gers M'as kept  up by unequal bridles, whose  roots M'ere evidently
lost in a hard, insensible layer, (plaque) covered with lumps of the
size of a small nut, and which  occupied almost the entire palm of
the hand.
  However this may be, experience has now proved that this species
of retraction, M'hich, as  M. Vidal says, principally attacks the ring
and little fingers, and which in certain rare cases only invades the
thumb and other fingers, and which is scarcely ever met with, ex-
cept in persons  whose  occupation demands a certain pressure or
frequent and continued extension  of the palmar surface of the fin-
gers, or of the hand, upon certain hard bodies, is not incurable.  It
was for this, especially, that the different kinds of operations which
I have described above, were proposed.
  If we  are disposed to follow the method of Dupuytren, M'e may
spread out the hand of the patient upon its dorsal surface.  While
an assistant holds it fixed in this manner, and endeavors to straighten
the fingers as much as possible, the surgeon, directing a straight or
curved bistoury upon the most tense part of the bridle, makes a
transverse incision there, which should include both the skin and
the sub-cutaneous fibrous tissue.   On the supposition that this first
incision suffices  for the complete extension of the finger, it is  not
repeated ; on the contrary, should  there still remain any of the cord
or stiffness beyond the first section, we perform a second one, and
even a third.   Acting upon these  principles,  M. Gensoul (Journal
Clin, des Hopitaux de Lyon, t. i., p. 496) has shown that the incision
of the bridles was sufficient for removing the  retraction of the fin-
gers and of the hand.   The hand is afterwards fixed by its dorsum
upon a palette properly padded. A few turns of a narrow bandage, 
390
NEW elements of operative surgery.
or strips of adhesive plaster of diachylon, passed betM'een or ante-
rior to the incisions, take a point d'appui upon the palette to main-
tain the finger in the necessary degree of extension.   The wounds
are, in other respects, dressed by the ordinary applications.
  According  to  M. Goyrand, (Gazette Medicate de Paris, 1835, p.
485,)  the  hand  being  lixed as above, the surgeon, armed m ith a
straight bistoury, held like a writing-pen, ought to incise the skin
in the direction of the  bridle itself, and to the extent of one or two
inches.  This being done, he cuts the fibrous cord from space to
space upon all  the points M'hich  appear tense, and even  excises
some portions of them, if they should seem to be too moveable, or
floating, as it were, at the bottom of the wound. He then unites by
the first intention, retaining the fingers in a state of complete ex-
tension.
  On the supposition that it might be  possible to insert a narrow
instrument between the skin and the abnormal cord, we should
make the  puncture of  the integuments on one of the sides of the
bridle, which latter must be previously stretched tight. In order to
relax it a little, and to  introduce the bistoury more easily under the
skin, it would be proper to increase the flexion of the  fingers  a lit-
tle, until the  instrument should have reached to the other side of
the transformed  tissue.  Then, having turned  the back of the instru-
ment forward, M'e should again extend the fingers, in order that the
bridle might,  in some  degree, be  enabled  to divide itself from be-
hind forwards.  After having repeated this  kind of section  by a
sufficient number of punctures,  and from space to space, it M'ould
become necessary here, also, to maintain the fingers in a state of
extension.  Only in place of agglutinative bandages, and of the or-
dinary dressing, it would be  proper to apply some resolvent  com-
presses, and to establish  a  moderate degree of pressure upon the
small  punctures.
  As to extirpation, I have already said, that, in performing it for
the first time in the beginning of the year  1833, I proceeded in the
same way that M. Goyrand did a short time after, and  that, not
being able to produce results more  advantageous than by the simple
section, it did not appear to me deserving of general  adoption.  I
M'ould, therefore, recommend not  to have recourse to  it but M'here
tumors or  certain kinds of nodosities should be found to exist under
the skin with the bridle.
  The operation being performed, and the wounds cicatrized, we
should still deceive ourselves, whatever may  have been the process
used, if we should look upon the patient as safe against any return,
and did not recommend to him  to adopt some  precaution.  Com-
plete extensions, often  repeated, and suspension of  the occupations
which had brought  on  the induration, the  massage of the  parts,*
oleaginous ointments, and mucilaginous baths,' are still necessary,
if we  wish the cure to  be radical,  as they might also have sufficed
  * [Le massage (see supra) means, pinching, twisting shampooing, and otherwise ex-
citing the parts.—T.] 
sub-cutaneous  bridles.
391
 in the first months of the disease, if the patient had been disposed
 to make trial of them.

                       § II.—The Forearm.

   When the forearm is found adherent (colle)  to the front part of
 the arm, in consequence of morbid cicatrices,  we remedy the de-
 formity by means of incision or excision of the new tissues.   This
 operation, however, should  not  be undertaken, unless the disease
 has supervened since the period of infancy, or  that M'e have  it in
 our poM'er to assure ourselves that the  articulation at the elbow
 preserves, or is capable of re-acquiring, a great portion of its mo-
 bility.   Otherwise, to  destroy  the cutaneous  adhesions could, in
 fact, have no object.
   When the adhesions have been  formed in early life, the articular
 surfaces are  so modified that they no longer  permit in adult age
 the forearm to be extended  or flexed, except by a kind  of sliding
 movement, (glissement)  If the  patient, however, is found in favor-
 able conditions, the operation must be undertaken as soon as pos-
 sible.
   Here the method of Delpech,  that is, the excision of the inodular
 tissue, and the immediate reunion  of the wound, will rarely answer.
 We  should not have  recourse  to it, except af.er  the practice of
 Benedetti, M'hen there are only simple narrow bridles.  In this case,
 also, Me should guard against extirpating the cutaneous  fold in its
 whole widlh; for by the extension of the limb, there might there-
 by be produced an enormous M'ound.   We should therefore incise
 the integuments along the borders of the bridle, from  one of its
 extremities to the other, in place of following  the angle of flexion
 at the  bend  of  the  arm.  The  excision  M'ould be thus limited
 to the  cord  which forms the free border of  the morbid  cicatrix
 or abnormal bridle.  In these cases, where this first kind of ope-
 ration seems insufficient, it is preferable to destroy the  adhesions
 by numerous transverse sections, or  by an  exact dissection of
 the agglu inated (conglutin'es) surfaces.  Malvani (Journ. Gen. de
 Med., t. cviii., p. 40) speaks of a patient who had the forearm thus
 flexed in consequence of an ulcer at the bend  of the elbow joint.
 He treated it by incisions.   After the extension  ihe wound attained
 the width of the palm  of the hand, but nevertheless resulted in a
 perfect  cure.   Demarque (CEuvres de  Jacques  Demarque, 1002, p.
 467) had already been tempted to perform the same operation on an
 individual whose  forearm, in consequence of a  burn, M'as adherent
 to the arm, up to the apex of the  shoulder ; but  the  patient, who
 gained his living  by this deformity, would not listen to any treat-
 ment.  I have  said above  that  such an operation  had been  per-
 formed in 1825. at the  hospital  of Perfectionnement,  on an adult
 man, M'ith entire  success, by M. Bougon.  In the two cases of the
 same  kind published bv M. Hourmann, and M. Berard, jeune, the
 success  was not less complete, though  the deformity existed in the
very highest degree.  The possibility, therefore, of curing patients 
392
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
laboring under this kind of disease, by simple incisions, may now be
deemed an established truth.
  The patient being seated, or lying down, and having the elbow
supported upon a cushioned table, or on the bed, is seized by the
shoulder and hand by an assistant, who endeavors gently to extend
them apart.   The surgeon then proceeds to the section of the bri-
dles, taking care to guard not so much  against the number as the
depth of his incisions.  If in the place of bridles there should be a
homogeneous agglutination of the skin, it  would be necessary to
guide the bistoury in such manner,  sometimes  in the direction of
the arm, sometimes  in that of the forearm, that the tM'o surfaces
might be rather unglued than really cut.  It would be much better,
therefore, to make the dissection by proceeding from the external
and internal grooves towards  the median line, than to proceed at
the very first from above downward.
  We may conceive  that the success of an operation like this de-
pends as much upon  the after-treatment as upon the action of the
bistoury itself.  It is  important, therefore, if the arm can be imme-
diately straightened, to extend it upon a well-padded trough, (gout-
tiere) which might reach from the neighborhood of the shoulder to
the root of the fingers, and to fix it in this trough by means of turns
of bandage  properly arranged.   By the aid of some compresses, a
long splint of pasteboard, and a bandage saturated with dextrine,
we could construct upon the spot a perfect apparatus, if the opera-
tion should not have  produced too long a wound in the bend of the
arm.  It would suffice, in fact, to pass some turns of bandages cross-
wise (en sautoir) upon the  elbow, in  order to have a roller bandage
on the parts towards the hand and the axilla, which should leave the
wound in the 'bend of the arm uncovered.  This wound, which it is
well to dress with the perforated linen and lint, and whose vegetations
must be often repressed  with nitrate of silver, should not be aban-
doned  to the retractile  power of the inodular tissue, until a long
time after the cure.   It is useful, however, in  order to give supple-
ness to the articulation by degrees, to exercise some movements of
flexion upon the forearm, towards the end of the treatment, at least
once a week.

                       § III.—The Arm.

  Demarque (ffiuvres, fyc, p. 467) relates that a pauper had the
arm completely glued to the rihs, and that in this man the con-
necting parts M'ere  so  loose  that  they followed all  the move-
ments of  the limb.   If  such an adhesion  should be met with, it
would be  necessary to proceed as at the fold of the arm, provided
the scapulo-humeral articulation had not lost  the power of resum-
ing its motions.  If  it was a simple bridle, we ought to divide it
either from above downward,  or from below  upward, while an
assistant should hold it as tightly stretched as possible, by drawing
the elbow from the trunk.
   In  a patient  who  had the  arm and forearm thus glued to the 
SUB-CUTANEOUS BRIDLES.                  393
chest, in consequence  of  a burn, M. Aertz  (Eixyclograph. Bullet.
Med. Beige, 1836, p. 154.)  succeeded in  excising the bridles, and
afterwards in keeping the limb extended  upon a splint.
  The precautions to be taken would then be the same as in the divi-
sion of the  intra-digital partitions of which we have spoken above.
We should, moreover, take care to approximate the edges of the
wound on the thorax as  much as possible, by means of adhesive
straps, or even by the suture, if it should be found to be possible to
place them in immediate contact.  If the wound of the arm should
have more than an inch in M'idth, I am of opinion that we should
run the risk of gangrene  of its edges in endeavoring to narrow it
by force, (mecaniqusment) and that it M'ould be better to treat it by
simple dressing, and to favor the cure by second intention.  In other
respects, if the bridle was rather wide,  there M'ould  be an opportu-
nity, perhaps, to proceed  in a different manner.  For example, I
should pass, at distances of six lines from each other, a sufficient
number of  threads near its attachment to the arm; then I would
introduce, near the  axilla, the  point of a straight bistoury, which
might shave off this bridle from above downward, keeping at the
distance of three lines to the outside of the  threads, which latter
we should  then only have to tie into knots, to have, formed to our
hand, that number of stitches  of suture,  capable of uniting imme-
diately all this portion of the solution of  continuity.
  The wound being cured on the side of  the arm, would no longer
be exposed to a return of the adhesions,  though that on the chest
might continue for a long  time.  It is evident, also, if the thing
should appear more easy, that we ought to practise the suture upon
the thoracic wound in preference to the  other, the  object in such
cases being to close one of the wounds  immediately, in order to
prevent the surfaces from having it in their poM'er to become re-
attached.
  In case we could not immediately close  either of the two wounds,
it would be necessary to dress  the arm in  such  manner that it
could be kept constantly separate from the chest, and in a position
varying but little from that of a right-angle ; for at the axilla, as
at the fold of the arm, the  cicatrices have an extreme tendency to
re-establish  themselves, and to reunite  the parts whose separation
has occasioned so much pain.

                       § IV.—The Toes.

  Sub-cutaneous bridles are seen in the toes, the  same as in the
hand, but they are infinitely more rare.  They depend almost ahvays
upon a disease of the musculo-tendinous system. I have not, there-
fore, to speak of them in this place, as they Mall be treated of in the
chapter on tenotomy.  1 have many times met M'ith retraction of
the toes from morbid cicatrices on the dorsum of the foot.  A young
girl of twenty-seven years of  age, whom I operated upon in 1832,
in the hospital of La Pitie, by numerous incisions, was  perfectly
cured of them.  I have attempted, nothing in other cases.
                              50 
394
NEW ELEMENTS OF OPERATIVE  SURGERY.
                        § V.—The Legs.

  Morbid cicatrices may glue the leg to the posterior surface of the
thigh, in the same way as the forearm to the anterior surface of the
arm.  A woman had her two legs thus glued together at the age of
ten years, in consequence of a  chronic Pemphigus.  Having  died
without being operated upon, the case of this woman  induced M.
Champion (Correspondence Privee, 1838) to study the cause of such
retraction.  While  the dead body was yet  M'arm, this surgeon in
vain endeavored to extend the two legs.  Having adopted the  sug-
gestion of incising the aponeurosis M'hich separates the adductors
near the tibia, he  immediately found that the two  legs  could be
extended with great facility.
  This unnatural flexion of the leg may arise from a great variety
of causes, such as  pure and simple  cohesion, the inodular tissue,
sub-cutaneous bridles, and also from the more deep  retractions,
which I shall have occasion to speak  of  hereafter.
  Here, as at the forearm, the deformity may present two distinct
modifications—1. Where the adhesions  have their centre in the
hollow of the ham, and are extended from thence to a greater or less
distance upon the leg or the thign, as in the  case of M. Champion;
2.  Or, as  was remarked in  a new-born infant, spoken of by  De-
marque, (Opera  Citata, etc., p. 468,) where the calf had contracted
adhesions with the posterior part of the thigh, leaving the popliteal
space free.  Here the operation M'ould offer every possible prospect
of success.  It would even be unnecessary, after the  separation of
the parts, to hold the leg forcibly extended by means of apparatus.
In the first case, on the contrary, besides that the dissection would
be very delicate, in consequence of the tendons of the biceps, semi-
tendinosus,  semi-membranosus, sartorius,  and  gracilis, which it
would be  important to avoid, we should have, moreover, to contend
against  the tendency of the cicatrix  to  re-establish the abnormal
adhesions during the cure of the  wound.  It would also be neces-
sary to maintain the leg in a state of complete extension, by means
of a suitable apparatus, until the wound was perfectly cicatrized, and
to proceed, in other respects, in every precaution to be taken, in the
same manner that we have described for cases of retraction of the
forearm.  By means of the simple section of the bridle, M. Mouli-
nie (Bulletin Med. de Bordeaux, 1836—Arch. Gin. de Med., 3e  ser.,
t. i., p. 113) has thus succeeded in curing a  remarkable retraction
of the ham." It is evident, in conclusion, that, during the operation,
the  patient should lie upon his  belly,  in order that  an  assistant
may hold the upper part of  the thigh, and another moderately
stretch apart the leg from it, while the surgeon divides the unnatu-
ral bands and bridles.

                       § VL—The Thighs.

   Many facts prove that the  thighs  may be glued together upon
their inner surface  to a variable extent, and particularly towards 
SUB-CUTANEOUS BRIDLES.
395
their upper part.  The child of which M. Demarque speaks, (CEu-
vres, etc., p. 468,)  and which had the right calf glued against the
corresponding thigh,  presented, moreover, an adhesion of the two
thighs at their upper part, and to the extent of three inches. Though
difficult to  cure radically, this deformity, nevertheless, should it oc-
casion inconvenience or pain, should be subjected to an operation.
We  find in the thesis of M. Lelong (No. 179, Paris, 1819) an in-
stance of the union of the thighs at their upper part, M'hich existed
frem the age of eighteen months, had been occasioned" by a burn,
and  was operated upon successfully  at  the  age of twenty-three
years by Quesnault.  It would be necessary, in such cases, to place
the patient upon his side, and to see that we raise up one of his knees,
while the other should be held against the bed. The disunion hav-
ing been effected from below upwards, as far up as to the neigh-
borhood of the perinaeum,  should be kept open by the means  and
precautions I have pointed  out in speaking of  the liberation (decol-
lement) of the arm ; if the  state  of the parts permitted, M'e should
attempt immediate union of the wound, at  least upon one of the
thighs; otherwise, we should, in order to prevent a new aggluti-
nation of the parts, permanently retain in the upper angle of the
division some compresses, or adhesive straps—in fact, some foreign
body, until the end of the treatment.   This M'ould be  a case, also,
for borroM'ing flaps of skin, by dissecting them off in front and be-
hind in the neighborhood of the anus and scrotum, and uniting them
in the form of a commissure between the tM'o  thighs, as I have
recommended for the fingers.

              § VII.—Abdomen and Genital Organs.

   In the patient mentioned by M. Lelong, and M'hich  M'as one of
Quesnault's, there was, also, adhesion of the scrotum to the penis,
and  of the thighs to the  scrotum.  A careful  dissection of the
parts, and the delicate dressings, which the  results of such opera-
tions require, did not, however,  effect a complete cure.
   M. Champion has  communicated  to me the case of a child of
twelve years of age,  in M'hom the upper half of the left thigh  was
closely glued to the M-alls  of the abdomen  from the  age  of four
years, and  in consequence of a burn.   After having separated the
thigh by dissection, this surgeon united  the wound by first intention
in its three lower fourths, by borrowing teguments dissected off in
the neighborhood, and by making use of adhesive plasters, together
with several stitches of sutures.   The  inodular cicatrix of the re-
mainder  of the  wound  partially re-established the flexion of the
thigh upon  the belly, but did not occasion a sufficient degree of re-
traction to  prevent the patient from walking almost erect.  Having
practised the section of bridles in the groin, M. Nichet, (Arch. Gen.
de Med., 3e ser., t. i., p.  114,) in a case of this kind, immediately
covered (combla)  the  wound  by  a flap borrowed from the neigh-
borhood, by the French method,  and cured his patient.
  It is well to remark, nevertheless, that, in  trying to separate the 
396
NEW  ELEMENTS OF OPERATIVE SURGERY.
penis from the scrotum, it would be important to avoid the urethra
and the  corpora cavernosa on the one hand, and the dartos and
other envelopes  of the testicle on the other.   If wc had to isolate
the scrotum  only, there would be  less danger in inclining the bis-
toury towards the side of the thigh than in the other direction.  To
obtain a complete separation of the thigh itself, when it adheres to
the M'alls of the abdomen, M'e should never lose sight of the fact,
that we are in the neighborhood of the femoral  artery, its  corre-
sponding vein, and the saphena  interna.   The intimate cohesion
(fusion)  of the parts  in this neighborhood could not, consequently,
be destroyed, but by operations of a delicate and  sometimes even
very dangerous nature.
  The most suitable dressing, to prevent a new agglutination du-
ring the cicatrization  of the wounds, would consist of a long piece
of pasteboard, extending from the lumbar region to near the ham,
and fastened by  a body bandage  above the hips, and by a circular
bandage above the knee; in such manner,  that this latter bandage,
previously  saturated M'ith dextrine, should make some turns on the
trunk, to redescend by one or more crosses upon the outer surface
of the breech and thigh to above the knee. If we were treating the
penis, we should take  care to keep it raised up  by means of adhe-
sive plasters upon the forepart of the abdomen.  If it was the scro-
tum that we had detached, (decolle)  adhesive straps, passed cross-
wise very near the upper part of the thighs, would suffice to support
and hold it up.
  As respects the bending back (renversement) of the legs upon the
thighs, of the thigh upon the abdomen, and of the whole lower ex-
tremity, back, forward, or to  the outside, as I have seen  in  many
new-born infants, it is almost always the effect of another order of
lesions: it  is to  diseases of the articulations or tendons that these
deformities must generally be attributed.

                      § VIII.—The Trunk.

  In no place do cicatrices and abnormal bridles so often produce
deformities as in the head. It is to these that M'e must refer almost
all the varieties of ectropion, the  greater part of deviations and co-
arctations, whether of the nose, lips, or ears ; but, as it will be ne-
cessary to return to this, in treating of anaplasty and other opera-
tions that are performed upon these different parts, I will say noth-
ing of them at present.

                    A. Bridles of the Neck.

  Burns of the neck sometimes cause a depression of the lower jaw
towards  the  sternum, as in the patient of whom Rideau speaks,
(Legons,  These, No. 179, Paris, 1819, p. 26,)  and sometimes an in-
clination of the  head  sidewise towards one or the other shoulder.
These deviations, which exist to a great extent, and of which frequent
examples are met with in practice, are generally of very difficult
cure.  A patient, mentioned by M. Lelong, (Ibid., p. 27,) was thus 
SUB-CUTANEOUS  BRIDLES.
397
bridled from the temporal extremity of the eyelids down to the fin-
gers of the left hand.  Some journals of medicine (L'Abeille Medi-
cate, t. iii., p. 454) described, about ten years since, a case as having
had a successful  issue after operations performed for this species
of deformity; but the patient, who was then a child, and whom a
great  many persons, as well as myself, saw at the hospital of La
Pitie, was never cured.  It would, in  such cases, be necessary to
divide transversely, by numerous  incisions, all  the cutaneous  or
sub-cutaneous bridles. Then, to prevent all new retraction, to have
the chin held up by a species of leather strap, (courroie,) or cord,
(lac) fastened firmly to a leather bonnet, which should also be at-
tached above and behind to an  inflexible upright, (tige) which
should be fastened  to the lumbar  region by means of a  cincture,
(Mellet, Manuel Pratique d'Orthop., p.  98.)  The upright having a
hinge and a spring at its upper part, M'ould also permit of the head
being moved and held, either backward,  or to  the right or the
left, a little deviated  from its  natural  direction, until the  cica-
trization of the wounds of the operation should  have acquired  all
its required solidity  and consistence.  The difficulty in these cases
arises from  the necessity in M'hich the patients are  placed of fre-
quently lowering the jaw, the feebleness of the forces provided to
raise up this bone by its  middle part  and the weight  which natu-
rally draws the head forwards.  If, therefore, it should not be found
possible to save the  skin of the chin, M'e should have little chance
of success, unless by covering immediately, by means of anaplasty,
all the wounds with flaps of skin borrowed from the  neighboring
regions.
  The bridles and adhesions upon the side of the neck are infinitely
less unyielding to surgery than those which we have just spoken
of.   After having divided them on many points, and to sufficient
depth, all that is necessary to prevent their reproduction, is, in fact,
to keep the  head held up, and then inclined in an opposite direction,
by means of a dividing bandage for the neck.  This bandage, which
could be rendered immoveable and very solid by connecting it  with
pasteboard, and then saturating it with dextrine, would have the
advantage of producing infinitely  less fatigue to the patient  than
the machine of M. Mellet.

            B.  Cohesion of Parts,  (Fusion des Parties.)

  Under this title, I cannot record any fact or operation in relation
to cicatrices and  abnormal bridles, which  has been the object  of
the slightest attempt at surgical relief.  Nevertheless, there exists
a species of deformity which is worthy of occupying our attention
a moment upon this occasion;  I mean diplogeneses.   These  mon-
strous associations,  which are  all congenital, and  which in my
opinion are  almost  always  produced  by the abnormal and  pro-
longed contact of tM'o  foetuses during the  period of intra-uterine
life, should be ranged in two great classes, in their relations to  ope-
rative surgery.   If there is  a close cohesion of the two beings by 
398
NEW ELEMENTS OF OPERATIVE SURGERY.
some important organ, it would  be dangerous, and in  some cases
criminal, to attempt to destroy it.  When there exist, for example,
two heads for one trunk, hvo arms or a single  one for each head,
and M'hen the two beings possess also a distinct chest, or that they
have only one for both, as Mas seen in Ritta-Clni-tina, the surgeon
M'ho should wish to meddle M'ith them would be culpable.  In ani-
mals the head is  the individual; and in man it Mould be as cruel
to remove one of  the heads of a bicephalous monster, in the view
of preserving the other, as it M'ould be to assassinate a new-born
infant.
  If, on the contrary, there existed four loM'er limbs, or some cohe-
sion of the lower half of the body,  M'ith a single chest and a single
head, moral obligations would not  be violated in attempting to de-
stroy the  supernumerary par's; but  then  the operation in itself
would be too dangerous for us to venture upon.
  In fine, as often  as the  two  bodies should be  united in  such
manner that the  cohesion  involved the  skeleton, whether on the
dorsal or sternal regions, or on the sides and pelvis, we should have
nothing to do M'ith it.  In all other cases, we may discuss the ques-
tion, v.hether it is prudent to separate the individuals  from  one
another ; M'e may here suppose a number of cases :
  1. Where the foetuses are born united by the cranium, either ver-
tex with vertex, or by the  forehead, or occiput, or  on  the sides;
then we should proscribe all manner of division if the cohesion  is
large and extends  to the bones.   If  its extent was small, or involved
only the integuments, we should not hesitate, I think, to destroy  it
by the  cutting  instrument.  If it  should be left  undisturbed, the
two beings would almost inevitably perish, without taking into the
account that if they live, their existence must be  a charge upon
society, and a misfortune for themselves.   By the operation, on the
contrary, we have many chances of restoring them to liberty.
  2. When the foetuses are united  by the anterior surface or their
posterior surface.   The dorsal and the sternal union should not be
declared incurable, unless it should extend deeper than the  thick-
ness of the integuments, and comprise a great extent of surface.
At the abdomen, also, we should shrink from an operation, if there
should appear to exist  the least communication  between the vis-
cera and between the peritoneum of the two individuals.  Other-
wise, that is to say, if the thoracic  or abdominal cavity is perfectly
independent in each of the two beings; if, as we  have seen in the
two young Siamese, the parts are  not united but by a large bridle
or cutaneous growth, (plaque) they may be separated.   The ope-
ration would, in such cases, be performed in the manner I have
described in speaking of adhesions of the arm to the chest, of the
fingers with one another, and those of the upper part of the thighs.
This, moreover, is not a mere suggestion.  Sue relates (Histoire des
Accouchemens, t.  ii., p. 251) that  Fatio had thus  operated  and
effected a cure, at Bale, in 1752,  in the case of two foetuses united
at the epigastrium.   This kind of operation has rarely been put in
practice up to the present  time  ; 1. Because most of the foetuses 
            ALTERATIONS OF THE TENDONS OR  MUSCLES.         399

thus formed die soon after their birth, if they do not die before the
termination of the labor;  2. Because those M'ho continue to  live,
contract such a habit from their position, that they feel no need of
changing  it; 3. Because, if they attain the age of reason,  they
almost always refuse every attempt having for its object their sepa-
ration ;  4.  Because many parents use these  monstrous beings for
objects of public curiosity and sources of gain.  For these reasons,
therefore, and in order that the operation may be the less danger-
ous, M'e  should perform it as soon as possible, and in general in the
first months after birth.
  3. When a foetus, or a portion of foetus, is as it Mere implanted
into a child otherwise well- formed.  When it concerns only a fin-
ger, leg. arm, or in fact a portion of limb, no one should oppose its
entire removal.  But if the  second foetus is implanted  upon the
head, chest, or belly, the case is more serious, and practitioners are
not agreed.  On the supposition that the pelvis, a  part of the ab-
domen,  and the lower limbs, should be appended to the sternum or
umbilicus of a living individual, as is related of a case  published
some years since, (Isidore Geoffroy  Saint  Hilaire;  Histoire des
Anomalies  de  I'Organisation dans I'Homme  et les Animaux, Paris,
1832-1 $30, 3 vol., in-8vo, fig.,) we might attempt its extirpation,
if a careful examination satisfied us that the other portion of the
supernumerary foetus did not project (proemine)  into  the splanch-
nic  cavities, and  if  the operation would not make  too  large a
M'ound.  It is, moreover, evident that none of these disunions and
extirpations can  be submitted to any special rule, and that it is
for the surgeon to  choose, in each case, the mode of operation which
suits the best.
                         CHAPTER IH.

DEFORMITIES FROM ALTERATION OF THE TENDONS OR MUSCLES.

  The deformities M'hich may result from an unnatural state of
the muscles or tendons are referrible to the division, adhesions, and
accidental retractions of these tissues, (organes.)

                Section I.—Accidental Divisions.

  The muscles and  tendons cannot be divided Mdthout producing
some disturbance in the locomotive actions.  The accidental divi-
sion  of the tendons, hoM'ever, should more frequently call the atten-
tion  of surgeons to this subject than that of the muscles.  I shall,
therefore, occupy myself in this place almost exclusively with what
concerns the division of tendons, persuaded that the reader will
apply without difficulty what I shall say of them, to wounds of the
muscles. 
400
NEW  ELEMENTS OF OPERATrVE SURGERY.
                Article I.—Tendons in General.

   All the tendons of the body, in fact, may be divided, either by
external violence, gangrene, or ulceration.   It is only those of the
limbs, however, and some of those of the neck or abdomen, which
can require the aid of operative surgery.

                  § I.—Pathological Anatomy.

   When an extensor tendon  is completely divided, the antagonist
muscle  unavoidably draws the part  into a  state of flexion.   The
disease  may then be compared to a  kind of paralysis.  If it were
to take  place with certain flexor tendons, the limb, on the contrary.
would remain in extension.
   The  division  of the  tendons  is followed by  a process, (travail)
which differs according as there exists at the same  time a wound
in the skin, or that  the  process takes place protected from contact
with the air.

                   A.  In Contact with the Air.

   If the solution of continuity is at the bottom of an ulcer or a
wound, the two ends of the  tendon  remain  for a long time pale,
.like an inert substance, (tige;) ultimately,  however, they become
vascular, and covered M'ith  reddish granulations.  These granula-
tions, M'hich encroach at the same time upon the surrounding cellu-
lar fibres, (feuillets) are the point of departure and the termination
of a vegetation, which results in filling up in part the void M'hich the
extremities of the ruptured tendon leave between them.  Here, then,
the solution of continuity is cicatrized by second intention ; cellular
tissue,  aponeurosis, vessels, sub-cutaneous  tissue, and tendons, are
all finally blended together in a single mass, which itself contracts
intimate  adhesions with the skin in the neighborhood.  It is this
which is observed, when, in consequence of gangrene, large ulcers,
and long-protracted suppuration, there has  ensued  an exfoliation
of tendons  at the bottom of the wound. In this case, the mobility
and play (glissement)  of the principal  organ cannot  take  place
 without communicating the same degree of motion to all the other
tissues  with which it has become associated.
   When the division of a tendon, notwithstanding it is hidden un-
der the integuments, and that the external wound has united, is fol-
 lowed  by purulent inflammation, there results from it the same
 process, and consequently the same dangers.  In that event, hov/ever.
 it is possible that the suppuration may be confined to the sheath of
the tendon, and to some few of the surrounding tissues, (lames;)
 and that after  the cure, the skin, and the  muscles and tendons,
 more  or less perfectly retain the  independent use and  play of
 their movements.  In  these two orders  of cases, as is readily per-
 ceived, it is next to impossible that the  disease, left to itself, would
 allow of a complete restoration of  the  functions of the wounded
 organ. 
ALTERATIONS of the tendons or muscles.          401
              B.  Protected from Contact with the Air.

   If the tendon is ruptured under the skin, or divided without any
 inflammation supervening, we must expect results of a totally dif-
 ferent nature, but which vary, according as the two ends of the
 tendon are kept in contact or remain apart.   The agglutination of
 the tendon is effected either by first intention if  the contact  is
 perfectly exact, or, in the  contrary case, through the  medium of a
 plastic matter, which, at first soft and gelatinous, (gelatiniforme)
 soon assumes a lamellar and  fibrous  appearance.  Blendino-  itself
 M'ith the tendon, this  material is converted  into a  sort of Ikernel,
 (noyau) or node, (nodus) which itself rarely fails to disappear at
 the expiration of some weeks or months.  Being neither stretched
 out, nor soldered (sonde)  to  the  surrounding  tissues, the tendon
 thus soon  recovers  all its primitive  power  and mobility.  When
 there is a separation of several lines  betM'een  the two ends,  there
 occasionally takes place in that part an effusion of blood, of fibrine,
 or of plastic lymph.   This effusion often becomes organized. Its
 liquid  and  coloring matters are gradually absorbed; the fibrine and
 plastic lymph harden as they become cemented to the two ends of
 the tendon, which they envelop in the manner  of a ferule, (virole.)
 Afterwards, becoming transformed  into fleshy  tissue, (se carnifiant
 ensuite)  we  may recognise, on the tenth or twelfth  day, an ap-
 pearance of fibres, or of a substance like felt, (feutrage) and an
 elasticity which continues to increase.   The  final  result is, that
 there is formed from this a portion of new tendon, which appears
 to have been created there for the purpose of giving greater length
 to the  old tendon.   It  may readily be conceived, that from this pe-
 riod a  part of the functions of the wounded tendon will be restored,
 but that its excess  of length will  not readily permit it to resume
 entirely all the power  it possessed in its normal state.
   When, with the separation which I have mentioned, the union of
 the teguments M'ith the cellular tissue at the bottom of the division
 has been effected before the effusion has taken place, and without
 any inflammation, the  tM'o ends of the tendon, if they are very far
 apart,  cicatrize separately, each one in its place, and remain with-
 out the new uniting medium, (sans lien nouveau) and as if  they
 were lost in the cellular tissue ; the action of the  corresponding
 muscles is,  in this case, completely destroyed.
   The  knowledge of this process (travail) shows, at once, what we
 have a right to expect, and what it  is  proper to do, when the conti-
 nuity of a tendon has been interrupted.

                        § II.—Treatment.

  Two classes of means are  placed at the  disposition of the sur-
geon to remedy the division of the tendons—position,  aided by ban-
dages,  and  the suture.  With this  is connected a question which
has always divided surgeons—should we. or should we not, practise
the suture of the tendons ?
                              51 
402
NEW ELEMENTS OF OPERATIVE  SURGERY.
  Confounding all the white tissues under the title of nerves, the
ancients considered  that  a wound of the tendons  was extremely
formidable, and that it exposed to convulsions, tetanus, and death.
So Galen, M'ho seems to allude to the suture of tendons, is far from
formally extolling it, whatever Guy de Chauliac  may say of it
(Edit, de Joubert, p. 263,  Rouen, 1649,)  and M'ho,  in venturing to
reject the doctrine which, according to him, had been falsely attrib-
uted to Galen, was  severely reproved for it by many of his suc-
cessors.  It  was  useless for Guy (Traict III., doct. 1, chap, iv.) to
invoke the authority of Avicenna, Lanfranc, and G. de Salicet, and
then to  add, that  he had " seen and heard it said, that in many per-
sons the cut nerves and tendons had been  so well restored by su-
tures and other remedies, that  no one would have afterwards sup-
posed that they had been divided,"  for he did not change the prac-
tice of his cotemporaries.  To change this opinion, it was necessary
to prove that the tendons, aponeuroses, and serous membranes, were
endowed only M'ith a feeble sensibility.   It is what Haller endeav-
ored to show, and M'hat  Castel (20 Janvier, 1753, These de Haller,
trad, franc., in 12, t. iii., p. 280-382) was especially desirous of de-
monstrating by a variety of experiments.  Other experimenters and
practitioners (Bagieu, Examen de Plus. Parties de la Chir., p. 575)
have, nevertheless, maintained, with the ancients, that the tendons
enjoyed an  acute sensibility, and that the  wounding of them  ex-
posed to serious dangers.
  Some casual observations, that  have  been,  from time to time,
made in favor of suture of the tendons, have finally awakened  the
attention of modern surgeons to this important subject.  Pare, who
limits himself  (Livre XXIIL, chap. 10) to the recommendation of
machines to restore* the actions of  divided tendons, relates, also,
(Livre XXV., chap. 17, p. 773,) the case  of a suture of the tM'o ten-
dons of the ham, performed with complete success by Tessier.  M.
A. Severin (Chir. Efficace, chap. 120, livre ii.) has no hesitation in
recommending it. Marchetis, (Collect, de Bonet, t. iii., p. 260,) who
accuses Severin  of having imperfectly  comprehended Galen and
Pare, in vain opposed the  suture of tendons, for it did not prevent
Verduc (Operat.  de Chir.,  p. 256) from extolling it, and describing
in detail the process that the Surgeon Bienaise then employed for
performing  it.  We may also see in Heister (Institut. Chir., vol. ii.,
p. 1087, cap. 172) the enumeration of the surgeons who, up to that
time, had declared themselves for or against the suture of the ten-
 dons.   Gauthier had noticed a case of this kind, which he  related
 to Wepfer,  (Ephemerides des Curieux de la Nature, 1688, ou  Collect.
 Acad.,  t. vii.,  p. 524 ;) De La Motte, (Traits de Chir., ed. Sabatier,
 t. ii., p. 162,) Balthasar, (Ancien Jour, de Med., t. lxviii., p. 142,)  and
 a great number of other  practitioners, also relate examples of it.
 [Notwithstanding these facts, the question still remains undecided.—
 T.] M. Barthelemey, (Jour. Hebd., t. ii., p. 222,) justifying himself by
 the practice of M. Larrey, published some cases of cures effected
 by  suture  of the tendons.  If the experiments which M.  Acher
 made, (These, No. 112, Paris, 1834,)  and the facts he has gathered 
ALTERATIONS OF THE TENDONS OR MUSCLES.          403
in the practice of M. Gensoul, confirm the opinion of M. Bienaise
and of Guy de Chauliac, we see M. Rognetta, (Arch. Gen. de Med.,
2e serie, t. iv., p. 206-215,)  on the other  hand, asserting that the
suture of the tendons is  useless and dangerous ;  so that, to recon-
cile all parties, M. Mondiere (Arch. Gen. de Med., 3e serie, t. ii., p.
57) considers that  it is sometimes useful, rarely indispensable, and
very often of no value.
  In my opinion, this question, examined in a proper point of view,
is less difficult to solve than one would at first sight suppose.  One
indisputable  fact is this:  the  more completely in contact the ends
of a divided tendon are, the more  prospect is there of restoring it
perfectly to its functions.  All  that we  have to ascertain, therefore,
is, whether  the suture will fulfil  this indication better than any
other remedy.
  At the time of Pare, surgeons believed  so  little in the union of
divided tendons, that,  in  speaking of  a noble  personage, who,  in
consequence of a wound of  the tendons, wished to have his thumb
amputated, this author  found nothing better to sooth him, not  to
cure him, as M. Mondiere thinks, (Arch. Gen. de Med., 3e serie, t. ii.,
p. 59,) than the employment of an apparatus which  enabled  him
to straighten or bend in a slight degree the wounded finger.
  An observation of Marchetis, that of Martin of Bordeaux,  and
that of Mareschal, (Arch. Gen. de Med^ 3e serie, t. ii.,) show, on the
other  hand, that the surgeons of the seventeenth  and eighteenth
centuries had, at that time, made actual cures by means of position
and bandages. The rupture of the tendo-Achillis, of which Monroe
had seen sixteen cases, (Journ. d& Chir., par Desault, t.  ii., p. 50-
64,) the instances  of this  kind which are related by Bagieu, (Exa-
men de Plus. Part, de la Chir., p. 461,) Thiebault, (Jour, de Desault,
t. ii.,  p. 268,) and  Mothe, (Mel. de Med. et de Chir., 1812,)  a fact
recorded in the practice of A. Petit, {Ancien Jour, de Med., t. xliii.,)
and the facts related by MM. Rognetta (Arch. Gen. de Med., 2e ser.,
t. iv.,  p. 206-215) and Mondiere (Ibid., 3e serie, t. ii., p. 61) are not
less conclusive.  I have myself seen many cases of wounded ten-
dons, among which was a sausage-maker's boy, (gargon charcutier)
who had had the middle and ring fingers almost entirely severed ;
also a young batcher, who had a simple wound in the fore and
middle fingers, and both of whom recovered the perfect movement
of the parts, though I bad employed in their cases no other means
than position and bandages. Another case occurred in the hospital
of La Charite, in August,  1838.  The extensor tendons of the fore-
finger had been completely divided.  Bandages only were employed
to unite the wound, and the  cure was effected at the expiration of
twenty days.  Nothing of all this, however, positively proves that
ihe union of the tendons has been effected by the actual contact of
the ends of the division; everything, on the other hand, demon-
strates that there is a sort of  bridle formed in these cases, a new
production, which extends from one end of the division to the other,
like a band added to the original length of the tendon itself. It is
thus that the continuity of the parts is re-established, not only after 
404           NEW ELEMENTS OF OPERATIVE SURGERY.

the rupture of tendons which are acted upon by powerful muscles,
but also after the fracture of certain bones, as, for example, the pa-
tella and olecranon.
  The experiments made in our times, and the examples of sections
of tendons with the view of remedying deformities, have, moreover,
most  abundantly proved, that  the substance which  is formed be-
tween the tM'o ends of a divided tendon  in no respect destroys its
action.
  It follows, hence, that the operations which should be performed
in cases of accidental division of the tendons should vary, according
to the different circumstances—1. According  as there is, or is not,
at the same time, a wound of the skin; 2.  According as it is, or is
not,  possible  to  obtain  a perfect contact  by means of bandages;
3. Aceoiding as the tendon, either from the position  it occupies, or
the functions it performs, has need or not of being replaced exactly
in its primitive position.
  That class of divisions of the tendons, which is not accompanied
with  Mounds of the integuments, almost wholly forbids the  use of
the suture.  We should  not, at  least, allow ourselves to think of
an operation in suc\> cases until after having vainly attempted re-
lief by position and bandages.  In  regions where the delicacy and
multiplicity of the movements are  not the principal functions, the
suture is equally unnecessary.  A separation of half an inch, or
even an  inch, would not hinder the  triceps or biceps from extending
or bending the forearm.   I ha.ve often seen a separation of one,
two, or even four fingers' width, from a  transverse fracture of the
patella, together M'ith rupture of the ligament of the patella, or of
the  tendon of the rectus  femoris,  produce only a slight inconve-
nience in the movement of the leg. In the  hand and wrist, wounds
of this kind exact a little more attention.  In these cases, however,
as well as in others, if, by means of a position properly chosen, we
can  oblige the ends of the tendons to touch each other, we can dis-
pense with the  suture.   In the contrary  case, the suture is an ope-
ration which would be formally indicated.  [Dr. Mott does not ap-
prove of stitching tendons ; you might as well  wire bones.  Posi-
tion, in his view, is every thing.—T.]
   Compared to position and bandages, however, the suture of the
tendons  has inconveniences  and advantages which the surgeon
 should' carefully weigh.   We may reproach him  for introducing
 into  the wound a substance necessarily extraneous, and of thus
 rendering it  impossible to effect  a cure by the first  intention; but
 by this remedy the contact of the ends of the tendons is made more
 perfect than by means of bandages, and the patient is not confined
 to any position, or  to any fatiguing compression.  Dispensing with
 the  suture, we  may  immediately close  the wound  of the integu-
 ments, and obtain a cure without suppuration, but the union of the
 tendon is not immediate ; whereas, though the  suture almost una-
 voidably causes suppuration,  and requires more time for the exter-
 nal cicatrization, it gives, as a compensation, a  direct union of the
 tendinous cord.  We thus perceive, therefore, what are the cases 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         405

in which we should be at liberty to resort to one of these methods
in preference to the other.

                         A.  Position.

  When we have recourse to position and bandages, we must first
place the part of the wounded limb in a state of complete exten-
sion, if it is the extensor tendons, and in  a moderate degree of
flexion, if it is the flexor tendons, and then proceed immediately to
the union of the wound, either by adhesive plasters,  or by the su-
ture.  There is some advantage in conforming, in such cases, to the
precept  of M. Champion, who recommends that we should, if pos-
sible, make the two ends of the tendon ride a little over each other,
(chevaucher)   It is also important, as this practitioner has shown,
that the bandage should make but little pressure opposite to the
solution of continuity, that it may not tend to displace the extremi-
ties of the tendon which we wish to unite.  The most convenient
position having been given to the limb, we  immediately apply a
roller bandage, taking care to commence at the origin (racine) of
the muscle, and to act upon the parts in such manner as if to draw
them towards the wound. It is often serviceable to associate splints
of wood or  pasteboard, or troughs straight or  bent,  with the rest
of the dressing, in order to give it  greater steadiness.  The obser-
vations  of modern orthopedists have proved, that, in order to cure
the division of  a tendon without any intermediate substance, it  is
necessary to keep their ends in contact, (i-approches) at least during
twelve  to fifteen days.   We  should, therefore, guard against pre-
maturely making the least movement of the part.   We should not,
therefore, lay the bandage aside until after the  fifteenth or twenti-
eth day, it being understood that the hardest  portions of the dress-
ing shall have been taken away at the tenth or twelfth day.   We
then proceed to make gentle and gradually increasing movements
of flexion and  extension of the wounded tendon.  The other pre-
cautions are the same here as in the cases of stiffness, which suc-
ceeds to diseases of the joints.

                        B.  The Suture.

  When we have decided in favor of the suture, it may be advan-
tageous to enlarge and equalize the wound of the tendon.  Ordina-
rily we find the lower end of this cord above the lower lip of the
division of the  skin; the  other end, on the contrary, retracted by
the action of the muscles, is raised to a considerable distance be-
neath the integuments.  If the wound is recent, and by  a cutting
instrument, we may insert the suture without previously cutting it
smooth, (sans avivement prealable.)   [Dr. Mott would not  touch it.
—T] If the wound has existed for some days, and is accompanied
by laceration (ecrasement) and contusion, it would be  more prudent
to cut off the ends of the tendon, in order that we may have a fresh
wound to unite.
I 
406
NEW  ELEMENTS OF OPERATIVE SURGERY.
  It is possible, moreover, that the wound of the integuments may
have completely cicatrized, or that there has never been any.  If,
as  Severin and Verduc  have advised, and as Petit has  practised,
(Mondiere, Archiv. Gen. de Med., 3e serie, t. ii..) we should, in a case
like this, M'ish to insert a suture, it  would be necessary to divide
the integuments, to bring the ends of the  ruptured tendon together,
and cut  them off smooth, and afterwards to proceed as in the two
preceding cases.  As to determining  whether it  is better to follow
the process of Bienaise than that of any other,  it is a question of
but little importance ; we may succeed  with all the  modes. For
seizing the tendon, I prefer the hook-forceps (pinces a crochet) \o
the ordinary forceps ;  I begin with the lower end rather than M'ith
the upper;  I use small  spear-shaped needles, slightly curved at
their point,  in  place of the  ordinary semi-circular needles, and I
substitute the common thread for  all  those of a special character.
  If the  tendon has not more than two lines of breadth,  one stitch
of suture suffices ;  and I insert it at the distance of from two to
three  lines from each end of the division.  Two stitches would be
requisite for  every tendon of three  lines of transverse  diameter.
We would only apply three, or a greater number  of them, when op-
erating upon one of the largest  tendons of the muscular system. It
is advisable that each stitch should embrace the entire thickness of
the two ends of the tendon.  The simple suture, also, is here prefera-
ble to  the twisted.  After having placed a  sufficient number of
ligatures, M'e cut one of the tM'o threads of each  very near its knot,
the same as after ligatures upon arteries ; each  remaining thread
is then brought out by the shortest direction to the skin, the wound
in which latter is then united as  accurately as possible.   Nothing
is afterwards required but a simple dressing and an immoveable
position,  to allow nature to agglutinate the parts.
  In the  suture to tendons, the threads generally  detach themselves
very slowly, since they cannot come off until after having divided
the densest fibrous tissue  of the animal economy.  It  is important,
however, not to make any traction upon them, but to leave them
to separate of themselves, or, as it were, spontaneously.
  In a case where it was impossible to bring together, end to end,
the two portions of the same tendon, Missa (Gazette Salutaire, 1770,
No. 21) adopted the plan of attaching the upper one to the edge
of the neighboring  tendon.  Two muscles were  thus charged with
the duty of moving the same finger.  M.  Champion writes me that
he  proceeded  in the same way, after the exsection of the  fourth
metacarpal bone.  We shall see, in  treating of  suture of the ten-
dons of the fingers, in what cases it M'ould be advisable to adopt
this mode.
  In respect to the subsequent treatment, also, we must proceed
after the suture, as after  the attempts to unite by bandages or  the
simple position. 
ALTERATIONS OF THE TENDONS OR MUSCLES.         407
               Article II.—Tendons in Particular.

                 § I.—Tendons of the Fingers.

  In order that the functions of the fingers may be preserved, it is
necessary that their tendons should neither be elongated nor short-
ened, nor more nor less adherent than in their natural state.  There
is, therefore, no room here  for hesitation ; we should, when they
have been accidentally divided, do all in our power to re-establish
their continuity.  Formerly, surgeons contended that the partial
section of the tendons exposed to accidents as serious as the partial
section of the nerves.  Wagert (Observ. de Med. et Chir., p. 211) re-
lates that, in 1717, there was a great discussion, with the view to
determine whether, in a case where the last three flexor tendons
of the fingers had been half divided by the cut of a sword, the sec-
tion should be completed  or  not.  But since that  epoch, Chabert
(Observ. de Chirurg. Prat.,  p. 215) has related the case of a partial
section of the extensor tendon of the  fore-finger, which recovered,
like the case of Wagert, though the complete division had not been
performed.  M. Champion  and a great number of modern surgeons
have made the same observation.  I myself have more than twenty
times seen  partially divided tendons gradually reacquire all their
functions, and  I have  never observed any accidents that could be
imputed to the undivided state of a portion of their fibres. Though
ever so few, therefore, remain, we ought  to preserve  them with
scrupulous care ; for, were it but a few filaments, these answer as
substitutes for the  suture and bandages, and to enable  the  plastic
lymph or modified cellular tissue to fill up in a very short time the
notch  in the  division.   If, therefore, the tendons of the fingers are
only incompletely divided,  we  should not  have  recourse either to
the suture  or  to fatiguing bandages ;  all that would be required
would be, to keep  the finger in  a state of immobility from ten to
fifteen days.  In case the division of the wounded tendon should be
complete, we should proceed in a different manner, according as it
related to the extensor or to the flexor tendons.

                      A. Extensor Tendons.

   Whether the division takes place on the dorsum of the metacar-
pus, or upon the fingers, it nevertheless includes  in it, sometimes
the tendon or tendons  of one finger only, sometimes the tendons of
several fingers at the  same time.  Here, more than in other cases,
it is necessary to obtain as exact a reunion as possible.
   I Position.  By means of the position only, Mareschal cured  a
soldier whose extensor tendons of the four fingers had been divided
 by the cut of a sickle, (Mondiere, Arch. Gen de Med  3e serie, t n.,
p  60.)   It was in the fingers, also, that Heister (De Sutura Tendinis
in Manibus, $c.; Institut.  de Chirurg., vol. ii., p. 1087, caput 472)
has seen take place  a  union of the tendons without the aid of  a 
408           NEW ELEMENTS OF OPERATIVE SURGERY.

suture.  In the work of Mothe (Med. de Med. et Chir., Paris, 1812,
t. i., p. 813)  we find the case of a section of two extensor tendons
of the fore-finger that got well in the same manner.   I have men-
tioned above a similar fact, observed by me at La Charite, in 1838.
A. Petit (Anc. Journal de Med. t. xliii., p. 449)  gives  the case  of
three  of the  extensor tendons of the fingers which were completely
reunited in ten days by the aid of simple bandages.  Similar facts
are detailed in the journal of Desault.   Many of the cases of Bar-
thelemey,  Acher, and Rognetta, and the two cases recently pub-
lished by M. Mondiere, are additional examples of this kind.
  When the solution of continuity exists in several tendons, Lc
Dran  (Consult. Chirurg., p.  357) recommends that we should make
use of a trough, (gouttiere) with a  hinge (brisee)  near the wrist.
Another gutter, more  complicated, had  already been proposed by
Arnaud, (Garengeot, t. iii., p. 260,) and M. Champion  informs me,
that he has succeeded very well with  a palette of tin without a
hinge, but which inclined the wrist and fingers backward as much
as was desired.
  If it were the  tendons of the thumb, as in the patient spoken
of by  A. Pare, it would be necessary, after having surrounded this
finger with a layer of roller bandage and some turns of spica, to place
on its palmar surface  a  small  splint of pasteboard, M'hich  should
reach to the root of the hypothenar eminence, and which should be
fastened by one or two more layers of the roller bandage.  In this
manner the thumb would be maintained in a permanent state of
extension, and in the most perfect immobility, Mdthout  the rest of
the hand or other fingers experiencing any inconvenience from it.
For the fore-finger we should also apply a layer of roller bandage
fixed by one or two turns on the wrist, as is done for each finger in
the application of the gauntlet.  A splint of pasteboard, extended
backward to the thenar eminence, should then be  applied,  and
fixed upon its palmar surface, in the  manner I have just described
in speaking of the thumb.   It is evident that we  should proceed
after the same rules  if  we were treating the middle, the ring, or
the little finger.   The essential point is not to  confine all the fin-
gers, because there is a wound in only one of them.  It is impor-
tant, nevertheless, for greater  security, to hold them all in a state
of immobility during a certain time, though there may be only one
of them wounded ; in the four last fingers, especially, it would be
difficult to communicate  motion to those that were sound, without
involving  to some extent the metacarpal bone of the finger whose
agglutination we were desirous of effecting.
   An exceedingly easy and secure  mode of dressing, consists in
placing the  roller bandage  of each finger  in such manner as to
leave the seat of the wounded region uncovered, then to besmear
the surface of this first layer of bandage with a solution of dextrine,
then  to place on the splint  of pasteboard saturated with the same
matter, and finally a second layer of roller bandage, also saturated
with  dextrine.  We have  in  this way an immoveable  dressing,
which does not prevent our examining  and dressing the wound of 
             ALTERATIONS OF THE TENDONS OR MUSCLES.          409

 the integuments and tendon as often as we desire.  When several
 tendons are divided at the same time, it is generally better to sub-
 stitute the palettes or large splines in place of the separate tongued
 splints, of which I have just  been speaking.   On the  supposition
 that the wound was upon the fingers themselves, it would be better
 to make use of a palette with perfectly distinct digitations, than of
.a splint or one entire sole. This foreign body, which is placed on the
 palmar surface of  the forearm, wrist, hand, and fingers,  should
 always be separated from the skin by some folds  of linen or turns
 of bandage.  As the extension requires in such cases to be carried
 beyond the axis of the limb, the ordinary palettes  and splints  of
 wood would require fillings, which  in the gutter  of Le Dran and
 the splint of M. Champion are advantageously dispensed with.  But
 I substitute, for all these  objects, palettes or pasteboard softened
 with a solution of dextrine, and fastened on by means of a bandage
 saturated with the same liquid.  We obtain thus  an immoveable
 bandage, which we may bend at  pleasure,  and  mould exactly
 upon the  elevations and depressions of the region  until  it has com-
 pletely dried.
  II.  Suture.  If the patient is intractable, and especially if we are
 treating a wound accompanied M'ith laceration, and upon the back
 of the fingers, the suture would offer more security than the simple
 position.   The  surgeon Mainard  made use of it successfully to
 unite the tendons of the fingers that had been divided by a knife,
 (Moinichen, lib. iv., p. 123.)   M. Mondiere quotes from Baster the
 history of a young peasant, who had the  tendon of the supinator-
 longus divided, and which this surgeon cured by means of a single
 stitch of  the suture.  We find, also, in Delaisse, (Observ. de Chir.,
 p. 148,) a case of suture of the extensor tendons of the thumb ; that
 of Balthasar (Ancien Journal de Midec, t. Ixviii.,  p.  142) was  a
 case of suture of the extensor tendon of the fore-finger.  We see,
 also, in the thesis of M. Acher, that the fortunate  results  obtained
 by M. Gensoul  also relate  to the extensor tendons of  the fingers.
 The operation would present but very little difficulty in  this region,
 the tendons there being covered only by pliant skin, and having for
 their  foundation a solid plane.  The thread should be  passed first
 through the digital end of the tendon, (which is at the same  time
 the least  sensitive and  the easiest to seize,) then through the mus-
 cular end, previously disengaged  and  drawn out by means  of a
 hook  forceps.  It M'ould suffice, afterwards, to keep the hand and
 fingers gently extended upon a common palette, or, better still,  on a
 long piece of pasteboard, fastened  by  a  bandage saturated with
 dextrine,  in  such  manner as  to allow, when necessary, the points
 occupied by the suture, to be uncovered Mdthout in any manner de-
 ranging the rest of the dressing.  M. Robert de Chaumont (Com. Pri-
 vee de M. Champion) having to treat a division of the tendons, ac-
 companied with considerable retraction, nevertheless succeeded in
 effecting, by means of the suture, as I have already stated, the cure
 of his patient, without leaving any deformity.
  If, contrary to all expectation, it  should happen that we could
                               52 
410
NEW  ELEMENTS OF OPERATIVE SURGERY.
not join  the  tM'o ends of the divided tendon, perhaps it. would be
better, rather than attempt  nothing, to imitate Mis.sa, and to sew
the upper end to the neighboring tendon, and the lower end to the
tendon along side of it.   We see, in fact, in the case of Missa, that
it'Mas the tendon of the middle finger; that  the muscular pordon
of this tendon was united to the tendon of the fore-finger, and the
digital portion to the tendon of the ring linger; so M'ell that the mus-
cles of this last could be used for the motions of the wounded linger.
We may still more easily comprehend the utility of attaching the
tendon of a finger which has been amputated to one of the collat-
eral tendons,  after the manner that M. Champion adopted after the
exsection of the  fourth bone of the metacarpus.  It is certain, how-
ever,  that  this  connecting together  (accollemenl) of tendons can
rarely be required, or, I may add, be  advantageous, on the dorsal
region of the fingers or hand.

                       B. Flexor Tendons.

  The section, rupture, or division  of the flexor tendons of  the
fingers, is infinitely less common than that of their extensors; it
is, at  the same  time, much more serious.  It  is, in almost every
case, in fact,  complicated with  division of the  nerves, arteries, or
some  other important parts; and m hether it takes place on  the
palm  of the hand, or on the forepart of the fingers themselves, it is
frequently followed by an inflammation, M'hich may be  attended
with most serious consequences. The resources  M'hich art borrows
from operative  surgery to remedy this species of injury, are here,
also, position  and the suture.
  The suture in these cases has not the same  advantages as for the
extensor tendons. It is easy, in fact, to perceive  that, in addition to the
difficulties of the operation, the suture of the flexor tendons, whether
in their sheath, (coulisse) or in the palm of the hand, M'ould also incur
the risk  of propagating inflammation or suppuration towards the
wrist  and fore-arm by means of the  synovial membranes, (toiles)
There would, also, almost inevitably result from it such expensive
adhesions as to interfere with the play of the tendon.  It appears,
however, that it has occasionally been performed with success. In
Gautier's case, for example, the suture  was applied to the flexor
tendons.   It was the  same, also, in the old soldier whom M. Blan-
din mentions, (Diet, de  Med. et  de Chirurg. Prat., t. xiii., p. 234.)
There are, however,  but  a  very small number of such cases ; it
must  also be  added, that some of them relate much more to the ten-
dons of the wrist than to those of the  fiagers.
  Simple position, on the  contrary, succeeds in this region with its
usual effectual results.  In a patient of Warner, (Observ. de Chir.,
trad,  francaise, p.  179,)  the flexion of the hand, and pressure made
from  above downwards upon the forearm, alloM'ed the flexor ten-
dons, which had been divided by a piece of glass, to resume their
functions.  Martin relates (Ancien Journ. de  Med., t. xxiii., p. 555)
that a woman, who had the flexor tendons of the fingers and wrist 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         411

divided by the cut of a sabre, was  perfectly cured in three weeks
by means of simple position.   In the first volume of the Melanges
of Mothe there is a similar case, in relation to the flexor tendons
of the ring and little fingers.  I have myself several times seen the
entire section of one or more of the  flexor tendons of the fingers fol-
lowed by an exact reunion of the divided ends, solely by means of
the position of the  parts.  In truth, flexion is, to a certain extent,
the normal position of the fingers of the hand.  It is, then, quite nat-
ural that this flexion, methodically sustained, should suffice to re-
place the two extremities of the tendon in contact.  There is, also,
an anatomical arrangement in these parts which is entirely to the
advantage of position and bandages.  I allude to the kind of fibro-
sy no vial  sheath  (etui)  which resists every deviation of the flexor
tendon, before as  well as after its  division; a sheath  which, it is
true, does not exist  in so perfect a state in the palm of  the hand,
but is replaced in that part by an aponeurosis  or muscular masses,
which still, however, possesse  the power of restricting the tendons
to a very limited space.
  Consequently, the suture would not be indicated upon the palmar
surface of the fingers  or of the hand, except  where  the divided
tendon projected into the interior of the wound, or where its ends,
disengaged  from  their  sheath, exhibited too great  a  tendency to
separate from each other, and that  it should appear next  to impos-
sible to cure the wound without suppuration.
  As to the  position and dressing, we may proceed in two ways—
1. After  having approximated and united the lips of the wound,
and  properly flexed  the wrist and  fingers, the hand is to be filled
with lint and compresses.  The M'hole is then  fixed in this position
by means of a roller bandage, surrounding a dorsal splint, and a
cushion,  M'hich are prolonged to the extremity of the metacarpus.
2. We then  mould upon the dorsal surface of the forearm, wrist,
and fingers,  a piece of wet pasteboard, curved into a semi-circular
shape below, and maintained by means of a bandage saturated with
dextrine.  We thus obtain an immoveable bandage, which, leaving
the wound uncovered, alloM's also of our dressing it  separately, at
such time and in such  manner as M'e wish.  Being moulded upon
the parts, the layer of pasteboard causes no inconvenience scarcely,
and furnishes to the  parts a support which they do not find either
in splints or in pieces of wood or metal.
  If one finger only M'ere wounded, there would be  an advantage
in keeping that one only flexed, so much the  greater because the
extension of the others would rather draw down than cause a re-
traction of the upper end of the divided tendon.
  Moreover, we must not  forget that the flexor tendons of the fin-
gers, surrounded by synovial membranes, or close fibrous sheaths,
lose a great part of their mobility as soon as they contract the least
adhesion with the surrounding tissues, and that, if the wound, of
which their  division constitutes one  portion, should pass to the state
of purulent  inflammation, they would rarely reacquire the  perfect
integrity of their functions. 
412
NEW ELEMENTS OF OPERATIVE SURGERY.
                   § II.—Tendons of the Hand.

  The muscles which move the hand, without extending to the fin-
gers, are on the forepart—the flexor carpi ulnaris, the palmaris lon-
gus, and flexor carpi radialis ; and on the back part, the  extensor
carpi  ulnaris, the extensor carpi radialis longior, and  the  extensor
carpi  radialis  brevior.  It  is evident that, if the tendons of these
muscles should be divided, the power of flexion or extension of the
wrist  would be  greatly enfeebled.  Nevertheless, there is not on
record a known instance of paralysis of the hand solely imputable
to the division (interruption) of these tendons.   This is so true, that
no one has scarcely ever suggested for them the application of the
suture.  We find, however, by  a case of Gautier,  (Archiv Gen.
3e serie, t. ii., p. 57,) that  this operation was performed with suc-
cess  in a patient who had had the flexor tendons of the carpus
completely divided.  Job. Baster,  cited by M. Mondiere,  (Ephem.
Curios. Nat., 1688,)  speaks, also, even of a case of division of the
tendon of the supinator longus, which was treated by suture.  But
to some facts which might be adduced of this kind, we could op-
pose a great number of others which attest the success obtained by
the simple position or bandages.   In the case of Warner, (Observ.
de Chir., etc., p. 179, trad.,) for example, all the flexor tendons of
the carpus had been divided at the same time with those of the
flexors of the fingers. I have cured in the same way—1. Two men,
who had had the tendon of the flexor carpi ulnaris divided ; 2. Sev-
eral patients, in whom the tendons of  the flexor carpi radialis and
palmaris longus  had  been divided,  together with  some of the
other  flexors ;  3. The  same thing  has  occurred to me with the ex-
tensor carpi radialis longior, the extensor carpi radialis brevior, and
the extensor carpi ulnaris.  These are a kind of wounds so frequent
that it would be impossible to enumerate them.
  A great number of reasons unite here to  forbid the use of the su-
ture.   In respect to the supinator longus, it would be, I should sup-
pose,  an entirely superfluous precaution;  for, if this tendon should
attach  itself  (cclldt-il) at an inch higher up the radius, it would
still  act upon the  forearm full as M'ell.   Nor is the action of the
flexor carpi radialis and of the palmaris longus sufficiently important
in their detailed movements to  make it necessary to devote any
particular care to restoringthemtoaperfect condition.   The flexor
ulnaris muscle, being  fleshy to near the wrist, retracts itself but
very little; the same, nearly, may be said of the extensor carpi ul-
naris.  Whether these tendons are a little longer or a little shorter,
or draw the hand inwards a little more or a little less forcibly, is a
matter of very  trivial moment.   The same must be said  of the
extensor carpi radialis longior and brevior, which, being held  in a
sort of fibrous sheath on the postero-external face of the radius, are
thus prevented from deviating either backward or forwards.   The
reasons stated, therefore, when  speaking of the flexor tendons of
the fingers, could be those  alone which would justify the suture of
the flexor tendons of the hand. 
ALTERATIONS OF THE TENDONS OR MUSCLES.         413
   A bandage, whose solid part, in order to leave some freedom to
 the fingers, does not go beyond the level of the metacarpo-phalan-
 geal articulation, is sufficient for keeping the hand in a convenient
 position.   If we are treating the flexor tendons—that is to say, the
 flexor carpi ulnaris, the flexor carpi radialis, and the palmaris lon-
 gus—the pasteboard splint, placed behind, will  conveniently raise
 up the hand and wrist into a state of flexion. In the case of the sec-
 tion of the extensors,  it is necessary  to place the splint on the op-
 posite surface of the limb, to raise up  the metacarpus in a state of
 extension.  This pasteboard should be fixed on the  radial side of
 the forearm and hand, if the section was that of the adductor ten-
 dons—that is to say, of the tendons of  the flexor carpi ulnaris, or
 of the extensor  carpi ulnaris only; finally, it should be placed  on
 the inner side, if the section was that of the extensor carpi radialis
 longior, or of both  the extensor carpi  radialis longior and the bre-
 vior.   With the  immoveable dressing, we should have, in these dif-
 ferent cases, to leave a  space opposite the wound, in order to be
 able to examine M'hat  is passing, and to  watch the process of cica-
 trization, without incurring the risk of disturbing the position which
 it has  been thought proper to give to the parts in the beginning.

                   ^ III.—Tendons of the Elbow.

   In the humero-cubital  region there  are, in  reality, but two ten-
 dons M'hich can, when divided, claim the aid of  operative surgery:
 they are the tendon of the biceps in front, and the tendon of the
 triceps behind.

                    A. Tendon of the  Biceps.

   Destruction by ulceration or gangrene, a rupture purely mechan-
 ical, and a division by external violence, may occur  in the  tendon
 of the biceps. As this muscle is the principal flexor of the forearm,
 it is natural to  suppose, that  the solution of the continuity of  its
 tendon M'ould produce in this part a manifest difficulty.  Being iso-
 lated from  the  radius to the scapula,  and detached near its lower
 extremity, the biceps muscle M'ould seem, moreover, calculated to
 undergo a considerable degree of letraction at its humero-cubital ex-
 tremity.  We must, then, regard its division as a very serious matter.
 and endeavor to remedy it as perfectly as possible. Experience, never-
 theless, tends to  show that it is less serious than one would at first
 suppose.  Haller, citing Molinelli, speaks of a patient who, having
 for a long time a retraction of the forearm, broke the tendon of the
 biceps by a sudden extension, felt at the same moment a cracking
 noise accompanied  M'ith pains, and soon  after found himself com-
 pletely cured.
   We  find  in the  Bibliotheque of Planque, a case related by
Granier and requoted by Lafaye, (Dionys. Optr., t. ii., p. 681,) the
result of which was, that  the  section of the tendon of the  biceps
did not prevent the  movements of the arm and forearm from being
restored after the cure of the wound.. 
414
NEW  ELEMENTS OF OPERATIVE SURGERY.
  Among the facts which I could adduce in support of the observa-
tions of Granier and Molinelli, I will confine myself to the follow-
ing.   A young printer came to the hospital of La, Charite, in 1836,
for a large  contused wound, M'hich had divided not only the skin,
but the aponeurosis, and the M'hole of the biceps, and even a part
of the brachialis-anticus,  immediately above the  articulation.   I
took upon myself to say. that if this young man got well Mdthout an
amputation, he would at least remain incapable of flexing the lore-
arm.  I was in this point  deceived;  the cure took  place, and the
movements of the limb Mere almost perfectly restored.
  We may, therefore, be  permitted  to say, that solutions of con-
tinuity in the biceps do not inevitably lead to a loss of the  move-
ments of flexion at the elbow.  These movements are  preserved
after wounds of this  kind, both by  the  action of the brachialis-
anticus, and by the re-establishment of the continuity, either me-
diate or immediate, of the divided tendon.
  The course to  be  pursued,  under  such circumstances,  varies
according to the  simple or complicated nature of  the wound.   If
the wound is large, if the two extremities of the tendon  are easily
seized, and if there is a hope of obtaining a direct agglutination,
the suture ought to be applied.  The simple position might suffice to
bring the two extremities of the tendon in a line M'ith each other,
but it M'ould not suffice to keep them in contact without any devia-
tion during the time necessary for their adhesion.   In other cases,
that is to say, when, cither in consequence of the conditions in M'hich
the wound itself  is found, or for any reason M'hatever, the direct
union appears  next to impossible, it is better to have recourse to
the use of bandages, which ought, moreover, to be associated with
the suture, when it is judged advisable to  employ it.
  The bandages required  in cases where there is a section of the
tendon of the biceps at the bottom of a wound, should keep the
forearm  in  supination, and the  flexion at a right-angle, M'hile it
prevents every kind of movement in the articulation of the elbow,
during the  period of treatment.  I make this dressing without any
difficulty by means of a long bandage saturated M'ith dextrine, and
a piece of  pasteboard behind, which extends from the shoulder to
the wrist.  A course (plan) of roller bandage is first applied to the
skin; the pasteboard splint comes next, then the dextrine bandage,
to make a second, or even a  third circular layer.  The  whole
should leave an opening  opposite the M'ound,  that is to  say, in
front of the  articulation.   If it  should be found necessary to  in-
crease either the flexion  or extension  of  the forearm, it  would be
sufficient to moisten the bandage opposite the elbow ; then leaving
it afterwards to dry, it would be enabled  to reassume all its immo-
bility.

             B. Tendon of the Triceps, and Olecranon.

   At the elbow, the tendon of the  triceps is  liable to  the same
lesions as  that of the biceps.  Only one  example, and  that very 
ALTERATIONS OF THE TENDONS OR MUSCLES.
415
doubtful, (M. A. Severin, Med. Efficace, Bibliot. de Bonet, p. 593,) is
recorded of its rupture or section; its wounds, in fact, have, up to
the present  time, generally been passed over in silence.  In the
place, however, of rupture of the tendon of the  triceps, science
furnishes numerous cases of fracture of the olecranon.  But these
fractures, also, which have so much attracted the attention of prac-
titioners, and which are accompanied  with a separation of  from
two to fifteen or eighteen lines, do not destroy the extension of the
forearm, even when they are not submitted to any course of treat-
ment.   The case of a woman, M'ho, in  consequence of a fracture
of this kind, had the olecranon for six years drawn up  more  than
an inch from the ulna, without suspecting it, or experiencing any
sensible inconvenience in the movements  of the limb, emboldened
me to leave many fractures  of this  kind without dressing; and I
ought to say, that they have appeared to  me to recover more rap-
idly and more perfectly than those that have been treated with the
most ingeniously devised bandages.  Every thing shows that the
division of the triceps ought not to lead us to form too unfavorable
a prognosis.  Either by the aid of the suture or of simple position,
we could effect its union, either direct or indirect, and so perfectly,
that the function of the forearm would be scarcely in the least de-
gree impaired.
   If the wound was smooth,  or by a  cutting instrument, the suture
would be preferable to bandages.  We should proportion the  num-
ber of the stitches to the  width of  the divided tendon, that is, it ,
would require from three to six, according to the age or muscular
development of the individual.  It would be advisable, also, that
the stitches of the  suture  should include  only two-thirds or three-
fourths of each  end of the tendon.
   Supposing that the wound should be contused, and  the suture
seemed impracticable, or of too difficult application,  we should
then place  the  limb  in  a  state of moderate extension, by means
of a roller bandage, and a long splint of pasteboard, adjusted  upon
the anterior surface  of the  arm and forearm,  the whole  having
been saturated with dextrine, and so  arranged as to leave an open-
ing (fenetre) opposite the wound.  It is obvious  that this wound
should be treated, moreover, by the knoM'n uniting means, and that
the roller bandage should press down  the soft  parts  towards the
elbow as much as possible.
   For a fracture of the  olecranon, indeed, it would be  necessary,
in order to prevent the retraction of  the fragment, to slip between
the bandage and the upper fragment  some pieces of linen, in fact, a
graduated compress, to crowd it downward towards the ulna; but
this compress would be extremely injurious if we were  treating a
division exclusively of the tendon of  the triceps.
   In the case of rupture of the extensor or flexor tendon of the
forearm, we must, as in rupture of  the tendons  of the wrist and
fingers, be  prepared in due time to  encounter a stiffness (roideur)
in the neighboring articulations.  If the  cicatrization appears to
progress regularly, we  commence at the  twelfth  or fifteenth day 
416
NEW  ELEMENTS OF OPERATIVE SURGERY.
to moisten the bandage a little opposite to the joint.  Eight days
after, we need have no fear of increasing the motions a little more;
and the dressing is finally removed before the end of the month. From
this time we are to take the same precautions as if we were treating
a fracture whose  callus was not completely consolidated.
  We  ought,  perhaps, to say a word here of the section of  the
muscles of the axilla and shoulder, and more especially of the ten-
dons of the pectoralis-major  and pectoralis-minor ; but it has never
yet  come to my knowledge  that any one has proposed to  perform
the  slightest operation on them, with the view of re-establishing
their continuity.  I will remark  only, that those tM'o muscles have
been very often divided, either to allow of the axillary artery being
tied, or for the extirpation of certain tumors; and that in patients
who have survived  these serious  operations, it has not been  ob-
served that  the movements of the arm were perceptibly changed.
In the only case  of this kind which I have had an opportunity of
seeing, an intermediate substance, a kind of fibro-cellular mem-
brane of great thickness, which had restored the continuity of  the
two divided muscles, explained to me how  the arm had lost nothing
of its power.  No doubt  the same thing would take place in  the
deltoid, if it should happen  to be cut through  a great  part of its
breadth.

                  § IV.—Tendons of the  Foot.

  The extent, variety, and  importance of the movements of the
fingers, make an important distinction between them and those of
the  toes.  So also has the  division  of the tendons of the  foot  oc-
cupied  the  attention  of practitioners infinitely less  than those
of the  fingers. Admitting that the  solution  of continuity of the
extensor tendons  of the toes should render it  impossible to raise
those appendages at will, we do not perceive, therefore, that this
would  thereby be attended with so  much inconvenience as to re-
quire any great precautions, or an operation that is at all difficult.
It would suffice, then, in case of a wound  of this nature, to confine
ourselves to containing and uniting bandages, without recurring
to either a suture or any fatiguing extension.
  I should say the same, also, of the flexor tendons, whose entire
division, however, appears to be a  very  rare occurrence.  Here,
moreover, the indication would  be,  to keep the toe or toes corre-
sponding to the wounded tendons as strongly flexed as possible.
Having a great tendency to turn back upon the dorsum of the foot,
they might,  Mdthout  this  precaution, be injuriously drawn in this
direction by the antagonist extensors.

            A. Tendons of the Tarsus and Metatarsus.

  . We find about  the lower-part  of the leg the tendons of the three
peronei muscles,  the tibialis-anticus, the  tibialis-posticus, and the
tendo-Achillis, besides those  which extend to the toes. 
            ALTERATIONS OF THE TENDONS ORjMUSCLES.         417

  I.  The Anterior Tendons.  If the tendon of the  tibialis-anticus
only was cut, perhaps there would result from it but little  incon-
venience to the movements of the foot;  but if there should exist
at the same time  a division of the extensors of the toes, we  should
have to fear the loss of movement in the flexion of the tarsus, and
consequently the  formation of a pes equinus, [a variety of club-
foot.—7'.]
  Surgery has consequently a part to play here.   If the conditions
of the wound  permitted it, we should apply the suture to the divi-
ded  tendons.  Supposing,  unfortunately, that some articulation
should have been laid open by the same blow, it would, in order to
avoid suppuration M'ith greater certainty, be much better to confine
ourselves to  the  employment  of bandages.   The bandage  could
then consist of a sort of stirrup, (etrier) fastened by any  contri-
vance whatever to the neighborhood  of the knee.  That  which
offers the greatest security, and at the same time the greatest solid-
ity, is the roller bandage saturated with  dextrine, especially if we
take the precaution to insert between  its layers (entre ses plans) a
wide and long strip  of moistened  pasteboard.   After leaving  an
opening on  the instep, and keeping  the  foot forcibly raised up  by
means of a loop of bandage, until the dextrine is consolidated, there
is nothing more to attend  to.
  II. Tendons of the Peronei.   The section of the peroneus-tertius
would require the same treatment  as  that of the tibialis-anticus;
except that it  is far from having the same importance, and it would
be important to raise up the foot at its  outer edge at the same time
with the extension, while with the tibialis-anticus it is directly the
reverse.
   Tendons of the Peroneus-Longus and Peroneus-Brevis.  Concealed
as it were behind the external malleolus, and enclosed there in a
kind of fibro-synovial groove, the severing of these tendons must
necessarily be a rare occurrence.  Their division would inevitably
cause the turning of the  foot inward,  and would put this part of
the limb in the same state as if there were a paralysis of the outer
muscles of the leg.  This occurred in a case which I saw:  one of the
tendons had been completely divided, andthe other was half torn
off by large broken fragments of a vase  of Delft ware.  The foot,
strongly turned inM'ard, could no longer  be brought to its natural
direction by the will of the patient.  We should apply to this divi-
sion, also, what I have said of the tibialis-anticus; we should make
use  of the suture, if the ends of the tendons, though visible, do not
.appear  disposed to put themselves in contact by the aid of position,
and provided  the wound  be sufficiently smooth to leave scarcely
any thing to apprehend from suppuration.  The position only should
be reserved for the other cases.  We should have so much the less
motive  for the employment of the suture,  from  the fact that even
with an intermediary cord, the continuity of these' tendons would
be sufficiently well established to restore to the foot  afterwards  all
its required force and agility.  In a patient I attended, and  who is"
a distinguished physician  of Paris, I confined myself to applying a
                              53 
418           NEW <£LEMENTS OF OPERATIVE SURGERY.
suture to the integuments, to keeping the foot in abduction, and to
subduing the inflammatory symptoms ; and although some purulent
collections were formed, and the skin seemed  to contract adhesions
with the subjacent parts, the foot, nevertheless, regained its power
and natural mobility.
  The dressings  in these cases would require only a slight modifi-
cation.  The opening should be left on the outer part instead of in
front; the pasteboard splint should be on the inner side in place of
behind; a large cord, fastened between the turns of the roller band-
age, on  the inner  side, and passing in  form of a bridle under the
sole of the foot, M'ould serve to raise the outer edge of this member,
by being fixed to the outer surface of the knee.
  III.  Posterior Tendons.   The tibialis-posticus and the flexors of
the toes, in the event of being divided, should  be  subjected to the
same  rules of treatment as those which I have just described, ex-
cept that it would be more difficult to apply the suture to them ; so
that position, associated  with bandages, would, of themselves, be
generally quite sufficerrt.

                     B.  The Tendo-Achillis.

  A solution of the continuity of the tendo-Achillis has  always
seemed  a very serious  matter.   Desport  (Traite des Plaies par
Armes a feu, p. 166 ; Bagieu, Examen., SfC, p. 463) relates, that, but
for Mery and Thibault, amputation of the leg would have been per-
formed, at the Hotel-Dieu, upon a patient who had had this tendon
divided, and who, moreover, recovered perfectly without the neces-
sity of this mutilation.  The solutions of continuity of this tendon
have  also  been  regarded in various points  of view;  some facts,
for example, lead  to the  supposition that its incomplete divisions
expose  to  more  dangers than those  that  are complete.  Moli-
nelli  speaks of an  individual who, having  a  partial  division  of
the tendo-Achillis, caused by the  cut of a  scythe, was  seized with
a violent fever, pains, and delirium, from which no relief could be
obtained but by completing the section of the wounded tendon.
  In  another patient, in whom the tendo-Achillis M'as almost en-
tirely divided, who was  tormented with pains and by a  violent
tension, the symptoms were  arrested by excising a portion of the
tendon  of the plantaris, which was found in the form of a fold at
the bottom of the wound, (Mem. de I'Acad,  de Bologne, t. ii.,  ou
Supp. a la Trad. d'Heister.)   Clement of Avignon (Heister, ibid., p.
135) relates the case of an individual who, after having the tendo»
Achillis cut three quarters through, was seized with inflammation,
gangrene,  and a kind of hydrophobia, but in whom these  symp-
toms  suddenly ceased as soon as the remainder of the tendon was
divided.
   We should, nevertheless, be wrong in concluding, from examples
of this kind, that the surgeon should always terminate the divisions
begun in  the tendo-Achillis.  If it be true, that some  of the fila-
ments of this tendon may transmit the inflammation and pain both 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         419

above and below, when they are found at the bottom  of a large
purulent wound, it is also true, that they must frequently serve as
a point d'appui for the deposite of the new material  which is soon
to re-establish the  continuity of the parts.   A man has tM'o-thirds
of the thickness of the tendo-Achillis removed by the kick of a horse.
The wound, an inch  and a half M'ide, is cleansed, purified, granu-
lates (se comble) and cicatrizes,  and the patient is completely cured
at the end of a month.  In any case, however, the tendo-Achillis,
when once ruptured, merits all the  attention  of the practitioner;
for it cannot be denied that,  in some cases  at least, its rupture
might involve a severe infirmity.   In a patient thus wounded by
the cut of a scythe, the reunion did not take place, and walking
was  utterly impossible, when  M.  Syme, (Arch. Gen. de  Med., 3e
serie, t. i., p. 112,) who relates the case, undertook its cure.
  Bandages and sutures have often been made trial  of to prevent
the dangerous consequences which might  result from the section
of the tendo-Achillis.  In  two cases of Molinelli, as in that of
Clement, the cure  was complete, and, nevertheless, bandages only
were used to effect it.  In another case, (Collect. Acad., t. x.; Mem.
de VAcad.  de Bologne, t. ii.,) the tendo-Achillis, though entirely cut
through, and  indurated  and tumefied  at  its inferior  extremity,
was  redissected at two different times in the direction of the os
calcis, (calcaneum) without the cure being thereby impeded.  The
heel, which was at first drawn  upward, ultimately, in fact, became
depressed.   The following three facts are still  more conclusive, but
resemble each other so  much  that  the  question  might  very natu-
rally be asked, if they do not  relate to the same patient, though
recorded by three  different authors.  One is found in the disserta-
tion of Behr, (De Tendinis-Achillis Soluti Sanatione, Halle,  1765 ;) it
relates to a  man aged forty years, mIio had the tendo-Achillis divi-
ded,  from the  blasting of a rock.  When the  tendon  itself was
pinched, the patient was not sensible of it, but  complained severely
as soon as the sheath of this fibrous cord was touched.  The suture
was not applied, and the wound M'as found filled up  at the expira-
tion of six weeks. The patient, who was exceedingly intractable, as it
appears, ruptured his tendon anew; incisions were made to evacu-
ate the effused blood, and the reunion took place still more promptly
than on the  first occasion.  Care was then taken against a return,
by fastening the heel to the side of the knee by means of a leather
strap, (Gaz. Salutaire, 4 Dec, 1766, No. 49.)  The  second of these
facts  is related by Juvet, (Journal de Med., Mars, 1760, ou Bibliot.
de Planque, t. x., in-4°, p. 867.)  An officer of the horse  grenadiers
had the tendo-Achillis divided by a basin of Delft ware which broke
under his foot.   At the end of  six weeks the union appeared com-
plete.  An imprudent effort to disengage the foot from beneath the
rounds of a chair, reproduced the disease.   A separation of more
than an inch took place between the ends of the tendon.  Treated a
second time, and without the suture, the wound got well as at first,
leaving, however, a sort of ganglion, of the size of a small nut, on
the very place where the rupture of the tendon had been. In the 
420
NEW  ELEMENTS OF OPERATIVE SURGERY.
third case, related by Herice, (Mid. Eclairee par les Scienc. Phys.,
t. ii.,) there Mas a divided tendo-Ichillis, which cicatrized with the
aid of bandages alone, which again became  ruptured, and  was
reunited anew by means of the same treatment.
  If it is certainly true that these  three facts relate really to three
different persons, they prove indisputably that the section  of the
tendo-Achillis is far from  always  requiring the suture.   Lieutaud
d'Arles, (Bibliot. de Planque, t. x., in-4°, p. 870,) also, relates the case
of a patient  M'ho had the tendo-Achillis divided  by a ploughshare,
and  in  whom  the  cure Mas effected by simple bandages.   The
same thing took place in a man of whom Beson  (Desault, Journ. de
Chir., t. ii., p. 50) speaks, and in M'hom the tendo-Achillis had been
divided by a  saMr.
  We see, moreover, by the cases that Desault refers to, and by a
multitude of  other facts, that the  tendo-Achillis,  after its divisions,
may generally resume its functions M'ithout the intervention of a
suture.  According to what Dupouy says, (Desault, Jour, de Chirur.,
t. ii., p.  60,) Pibrac had often seen the rupture  of the tendo-Achillis
recover by rest alone.   Gauthier, (Ibid., pp.  60, 61,) who rejects
bandages, gives  two facts in support of the  doctrine of Dupouy.
Rodbard, (Ibid., p. 62,)  convinced that the reunion is, in these cases,
effected by the deposite of a new material, had no apprehension from
walking the day after it occurred.  Another patient, treated in the
same manner, recovered as well as he did.
  One of  the most conclusive proofs in favor of this assertion is the
fact communicated to Garengeot (Traite d'Oper., t. iii., p. 267, 2* ed.)
by Poncelet: There was a fracture of the os calcis ; it was thought
necessary to  open a deposite of blood which was  connected with
it;  the surgeon cut the tendo-Achillis above, and removed its infe-
rior extremity,  with the moveable fragment of the os calcis; the
patient got Avell without any deformity.   The  suture, nevertheless,
deserves to be still retained in some cases of solution of continuity
of'this  tendon.  Coste (Garengeot, t. iii., p. 266)  had  long since
practised  it several times with success.  A case of the same kind is
related by CoM'per, (Philos. Trans., 1699, No. 252, ou Bib. de Planque,
t. x., m-4°, p. 864.)  In the article  of Desault (Journ. de  Chir., t. ii.,
p. 54)  there is also  a case of reunion of the tendo-Achillis obtained
by suture.  There is to be found  another case in the report of the
Hotel-Dieu of  Lyons for 1822.
  Recapitulation. In conclusion, the functions of the tendo-Achillis
are too important to make it prudent, where it  is divided and easily
seized at the bottom of a wound, to rely alone upon position and
bandages.  There is no doubt that, where there exists a contused
wound and bruised tissues, and a  large surface in suppuration, we
should be satisfied  M'ith bandages and  dispense with the suture;
but should the wound be recent, and still free of inflammation, and
resemble wounds from a cutting instrument, and present the possi-
bility of bringing the ends  of the tendon in  contact, the  suture
merits the preference.
   To apply the suture here, it is necessary to have needles that are 
ALTERATIONS OF THE TENDONS OR MUSCLES.          421
very sharp and strong, because of the firmness of the tendon. Also,
it is better to use single than double threads.   However fine may
be the stitches of this suture, we have  scarcely any reason to fear
their cutting through the parts embraced by them.  Three, four, or
six stitches may be required in these cases. As with the* fingers, and
the other tendons in general, it is better to keep one extremity of
these threads outside, and  to await its  separation.  We clean and
then unite the wound in a proper manner, before putting the limb
in the position it requires to be kept in  until  the termination of the
treatment.  This position, which is the same  as where we dispense
with the suture, has for its object  to relax the  muscles of the calf.
The machines  contrived for  this  purpose, whether those of J. L.
Petit, (Acad, des Sciences,  annee 1722, ou Bibliot. de Planque, t. x.,
p. 852,) or of Monro,  (Jour, de Desault, t. ii., p. 52,) appear to me
to be utterly useless.  The observations of Rodbard, Dupouy, &c,
above referred to, prove even that they would be injurious.
  If the immobility of the knee and the flexion of the leg were in-
dispensable, nothing would better answer for this purpose than a
long splint of pasteboard, moulded on the forepart of  the thigh,
knee, leg, and foot, and enclosed in a roller bandage, M'hich, without
compressing the limb, would  confine it in the position in which it
would be desirable to maintain it  during the whole course of the
treatment.  But when we use  the suture, this position  is entirely
superfluous, and when we do not use it, a few lines, more or less,
between the two ends of the tendon is a matter of too little conse-
quence for the discreet surgeon to incommode his patient  on this
account.   The ordinary roller bandage, extended from the roots of
the toes to below the knee, and made  more secure in  front by a
large splint of pasteboard  moistened, will be sufficient in such cases.
A band, in the form of a strap, under the sole of the foot, and fast-
ened near the ham,  keeps the heel raised  up until the bandage,
saturated with dextrine, has become thoroughly dried.  An open-
ing, expressly reserved, alloM's the wound to  be dressed separately,
and the whole occasions but very little inconvenience.
  If we were  treating  a fracture of the os calcis, this bandage
would require no other modifications than the addition of a gradu-
ated compress, analogous  to that  which I have spoken of in treat-
ing of the  olecranon, and which should be fixed above the heel.
  The ordinary rupture  of the tendo-Achillis would do equally well
with the same dressing.   It would be sufficient, then, in order  to
have a perfect bandage, to leave no opening, and to place no grad-
uated compress between  the turns; a long splint of pasteboard,
moreover, could be  applied upon the posterior surface  of  the leg
and the plantar surface of the foot.
  In place of leaving the  foot immoveable in this position  for two
months, as many writers recommend, it is proper, in the  division of
the tendo-Achillis, whether complicated or not with wcunds of the
integuments, that we should discard the immoveable dressings and
extensor apparatus  towards the end of the  second week, in order
from that time to impart gradually more and more extended move- 
422
NEW ELEMENTS OF OPERATIVE  SURGERY.
ments to the parts.   For a long time I have used with such of my
patients  as  have been affected with rupture of the tendo-Achillis
no other treatment than this.

            § V.—Tendons of the Femoro-Tibial region.

  The solution of continuity of the fibrous prolongations, that are
destined  to move the leg, should be examined,both, at the ham and
knee.
                    A. Tendons of the Ham.

  The projections that these make behind in certain  positions of
the leg sufficiently show, that the biceps, on the outer side, and the
sartorius, and gracilis, and semi-tendinosus, on the inside, may be
reached and divided in certain wounds of the popliteal region.  I
have found no case in authors of solution of continuity of the ten-
don of the biceps, properly so called.  It  is not so with the tendons
which form the inner border of the ham.   Two facts, at least, prove
that the division of these tendons does  not involve an irremediable
loss of the motions of the knee, when treated by simple position and
the suture.
  A member of the  ancient academy of surgery, Boucher, (Mem. de
VAcad. Royale de Chir., in-8°, edit. 1819, t. ii., p. 205,) relates the
history of a wound from firearms, which included two orders of
flexors in the  leg, and M'hich, in spite  of destruction of parts sus-
tained by the condyle of the femur, nevertheless allowed of the per-
fect restoration of the movements of flexion at the knee.
  Pare (CEuvres Completes, 9e edit., 1633, in-fol., p. 773) relates the
folloM'ing fact, as among strange things, (choses  elranges)  Etienne
Tessier,  says  he, a  master barber-surgeon,  has  told me that  he
dressed  Charles Verignel, for a wound which  he had in his right
calf, with complete incision of two of the tendons which flex the
leg.  He  sewed these two  tendons  together, end to end, and treated
his patient so well that the wound consolidated perfectly.
  It may be conceived that, in a region  like this, the suture could
not be attempted,  unless  it should appear easy to reach and ap-
proximate together the two  extremities of the  divided tendon.
This suture would be so much the more necessary, as the tendons
of the ham retract, in general, to a great distance  in the direction
of the thigh.  If, however, it should not seem prudent or practica-
ble to apply it, we should  have no great  reason to regret it,  seeing
that the divided tendons, ultimately becoming attached to the mus-
cles which  remain fixed  upon  the tibia, would, in fact, make use
of these last to transmit their action to below the knee.  The best
position of the limb, in such cases, is that which keeps the leg in a
state of flexion and the thigh in a state of extension.

                     B.  Tendon of the Knee.
   The extensor muscles of the leg, arriving at the knee, all unite
together to form one single tendon. Interrupted by the patella, this 
             ALTERATIONS OF THE TENDONS  OR  MUSCLES.         423

tendon, which is more especially the termination of the rectus fe-
moris, is inserted, as we know, upon the  tubercle  of the tibia, after
having taken the name of the inferior ligament of the patella.
   We may thus comprehend how it may be divided in three differ-
ent regions—that is, above and below the knee, and also on a line
with  its articulation.  These three different kinds of solution of
continuity are, moreover, represented by the transverse fractures of
the patella, by the ruptures of the sub-patellar ligament, and, by the
solulions of continuity of the tendon of the  rectus femoris.
   Whether viewed in its ensemble, or in one  of its regions, the ex-
tensor tendon of the leg has never been divided without creating
great anxiety in the minds of surgeons.  The numerous dressings
devised for curing  fractures of the patella are a proof of it.   As
bandages have less hold on the ligament of the patella and the ten-
don of the rectus femoris, than on the fragments of the patella,
properly so called, authors have been' still more alarmed Math the
pure and simple division of the tendons of the knee than with frac-
tures  of the patella itself.  Seeing that the muscles of the thigh had
thus lost all their attachment to the tibia, it  was thought that the leg,
no longer able  to extend itself, would then be inevitably drawn
backwards by the flexor tendons.
   Fracture of the Patella.  An attentive observation of facts happi-
ly shows, that practitioners, on this point, have been deceived by
false inductions.  The  numerous  examples, however, of fractures
of the patella remaining with an extended separation of the frag-
ments, and without the functions of the knee having thereby lost
their power or  agility,  ought to have awakened  attention  on this
point.   For my own part, I have seen facts of this kind of the most
conclusive character.  An ancient officer of marine, M'ho had a sepa-
ration of five fingers' width between the two fragments of the pa-
tella,  nevertheless executed with  this leg all the functions and all
the movements that the other M'as capable of.  I have since met with
at least a dozen persons who thus had from six lines to an inch, and
even two inches, of separation, resulting from former fractures, yet
experienced no inconvenience.  Also, since 1832,  I have dispensed,
in patients affected with this fracture, with all annoying dressings;
to prevent the  consecutive stiffness of the  articulation, I permit
them to get up  and M'alk about at the end  of twenty to thirty days,
and even sooner, if the separation is inconsiderable. In proceeding
in this manner, I have  seen fractures of the  patella recover more
perfectly, and with infinitely less trouble, than by the long-protract-
ed employment of the most ingenious dressings.   In this very year,
(1838,) I have twice observed this fact, and in the same patient, at
the hospital of La Charite.  A cooper's boy,  of strong and robust
make, breaks his patella; the two fragments of bone,  separated
more than two inches, are brought together at the distance of some
lines from each other, and kept in contact by the uniting bandage
for transverse wounds, associated with the roller bandage, which
has been rendered immoveable by the solution of dextrine.  It was 
424          NEW  ELEMENTS  OF OPERATIVE SURGERY.
impossible to prevent this patient from getting up and walking on
the tenth day, and, in fact, from quitting the hospital at the end of
a month.  Annoyed by this bandage, he found means of getting rid
of it before the fortieth day, and came from Passy on foot to show
me, at the public consultation, that  he  was perfectly cured  and
limped no more.  A thick and firm bridle, an inch long, united the
tMro fragments of the divided patella to each other.  A month later
this boy fell on his knee again and broke the patella a second time,
or, to speak more properly, the intermediate substance M'hich  had
restored its continuity.  This time we found a separation of four
fingers' width. The sarrie bandage Mas applied, and the young man
left the hospital at the end of three weeks.  He took off the dres-
sing himself fifteen days later, and again came from Passy on foot
to show me his knee at the consultation.  He walked then without
limping, and felt no weakness in his  knee, except when he attempt-
ed to run, or to give a kick with his foot.   The tMo fragments of
the patella, however, remained separate by more than twenty lines,
and the patient was still only at the sixth M'eek from his second
wound.   I saw him two months after, and he thought no more of
his fracture.
  What I have said of the  patella  is applicable, in every respect,
to the superior and inferipr ligaments of this bone.  We see. in
fact, that the extension of the leg ultimately becomes re-established
in patients who have rupture of the  tendon of the patella, or of the
rectus femoris of  the thigh.  There came into the hospital of  La
Charite, in 1838, two men  with rupture of this last tendon ; though
it was not practicable to effect the union by immediate contact,  the
cure,  nevertheless, took place in  both patients Mdthout the  func-
tions of the  leg  being perceptily disturbed.  It  may also be  re-
marked, that the  patient  who had  been the longest under treat-
ment, and by  the most ingenious dressings, retained much  more
stiffness in the knee than the one who began to walk at the fifteenth
day from the accident.
  What makes the solution of continuity of the extensor tendons
of the leg cause less lameness than one would at first suppose is
this, that the new tissue which unites the two ends is itself ulti-
mately transformed into a substance which almost perfectly repla-
ces the  primitive tendon.   All, therefore, that results from it  is,
that the cord is found a little longer than it was in its natural state;
but, as the retraction of the  muscles soon compensates this excess
of length, the movements of the limb experience, in reality, but a
very slight degree of derangement.
  It is also  very  clear that,  at the knee more than anywhere else,
the rupture of the tendons  with wound of the integuments must be
infinitely more serious than that which takes place under the skin.
In this last  case, however, a roller  bandage saturated with dex-
trine, (dextrine) with the interposition of a pasteboard splint from
the ischium down to the  heel, and  associated with  strips of  the
uniting bandage for transverse wounds, is almost alM-ays sufficient.
Rendered immoveable and maintained in a sufficient degree of ex- 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         425

tension by this bandage, the limb allows of walking at the second
week of the accident, and the patient may, without danger, divest
himself of all the dressing by the thirtieth or fortieth day.
  In the event of there being an opening in the skin at the same
time that there, is a division of the tendon, it would be necessary to
apply the same bandage, if we should be called before the acces-
sion of the inflammatory symptoms, but in such manner as to leave
an  aperture, of greater or less size, opposite  the  wounded or in-
flamed region.   In this case, we must do every thing to obtain as
perfect a coaptation as possible ; and as this coaptation never takes
place in an exact manner by the aid of simple bandages, M'hen we
are treating the supra and sub-patellar ligaments, it would become
necessary to resort to the suture.   For the tendon of the rectus fe-
moris, there  would be an advantage in inserting the needle first on
the femoral  end, the only one which  has any tendency to retract
and to become concealed under the integuments ; for the  ligament
of the patella, it would also be advisable to begin with the upper
end, which, in  these  cases, is the most  moveable  and  flabby,
(flasque.)
  I have no necessity of adding,  that the  surgeon must expect,
also, in these kinds of sutures, to meet with great resistance on the
part of the tissues, and that he ought to provide himself with very
sharp-pointed needles.
  The suture being inserted, we apply upon the region left uncov-
ered by the immoveable bandage a simple dressing, or cooling com-
presses, or emollient applications, according to the indication.  If
too much inflammation should supervene, leeches should be placed
in sufficient number in the aperture of the bandage, which also al-
lows perfectly well of the application of  poultices.   On the suppo-
sition that the wound occupies the ligament of the patella, we
should depress the bandage  in such manner that, in arriving at the
knee, it would push down the patella with a certain degree of force
in the direction of the leg.   For the rectus femoris, the position of
the bandage applied to the  leg should, on the contrary, be raised
sufficiently high to  crowd the patella as  much as possible towards
the thigh.   It is,  therefore, only for divisions of the patella itself
that it would be proper to approximate the edges  of the aperture
of the bandage to an equal  distance upon each of the fragments,
and to associate with the immoveable bandage  (bandage inamovible)
the uniting bandage for  transverse wounds.   On the  supposition
that the section should not  extend into the capsule of the joint, it
would be alloM'able, if there should  supervene no  accident to the
wound, not to retain the  patient in bed longer than from fifteen to
twenty days.  In the contrary case, no  certain rule can be given
for the precautions to be taken.  All that we can say is, that, after
a perfect  cicatrization  of the wounds of the  integuments, there
would be  no great risk  in alloM'ing the patient liberty to get up
and perform some movements at  the  expiration  of  five or six
weeks.
                             54 
426
NEW ELEMENTS OF OPERATIVE SURGERY.
            § VI.—Tendons and Muscles of the Thigh.

  I have once seen a sub-cutaneous rupture of the sartorius  mus-
cle, and several times the section of the muscles which go from the
pelvis to the leg.  But those muscles are much more apt than their
tendons to unite by the  aid of a cellulo-fibrous deposition, which
speedily and  effectually re-establishes their functions.   It follows,
therefore, that the section of the muscles of the thigh, like those of
the leg and arm and forearm, have no need of the aid of operative
surgery, and that the treatment it  requires is reduced to the keep-
ing of the limb at rest for the space of a few days.


   Article II.—Deformities by Retraction of the Tendons or
                           Muscles.

  Numerous  deviations are caused by certain  muscles or tendons
becoming permanently retracted and shortened.

                        § I.—Treatment.

  Topical and orthopedic remedies on one hand, and the operation
on the other,  are the only resources which science at the present
time employs for the permanent retraction of the tendons.

                    A.  Topical Applications.

  The deviations produced by the retraction of the tendons, and for
counteracting which, applications  of opium and belladonna,  also
the massage, electricity and sudden fright, (surprise) and an infin-
ity of remedies, have enjoyed a reputation, seem to have now found
a more efficacious resource in the methodical section of the tendons
or muscles themselves.  I shall, therefore, in this chapter, have to
treat of an operation which, so to speak, is new, and not of ortho-
pedic means, properly so called ; an operation designated under the
name of enervation by some veterinary surgeons, which is more
generally known at present under the title of tenotomy, but which
would require another epithet to make it applicable at once both to
the muscles and tendons.

                         B.  Tenotomy.

  The section of the tendons should not be performed but for  per-
manent deviations that are already old, or at least of some months'
duration.  Before deciding upon it, we should be  assured that the
deviation does not proceed from  some articular rigidity, (roideur)
nor from sub-cutaneous bridles, nor inodular cicatrices; that it de-
pends, in fine, if not exclusively, yet in great part, upon a shorten-
ing and unnatural stiffness in some of the tendons or muscles. 
             alterations of the tendons or muscles.         427

   Though apparently modern, tenotomy dates, nevertheless, from
 an early period.  Holland was, it may be said,  its cradle.  Tulpius,
 the first who speaks of it, mentions Isacius Minius as having prac-
 tised it, (Tulpius, Observationes Medicce,  liber iv., caput 58, p.  372,
 1685.)  It appears, moreover, that Solingen, (These de Jaeger, 1737,)
 also, performed it in the seventeenth century.   Meckren,and Roon-
 huysen, whose cases Heister (Inst. Chir., t. ii., p.  672) cites,  had
 also followed, together  with Blasius, Tenhaaf, (Chelius. Man. de
 Chir., trad, de Pigne, t. i., p. 463,) and Cheselden, (Rust's Handbuch
 der Chir., vol. iii., p. 629,,) upon the steps of Minius and Tulpius.
   The dangers of wounds of the tendons were so great in the eyes
 of most practitioners, that, in spite of such essays, tenotomy fell
 into complete oblivion.   A memoir,  published in  1742, by de la
 Sourdiere, still terminates in this wise:  "  We ought, therefore, to
 avoid the  section  of the tendons."  The sensibility of these organs,
 as maintained by Boerhaave, explains,  moreover,  the timidity of
 surgeons  on this subject.   And it is not until the year 1782, that
 we find any new examples of tenotomy.  Lorenz, who, according
 to the  assertion of Thilenius, (Chirurgische Bemerkungen, 1784,
 ou Ammon,  De Physiologia Tenotomia, etc.,  1837,)  practised it at
 this epoch,  was but imperfectly imitated by Michaelis, (Hufeland
 und Himly's Journal,  Novembre,  1811,  t.  xxxiii.)   Michaelis, in
 fact, only partially divided the  tendon, and denies having made
 a complete section of it.   It is astonishing that  Sartorius, (Gaz. de
 Saltzbourg, t. iv.,) who put it in practice in 1812, has not, however,
 succeeded in  causing tenotomy to  be adopted in Germany.  It
 was no longer spoken of  in  any country, when Delpech, (Malad.
 Reput. Chir., t. i., p. 669,) who had already mentioned it in-favor-
 able terms,  introduced it into France in 1816.  The attempt of the
 professor of Montpellier,  however, had the same fate as that of the
 German physicians.  The veterinary surgeons, nevertheless, of that
 period, made frequent trials of it.  From 1820 to 1836, there have
 appeared  the observations  of Lafosse, Bruchet, Debaux,  Bouissy,
 Delafont, Choppin, Lortau, and Casten, (Diet. d'Hurtrel d'Arboval;
 Manuel de Watel; Proces Verbal de I'Ecole de Lyon, 1822; Journal
 Pratique de Med. Veterin.,  1826; Recueil de Med.  Veterin., 18J4,
 1830, 1832, 1835,) who all  demonstrate the advantages and safety
 of tenotomy.  Two observations, also, taken from the practice of
 Dupuytren,  show that this surgeon had performed it on men in
 1822 and  1823.   There  was scarcely any notice, however, taken
 of these facts, when M. Strohmeyer (Journaux  de Rust, de Casper,
 de Blasius, et Archiv., Gen. de Med.,  ser. 2, t. iv., p. 100—ser. 2, t.
 v., p. 194) published  successively six cases, and made known  the
 experiments M'hich he had performed in conjunction with the vete-
 rinary  surgeon, M. Gunther.   Since then, tenotomy has become so
general in France, England, and Germany, that it ought to take a
definitive rank in the departments of operative  surgery.  M. Dief-
fenbach told me, in 1837, that he himself had  performed it more
than two hundred times.  M. Syme, M. Lyttle, and some other Eng-
lish surgeons, have also had recourse to it. In France, M. V. Duval 
 428           NEW ELEMENTS OF OPERATIVE SURGERY.

 gives more than two hundred cases of it, (T. Duval, These, No. 342,
 Paris, Aout, 1838.)  MM  Bouvier, Stoess, Serre, Scoutetten, (Cure
 Rud.  des Pieds Bots. 1838,) and Jules Guerin, also, give numerous
 example^ of it.

                      Tenotomy in General.

  Scattered facts in scientific works ought, also, to have sufficed to
 show how little dangerous is the section of the tendons.  Almost all
 those I have spoken  of, in treating of  the  suture and wounds of
 tendons, are of this kind.   It has also been proposed for carrying
 out two very different kinds of indications.  Some surgeons, in fact,
 have had  recourse to  it with the view of remedying the accidents
 from  certain wounds, while tenotomy at the present time is  em-
 ployed only for simple deformities.

                a. Tenotomy in Cases of Wounds.
  One of  the cases mentioned by Molinelli, and where the  tendon,
at first partially divided, was afterwards completely cut  through
by the surgeon, nevertheless recovered perfectly.  In a case M'here
purulent collections (fusees) and gangrene M'ere making rapid ad-
vances, the excision  of a  gangrenous portion of the tendon put a
termination to the progress of the  mischief. In a third case, the
unpleasant symptoms caused by a wound which included the tendo-
Achillis, were  subdued  after the  excision of the plantaris, which
was seen  at the bottom of the division.  A more remarkable case
 still, was that of a tendo-Achillis M'hich it was necessary to dissect
 off at two different times from the side of the os calcis, to prevent
the denudation and purulent collections, M'hich continued to extend
themselves.  Under this point of view, the observation of Clement,
 already quoted, is equally important.  I have also said that Ponce-
 let  had thought  it advisable  to open a deposite of blood M'hich
 covered a fracture of the os calcis,  and  to cut the tendo-Achillis to
 extract the fragment of broken bone.  We have seen that Desport,
 also, divided the tendo-Achillis, because of an ulceration which had
 invaded it, and of the serious consequences that appeared to be con-
 nected with this ulceration. It would, without doubt, be difficult to
 say, at the present time, whether, in the cases which I have referred
 to, it was really advantageous to terminate the  section, or to  ex-
 cise a portion of the M'ounded tendons.  We are struck, however,
 with the termination of the difficulties as soon as these operations
 were performed.  On the supposition that  such  results were  not
 imputable to pure coincidences, it would not, perhaps, be impossible
 to give an explanation of them.   At the present time, no one, as it
 seems to me, believes in the extreme  sensibility of the tendons, in
 the necessity of their exfoliation M'hen they have been in contact
 with  the air, or in the dangers of their wounds; but u'hen we con-
 sider that they are surrounded with synovial networks, or sheaths,
 sometimes cellular, and at other times fibrous,  it appears quite
 natural that the inflammation M'hich is established at the bottom 
ALTERATIONS OF THE TENDONS OR MUSCLES.         429
of, or around their  wounds, should readily take on a  diffusible
character, and thus soon cause extensive devastations.
  Everybody, moreover, knows  that  suppurative "inflammation,
M'hich spreads along the tendons and synovial membranes, is soon
accompanied with acute pains, cerebral reaction, gangrene, or con-
vulsions.  Now is this a sufficient reason that the excision of a de-
nuded tendon, or its  section when it is  found only partially divided
at the bottom of  a wound, should be recommended ?  For myself,
I am disposed to believe not; but I admit that  we  have, perhaps,
still further occasion of consulting experience upon this subject.

                 b.  Tenotomy, properly so called.
  It  is,  therefore, for the purpose of  remedying deformities that
tenotomy should,  in fact, be reserved.   Under  this point of view
it is applied,  and  may be applied, to all the tendons and long mus-
cles that are  not  separated from the skin by any  important organ.
It has already been practised upon the toes, around the tibio-tarsal
articulation,  at the lower part  of the  leg, upon  the ham, fingers,
and neck.  No doubt it is equally applicable to the wrist, bend of
the arm, axilla, and knee.   Hitherto  surgeons  have performed it
either by dividing, transversely, both  the skin  and the  tendon, or
the tendon or  muscle,  by  drawing it  outside through  a longitu-
dinal opening in the integuments, or by not dividing the skin except
upon the side or sides of the tendon ;  from thence come three dif-
ferent methods of tenotomy, of which one  only, as it appears to
me, should be retained, under the title  of a general method.
   1. The Dutch  Method.  Tulpius and Minius scarified the skin
(escarrifiaient la peau) before  dividing the tendon.  It appears
that others made use even of fire or the hot iron for  the  whole
operation.  Joeger, (De Capit. Obstip.,  etc., Tubing., 1737,) who re-
jects caustics, and prefers the scalpel to the scissors, recommends,
like  Heister  and  Solingen,  that the incisions should be transverse,
and  as near as possible to the clavicle.  It is in  this  manner that
Dupuytren still proceeded in 1822.   Lorenz, and Michaelis also,
divided both  the tendon and its  envelopes.  This method,  which
M. Roux and M. Amussat have  more  recently put into practice,
ought at the  present time to be wholly rejected.   Besides the pain,
inflammation, and suppuration it may cause, it has the serious incon-
venience of making a wound which tends to the formation of an inod-
ular cicatrix, which may at a later period reproduce the deformity.
   2. Method  of Sartorius.   In  place  of dividing the skin  trans-
versely, M. Reiche,  (Held, These,  Strasbourg, 1836,) adopting the
practice of M. Sartorius, divided the skin lengthwise.   This first
incision, more than three inches long, as practised by M. Sartorius,
had  but an inch and a half of extent in the patients of M. Reiche ;
allowing either the tendon or muscle to be raised up, and to  be cut
immediately  upon a grooved director, it renders the operation very
easy.  In proceeding thus,  we should doubtless have more chances
than by the transverse incision, of obtaining an immediate reunion
of the wound of the integuments, and which, at the same time, 
430           NEW ELEMENTS OF OPERATIVE SURGERY.
would not hinder the separation of the two  ends of the divided
tendon;  but there would be  too much to apprehend from inflam-
mation and suppuration to make it advisable to confine ourselves
to this method, which M'as put in practice  by JM. Magendie,  and
which M. Bouvier, (Bouvier, Mem. de I'Acad. Roy ale de Med., t. vii.,)
also, seems to prefer.  M. Reiche, also, himself admits that in one
of his three patients the wound went on to suppurate for several
weeks.
  3. Method of Delpech.  Delpech had recourse to another method:
having first laid it down that the tendon ought not to be denuded,
he believed that  in order to  effect its  section it was necessary to
make a  kind  of  circuit, (detour.)  A bistoury, held flatwise, was
inserted  by the side of the  tendon, and slipped along  under the
skin to the opposite side, as in the  manner of inserting a seton.
Having given about an inch in length to each of the M'ounds, Del-
pech introduced in the place of the bistoury a small convex knife,
which served to divide the tendon through, in cutting from the skin
towards the deep-seated parts.
  This method differs from the two preceding in an essential point;
its avowed purpose is not to permit the tendon to remain on a line
with the M'ound. It includes at present a certain number of processes.
  Practised in the manner it was by Delpech, it gave place to two
wounds of too great length.   In suppurating, these wounds might
transmit  the inflammation to the two ends of the  tendon.   It is
M'hat actually took place in  his patient, since exfoliation did  not
allow him to commence with  the extension before the twenty-sixth
day, while  close adhesions were formed between the sides of the
tendon and the cicatrix of the two external wounds.
  Process of Dupuytren.  M.  Strohmeyer,  while he  adopted  the
method of Delpech, subjected it, after the example of Dupuytren,
to an important modification.
  Provided  with  a narrow bistoury,  a little  convex towards its
point, the operator penetrates by a simple puncture  from one side
of the tendon to  the  other, and then divides the tendon by a saw-
like movement from its deep-seated surface to the integuments. In
this manner tenotomy is reduced to a simple puncture, M'hich is not
followed  by any flow of blood, and the wounds of which have all
the  chances possible of cicatrizing immediately.
  This process appears to have been modified in France, almost at
the  same time, by M. Stoess and M. Bouvier.  M. Duval, who, on
his  part, believes that  he has brought it  to  perfection, (Picain.
These, No.  212, Paris, 1837,) gives the same position as Delpech to
his  patient, and inserts the tenotome upon the deep-seated surface
of the tendon ; then turning upward the cutting edge of the instru-
ment, he  immediately divides the tissues from the deep-seated parts
towards  the skin, as M. Strohmeyer does, taking care, as M. Du-
puytren and M. Syme had already done before them, not to let the
instrument perforate through the skin on the side opposite to that
of its entrance.
  Process of Stoess. The simple puncture on one of the sides of the 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         431

tendon, with the precaution of not disturbing the continuity of the
integuments upon the opposite side, now constitutes the most sim-
ple process that science possesses.  So, also, does this already com-
prise at least two shades of modifications quite distinct, which be-
long, one of them to M. Stoess, and the other to M. Bouvier.  That
of M. Stoess (Held, These, Strasbourg, Juin, 1836, p. 53) is no other
than the preceding.  It is, moreover, seen, by the details given by
M. Held, that  it was performed at  Strasbourg in 1835, M'hile  M.
Duval could not have used it until a year later.
   In approximating dates, in fact, we are induced to think that it
was put in practice nearly at the same epoch ; that is to  say, in
January or February, 1836, by M. Stoess and M. Bouvier.   M. Du
val, in fact, adhered  to the primitive process of M. Strohmeyer in
his operation in the month of October, 1835, and has not spoken of
that which M.  Pivain attributes to him until at a much later period.
I have, also, already said, that this modification of tenotomy had
previously been projected by Dupuytren in 1822, before, therefore,
the trials of M. Strohmeyer, and that  MM. Syme and Dieffenbach
had adopted it since  1829 and 1833.
   Process of Bouvier.  Besides the process of which we have been
speaking, and which M. Bouvier claims, he has, also, occasionally
followed another, which consists not in gliding the instrument be-
tween the tendon and  deep-seated parts, but, in fact, between the
tendon and the teguments, so that he divides the retracted cord in
going from the skin towards the centre of the limb. It is a process
which some other surgeons also have used, and which, it  is said,
was suggested by M. Dieffenbach in the year 1830. We should do
wrong, after all, in  attaching any great degree of importance to
any one of these varieties of tenotomy over another*.  Tlhey are all
good, and the  surgeon  should be at  liberty to use each of them in
their place, according to the indication.
   Whatever may be the mode of operation preferred, we hear, at
the moment of the section, a characteristic crackling sound, (cracque-
ment) which does not cease but with the division of the last fibres
of the tendon.  At the instant  when the  tenotomy is terminated,
there takes place a separation between the extremities of the divi-
ded tendon M'hich may reach to two or three fingers' width.   The
retracted part being no longer drawn in the direction in which it
had until that  moment been confined, renders it now practicable to
restore it to its natural direction.
   The pain caused by  this operation is generally slight.  We now
do all in our power, also, to effect the immediate union of the punc-
ture in the skin, and  to prevent suppuration from establishing itself
underneath.

                 c.  Appreciation of the Methods.
   The relative value of the different modes of practising the sec-
tion of the tendons is easy to determine. It is evident at first sight,
that the Dutch method, or that of Tulpius—that is, the one which
consisted in dividing successively, or  with one incision, both the 
432
NEW ELEMENTS OF OPERATIVE  SURGERY.
integuments and the tendon,  belongs to  the  infancy  of the art,
and  should be totally rejected.  At  most, it should be reserved
for those cases where the tendon upon its external face is blended
with the integuments.
  The method of Michaelis, having for its object to divide only a
part of the thickness of the retracted  tendon, whether including in
it  the tegumentary division of the method of Tulpius, or adopting
the first stage (premier temps)  of the method of Delpech, is out of
the question at this day.  It is  also clear, that the method of Sar-
torius, in M'hich the skin is incised in the direction of the  axis of
the tendon, and the latter afterwards raised up  to be  divided
upon a grooved director, has all the  inconveniences, without the
advantages, of the improved method of Delpech.  These, then, are
the three methods that no longer merit being preserved, except as
applicable to some special cases.
  The two long  wounds connected with the process which  proper-
ly belongs to Delpech, M'ould not  give to his method a manifest
preference over that of Sartorius, since it would be  often difficult
in that case to obtain an immediate cicatrization of the division of
the integuments, and to prevent inflammation from  proceeding to
the extept of suppuration between the two ends of the  divided ten-
don ;  but those who have  modified it since have  remarkably en-
hanced its  value.  It is only necessary to add, as  I  have already
said, that the difference between  the  processes of M. Strohmeyer,
M. Bouvier, M. Stoess, and  M. Duval, is not of sufficient importance
to require that we should necessarily, and in all cases, adopt one in
preference to the other.  M. Strohmeyer, M'ho, in one of his patients,
only partially perforated  the skin on the side opposite  to the point
where the instrument had entered, and who, on this account, M'ould
perhaps be entitled to claim for himself the  processes M'hich now
have the most repute in France, were it not  that his own  method
itself reverted of right to Dupuytren, maintains that the tMro punc-
tures have no greater inconvenience than a single one, and that
they render the section of the tendon  more easy.   After  that,
M'hether the tendon is divided from before backwards or from be-
hind forwards,  from right  to  left or from left to right, cannot, in
reality, be a matter of any  importance. Whether the wound of the
integuments,thesameasthatof the tendon, is transverse,or longitu-
dinal, as MM. Bouvier and Duval practise it, is also a matter of
secondary consideration.  In fine, whether we employ for%the M'hole
operation an ordinary and rather narrow bistoury, or a kind of
small scalpel with a convex point, or begin by a puncture Math the
lancet, to recur afterwards  to the tenotome of M. Stoess, M. Bouvier,
M. Duval, or M. Scoutetten, will not, as I conceive, in any respect,
either take away from or add to the danger of the operation.
   In fine, the process which consists in making only a single punc-
ture in the skin, and in which we divide the tendon from its super-
ficial part  towards its deep-seated part, is, all other things being
equal, the one which merits the preference.  In associating with it
an incision of the integuments parallel with the axis of the tendon; 
            ALTERATIONS OF THE TENDONS OR  MUSCLES.         433

in making this incision with the point of a lancet; in inserting af-
terwards, flatwise, through that puncture, an ordinary blunt-point-
ed (boutonne) bistoury, or one of the tenotomes of which I have just
spoken, while with the other hand we raise up the skin in the form
of a fold ;  in  thus  forcing the instrument onwards, until it has
passed beyond the limits of the other border of the tendon; and in
then turning down its cutting edge upon the cord to be divided, and
which  is Immediately made tense, in order that, by means of gentle
saw-like movements, it may permit itself to be cut through by the
bistoury, we have an  operation almost entirely destitute of  pain,
which  scarcely causes a drop of blood, whose puncture is generally
cicatrized upon the succeeding day, and M'hich, nevertheless, accom-
plishes all the indications desired.
  Nevertheless, we should not be too much alarmed, if the  point
of the  bistoury should  make two punctures in  the skin, instead of
one; or if, in finding some difficulties in passing between the skin
and tendon, we should see ourselves compelled to divide this last
from its lower to  its  cutaneous surface, provided we take care, in
terminating the operation, to avoid the internal surface of the in-
teguments.  There  are circumstances, moreover, in which one of
these processes should have  the preference  over the others.   We
may, in fact, conceive that kind of arrangement of parts, either an-
atomically or pathologically, which might render the  process of M.
Bouvier impossible, while permitting the application of that of M.
Stoess, and again, in some other cases, we could scarcely dispense
M'ith that of Dupuytren or M. Strohmeyer.
  I shall have occasion to return to this question again in treating
of the  section of particular tendons.
  The tendon being once divided, it is generallj' possible to straight-
en the retracted parts, unless there should be some complication in
respect to the neighboring articulations or bones.  If that should be
the case, however, the deformity would rarely fail to be reproduced.
On this subject there are now prevailing two principles, which are
quite opposed to each other.   M. Strohmeyer  recommends not to
straighten the parts  but by insensible degrees ;  M. Bouvier, on the
contrary, that  they should immediately be brought into their nor-
mal position, when it is possible so to do.
  The practice of M. Strohmeyer, which was also that of Delpech,
and  which M. Held also extols, is based upon this, that the two
ends of the tendon being for several days very nearly approximated
to each other, the material which fills up the space between them is
then alloM'ed to distend and elongate itself without disturbance ;
while at an earlier period it might be ruptured or not be formed. M.
Bouvier, however, maintains that we may from the very first,  with
perfect safety, keep the ends of the. tendon  at one or two inches
apart,  and that we can thus obtain a more certain elongation, and
one full  as  solid  as by the other mode.   In order to decide who is
wrong or right in such a question, we must interrogate pathologi-
cal anatomy and direct experiments.
                              55 
434           NEW ELEMENTS OF OPERATIVE  SURGERY.

                   d. Pathological Anatomy.

  Delpech, (Cliniq. Chir. de Montp., t. 1., 1823 ;  Orthomorphie Hu-
maine, 1828, t. ii.,)  returning to his favorite idea, asserts that the
two ends of the  tendon are united by means of an inodular tissue.
M. Acher (These, No. 112, Paris, 1834) relates experiments Mhich
would tend to the opinion that this union is effected by an effusion
of lymph or glutinous liquid, (sue glutineux ;) M'hile M. Held attrib-
utes it to an agglutination of the M'alls of the sheath of the tendon.
M. Duval, also, experimenting on rabbits, thinks he has ascertained
that the  new substance is composed of  a  melange of fibrine and
plastic lymph ; but the experiments the most detailed, which have
been published up to the present time, with the view of elucidating
this question, are those of MM. Ammon, (Tenotom., etc., ou Exper.,
t. i., p. 155,) and Bouvier, (Bullet, de VAcad., Nos. 5, 6, 8, 11, 20, t.
i., et 15, 16, t. ii., ou Mem. de VAcad. Roy. de Med., t. vii.)
  1. Ammon. Operating  on horses, M. Ammon has, at the expira-
tion of twenty-four hours, found the two ends of the tendon lost, as
it were, in the midst of a mass (magma) of strongly adherent blood.
At  the end of two  days, the extremities of the  tendon  Mere sur-
rounded with a clot of blood, (caillot)  one portion of which seemed
already imbued with plastic vitality.  On the fourth day, the inter-
vening space (I'ecartement) of the division of the tendon-M'as still
filled with blood. On the upper end was perceived a small cone of
sanguinolent plastic lymph ; a similar cone was also found upon the
lower end.  On the seventh day, the two ends of the tendon having
become tapered down into a conical  shape, were considerably ap-
proximated to each other.  Plastic, thread-like exudations extended
from one to the other.   In  a fifth horse, examined at the end of a
month, the tendon appeared to be all of one piece; the  intermedi-
ary substance was an inch long,  and differed but little from the
structure of the tendon itself.
   Repeated upon  rabbits, these experiments have not  been  con-
ducted with sufficient rigor to enable  us to deduce any thing of a
positive  nature  from them.  The author thus sums up the results
of his observations:  After the section of  a tendon, the wound  is
filled with a compact clot of blood, which soon becomes confounded
 with the neighboring tissues  and tendinous surfaces.   A plastic
 lymph, which exudes from the cut of the tendon, gives birth in its
 process of organization to filiform prolongations, which go from one
 end of the  divided part to the other.   At a period somewhat later,
 this lymph is replaced by a tissue very analogous  to that of the
 tendon, which tissue preserves a bloody aspect, and finally assumes
 a bluish tint.
    2.  Bouvier.   In the manuscript which he has had the kindness
 to send to me, M. Bouvier speaks in a  different manner.   From the
 second to the third day this physician has found  the cellular sheath
 thickened,  more consistent than  in the natural  state, and forming
 a species of canal, which embraced by its  extremities the two ends
 of the tendon.   Ecchymosed as it were, or of  a bright red  color 
            ALTERATIONS OF THE TENDONS  OR MUSCLES.         435

internally, this sheath was also in contact with itself, (en contact
avec elle-meme.)  On the ninth day M. Bouvier found it of a gray-
ish color, and destitute of fibres.  At a later period, and towards the
twelfth day, the canal of this sheath  began to be effaced, and the
two ends of the tendon were still distinct in its interior.  It  pre-
sented the  form and nearly the  size  of  the tendon towards the
eighteenth  day, though it  still contained  a certain  quantity of
serous liquid.   By the twenty-fifth day, it was almost entirely  sim-
ilar to the tendinous tissue itself, at least in consistence.  M. Bou-
vier concludes, from these  experiments,  that  the new tendon  is
formed at the  expense of the  surrounding cellular tissue, which,
converted at first into a canal with contiguous walls, changes, little
by little, into a solid cord  of fibrous substance.   In this, M. Bou-
vier differs  essentially, as is seen, from M. Ammon, and approxi-
mates much nearer to M. Held  or M. Acher.
  According to M. Ammon, the union of tendons could be explained
by the doctrine of Hunter.   The  blood effused between the ends
of the fibrous cord would, in concreting, attach itself to them, and
would become organized by mingling with an exudation of plastic
lymph, capable of acquiring, by degrees, the consistency and a part
of the  other anatomical characters of the  tendons.  The experi-
ments of M. Bouvier would conduct  us rather to the  doctrine of
Bichat, since, according to the  satement  of this  author, the inter-
mediate substance should be no other than the cellular tissue which
naturally surrounds the tendon, and which, by a  nutritive process,
(nutrition)  incidentally increased,  (exageree) becomes thickened
and hardened, and transformed by degrees into an  actual fibrous
tissue, and ultimately converted into a true tendon.
  3. The Author.  For  myself, I ought to avow, that the experi-
ments  of M. Ammon have not  to me  appeared conclusive; almost
all of them, in  fact,  have been complicated with some accident,
whether in relation to the tegumentary wounds, or to the division
of the  tendon  itself.  The  clots of blood which the  author speaks
of, are themselves nothing but an accident.  Tenotomy, as it  is
practised at Paris, has not produced any thing similar to them.
  Without  having  made direct experiments on animals, I believe
that I  may  be allowed to  speak  of the union of tendons accord-
ing as I have observed it in  man.   One  of the patients whom
I attended for a rupture of the tendo-Achillis, had, for a few days
only, a very slight  ecchymosis opposite the  wound.  I did  not
observe in  this point any trace, either of effusion or of clots of
blood.  The rupture, which was recognisable with the aid of the
finger, filled up little by little, while it preserved the characters of
a cellular tissue, gradually passing into a fibrous transformation.
Having watched with  much attention the process of consolida-
tion  in fractures of the patella, I  had  here  also satisfied myself,
that the bridle, which finally re-establishes the continuity of  the
bone, does not result from an effusion of  fibrine, or an effusion of
plastic lymph, at least in a majority of cases, but that it results in
reality from the approximation, concentration, hypertrophy, or fibrous 
\
436           NEW ELEMENTS OF OPERATIVE  SURGERY.

transformation of the cellular lamella) in the neighborhood. I have
also  had it  in my power to observe and M'atch  this action, in a
manner to leave no doubt of its nature, in two cases of rupture of the
tendon of the rectus-femoris, in many cases of fracture of the ole-
cranon, and in an individual who had had the os calcis shattered.
  The action of  which I  have just spoken, is connected, also, with
a great  question in anatomy, or organic evolution, properly so
called.  Minute  dissections  and  observations, detailed in the last
edition of my Treatise on Surgical Anatomy, prove, if I do not de-
ceive myself, that cellular tissue may be transformed into fibrous
tissue, and this latter into muscular tissue, and vice versa.
  If this be the fact, not only the section of the tendons, but also the
treatment of accidental ruptures of these  parts, should be subjected
to rules that the doctrine of Hunter, sustained by the experiments of
M. Ammon, and by some of those  of M. Duval, would reject as
imprudent or dangerous.
  Every thing shoM's, also, that the union of the tendons is effected
nearly in the same manner as that of the bones.  At the bottom
of M'ounds, or where the division of the tendon enters into suppu-
ration, or remains a long time in communication with  the atmo-
sphere, it is by a sort of cellulo-vascular vegetation, by the produc-
tion of a kind of inodular tissue, that the union takes place.  If no
inflammation nor accidental suppuration supervene, and the two
ends of the tendon are kept in exact contact, the cicatrix is formed
by a true callus, that is to say, by a direct agglutination, or a kind
of imbrication of the fibres of each divided end.   When a perfect
state  of immobility has not been maintained, this union is effected
by a kind of fibro-cellular thickening, (renflement) in some degree
analogous to the ferrule (virole) of Duhamel or of Dupuytren. This
species of swelling which I speak of, and which sometimes remains
during life, on the point of contact of the two ends of the tendon,
is not alone seen, as M. Mondiere believes, in cases where the suture
has been employed.  I have observed it twice  after the rupture of
the tendo-Achillis, once in the extensor tendons of the fingers, and
once  after the section of the tendon of the flexor carpi ulnaris.
Some observers  mention it  even in certain cases where the two
ends  of the tendon were decidedly united by an  intermediate sub-
stance, (Lenger, Encyclograph. des Sc. Med., 1838, p. 145.)
  When the union of a ruptured tendon  is effected under the skin,
which remains unbroken, and without our endeavoring to approx-
imate its two ends, the effusion of blood or plastic lymph betM'een
them M'ould only be incidental.  The cellular sheath yields, elon-
gates itself, and  is converted into  a kind of canal, more or less
flattened.  Connecting itself with the common sheath above  and
below, this canal seems as  if it were strangulated  in its middle
portion.  In a short time it becomes the centre of an  afflux [of
blood,] which augments  its nutrition ; the cellular filaments in the
neighborhood attach themselves by degrees to its external surface.
The cellular tissue of each end of the tendon swells, and thickens
at the same time, which  gives rise there to a kind of enlargement, 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         437

(renflement.)  The more  it progresses, the more the hypertrophied
sheath of the tendon approximates to the form of a ligament, and
loses its attributes of a canal.  Projecting in form of a cone, each
end of the tendon becomes imperceptibly blended with the kind of
double funnel (double cntonnoir) M'hich covers (embrasse) its extrem-
ities.   The molecular process continuing, the entire mass finally
forms  a  cord,  sometimes strangulated in its middle, and as if em-
bossed (comme bossele)  at its two  ends,  and which  in other cases
acquires  such density and  force of resistance, that the muscular
action is  transmitted through this part in the same  manner  as
through the sound tendons.  Perhaps, says M. Bouvier, the sheath
in question would remain too weak, and would retain the charac-
ters of cellular tissue towards its middle, if the separation of the ten-
don was  too wide, or exceeded, for example two or three  inches.
I will remark, hoM'ever, that in a patient who had taken no repose
after  the  accident, and who, in  consequence of a fracture of the
patella, had, in front of the knee, a separation of at least five fin-
gers width, the supplementary bridle  had,  nevertheless, sufficient
force  to transmit  to the leg  all the power of the anterior muscles
of the thigh.
  After these facts, I regard it as very important to practise tenot-
omy:  1. By a narrow puncture into the skin; 2. By cutting through
the tendon as effectually as it is possible to do it, while taking care
to avoid  its cellular sheath; 3. By avoiding with care the  vessels
that might cause  the  least  effusion of blood; 4. By straightening
the leg immediately, should it not be necessary to obtain a sepa-
ration of more than an  inch  and  a half:  5.  By augmenting this
separation little by little, after the tenth  or  fifteenth day; 6. By
immediately applying a bandage or apparatus, which prevents the
deformed part  from reassuming its morbid position; 7. By mode-
rating with the dressing  every species of movement in the divided
region, for the  space of some ten days;  8. By proceeding after-
wards, by degrees, to movements more or less extended, in the
direction opposite to that of the flexion or extension which we have
wished to overcome.  We  shall also  see that the employment of
apparatus, or auxiliary  mechanical means, should be continued
much longer for some tendons than for others.
  Perhaps, after all, there would be fewer inconveniences than ad-
vantages in allowing the patients,  immediately after the operation,
to make repeated movements every day ; but experience not hav-
ing yet determined this question, it  appears to me prudent not to try
the extension until after the  time when the  new production has
already attained a certain degree  of force  and density.  Even  on
the supposition that the tendon had not only been cut in the exterior
of its  sheath, but  that this sheath  itself was also comprised in the
section, this ought  not, as I think, to  be a source of disquietude.
The approximation of the deep-seated lamellae of the sub-cutaneous
fascia, and of the other lamellae which  are found in the neighbor-
hood,  would secure us from all inconvenience  in this respect.  So
that if it  is better, in fact, to adopt all the precautions required 
438
NEW ELEMENTS 01 OPERATIVE  SURGERY.
by the method  of Delpech, as simplified by Dupuytren, and after-
M'ards by MM. Strohmeyer, Bouvier, and Stoess, it must also be
conceded that the operation Mould not necessarily fail, merely be-
cause we had deviated from the most simple processes.

            —       Tenotomy in Particular.

  Certain deformities of the foot, leg,  hand,  forearm, and neck,
may find their  principal remedy in  the section of the tendons or
aponeuroses.
                         a.  The Hand.

  It was formerly believed, that the deviations of the fingers and
of the hand  Were almost all caused by the retraction of the tendons.
We have  seen, in one of the preceding chapters, that the greater
part of these deformities are  at present ascribed to  cutaneous or
sub-cutaneous bridles.  But in this question, as in many others, one
error has been destroyed only to give place to another.  It is  cer-
tainly true, that the  retraction of the fingers, whether backwards
or forwards, is.  sometimes produced  by  the shortening of the  ten-
dons or muscles. Consulted in cases  of this kind, the surgeon ought
not to hesitate.  The section of the diseased tendon M'ould present
every possible chance of success.
  1. Extensor Tendons.  In the fingers and on the back of the hand
it would, if  it were  practicable, be  advisable to take up a fold of
the skin behind the retracted tendon, to  insert a narrow bistoury or
a small tenotome on  one of the sides of the fold, and  to turn it im-
mediately towards the tendon itself,  the tension of which should be
increased by trying to straighten the finger.  On the  second  pha-
lanx no vessel  could be wounded, while on the first and on the
metacarpus  it  would be  important  to  avoid  the veins, M'hich in
these places are sometimes of considerable  size.   If there  were
many retracted tendons, we should have recourse to the same  ope-
ration for each.  On the metacarpus, however, it would not be im-
possible to insert the bistoury sufficiently deep under the skin to
divide  two and even three tendons by the same puncture.   Here
the rule  advises that we  should incise the tendon upon its most
projecting portion, taking care, nevertheless, to avoid the line (ni-
veau) of the  articulations.
  If the case was one of the retraction of the radial  tendons, viz.,
of the extensor secundi internodii pollicis, or the extensor ossis meta-
carpi pollicis, M'e could  effect  the section without danger, in spite
of the neighborhood of the radial artery, by taking care, M'hile the
bistoury  is being introduced  under  the skin, to force the thumb
strongly into extension and abduction.  Nevertheless,  for the radial
tendons only, it would be much better that the hand, turned slightly
backward, should  be completely shut.   We ought, also, in those
two cases, to force the  tendons, in  a certain sense, to make their
own division against the bistoury.  The extensor carpi ulnaris, not
having in its neighborhood any large artery, would exact fewer pre- 
ALTERATIONS OF THE TENDONS OR MUSCLES.
439
cautions.  It would be necessary to make its section between the
head of the  ulna and the upper extremity of the  fifth metacarpal
bone.  After the section of these tendons, we straighten the hand,
and incline it slightly into a flexed position by means of a prepared
splint, which extends upon  the palmar region of  the forearm  and
hand ;  a pasteboard splint, properly curved, would constitute a sup-
port evidently preferable to a wooden splint, if we should associate
with it some turns of bandage saturated with dextrine.   At  the
end of six or eight  days, we should have to increase the inflexion
of the parts, if the  opposite tendency still existed ; but  we should
take care to stop as soon as the extension ceased to predominate.
From that period,  moderate  movements of flexion and extension
should be persisted in, until the hand should have recovered the free-
dom of its motions.
  2. Flexor Tendons. The section of the flexor tendons  of  the fin-
gers is evidently more delicate than that of the  extensors.   On the
one hand, it might involve an opening into the fibro-synovial sheath,
whose inflammation is extremely dangerous; and, on the other, I do
not perceive how, in effecting  it by the process  of simple puncture,
we could be assured of the certainty of avoiding  the collateral ar-
teries.   In all cases it should be performed only on the palmar  sur-
face of the first or second phalanx.  In place of perforating the  skin
altogether upon the outside, it would be better to enter on the  side
of the finger near its anterior surface, and afterwards to divide the
tendon,  while separating  it as much as possible from the bone,
without carrying the point of the instrument to any great distance
towards  the opposite side.  Supposing, however, that  one of the
arteries should have been wounded, its hemorrhage probably could
be easily arrested by compression,  properly made, upon the  two
borders of the upper part (de la racine) of the finger, or above the
wrist, upon  the radial and ulnar arteries.  If it  were necessary to
apply a ligature to  the vessel, I would  prefer seeking for it at the
upper part of the finger than enlarging the first  puncture for  that
purpose.
  If the  retraction of the tendons occupied the palm of the hand,
tenotomy would also be attended M'ith real danger; to  perform it,
it would be  necessary to cut through the aponeurosis, and  to  ma-
nipulate  in the midst of nerves and  vessels of large size, besides
that the synovial membranes render the inflammation far more  for-
midable here than on the forepart of the fingers.  Only that the re-
tracted tendon, being so stretched as to become sufficiently promi-
nent, would allow of our directing  the  point of the bistoury upon
its opposite border,  and of cutting the tendon from  one  side to the
other, rather than from before backwards, and  without  encounter-
ing the branches of the superficial palmar arch.  The retraction of
the radial muscles,  especially of the palmaris longus, would be  one
of the easiest things to remove by tenotomy. The hand being mod-
erately flexed, while the  patient endeavors to  approximate  the
thenar and  hypothenar eminences,  or, better still, the upper part
(la racine) of the thumb to that of the little finger, renders the  ten- 
440
NEW  ELEMENTS OF OPERATIVE SURGERY.
don of this last mentioned muscle so projecting that there would be
neither risk nor difficulty in dividing it.  If the section of the flexor
carpi radialis should be necessary, it could be effected by avoiding
the palmaris longus by means of the indication which I  have  just
given.  The puncture of the teguments should then be made on the
outside of the  tendon, butinside of the radial artery.  Carried hori-
zontally  under the tendon of the palmaris brevis, the bistoury,
whose  handle should be held a little raised, M'ould then, Mdthout
difficulty, effect  the  section of the flexor carpi radialis  with very
little danger to the radial artery.  As to the section of the tendon
of the flexor carpi ulnaris, we may conceive that the neighborhood
of the artery would render this operation above the wrist somewhat
dangerous.
  After the operation, also, in whatever region it may be perform-
ed, we must do  all in our power to close up the small wound im-
mediately.   The same splint as the preceding would serve, also,
after the  section of the flexor tendons.  In the palm of the hand it
would suffice, in order gradually to increase the extension, to add to
the number of paddings (remplissages) on the lower extremity of
this splint.  Prolonged towards the fingers, it would elongate them
also, at the pleasure  of the  operator.

                b. Elbow  and Bend of the Arm.
  At the humero-cubital articulation we find only two tendons—
that of the triceps posteriorly, and  that  of the biceps  anteriorly
—which  might by their retraction become the sources of deformi-
ties.
  1. Triceps. I know no case of permanent  extension of the  fore-
arm produced by the shortening of the triceps; but should it be
met with, the  manner in which ruptures  of  the anterior  tendon of
the thigh or of the ligamentum patellae are cured, sufficiently show
that its section would be clearly indicated.  Nothing, in fact, could
be more  simple than this section.  Inserted  by puncture from the
outer side towards the inner, or from the  inner towards  the outer,
the instrument,  passed under the skin, would cut the tendon from
behind forM'ards, Mdthout incurring the least danger, since there is
no important organ to  avoid.   It M'ould be  necessary, however, to
take the  precaution to  make  this section at about an  inch above
the olecranon, in order to be more sure  of  avoiding the synovial
capsule of the joint.  We should also take care to avoid the ulnar
nerve, which is found [running close to]  the  posterior surface of
the inner condyle, (epitrochlee)  The forearm, placed immediately in
quarter flexion, should be brought into semi-flexion in the space of
from eight to fifteen days.  We should,  after that,  give it slight
movements  of flexion,  extension,  pronation,  and supination, not
forgetting, in  the  interval of these  exercises, tc  support  it by a
scarf for the space of about a month.
  2. Tendon of the Biceps. The retraction of the biceps is met with
quite frequently; I have already seen seven or  eight cases of it,
some congenital, others resulting from disease.  I have not  learned 
             ALTERATIONS  OF  THE TENDONS OR MUSCLES.         441

that this  retraction, whiph holds the forearm, to a greater or less
degree, in a state of permanent flexion, which is characterized by
a  cord  in a strong state  of tension, whenever we endeavor to ex-
tend the  arm—a cord which descends from the anterior region of
the arm into the hollow of the forearm, has up to the present time
ever been submitted  to tenotomy;  but science at the  present day
possesses  facts sufficient to justify its trial.  I have already recurred
to an observation of Granier,  and  to two facts of my own, from
which it results that the complete division of the tendon of the bi-
ceps,  causing thereby the destruction of  a part of the  muscle,
does not  destroy the functions  of the limb.   An observation  still
more  conclusive has been published  in  England  by M. Ballin-
gall, (Edinburgh Medical and Surgical  Journal, January, 1835 ;
Archives Generates de Mcdecine, 2e serie, t. vii.,  p.  264;  Revue
Medicate,  1835, t.  i.,  p. 393.)   It relates to a sub-cutaneous  rup-
ture of  the tendon of the  biceps, which was in some degree left to
itself, but which,  notwithstanding, soon got  M'ell, leaving only a
slight weakness in the limb.  In the  case of retraction of the biceps
which Molinelli speaks of, (Haller, Mem. sur VIrritabilite, etc., t. iii.,
p. 33,) a  sudden extension of  the  forearm, accompanied  with a
crackling  sound and with  pain,  relieved the patient of his infirmity.
It is, moreover, one of those sections of tendons which arejdie easiest
to perform; I have many  times practised it on the dead body with-
out the  least embarrassment.  When stretched tense, and strongly
projecting, the biceps, in  such cases, is separated to a very consid-
erable distance from the brachial artery.  The point of the bistoury,
inserted at  its outer side  by puncture, and afterwards  raised so as
to glide under the  skin till it reaches on a line with the inner edge
of the tendon, allows of our then immediately turning the cutting
edge of the instrument backwards.   We then increase the rigidity
of the muscle by trying to extend the forearm.  With these  pre-
cautions, we have only to press moderately, and in a sawing move-
ment from before backwards, in order to divide the whole thickness
of the tendon, while we are at  nearly the distance of half an inch
from the  artery.   In operating too  low down, we might  not reach
the fibrous  expansion which goes  from the  biceps to  the inner
muscular  mass at the fold of the arm ; but this bridle is  ordinarily
unconnected with the deviation. Nothing, however, would prevent
our dividing it in  its turn with a second stroke, if it appeared to
interfere, in any manner whatever,  with the extension of the limb.
It  is unnecessary to remark here, that we should put ourselves on
our guard against  the puncture of  the median basilic  and median
cephalic veins, and that it would also be well to avoid the trunk
of the cutaneous nerves, both internal and external.  To keep the
limb afterwards  extended, nothing  would be  more effectual than
the bandage saturated with dextrine, which I have already spoken
of in treating of sutures of the tendons  in the bend of the  arm.
This extension we  should  also be under the necessity of protract-
ing for  several weeks, in order to  overcome  the tendency of the
parts to resume their morbid position. 
442
NEW  ELEMENTS OF OPERATIVE  SURGERY.
               c.  Tendons or Muscles of the Axilla.
   The permanent depression (abaissement) of the arm M'hich may be
caused by cutaneous cicatrices.the formation of iibro-cellular bridles,
or by a complete or incomplete consolidation of ihe scapulo-humeral
articulation, have appeared to me to be also produced in many pa-
tients by a retraction of the tendons  or muscles.   The pecoralis-
minor, the pectoralis-major, the  teres-major, the latis.dmus-dorsi,
and the edges of the deltoid itself, are, in my opinion, susceptible
of being thusTetracted.  In some cases, I have remarked that these
different muscles or their tendons always took on the appearance of
hard, inelastic, though indolent cords, at the moment M'hen I tried
to separate the arm from  the  thorax;  and this in two  patients,
among others, one of whom had had, several years before, a severe
wound in  the forepart of the shoulder, and the other an extensive
abscess in the fold of the axilla.  Would it not, then, be alloM'able
to perform the section of these parts after the modes above pointed
out?  For the pectoralis-major,  or ihe anterior border of the del-
toid, a sharp-pointed bistoury, passed either upon the cutaneous or
deep-seated surface of the muscle, would, without difficulty, allow
of our dividing it from behind forward, or  from before  backward.
The pectoralis-minor M'ould require that the point of the  bistoury
should be carried down to its lower border, that we might there
divide  it by a swinging"movement from  below upward, and from
behind forM'ard.  We might reach the latissimus-dorsi, or the teres-
major, or the posterior edge of the deltoid, by dividing them either
on their posterior or anterior surface.  In M'hat ever M'ay performed,
it would be  necessary afterwards to keep the arm eleva'ed almost
at a right-angle, by some apparatus or bandage, for the space  of
three weeks or a month.  Up to  the present time,  no one appears
to have treated of this kind of operation.

                     d.  Tendons of the Toes.
  In the toes, as in the fingers, there may be  retraction both of the
extensor and flexor tendons.
  1. Extensors.  The-retraction of the  extensor tendons of the toes,
existing to such an extent as to elicit the attention  of the  surgeon,
is  a rare  occurrence.   I have,  however,  seen some  examples of
it;  some in which the retraction comprised,  at  the same time,
all  the  tendons;  others, in which it  was only the tendon of  the
little toe,  or that of the great  toe.  which  M'as  thus  shortened.
If the  deformity  should exist to so great a degree as to cause
any real inconvenience, either in  exposing the skin  to excoriations,
or by rendering it difficult to wear shoes, (des chaussures)  it Mould
be necessary to have recourse to  tenotomy.  As there are neither
nerves nor arteries of large size on the dorsum of the metatarsus,
the only place where it would appear to be advantageous to divide
the extensor tendons of the toes, tenotomy in that locality M'ould be
extremely easy ; it should be performed in the same M'ay as on  the
back of the hand, by a puncture for  each tendon, or even by one 
ALTERATIONS OF THE TENDONS OR MUSCLES.
443
single puncture for the whole of the retracted tendons, preferring,
as  everywhere else,  to  make the instrument act from  the  skin
towards the deep-seated parts.  M. Dieffenbach (Bouvier, Mem. de
VAcad.  Roy. de Med, t. vii.) is the only person, I believe, who, up
to the present time, has had recourse to this operation on the living
subject.  M. Davidson (Gaz.  Med. de Paris, 1838) has also per-
formed  it, but by excising a portion of the common extensor, and a
cicatrix on the dorsum  of the foot, rather than in the light of an
operation for tenotomy.
   2. Flexor Tendons.  The retraction  of the  toes,  in the sense of
flexion,  can but very rarely occur to such a degree  as to constitute
it a disease.   These appendages are so short, and are so well pro-
tected (abrites) by the sole  of the  foot, when they are strongly
flexed, that their  retraction can hardly claim the aid of surgery.  It
is necessary, however, to  observe that the great  toe, both by its
size and length,  and its importance  as an  organ of sustension
and progression,  is excluded from  this remark;  so, also,  has it
been the object of some special attentions under this point of view.
M. Syme (Archiv. Gen. de Med., 3e serie, t. i., p. 115) is the first, as
it appears to me, who has divided its flexor tendons, to remedy a
retraction  produced by a previously existing inflammation.  The
operation, performed  on  the first phalanx, was followed by entire
success. It would appear,  also, that M.  Dieffenbach,  (Bouvier,
Mem. de VAcad. Roy. de Med., t. vii.,) on his part, has once had
recourse to it, with results not less satisfactory.
   It would be preferable to perform the tenotomy of the great toe
on the plantar surface of its first phalanx ; but if the retracted ten-
don should be more particularly prominent  upon the inner border
and at the sole of the foot, nothing would interfere with our dividing
it at this point.  As in the  fingers, we should here have to fear the
lesion of some vessels ; but being of infinitely less  size than in the
hand, the plantar arteries and the  collateral arteries of the toes
could not, in such cases,  occasion any very serious apprehension.

                     e.  Tendons of  the Foot.
   The foot may  be deviated  by the  shortening  of many orders
of tendons.  I shall  proceed  to examine, under  this head,  the
retraction of the  peronei and  the tibiales, then that of the tendo-
Achillis and the plantar aponeurosis.  These retractions give rise
to the deformity  known under the name of club-foot, (pied-bot) a
deformity which  may equally proceed from an alteration  in  the
bones or articulations, but  of which I do not now intend to speak,
except so far as it is caused by the action of the tendons.  There
are four principal kinds of  club-foot: the foot turned inward, or
varus ;  outward, or valgus; upward, (en avant) or talus; and back-
ward, or pes equinus, (pied-equin)
  The pied-equin, one of the most frequent, depends, almost always,
on a shortening of the tendo-Achillis.  In that case, the heel is more
or less raised towards the  calf, and the patients walk on the point
of the foot, that is, on the heads of the bones  of  the metatarsus 
444
NEW ELEMENTS OF OPERATIVE  SURGERY.
and the plantar surface of the toes.  It may even happen, as I
have seen in three instances, as in the example M. Stoltz (li-pert.
dVAnat. et de Physiol. Pathol, 1827) has  described, the five  cases
cited by M.  Duval, (These citee, p. 7,) and as has been observed,
also, by M.  Scoutetten (Oper. Citat., p. 107, pi. 2) and  other  prac-
titioners; it may happen, I say, sometimes, that the foot  is so turned
backward, as to oblige the patients to support themselves on the
dorsal surface of the tarsus.   The three  patients submitted to my
examination, walked on the dorsal surface of the tarso-metatarsal
articulations of the cuboid and third cuneiform bone.   The M'hole
three had in that part a large sub-cutaneous bursa-mucosa. In one
of them, who was an in-door pupil of the hospitals of Paris, this
variety  of the pes-equinus  appeared to  me to depend upon  the
retraction of the plantar aponeurosis, which extended itself, under
the form of a very hard and distinct cord, to the head of the second
and third bones  of the  metatarsus.  It is, however, rare that  the
four  kinds of club-foot, which I have just  mentioned, remain per-
fectly distinct, or that one of them is not soon  complicated, in a
greater  or less  degree, with some  one of the others.   In the pes-
equinus, the metatarsus, also, may be strongly bent back upon the
tarsus, as happened in the case of the young physician I have just
mentioned, at the  same  time that  the heel was  drawn up by the
muscles of the calf.  The pes-equinus is  often, also, complicated
with varus or valgus.   It is so much the more important not to for-
get this remark, that the number  of tendons to  be divided,  when
we wish to remedy club-foot, is always in proportion to the varieties
or combination  of the deformities  which it is  our  intention  to
destroy.
  Perhaps, also, it would be necessary to admit two simple varie-
ties of pes-equinus, that  which results  from a  retraction of the
aponeurosis or muscles of the plantar surface of the foot, and that
which is caused  by a retraction of the tendo-Achillis.
  1.  Plantar Surface of  the Foot.   If, as occurred in the young
physician above mentioned,  an instance of which  M. Duval, (Pi-
vain, This., No. 212, Paris, 1837, p. 24,) on his part, appears also to
have met with, the  plantar  surface (la plante) of the foot is  found
in a certain sense folded upon itself, it is possible that the deformity
may arise from a retraction  of the plantar aponeurosis, or of the
flexor brevis digitorum pedis, much more than  from  a shorten-
ing of the tendo-Achillis.  In this  case  it would be  necessary to
begin by an operation which, up to the present moment, has  not, I
believe, been advised by any one, that is, by the  section of the re-
tracted cord of the sole of the foot.   The patient having the foot
extended, and held so by an assistant, would enable the surgeon to
introduce the instrument by puncture between the teguments and
fibrous bridle, from right "to  left, or from left to right, almost  indif-
ferently.  After having turned the cutting edge of the tenotome, it
would suffice to hold its handle a little below the plane of the  lower
surface  of the foot, to prevent all danger while dividing the cord
from its cutaneous  towards its deep-seated surface.  As it is quite 
ALTERATIONS OF THE TENDONS OR MUSCLES.
445
difficult in this region to distinguish M'hat belongs to the aponeu-
rosis, and what to the short flexor muscle, or to its tendons, it would
be better to carry the incisions as far backward as possible, unless
the bridle should be much more projecting, or more conveniently
raised up in front than towards the  os calcis.  The important part
of it would be, not to carry the cutting edge of the instrument too
much outward nor too much inward, seeing that  nearly the whole
of the plantar artery lies under the borders of the foot.   If, after
having divided the  principal bridle, we should be enabled by the
finger to discover others in the neighborhood of the first, we should
endeavor to reach them Mdthout stopping the operation, (desempa-
rer) and divide them through the  same opening in  the integu-
ments.
  As this variety of the pes-equinus is almost always accompanied
M'ith a greater or less  degree of luxation of the  second range of
the bones of the tarsus upon the first, the section of the tendon, or
of the plantar aponeurosis, will rarely allow of an immediate re- -
adjustment (redressement)  of the foot.  We must look, therefore, for
some difficulties in this direction, and rely upon the aid of an appa-
ratus to complete the success of the operation.   If,  however, the
difficulty of adjusting the  foot in such a case should arise from the
concomitant retraction of some other tendon, it would be advisable
to divide that,  as  well as those of the sole of the foot.  It is thus
that the section of the  tendo-Achillis, of the  flexor longus pollicis
pedis, and of the  peroneus longus, or of the  flexor digiWum com-
munis, might be requisite after that of the  flexor brevis, or of the
plantar  aponeurosis.
  In conclusion, I have, up to the present time, seen but one case
where the operation which I describe has appeared to me to be prac-
ticable ;  I am  aware, moreover, that M. Duval (Pivain, These citee,
p. 24) has cured club-feet with  reversion of the dorsal surface of
the metatarsus, by confining himself to the division  of the tendo-
Achillis.                                                       .
  2. Section of ihe Tendo-Achillis. The section of the tendo-Achillis,
which it is said was long  ago practised in the Limosin, (Scoutetten,
Mem. sur la Cure Rad. des Pieds-Bots,  Paris, 1838, p. 12,) is now
one of the most important operations in surgery.  In the cases of
Poncelet, Desport, Molinelli, and some others, of whom I have spo-
ken  above, it  was performed for reasons altogether different than
for those of a deformity of the foot.
  A.  The history of this operation, however, is not difficult to
be given at the  present time.   The first surgeon who has spoken
of it, in relation to club-foot, is Thilenius, (Obs. de Med. et Chirur.,
Francfort,  1784.)   It was Lorenz, moreover, who  performed it
March the 26th, 1782, and not Thilenius himself, as  has generally
been often asserted  among us.   More  recently, in 1809 and 1810,
Michaelis, a surgeon of Marbourg,  published a memoir,  (Gaz. de
Saltzbourg, et Journal de Hufeland, 1811,) tending to demonstrate the
advantages of the partial section of the tendons in certain cases of 
446           NEW  ELEMENTS OF OPERATIVE SURGERV.
   old deformities, and more particularly the section of the  tendo-
   Achillis.
     Sartorius (Journal de Siebold, t. iii.) also made knoM'n, in 1812, a
   case of section of the tendo-Achillis for the removal of a pes-equi-
   nus produced by a previous suppuration in the posterior part of the
   leg.   Up to that time  there had been nothing said of tenotomy of
   the tendo-Achillis  in France; and  when Delpech had recourse to
   it in 1816, .on a boy then six  years  of age, and M'hom  M. Bouvier
   afterwards  met M'ith in Paris, in 1837, it was  everyM'here thought
   that it M'as an operation absolutely new.   Having  been badly de-
   scribed, or badly understood, the section of the tendo-Achillis  was
   a second time forgotten, both in France and Germany,  though  ma-
   ny veterinary surgeons (Miquel, Debaux, etc.;  Blanc, Jour. Pratiq.
   de Medec. Veter., 1826,  p.  202; 1828,  p. 283; 1830, p. 346) soon
   availed themselves of it, and  demonstrated its advantages in the
   horse ; but the six cases, collected from 1831 to 1834, and published
   by M. Strohmeyer, (Magas. de Rust, t. xxxix.; Arch. Gen. de Med.,
   2e serie, t. xii., p. 116, etc.,) finally  brought back public attention
   to this subject.   It Mras from that time performed, on the 23d of
   October, 1835, by M. Duval, the 15th of January, 1836,  at Paris, by
   M. Bouvier, and about the same epoch by M. Stoess, at  Strasbourg,
   (Held, Dissert, sur le Pied-Bot, p. 69.)   To set  out from this period,
   the tenotomy of the tendo-Achillis has been performed anew  by M.
   Strohmeyer  on M.  Little, an English physician, (Bouvier, Mem. sur
   la Section du Tendon d'Achille dans le traitement des Picds-Bots;
   Mem. de VAcad. Royale de Med.,  t. vii., p.  411;) by M. Reiche, a
   surgeon of Magdebourg, (Held, These, Strasbourg,  1836 ;) by M.
   Dieffenbach, at Berlin ; by M. Serre, (Correspond. Privec. 1837,) at
   Montpellier; by MM.  Roux, Blandin, and Laugier, at Paris; by
   M. Lenger,  (Encyolograph, des Sc. Med., 1838, p. 145,) in Belgium;
   by M. Little, in England;  and by M. Scoutetten, (Mem. sur la Cure
   Radicale des Pieds-Bots, 1838, in  8°, avec 6 pi.,) at  Metz.   M. Pi-
   vain asserts that, up to the month of July, 1837, M. Duval  alone
   had performed it more  than eighty times ; his brother, M. T. Duval,
   (These, No.  342, Paris, Aout, 1838,) now claims for him  as many as
%   two hundred cases ; and M. Dieffenbach told  me, in the month of
   October, 1837, that he had performed it one hundred and forty-five
   times.  In his last memoir, M. Bouvier also claims about twenty as
   the number  of his cases.  It is, therefore, an operation  which may
   count at the present day more than four hundred examples.   Nor
   does it appear, up  to the present time, that the life of a single per-
   son has been sacrificed to it, and, if Me believe to the  letter what
   its declared partisans say of it, it has never, so to speak, been un-
   successful.  Every thing at least shows, that it has  in the greatest
   number of cases succeeded, and that the only  accidents that have
   accompanied it have been violent  pains, as in the patient of Sar-
   torius ; an abundant suppuration, as in that of Delpech; and some
   gangrenous eschars, of which examples have been mentioned by
   MM. Duval Blandin, and Bouvier.
     It would  be in vain, then, that surgeons should raise the objection 
ALTERATIONS OF THE TENDONS OR MUSCLES.
447
of danger of destroying the continuity of the extensor tendon of the
foot.  Modern experience, on the contrary, tends to prove, that the
fatiguing dressings, so difficult  to maintain, and  devised by J. L.
Petit, Monroe, Desault, and so many others, to remedy the rupture
of the tendo-Achillis, are only calculated to aggravate the disease.
From the year 1832, I began to treat the rupture of the tendo-
Achillis by no other means than  simple rest and the immobility of
the limb for the space of three  weeks or a month.  The two first
cases which I submitted to this kind of treatment, the one in  1832,
the other in 1833, did so well, that it M'as not possible to keep them
in the hospital over three weeks.
  B.  Appreciation. The tenotomy of the tendo-Achillis is not  prop-
er, except in the pes-equinus, whether that be simple or compli-
cated with deviation of the foot towards one of  its borders; also,
there must  not be any consolidation (soudure) between the bones
of the tarsus, or  in the  tibio-tarsal  articulation.  We should not
perform it until after the section of the plantar aponeurosis and of
the flexor brevis digitorum pedis have  proved ineffectual, in  cases
where there is pes-equinus  with  the turning  under  (renverse-
ment inferieur) of the dorsal surface of the metatarsus.  I should
add, that the section of the other tendons around the joint should
sometimes be associated with that of the  tendo-Achillis.  The ob-
servations hitherto collected show, that it is applicable to all ages
and to both sexes, since it  has been  performed with equal success
from the age of two years to that of fifty, and upon women as M'ell
as  upon men.  By the modern processes, a month or two is suffi-
cient to put  the patient  in a condition to M'alk, with  the foot rest-
ing upon the ground throughout all its plantar surface.  It is true
that some patients, treated by the section of the tendo-Achillis, could
have been cured without that operation.  I have myself cured many
by the aid of the apparatus constructed by M. Mellet.  We effect
the same results with the apparatus of Bruckner, Joerg, D'lvernois,
and Dieffenbach. By enveloping the limb, while it is stretched out
straight,  in a mould  of plaster, as  M. Guerin has done, or in a
dressing rendered immoveable by starch, as M. Seutin has proposed,
or by dextrine, as I have twice done, M'hile making use of the bus-
kin (bottine) of M. Stoess, extolled by M. Held, we should, without
doubt, be enabled, with time and patience, to render the section of
the tendo-Achillis unnecessary in a  great number of cases.   But
this  operation is so simple, so little painful, so easy, and so little
dangerous, and its results are so prompt and so perfect, that, unless
there is a very decided repugnance  on the part of patients, it de-
serves to be almost  universally substituted for the employment of
those apparatus and dressings M'hich, up to our time, had, in truth,
so imperfectly supplied its place.

                    c. The Operative  Process.
  All the processes I have  mentioned,  in speaking of tenotomy in
general, have been applied to the section of the tendo-Achillis.  It
was the method of Tulpius which the surgeon Lorenz  followed. 
448
NEW ELEMENTS OF OPERATIVE SURGERY.
Sartorius made a long longitudinal incision on the posterior surface
of the tendon, and it  is this method which M. Reiche still  prefers.
The  method of Delpech relates only to the tenotomy of the tendo-
Achillis.   It is the same  with the processes of MM. Strohmeyer,
Bouvier, and Stoess ;  M. Bouvier, indeed, says he had practised it
in four different ways.  At  first  he  made  use of a  very narrow
curved bistoury, convex upon its  cutting edge, which bistoury he
inserted by puncture between the tendon and the deep-seated parts,
in the manner of M. Strohmeyer, but without  piercing the integu-
ments upon the  opposite side.  The second process tried by this
practitioner consisted in a transverse puncture, M'hich was made
in the skin near one of the borders of the  tendon by means of an
ordinary bistoury or lancet, and into which  was introduced a nar-
row  bistoury with a blunt point.   In the third process, M.  Bouvier
pierces the  skin lengthwise with a straight or curved  bistoury,
having a narrow blade, which he  glides  flatwise between the ten-
don  and  the integuments, and which is  then  turned to divide the
parts from the skin towards the deep-seated tissues.   His last pro-
cess  is composed of two stages.   A longitudinal puncture, of one
or two lines in length, being  made with the point of a lancet, or a
simple bistoury, on the  side of the tendo-Achillis, allows of intro-
ducing therein a blunt-pointed tenotome, which then divides the
tendon from behind forwards, or from its  superficial towards its
deep-seated surface.   The tenotome that M. Bouvier now uses is
a kind of cutting needle, a line in breadth at its base, a little nar-
rower  and  rounded  at its  point, and  shaped  (disposee)  nearly
like  the cystitome of the cataract case.  We see that the processes
of M. Stoess and M. Duval belong to the  same order as those of
M. Bouvier, and that all have been designed for the tendo-Achillis.
M. Scoutetten, (Cwe Rad. des Pieds-Bots, p. 75,) who operates like M.
Duval, insists  strongly, but  erroneously, as  I think, that  the punc-
ture should be made inside and not outside  the tendon.
   The Operation.  Whatever may be the method adopted, it is ad-
visable to place the limb on its tibial surface, and in such  manner
that the  foot,  remaining  free, may  be inclined  by an  assistant
charged with holding it, in this or that direction, according to the
pleasure of the  operator.  The surgeon having the posterior sur-
face of the limb before him, places himself  opposite to the plantar
surface of the foot.  With the  right hand, armed M'ith the lancet,
M'ith a straight bistoury, or a straight needle like the ancient cata-
ract-needles, he pierces the  skin on the external or internal side,
and  in a direction parallel with the tendo-Achillis.  If he has used
a bistoury or lancet, he immediately seizes one of the tenotomes
of which I have spoken, and glides it by slight movements forward
and backward (va et vient) under  the  skin, grazing (rasant) rather
the  surface of the tendon than that of the teguments, until he ar-
rives upon the opposite side, carefully avoiding wounding the  skin
in this last direction.  At  this point of the operation, the surgeon,
who had held his instrument  flatwise, turns  the  cutting edge upon
the axis  of the limb.  It is then that it becomes advantageous to 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         449

lower the heel.  We in this manner give such a degree of rigidity
to the tendon,  that its section is, to a certain extent, made of itself.
Gentle saw-like movements with the bistoury then quickly complete
it, and the operator marks the moment that  it is finished by a
crackling sound, and by a sudden  separation, which he instantly
perceives.  Turned back  again, flatwise, the instrument is with-
drawn through the puncture by which it entered, so as to make no
additional wound of the skin.
  If there should be any particular difficulties in the way, to pre-
vent our passing between the  teguments and the subjacent parts,
the operation  would  differ  from the  preceding only in this, that
after the puncture we M'ould cause the bistoury to glide flatwise
upon the anterior [i.  e., the deep-seated or internal—71.] surface
of the tendon,  which M'ould then be divided from before backward.
I need not add, that the operation would be the same, if,  in place
of a special instrument, M'e should prefer employing the  straight
bistoury, or the  ordinary blunt-pointed (boutonne)  bistoury.  The
wound in the integuments being longitudinal, closes of itself by
the adjustment of  the foot;  being reduced to the state of a simple
puncture, it generally disappears in twenty-four hours. The slight
ecchymosis, also, M'hich is  sometimes seen under the skin, should
create no apprehensions.
  When the tenotomy is finished, M'e  straighten, and may without
danger readjust the point of the foot in such manner, that the two
ends of the tendon are separated at least an inch asunder.  If, in
order to replace the foot at  a right-angle upon the leg, it should be
necessary to carry this separation to more than an inch and a half,
prudence would dictate that we should not proceed any further for
the moment, and that we  ought not  to endeavor to increase this
separation until after ten or fifteen  days.
  Moreover, the buskins and apparatus for straightening the foot
may be applied as Lorenz and Sartorius have already done, immedi-
ately after the operation.   MM. Bouvier, Duval, Lenger, and Scou-
tetten, (Cure Radicate des Pieds-Bots, p. 90,) who have adopted this
course in a great number of cases, have proved by their success
that the scruples of Delpech on this  point, and the fears of MM.
Strohmeyer and Stoess, are not well grounded.
  Patients who have undergone'the section of the tendo-Achillis,
begin to walk, with a certain degree of freedom, from the tenth to
the twentieth day, and they are  nearly perfectly cured  in  the
course of the second month.
  3. Club-Foot turned forward, or Talus.  Club-foot with the foot
turned upward towards the front part of the leg, is rare.  I have
seen it twice in foetal monsters. I have not, as yet, seen any ex-
amples of  it  in living persons. M. Duval says he has  seen two
cases of  it, (Pivain, These citee, p. 7,) Delpech, (Orthomorphie, $c.,)
M.  J. Lafond,  (Difformites du Corps Humain, Paris, 1829,  in-4°, p.
300,) and M. Stoess, (Dissert, sur le Pied-Bot, p. 3,) each  give  an
example of it, and M. Scoutetten, (Cure Radicate du Pied-Bot, pp.
27, 28, pi.  v.)  appears also  to  have seen several cases.   Though 
450           NEW ELEMENTS OF OPERATIVE SURGERV.

one of the patients mentioned by M. Duval was  cured by moans
of plugs (tampons) of lint and simple tractions, it is not the  less
probable,  that in individuals  more advanced  in  age, the section
of the tendons M'ould be the best, and perhaps the only remedy for
talus.  In these cases, the  infirmity is  imputable  evidently to the
retraction of the tibialis-anticus only, or to that of the tibialis-anti-
cus and peroneus-tertius, or that of the extensors of the toes
  I have not learned that the tendons of the extensor-eommunis
and  of the  peroneus-tertius have, up to the  present  time,  been
designedly divided to remedy any deviation of the foot.  It Mould,
however,  be an easy operation, and of little danger.   We might
perform it either above or below the anterior annular ligament of
the tarsus.  It would be much better above, inasmuch as the ten
dons below, being  already more or less separated, could not be so
easily divided with the same stroke of the bistoury.   The anterior
tibial artery, or the commencement of the dorsalis-pedis, could alone
create any apprehension; but  the  tendons in such cases are so
much the  farther removed from these arteries, in proportion to the
greater "degree of retraction.
  The leg being supported upon its posterior surface against some
sort of prop, (soutien) and held in this position by assistants, would
allow the  surgeon to place himself by the  side of the foot, in the
same manner as for the section of the tendo-Achillis. Armed with
a straight bistoury, the  operator should  puncture the skin on the
inside or outside of the bridle, according as he should make use of
his right or left hand, or operate upon one or the other leg.  Guided
between the tendon and the integuments till it reaches the opposite
side, the instrument  should be  used in other respects precisely as
has been said in speaking of the section of the tendo-Achillis. If
the extensor tendons of the toes only are implicated, the operation
in general should  be performed at the  distance of half  an inch
above or below the instep.   For the peroneus-tertius we should be
obliged to do it a little lower down.  After all, we must not forget
that it is the tendinous projection (relief) which more particularly
points out the place where it is  most advantageous to apply the
instrument.  On the  supposition that  the  tendon of the tibialis-
anticus has also been divided, there would remain  nothing more
than to straighten the foot, then to force it, by means of buskins,
(brodequins) or appropriate apparatus, to acquire the proper degree
of extension, and to lose its tendency to abnormal flexion. It is, fur-
thermore, presumable that this species of club-foot would be one of
the most difficult to cure radically, and one of the least favorable for
the section of the tendons.
   4.  Varus. Whether it is found alone, or is complicated with pes-
equinus, the varus, which sometimes exists to such degree  as to
compel the patient to walk almost exclusively on the external edge
of his foot, very frequently requires that we should divide not only
the tendo-Achillis, but the tendon of the tibialis-anticus, the tendon
of the tibialis-posticus, and even those of the long extensors or long
flexors of the toes. 
             ALTERATIONS OF THE TENDONS OR  MUSCLES.         451

                A.  Section of the Tibialis-Anticus.

   We may conceive, from what I have said  in the preceding  par-
 agraphs,  that' the section  of the tibialis-anticus may be  useful
 in two varieties of club-foot, that is to say,  in the Talus and the
 Varus.  This operation, which M.  Held formally advises.  (Thise
 citee, p. 64,) which M. Duval appears to  have practised, (Pivain,
 These citee, p. 22,) and M'hich, according to M. Bouvier, (Mem. de
 VAcad. Roy. de Med., t. vii., p. 411,  et suiv.,) has also been  per-
 formed by M. Dieffenbach  and M. Strohmeyer, might  be  resorted
 to at once, if it should appear that in the distortion of the foot for-
 ward or inM'ard, the tendon of the tibialis-anticus M'as more forci-
 bly retracted than any other.  Up to the present time, however, it
 has not been had  recourse  to, until after having  ascertained  that
 the section of the tendo-Achillis was insufficient.
   The Operation.  Inserting itself at  the posterior and inner  part
 of the first  cuneiform bone, this tendon naturally makes a consid-
 erable projection  in front of the internal malleolus.  It would be
 advisable to place the leg in the same position as for the section
 of the extensor tendons of the toes, taking care to turn out the foot
 a little in the direction of its external border.  If the puncture M'ere
 made under and in front (en avant)  of the  apex of the malleolus,
 and behind the tendon, the bistoury should proceed along the inter-
 nal surface of the skin, from behind forward, and from below up-
 ward, before its cutting edge has been turned towards the instep, to
 effect  the  section of  the' retracted tendon.  But  this manner of
 proceeding, which should not be adopted but with the  view of
 being enabled to avoid,  with the utmost degree of certaint)', both
 the  extensor tendon of the  great  toe, and  the  arteria  dorsalis-
 pedis, would be manifestly more embarrassing and  more difficult
 than that which consists in making  the puncture on the outer  side
 and  in front, in order  to  penetrate  afterwards  from the  instep
 towards  the tendon.  By this  last  process,  it would  be almost
 always practicable  to insert the bistoury far enough towards the
 inner side (en dedans) to be certain of not wounding  either the ar-
 teria dorsalis-pedis, or the long extensor muscles of the toes.

                      B. Tibialis-Posticus.

  The section  of  the  tibialis-posticus, also recommended by M.
 Held, seems not yet  to have been performed but on the dead body.
 We cannot, however,  discover  any advantages from it, except as
 an auxiliary to the section of the tendo-Achillis in the pes-equinus
 complicated with varus; for it would be difficult  for the  tibialis-
 posticus itself to give existence to any kind of club-foot whatever.
 Though tenotomy of the tibialis-anticus and of the extensors of the
 toes be as practicable above as below the instep, it is not so m ith the
 tendon of the tibialis-posticus. Adherent as it were, (comme colli) to
 the posterior border of the  internal malleolus, and almost immediately
in contact with a large artery, namely, the posterior tibial, this ten-
don could  not be cut without danger before its entrance into the in- 
452
NEW  ELEMENTS OF OPERATIVE  SURGERY.
ternal groove of the os calcis. It is only, therefore, near its attach-
ment to the  postero-internal extremity of the scaphoid bone, that
we should endeavor to reach it.  For that purpose, we should place
the leg upon its  outer  side, (face  externe.)  A bistoury should be
inserted by puncture, at some lines in front of the internal malleolus,
a little under or behind the tendon of the tibialis-anticus.  Carried
afterwards almost  directly  downward, the instrument should  be
turned upon the tendon  [of" the tibialis-posticus] at  about half  an
inch under and in front of the apex of the malleolus. Taking care
not to lower the  point of it too much, and to incline it as little as
possible towards the plantar surface of the foot, we should be cer-
tain to avoid the internal plantar artery, the only one that can in
terfere with us in this region.

                 C.  Tendons of the Great Toe.

  The flexor tendon of the great  toe has been divided upon the
first phalanx of this toe, as I have  already said, by M. Syme, for a
retraction produced by  inflammation.   Michaelis appears also  to
have  advised the section of this,  as of all the other tendons, but
with the injunction to  do it partially only.   It was reserved for
MM. Strohmeyer and Dieffenbach to associate it with  that of the
tendo-Achillis, to remedy the pes-equinus varus.  In that case, also,
it M'ould be more proper to perform it, like M. Syme, upon the first
phalanx of the great toe, than to endeavor to accomplish it under
one of the  points of the internal border of the foot.  The tendon,
divided in its fibrous groove, would retract M'ith as  much freedom
as if we had divided it in the neighborhood of the heel.
  The foot, presenting its plantar  surface to the operator, would
give him an opportunity to raise the  great  toe,  and to cause
the instrument  to penetrate  from one side of the  retracted tendon
to the other, as has been  said in speaking  of the tendons  of the
instep.  In taking the precaution to insert the  instrument a little
nearer the plantar than the dorsal surface of the toe, we should,  as
in the fingers, avoid the lateral arteries ; nor can we see  that this
operation would be  in the least degree dangerous.
  The section of the extensor, also,  of the great toe, has been per-
formed  by  MM. Strohmeyer and Dieffenbach,  (Bouvier, Mem.  de
VAcad. Roy. de  Med., t. vii., p. 411,  et suiv.,) to  aid,  as  in the case
of the flexor, in the success of  the division of the tendo-Achillis.
It would also  be evidently more  easy, and  could  be performed
upon the whole extent of the tendon, from above the instep to near
the last phalanx  of the toe.  In making the puncture on its outer
side, in order afterwards to reach its inner border, we might divide
it with  a single stroke  of the instrument, without having to fear
the wound of any important organ.
   5. Section  of the  Peroneus Longus  and Brevis, in Valgus.  The
valgus form of club-foot, in itself a rare occurrence, and rare also
as complicated with pes-equinus, has, up to the present time, offered
but few occasions in which tho section of the  tendons could be 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         453

applied to it.   M. Pivain, (These citee, p. 23,) however, cites an ex-
ample of it, where M. V. Duval thought it advisable to undertake
this section before proceeding to that of the tendo-Achillis.   I also
possess a fact which proves that we should  be wrong in having
any fear from it in regard to the re-establishment of the action of
the muscles.  M. D*** had a deep wound made in the leg by some
fragments of Delft ware.  The  wound in the integuments, which
extended from the anterior  surface of the fibula to the posterior
median line of the leg, a little above the heel, comprised the whole
thickness of the peroneus-longus, and the half of that of the pero-
neus-brevis and of the tendo-Achillis.   The separation of the divi-
ded tendon was near two inches in width.  The integuments were
united by the twisted suture, and the foot adjusted by a prepared
splint, which I fastened upon the entire outer side of the limb. This
severe wound, which ultimately cicatrized, was followed by a very
considerable degree of feebleness in the power of  abduction of the
foot, for six to eight M'eeks; but at the end  of some months  the
patient recovered from  it, and  it is now a long time  since he  has
thought no more of it, and that  the functions of the foot have been
perfectly restored.
  It is said in the thesis of M. Held, that M. Stoess was upon  the
point of performing the section of the  tendons of  the peronei in
1836.  I do not know if this operation has, in our time, been intro-
duced into surgical science.   However that may  be, it  may be
performed, like that for the tibialis-anticus,  above or below  the
malleolus.  In the first point, it would  be  better to divide the two
tendons at one stroke. This could be done with most ease at about
an inch above the base of the external malleolus.   As for the rest,
I do  not think there would be any great advantage  in penetrating
from before backward, rather than from behind  forward.  I am of
opinion, however, that, in going from the fibula towards the tendo-
Achillis, we should render the operation a little easier, and that, in
strongly raising the handle of the  bistoury, at the moment of ma-
king the section of the tendons, we should have the advantage of
finding a point d'appui on the postero-external surface  of the fibula
itself, which would  be so much the more to our advantage, that
there would be  no  risk of  penetrating to the  bone.   Below  the
malleolus, we might divide the tM'o peronei together, or make their
section separately.  It would be at the distance of six lines in front,
and below the apex of this process, that it would  be necessary to
insert the instrument, if we wished to divide the tM'o tendons at one
stroke.  We could reach the tendon of the peroneus-longus, by itself,
at the middle of  the space which separates the point of the malle-
olus from the external tubercle of the cuboid bone.  As to the  pe-
roneus-brevis, we should have to look for it at the external border
of the fleshy mass of the extensor-brevis digitorjum pedis.   In all
cases the puncture should be made upon the inner side (cbte interne)
of the bridle to be divided, that  we may carry the  instrument from
within outward, between the teguments  and the tendon, before
making its cutting edge  act from the skin towards the bones. 
454           NEW  ELEMENTS OF OPERATIVE  SURGERY.

  These sections being performed, it will be necessary, as after the
section of the tendo-Achillis, to make use of buskins, gaiter-boots, or
bandages, to ensure their successful result, and to  adopt, also, all
the precautions required in respect to  the cicatrix, and  in  what
concerns the re-establishment of the movements and readjustment
of the foot, to prevent these dressings from  doing any injury.
  [Talipes, or Club-Foot.  A circumstance of importance, generally
overlooked, and one  which greatly diminishes  the danger, even
where  the large arteries are wounded, in operations for retracted
tendons or muscles in any part of the limbs, and especially for
club-foot,  is  the  atrophy or  shrivelled state of  the  limb  from
defective motion and nutrition, as noticed by Dupuytren.  So little
was known or thought of the  section of the tendo-Achillis in the
United States as late as 1834, that, according to  Dr. Reese, (see
his last edition of Cooper's  Surgical Dictionary, New York, 1842,)
an eminent surgeon of New York had recourse that year to the
amputation of the limb, in  a gentleman affected with club-foot!
In connection with what  we shall say farther  on of the Ameri-
can  pioneers in this  part of tenotomy, viz., Drs. Dickson, Smith,
and Detmold, we have also to state, that Dr. C. B.  Gibson, of Bal-
timore, has described a fifth variety of club-foot, in addition to the
four divisions generally enumerated by authors, viz.,  talipes pha-
langealis, where, (according to the  accounts given in  the last edi-
tion of the Institutes of Surgery, by his father, Professfcjr Gibson, of
Philadelphia,) the patient stands on the dorsal face of the cuboid
and cuneiform bones of the tarsus, the toes and metatarsus being
turned under the heel, and the forepart of the foot beneath the axis
of the  limb.  Dr. C. B. Gibson, and his  father, the professor, attri-
bute much more importance to the apparatus used after the division
of the  tendons, than is generally admitted.  The first-named phy-
sician  extols, for this purpose, the apparatus  of Dr. Heber Chase,
of Philadelphia.  From an examination of its principles, we do
not think it can obtain a preference over  the very ingenious con-
trivances of this kind, for every species of deformity, osseous, ten-
dinous, or muscular, perfected by M. Jules Guerin, of Paris, and now
successfully imitated by Tieman  and other surgical instrument
makers of New York, after the models and patterns  which Prof.
Mott brought with  him to  this country, and which were  made, at
Paris under the supervision of M. Guerin himself.
   Dr. Detmold, (New York  Journal  of Medicine and Surgery, 1840,)
by an  estimate of the cases of club-foot which have fallen under
his care, makes the proportion  of  males somewhat greater than
that of the other sex, and  also the number of cases  where both
feet were  affected  about  equal to that of  each foot separately,
the right foot in the  latter  being rather more frequently the  seat
of the disease than the left.  A very large  proportion were  con-
genital, and  almost all of these were otherwise well  formed.   In
the M'hole number of cases upon which his data were founded, (viz.,
at that time one hundred and sixty-seven)  two only had the whole
limb shortened, in one case of which the deformed leg was one-half 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         455

shorter than the other.  In one, there was also hare-lip; in seven,
strabismus ; in one, the toes were M'eb-footed ; and one had an addi-
tional  thumb on the hand corresponding to the  club-foot.  The
proportion of hereditary cases were on the father's side, because,
perhaps, as  is said, club-foot  females seldom  marry.   Of the
whole  number of cases, (93 being double.) two hundred and thirty
of the feet Mere talipes varus;  eleven, valgus; seventeen, equinus:
one  only of talus, but existing in both feet.  For this last variety,
Dr.  Detmold ingeniously suggests the  name of  equestris, as  it
resembles the position of the foot in the  stirrup in  riding.  In a
great majority of cases, the division of  the tendo-Achillis is, in his
opinion, all that is required, especially in young  subjects ; that in
most cases, this, with subsequent apparatus, generally suffices for
the  cure; and that  the  division of other tendons  may be made
afterwards, if necessary.   Dr. Detmold is opposed to the immediate
extension of the  foot by any apparatus, and  prefers waiting two
or three days, till the effusion of plastic lymph is perceived between
the extremities of the tendon.  He prefers, also, his own improvement
upon Strohmeyer's foot-board, and thinks well of Scarpa's shoe, but
rejects the mould of plaster recommended by Guerin.  In justice
to M. Guerin, it should be added, that his admirable  boot, as it may
be called, in all its  modifications, M'ith all the  necessary screws,
straps, and steel  supports, covered with leather cushion paddings,
is the  one which he now most uses; this surpasses, in ingenuity
and  practical utility, (in the opinion of Dr. Mott and others,) any
thing known. In tM'o hundred and thirty cases of club-foot, Dr.
Detmold divided the tendo-Achillis in one hundred and sixty-three,
and  in seventeen of these, he  made also the section of the other
tendons and of the plantar aponeurosis.   In three cases only was
the  tendo-Achillis divided a second time.  In eleven cases  of val-
gus,  two of talus, and forty-five of varus, mechanical means only
were used.   Dr. Detmold has now performed more than four hun-
dred operations on club-foot, and divided  more than one thousand
two  hundred tendons, on Strohmeyer's plan.   We have frequently
seen him operate, and must do him the justice to say, that he per-
forms these sections  with admirable adroitness and  astonishing ra-
pidity.   Dr. Detmold has divided, also, a large number of tendons
for other deformities in the limbs, &c.
  Dr. Mutter, of Philadelphia, who has, next to  Dr. Detmold,
treated more cases of club-foot than any other American surgeon,
enumerates  now two  hundred  patients of this  description, who
have fallen under his care within a very few years past.  He has
also  treated numerous other cases of distortion, as  torticollis, con-
tracted knees, eighty of strabismus, &c.
  Dr. A. G. Walter, of Pittsburg, Pennsylvania, (according to Dun-
glison's American Medical Intelligencer, May, 1840,) has made more
extensive sections in the lower extremity, in the same patient, than
any other American practitioner.  In a case of complicated deformi-
ties of the lower extremities, he is said to have made, with success-
ful results, the sub-cutaneous  section of the tendons  and muscles 
456
NBW  ELEMENTS OF OPERATIVE SURGl'.RV.
of the hip, knee, and ankles, viz., the adductor-longus, gracilis,
fascia-lata, sartorius, semi-membranosus, semi-tendinosus, and  the
tendo-Achillis and peronei  of each foot.  For the peronei he pre-
fers cutting beloM' the external malleoli.  In this  case, mechanical
means Mere  afterwards  used.  The ultimate issue is not given,
though  the  stature of the  patient had been, by  the statement,
increased six inches.
  Dr. Little,  of London,  mentioned in the text  of  this work, and
who, himself a subject of this disease, was cured by Strohmeyer,
remarks, in his published treatise on club-foot, that in  numerous
cases of the congenital description it is frequently found associated
with  the concomitant deformity  of a  club-hand, and  in some, as
remarked by  Dr. Detmold, with that of strabismus ;  also, in certain
other cases, with congenital stammering.  All these  clearly indi-
cate, in our opinion, an organic, pre-existing, contractile diathesis
of the voluntary muscles.
  Non-congenital cases of club-foot may lead to the  clew of the
causes in congenital cases.   In most of the former cases, Dr. Little
seems very justly, as we  think, to connect them with the period of
dentition, as being that when they most  usually first make their
appearance.  He might  have added,  moreover, that  a ready ex-
planation is here found  in the intimate, if not intense, organic or
metastatic sympathy naturally subsisting (and now actively exci-
ted by the irritation of dentition) between the peculiarly sensitive
mucous membrane of the alimentary  passages, especially during
infancy, and the organs of  voluntary motion.  A fact  well known'
to practitioners, as illustrative of the last mentioned sympathy, is
the violent spasmodic contraction of all the bulky flexor muscular
tissues of the limbs in Asiatic cholera, responding intimately and
directly with the equally violent  convulsive cramps of the muscu-
lar coat of the stomach itself.  This, too, is faintly seen in ordinary
cholera morbus, and often, also, in the  production of temporary or
even permanent contractions of the flexors of the thumb and fin-
gers,  and also strabismus,  M'hich all  are  equally well  known in
childhood, more especially, to be directly imputable to  chronic
cases of derangements of the intestinal tube from atony, acting di-
rectly through the ganglions or indirectly through the cerebro-spinal
system.  And also to this are to  be  ascribed  the permanent  con-
tractions of the  flexors of the thumb and fore-finger, noticed even
in adult age, and, as mentioned long since by Moseley and others,
as a characteristic feature in what is known as the dry belly-ache
of the West Indies.   In the  cases from dentition, varus, coming on
gradually, is the most frequent variety.  Dr. Little mentions ca-
ses, also, of club-foot in young women from habitual spasms of the
gastrocnemii, and of the  anterior  and posterior tibial muscles from
attacks of hysteria, [here too often primarily imputable to intesti-
nal derangement, no doubt.]  He properly remarks, that this  de-
formity may thus be produced non-congenitally, from any paralytic,
spasmodic, or nervous cause whatever, which permanently or forci-
bly disturbs the equilibrium or antagonism of the  muscles of the 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         457

limb, &c.   This rational etiology  will, of course, properly direct
the attention of the practitioner first to a judicious course of patho-
logical treatment, founded upon the functional derangement exist-
ing in the cerebral and cerebro-spinal centres, and in the ganglionic
system, as connected with the splanchnic viscera.   The general
medication, therefore, and mechanical means, should precede the
sub-cutaneous section of the tendons.
  Dr. Detmold has operated for club-foot as early as at the age of
three months.  Dr. Mott, and also Dr. Carnochan, of New York,
have operated as early as one month or six  weeks.  The earlier
the period of life after two months, the more  successful generally
is the operation, because of the pliancy of the parts.
  Mr. Braithwaite, in his valuable Retrospect of Practical Medi-
cine and Surgery, (January to July, 1840,) to illustrate the natural
curative power of the tendinous tissues, mentions a case of his, in
which a woman,  by some violent exertion, tore off a portion of the
os calcis, which, with the tendo-Achillis attached, protruded through
the integuments.   The bone was cut from the tendon, and the lat-
ter replaced.  The parts  then healed kindly, so that she walked
almost as perfectly with this leg as with the other.—T]

   [Excision of a  portion of the Tendons of the Leg for Paralysis.

  There would seem to be no end to the admirable uses to which
this branch of surgery  is extending itself.  Mr. James Braid, of
Manchester, England, (see Medical Gazette,  April 23, 1841,) has
proposed an entirely new application  of tenotomy, M'hich promises
to be of great value.  The cases were as follows:  In a  female, the
left leg was comparatively powerless for two years from a para-
lytic stroke ; it hung dangling by the side of her crutch, and in-
clined to varus.  After every effort at medication had  failed, Mr.
Braid made a, longitudinal incision  along the course of the peroneus
tertius, which he elevated, and then excised a portion of it to the
extent of three sixteenths of an inch,  closing the M'ound M'ith plas-
ter, and applying bandages and splints to approximate the edges of
the division and  maintain  them in contact.   In twenty days she
walked perfectly.  In a boy aged six and a half years, with talipes
varus ever since  he was one year old, such M'as the relaxed or par-
alyzed state of the extensors of the foot, that the latter could M'ith
ease be placed against the forepart of the leg.  He had no power
over it.   Three eighths of an  inch of the tendo-Achillis M'ere ex-
cised.   On the tenth day the wounds were closed.   At the end of
three weeks, in consequence of a fall, inflammation and suppura-
tion came on, which soon ceased and the wound healed.  In three
months  he could walk  perfectly M'ell, and extended  his  foot with
ease.  Caution, Mr. Braid says, is  required, that neither too much
of the tendon is excised, for fear of producing too great an excite-
ment upon the contractile power of the muscular fibre, nor too little
of it, for fear of  the opposite effect.   Here is a new process, the
reverse  of ordinary tenotomy, in respect to retraction of the part,
exclusion of air, and inflammation and separation of the divided
                              58

     » 
458
NEW ELEMENTS OF OPERATIVE SURGERY.
parts, yet deriving its utility from the  leading  principle of tenoto-
my—that of the division of the abnormal tendon.  Ii  is founded on
sound pathology, but the operation may prove hazardous, from the
necessity of laying bare the tendon.
  Mr. Braid remarks, that in pure talipes equinus, M'ith rigid con-
traction, it will generallv be found that, besides the tendo-Aehillis
and  plantaris, there are also implicated the flexor longus pollicis
pedis and flexor longus communis, tibialis posticus and  perofieus
longus and brevis.  He  admits that powerful extension may ulti-
mately  bring  the  foot  into its natural position, M'here the tendo-
Achillis is divided, but this will be attended with much  more tor-
ture, and  not  accomplished so soon, as where such of the other
named muscles as are rigid are also divided.  In this latter case, a
sufficiently firm reunion will have taken place in four or five days
to enable  the patient to extend the foot, if the operation has been
properly performed and the patient  is a healthy subject.   This di-
vision of the abovenamed muscles M'as suggested to Mr. Braid by
seeing a patient instantly walk across the room, with his toes out
and soles flat to the ground, after he had divided the tibialis posti-
cus and flexor pollicis pedis in  a case of slight varus. The division
of these muscles M'ith that of the tendo-Achillis is the mor neces-
sary, because, from their antagonists being more or  less feeble, if
extension only is  used, the disease will often return.  In equinus
and all  other varieties the leg should be bandaged to the knee, to
keep the  foot in its morbid  position  and to prevent the muscles
contracting, and thus  making  the separation too great before the
plastic lymph  is deposited.  Gradual extension should begin in two
days. In varus, also, he divides at once every tendon that can pos-
sibly retain the foot in its morbid position ;  also, the plantar fascia
and short flexors, should there be much contraction  in the sole of
the foot.  The muscles he generally divides in varus are the Achil-
lis, tibialis anticus  and posticus, flexor longus  pollicis pedis, flexor
longus communis,  and abductor pollicis,  if required.  In valgus, he
frequently divides  at  once the peroneus longus and brevis; some-
times, also, the Achillis, peroneus tertius, and the extensor longus
communis, and propius pollicis pedis.  In calcaneous talipes, (i. e.,
talus)  he sometimes divides at once the tibialis anticus, extensor
proprius pollicis pedis, extensor longus digitorum pedis, and pero-
neus tertius.   In most cases of equinus, even after the restoration,
the leg  is found a little shortened, which must be compensated by
a high-heeled sole. For adults,  Mr. Braid  uses a straight teno-
tome, one inch and a quarter long, and about a twelfth of an inch
broad ;  the point, being cut off at an angle of about sixty, is less
apt  to transfix the tendon and leave any portion of it undivided
than the curved or sharp-pointed blade.  Also, it is less liable to
make a counter-opening in the integuments. For infants and chil-
dren, a much  smaller blade Mill suffice.
   Mr. Braid prefers the  division to be made as follows: For the
tendo-Achillis, about  an inch  and a half from  its insertion in the
adult, and propCrtionably less in younger patients—and he prefers 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         459

cutting from without inwards; the tibialis anticus, neardts inser-
tion  in the os cuneiforme internum;  the tibialis posticus, near its
insertion in the os scaphoides; the flexor longus pollicis pedis and
flexor longus digitorum pedis, at the point of decussation in the sole
of the foot from within outwardly; and from this same wound, the
plantar fascia, also, when necessary.  The  peroneus longus and
brevis are best divided together above the  malleolus externus, but
separately  below it, near their points of insertion; the extensor
longus digitorum pedis, before the point of separation into distinct
tendons; the extensor proprius pollicis pedis, a little more inward-
ly ;  and the peroneus tertius in the same line, or near its insertion,
as may be preferred in the respective cases?;  all these latter from
within outwardly.
  Instead of Strohmeyer's foot-boards and Scarpa's shoe, which are
rather too costly for the poor, Mr. Braid recommends for extension
a sole-piece of hard-wood deal,  about three eighths  of an  inch
thick, and to be of the length of the foot and breadth of the sole at
its greatest width, with an edge two inches and a half deep to rest
upon the inside of the foot.  The  two pieces are fastened together
with screw nails, and a notch cut in the sole pieces anterior to the
malleolus externus, and  in the  side  piece behind the root of the
great toe, to  allow the bandage the better to embrace the foot and
make  it lie  close to  the wooden sandal.   This should be covered
with sheet M'adding or a  pad, and be bound firmly on the foot with
a roller, or with two or three straps and buckles.  A piece of wood,
from two to three inches wide, and sufficiently long to reach from
the foot to a little below the knee, with a notch at the bottom cor-
ner, and with an arm extending forwards to  about three quarters
the length of the foot, is now to be made fast to the foot and sole
piece, by means of  a bandage passing from the front of the leg
piece under and round the sole piece and foot, and then under the
posterior notch from without inwardly  and over the  dorsum of the
foot, passing again  round the foot and sole  piece, and placed at an
acute angle M'ith the sole, so  that it  may have sufficient leverage
to elevate the foot  when the upright stem is carried back to the
side  of the leg. An assistant is now to be requested to place a little
wadding or pad  at the  inner edge of the  leg piece, and carry it
back against the top of the tibia, the surgeon regulating the exten-
sion  to the degree that the patient can bear by allowing the ban-
dage to give way in the  mean time more or less, as  he judges ne-
cessary. He is now to pass the bandage round the foot, ankle, and
leg, from the foot upwards, embracing, also, this lever, with such
a degree of tension  as he may judge requisite to secure and main-
tain  the necessary  degree of extension the case requires and ad-
mits of.
  The above is a combination of the lever  and inclined plane, and
is capable of great power.  It is applicable to every variety of ta-
lipes.  It should  at first be  undone  and applied once or twice a
day, and the foot  oathed  with  spirit lotion.   Afterwards it is to be
kept on a longer time. 
 460           NEW  ELEMENTS OF OPERATIVE SCRCERY.

   Mr. Braid, in recommending  the above practical precepts, says
 he does so M'ith the greater confidence, from having tested their
 utility in a more extended practice in talipes than any other person
 in the United Kingdom.
   As permanent rigid contraction of the muscles and tendons pro-
 duces exhaustion of the muscular and nervous energy of the limb,
 coldness, and loss of feeling, so is their division immediately fol-
 lowed by an increase of temperature, not only in club-foot, but es-
 pecially in the hand and arm; and in such  cases  such has been
 the  almost miraculous restoration of strength, that patients over
 thirty years, who have not been able to raise their arms in five or
 six years, have in two or three minutes been enabled to lift them
 to their heads.  A patient aged seventy, M'ho had paralysis of the
 right side, and had been dumb for three  years, M'as, in eight or ten
 minutes after the operation, enabled to raise the  arm pretty freely,
 and on  the following  morning spoke for the first time since his
 paralytic seizure.  As connected with this subject and Mr. Braid's
 new process of curing paralytic limbs by excision of the relaxed or
 elongated tendons and muscles, (already referred to,) he mentions
 the  case of a boy aged ten,  with a dangling paralytic leg, and his
 head hanging down on the  shoulder, and general muscular weak-
ness, requiring crutches, and whose Achillis  he had divided for ta-
 lipes.   The patient  made out to walk in three  weeks, soon after to
 support  himself  on  his leg  and raise his head, and finally threw
 away his crutches and walked with a stick.   '• I could,"  says Mr.
 Braid, " adduce  other  instances where weak  and withered arms,
 almost  from birth, have thus been restored both to power and in-
 creased  size."      f
   Under this  point of view,  Mr. Braid notices three varieties of
 paralysis—1.  Where one class of muscles was  in constant rigid
 contraction ; 2. Where there was not morbid  tension, but morbid
 relaxation of one or more muscles ; 3.  Where there M'as a morbid
 relaxation of the whole member, say a leg or an arm, with wast-
 ing  of its substance.
   In cases of withering of the muscles and paralysis of the limb for
 years, Mr. Braid also  speaks  of another  extraordinary remedy
 which he has discovered besides excision.  It is merely a continued
 friction  for a short time by rolling a smooth cylindrical body (as a
 strong ounce vial) over the  limb, from the roots of the nerves and
 trunks of the blood-vessels  in a direction towards their extreme
 branches, establishing thus a free use of the limb in some cases in
 the  space of ten minutes !  The cases he gives  seem almost incred-
 ible ; and his treatment is based upon the pathology of a deficient
 supply of  nervous fluid, M'hich  he by this  process forces into and
 accumulates in the part.—(Vide Edinburgh Med. and Surg. Jour.,
 Oct., 1841.)
   Professor Gross, of Louisville, United  States, (see his edition of
 Liston''s Elem. of Surgery, Philadelphia,  1842,)  deprecates what he
 calls the rage or monomania for tenotomy, " carving of the ten-
 dons," &c, and  seems to agree with Dr. Chase, of Philadelphia, 
ALTERATIONS  OF  THE TENDONS OR MUSCLES.         461
that, in tM'o thirds of the cases under two or three years of age, an
apparatus properly constructed and  applied is  quite sufficient for
the cure.  It  happens that orthopedy, tenotomy, and myotomy, in
Europe, have, in the hands of such masters as Strohmeyer, Guerin,
Dieffenbach, Bouvier, Duval, &c, on the continent, so immeasura-
bly surpassed their advancement in all other countries, even in Eng-
land, that the profession,  so to  speak, with some one  or two rare
exceptions, perhaps, in our own country, and M'hich will be found
in the proper place, have been left behind the  rapid march of this
department of science abroad.  Many, therefore, M'ith a natural
feeling, decry or disparage such revolutionizing innovations as fear-
ful ; and as an illustration of this, it may be remarked, that even in
what are termed standard and perfect works on surgery, published
up to the present moment, either in  England or America, the sub-
ject is scarcely adverted  to; or in such a trivial M'ay,  we must be
allowed to say, as to have rather a tendency to cast doubts or ridi-
cule upon, than to inspire confidence in its efficacy. This is a radical
and unpardonable error.  For, to believe such authors, it M'ere only
necessary to make a few  slight  reminiscences of, and devote some
five or ten pages to, club-foot and torticollis, and enough is done to
satisfy the inquiring minds of the present generation on a subject
which is in every one's mouth for its brilliant  results, and which
already covers an immensity of space, to say nothing of its kindred
discovery, Anaplasty. The truth is, that the study of the whole sub-
ject of  the surgical anatomy of  the muscles, tendons, aponeuroses,
fasciae, ligaments, capsules, &c, which had hitherto  been almost
slurred over as a waste of time, has to be thoroughly gone into by
medical men of the present day to make them capable of compre-
hending properly the nature of this great  department of operative
surgery.  Hinc illae lachrymae !
   Professor Fergusson, of London,  (System of Practical  Surgery)
says of the operation for  club-foot, that, in the young  subject, the
tendons and muscles are all so near to each other that either of the
tibial arteries may occasionally be wounded, and that he is under
the  impression that in  children they are  frequently  wounded, in
which he has been confirmed in his own practice by the subsequent
flow of blood.  He adds, that a little pressure with a pad and ban-
dage has effectually restrained the hemorrhage, as I have also had
occasion to see in the case of a child, in which one or both these
arteries were unquestionably wounded in this operation.  Pressure,
he remarks, is equally effectual in divisions in the sole of the foot.
In adults, the wounding of the tibials might cause more trouble. P
every case the arteries should be carefully avoided.
   In the apparatus afterwards to be used, and which  is an impor-
tant part of the cure, Mr.  Fergusson hassometimes found a common
pasteboard or wooden splint, placed along the outside of the leg
more effectual, or  at least more  manageable,  in  children than
any other contrivance.  He would not apply any apparatus imme-
diately after the  operation, if it caused  much pain, or was done at 
462           NEW  ELEMENTS OF OPERATIVE SURGERY".

the risk of laceration or inflammation; but he believes the sooner
it can be applied the better.
  In accidental  ruptures of the tendo-Achillis,  Mr. Fergusson has
seen the parts, kept  in proper contact, become united as firmly and
appear as strong, even  in very heavy individuals, as any other por-
tion of the tendon.—7YJ

                    f. Tendons of the Leg.
  The flexor tendons only of the leg are those M'hich have been
charged M'ith producing a  deviation of this limb, and M'hose divi-
sion has attracted  the  attention of surgeons.  What I have  said
above, however, in relation to the rectus-femoris and the ligament-
um-patelke,  would authorize, us to undertake the  same operation
in front, (en  avant) if theqaudriceps extensor muscle should in real-
ity become the seat of a permanent retraction.  As the operation
in that case would be  more  easy,  and fully  as effective,  and
expose  us to  less  risk of  opening into the articulation,  below
than above  the patella, it would, in consequence, be the liga-
mentum-patellae, rather than the tendon of the rectus-femoris, that
we should divide, either from before backM'ard, or from behind for-
ward, but always by one of the modifications of the process of Du-
puytren.
  Indications.  Tenotomy in the ham should not be undertaken,
except M'here the joint at the knee is not anchylosed, the flexioJi of
the leg free from luxation, and the infirmity dependent in reality upon
a retraction of the  muscles, rather than upon an alteration  of the
ligaments, or a paralysis of the quadriceps extensor muscle  of the
thigh.  Examined under this point of view, the unnatural flexion of
the leg has not been sufficiently studied to enable us to know precise-
ly M'hether it is one of  the tendons of the ham only, rather  than the
others, or all of them  combined together, that generally  produce
it.  This, however, presents no difficulty in the operation, since the
surgeon limits himself to dividing those tendons only which  pre-
vent the natural mobility of the limb.   Many practitioners, doubt-
less fearful of thereby destroying the internal and external muscles
of the thigh, would still hesitate  to perform it for a  simple de-
formity which does  not prevent the patient  from walking  either
with crutches or on a wooden leg.
   The two cases taken from Pare and Boucher, which show that
in one case these tendons, when divided and then reunited by means
of suture, and in the  other in  spite of the loss of substance they
had undergone, have both,  nevertheless, reacquired their functions,
ought to have been quite sufficient to have given us confidence on
this subject, in addition to that which practitioners might also derive
from the details into which I have entered, upon the reproduction
of tendons and their mode of cicatrization.  Science, at the present
time, possesses facts of a still greater value. MM.  Michaelis,  Stroh-
meyer, and  Dieffenbach, (Bouvier, Mem. de VAcad. Roy. de Med., t.
vii., p. 411,) have for a long time applied their methods of tenotomy
to the tendons of the ham.   M. V.  Duval (Bullet, de VAcad. Roy. de 
            ALTERATIONS OF THE TENDONS OR MUSCLES.          463

Med., t. ii., exper. t. ii.) gave, in 1837, positive  proof that this ope-
ration  may be practised with as much success about  the knee as
upon  the  tendo-Achillis and the  other tendons  of the foot   The
memoir addressed by this  orthopedist to the  Royal Academy of
Medicine, contains facts which do not any longer permit a doubt
upon this  subject.  The seven persons thus operated upon, and of
whom M. T. Duval (These, No. 342, Paris, 1838) speaks, were all
cured or relieved.
  The Operation.   The patient, lying upon his  belly, has the thigh
extended and  supported by assistants. Placed on the side of the
tendons to be  divided, the surgeon, who  has already examined
them, inserts a  straight bistoury, by puncture, on the outer side of
the thigh if it is the biceps, or on the inner side  when the tendons
of the pes-anserinus are more particularly retracted.  After having
conducted his instrument to the opposite side  of the tendon to be
divided, either by grazing along the  internal surface  of the skin,
which always seems  to me the best mode, or by passing in front
(audevant)  of the stretched cord, he causes the aid  to  extend  the
leg of the  patient with a  certain degree of force.  Turning then
the cutting edge of the instrument downward,  (en bas.y or upward,
(en travers) he  divides, as I  have said of the tendo-Achillis, the
whole thickness of the shortened tendon.  The section of the biceps
would be then terminated, and there would be nothing remaining
but to withdraw the bistoury, and proceed to the dressing.
  On the inner border of the ham, the operation would be more
complicated.  There we may have to divide the tendon of the gra-
cilis muscle, the  semi-tendinosus, and the sartorius, successively.
Nor ought the  semi-membranosus itself,  as it is the largest, to be
spared in this case, if it was  in reality retracted.  We  should do
wrong, on  the other hand, to cut  those four muscles, if they were
not all diseased.  The section of one of the first three, or of the
whole three together, would not in reality be much more dangerous,
nor perceptibly more  difficult, than that  of the biceps.  Provided
the bistoury should not be carried  too far towards the  popliteal
space, or the posterior surface of  the femur, it would incur no risk
of wounding any important organ, the popliteal  artery, vein, and
nerves, being too deeply seated to be  reached in this way.   The
internal saphena vein and nerve alone would run some risk;  but
we know how easy it  is to avoid them. Unfortunately, it is not the
same  M'ith  the semi-membranosus muscle.  Being very near to the
posterior surface  and  internal border of the femur, as far up as its
termination, this muscle would require that the  instrument, intro-
duced by a puncture between its posterior surface and the tendons
which I have just mentioned,  should be held so as to divide it from
within outward, and from behind forward, going at the distance
of an inch at farthest above the internal  condyle of the femur.  I
ought, however, to add, that by introducing  through the puncture
in the integuments a blunt-pointed bistoury, or one of the blunt-
pointed tenotomes which I have already mentioned, there would in
fact be little risk incurred in the neighborhood of the popliteal 
464
NEW ELEMENTS OF OPERATIVE SURGERY.
 vessels and nerves.  It is, after all, at this height, or a little lower,
 that it is advisable to perform the  section of the tendon of the
 biceps and of those at the pes-anserinus, (patte d'oie)
   The operation being performed, we immediately give  the  leg a
 certain degree of extension.  If, in straightening it completely, there
 should not be produced  a separation of over two inches between
 the ends  of the divided tendon, we ought not to hesitate to  do it.
 In the contrary case, it is better  to increase this extension by de-
 grees, than to risk the formation of a cellular cicatrix only, by being
 too hasty.   In  the place  of the dressings and apparatus, more or
 less complicated, which the orthopedists employ in such cases, the
 surgeon may use a long splint provided M'ith a cushion, which is
 to be applied upon the forepart of the  thigh and leg, and which
 serves as a point d'appui  for the turns of bandage intended to  draw
 the limb  into  a state of extension.   A  roller bandage, with the
 interposition of  a long  strip  of pasteboard,  upon the  posterior
 or anterior surface of the part, which bandage should be rendered
 immoveable by dextrine, and should be left to harden while the leg
 is being stretched to the proper  degree of extension, is, however,
 the dressing most to be preferred  in  these cases.  In order to
 increase from time to time the extension  of the limb, we may soften
 the dressing by moistening it with tepid water on its middle por-
 tion,  or renew it every six or  eight  days.   It might  probably be
 advisable, also, to stretch the  limb, either suddenly or by degrees,
 into as great a degree  of extension  as  possible, and  to keep it so
 from one to two months, in order to secure it more effectually from
 all consecutive retraction.
   [Division  of the Tendons at the Ham.  In the division of the
 tendons at  the  ham, as when retracted in  white-swellings, and
 where  there is no anchylosis, Prof.  Fergusson enjoins here,  also,
 great  caution, especially in young subjects, for  fear of wounding
 the popliteal vessels  and the posterior tibial nerve.  He considers
 Amesbury's  double-inclined  plane a very good apparatus  for the
 gradual extension.  He severely censures the recommendation of
 M. Louvrier to stretch out the limb by actual force applied within
• the  space of a few  minutes,  and that  of Dieffenbach, to  do the
 same immediately after the operation.   He considers that this vio-
 lence, of bringing the foot suddenly up to the hip, and then as sud-
 denly straightening out the  limb, might fracture  the femur; and
 asserts that death has been thus produced by the excessive  inflam-
 mation and suppuration which had ensued, while amputation has
 been required  in other cases.—Pract. Surg., loc. cit.
   Mr.  B. Phillips, of London,  recently  effected  a perfect cure of
 extreme and permanent flexion of the leg on the thigh, which had
 existed for years, in a woman aged twenty-nine, from rheumatism
 affecting the  knee-joints and hands.   A straight blunt-pointed
 knife,  introduced through  a small wound  flatwise between the
 tendon of the  biceps and bone, divided those cords, and an  inch of
 separation  was obtained.  A modification of Amesbury's apparatus
 was used for aiding extension, and in a short time a  perfect cure 
ALTERATIONS  OF THE TENDONS OR MUSCLES.
46
was effected, and the leg slowly recovered its motions.—Medical
Gazette and Edinburgh Medical and Surgical Journal, 1840.—7'.]

                    g.  Tendons of the Head.

  Like tjhe limbs,  the head is  sometimes  drawn into an unnatu-
ral  direction  by the retraction of some  of its  muscles.   The de-
formity  which results from  this, and M'hich is generally known
under the  name of caput obstipum,  wry-neck, and  torticollis, is
of such  frequent occurrence  as to have caused it to be  noticed
by  authors of the  highest antiquity.   Most  surgeons,  however,
have neglected to define the cause of it.  Some of them had already
remarked, that torticollis might arise from  a retraction of the pla-
tysma myoides, the trapezius, the  scaleni, or the sterno-cleido-mas-
toid muscles.   But it is now almost demonstrated beyond dispute,
that this last muscle, if not the only cause, is  at least by far the
most frequent source of it, (le point de depart.)
  Whether the torticollis be congenital or accidental, recent or an
cient, spasmodic, convulsive, intermittent, or permanent, this is not
the place to examine the relative value of the different modes of treat-
ment that have been devised to effect its cure. The internal remedies,
and the different topical applications which the ancient  surgeons
were in the habit of using in such cases, are not, in truth, of any value
in the treatment of an ancient and permanent torticollis.  The  mas-
sage, still  recently extolled by M. Seguin, (Revue Med., 1838, t. ii.,)
the sudden movements forcibly and unexpectedly  applied to the
head of the patient, as in the young girl, who,  in her eagerness to
look out of the window at some fireworks, was suddenly cured by
violently turning her head to the  side opposite to that of  her  torti-
collis, could not succeed but in a very small number of cases. There
is generally, therefore, where we do not wish to abandon the infirm-
ity as incurable, no other remedy but a surgical operation which can
remove it.
  A. Indications. This  operation, already repeatedly performed in
the seventeenth century, and which some surgeons had continued
to make mention of, remained, nevertheless, out  of general practice
until in these latter times.  Embarrassed (arretes) by the  idea of a
concomitant deformity in the cervical region of the spine, or of even
a consolidation of the vertebrae, and believing,  also, that the  atro-
phied or shortened muscle, when  once cut, could no longer act on
the head or chest, practitioners were  induced to regard this opera-
tion as useless, and  one of considerable danger.  Such apprehen-
sions have now passed away.  Positive facts have proved, that the
section of  the muscles of the neck allows of the head being easily
straightened, however ancient may be the torticollis.  I have  seen
M. Bouvier, at the  Royal Academy of Medicine, divide the sterno-
mastoid muscle on  the dead body  of a girl aged twenty-two years,
and who had had  a torticollis from birth.  The head  could be
straightened immediately, and the vertebrae were scarcely in the
least degree altered. It is nevertheless true, as M. Guerin has par-
                              59 
466           NEW ELEMENTS OF OPERATIVE SURGERY.

ticularly endeavored to prove, " that in ancient torticollis there ex-
ists, in a direction opposite to that of the inclination of the head, an
inclination of the M'hole cervical column upon the first dorsal verte-
bra." But it was not this slight deviation of the spine, which, more-
over, disappears either spontaneously or under the influence o( the
proper kind of apparatus after the section of the muscle, M'hich had
embarrassed surgeons.   We now have cures of torticollis by the
section  of  the sterno-mastoid tendon  in  individuals deformed for
more than  twenty years ; so that  it is a question  definitively de-
cided.
  The history of the section of the muscles or tendons of the neck,
in cases of torticollis, is  that of tenotomy in general;  it was, in
fact, with this operation that surgeons commenced.  The observa-
tions published in Holland in the seventeenth century all relate to
this.  It is the only one  which was  spoken of before  Thilenius,
Michaelis, and Sartorius.  The facts mentioned by Tulpius, Job a
Meckren, Blasius, Tenhaaf, and Chesselden, all relate to torticollis.
Nevertheless, in  spite of what has been  said of it  by Richter, M.
Richerand, and Boyer, and notwithstanding the operations performed
by Dupuytren, M. Dieffenbach, M. Syme, and M. Strohmeyer, teno-
tomy, in cases of torticollis,  scarcely attracted attention until MM.
Guerin and Bouvier, in 1838, reawakened  the public  mind upon this
subject.  But the last modification (phase) of this operation, M'hich
goes back only to 1820,  had already reached to the highest point
of perfection and simplicity of which it is susceptible;  while the
section of the tendo-Achillis, though it was first practised in 1784,
was not enabled to attain the same perfection until 1837.
  B.  Operative Methods.  All the processes of tenotomy have been
applied to torticollis.   The operation of Tulpius, and that of other
Dutch surgeons, was performed in the following manner.  A caus-
tic M'as applied upon the skin; at a later period the bistoury was
used to divide the muscle above the clavicle.   Others occasionally
dispensed with the caustic, or with the bistoury, and had recourse,
some to a transverse incision, which should include both the tegu-
ments and the  muscle,  and others  to a  scarification (escarifica-
tion) of the parts.  It appears that no other than this method was
practised up to  1821, and  that Dupuytren, for still using it  at
that epoch, was  strongly censured by M. Ammon,  (Parallele de la
Chirurg. Francaise et la Chirurg. Allem., etc., Leipsic, 1822.)  Re-
cently, also, there are distinguished surgeons who have still thought
it advisable to follow this mode.  M. Amussat had adopted it in a
case which he communicated to the  Academy, with this difference,
that, like Michaelis, he contended for a partial section of the mus-
cle.   In 1836, M. Roux also  divided the teguments transversely be-
fore dividing the sterno-cleido-mastoid muscles.  It appears that M.
Magendie, who, after the manner of Sartorius, made first a longi-
tudinal incision  in the skin, thought it necessary, in order to reach
the muscle more readily, to  change this M'ound into a crucial incis-
ion, (Experiences, t. i., pp. 511, 541, 542.)  It is easy  to recognise in
the midst of these facts that the incision has been sometimes made 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         467

upon the body of the muscle, and at other times towards its extrem-
ities; that it has occasionally comprised  the  whole, and at other
times only a part of it, without there having existed in this respect
any fixed plan of proceeding in the minds  of the operators.
  The second method, and which M. Guerin has thoroughly inves-
tigated,  is composed  of three essential particulars—1.  To  divide
the tendon of the muscle, and not the muscle itself; 2.  To divide
only one of its  portions (faisceaux)  when, as frequently happens,
they are not both retracted;  3. To  perform this section by punc-
ture, and not through an incision of the integuments.
  Heister (Institut. Chirur., t.  ii., p. 673) had already indicated, in
a formal manner, the place where  it would be proper to cut the
tendon of the sterno-mastoid muscle ; he has even had the precau-
tion to mark this point in figure 12 of plate 21 of  his book.   So
also has Joeger.    M.  Chelius, (Traite  de  Chirurgie,  trad,  par
Pigne,  Paris, 1835, t. i., p. 463,) M'ho also designates  it, recom-
mends that it should be at an inch above the sternum, and that the
incision should  be transverse.  On the other hand, Richter had  said
that in torticollis it  sufficed to cut the portion of the  muscle  which
is attached to the sternum, and that we should proceed to the  sec-
tion of the second portion, when that of the first did  not appear to
answer, (Exper., t. i., p. 539.)   Every thing, also, shows that  Du-
puytren (Coster, Manuel de Med. Oper) had used in 1822, and with
entire  success, the process of puncture for the section of the sterno-
mastoid muscle.
  The operation  which Dupuytren performed  in  this manner, in
1822, was not published by him ; but the account of it  was given
in France by M. Coster, (Ibid.;) in England by M. Averill, (Treatise
on Operative Surgery,  1823 ;) in Germany by M. Ammon, (Parol, de
la Chir. Franc, et de  la Chir. Allem., 1823 ;) and then by M. Fro-
riep, (Notizen, &c, t. v., p. 142.)   M. Michaelis also mentions it in
the  Journal of  Graefe and Walther.   According to these different
authors,  Dupuytren, operating on a young girl, made a puncture
into the  skin on the inner side of the sterno-mastoid muscle,  and
through that introduced upon the posterior surface of the muscle a
blunt-pointed bistoury, the  cutting edge of which he  afterwards
turned forward to divide the retracted muscle from its deep-seated
to its cutaneous surface.   Dieffenbach, (Rust's Handbuch der Chir.,
t. iii., p. 629,) who knew this method, announced, in 1830, that he
had  followed it with  success  in an entire series of cases, and that
with him the division  of the sternal portion only of the muscle  had
been generally found to answer.  A surgeon  of  Edinburgh, M.
Syme, (Edinburgh Med. and Chirurgical Journal, t. xxxix., p. 321,)
having imitated Dupuytren, published all  the details of  his opera-
tion in 1833. It appears, also, that M. Strohmeyer (Experience,  t. i.,
p. 511) had had recourse to the same method in 1835.  I have re-
cently seen, by a letter dated June 1,1838, that M. Dieffenbach  has
for ten years performed tenotomy upon the neck after the method
of Dupuytren, and that he has, up to  the present time, had thirty-
two cases of it.  M. Bouvier affirms, on his side, (Ibid.) that he 
468           NEW ELEMENTS OF OPERATIVE  SURGERY.

had put it in use at Paris in the course of the year 1836. It is nev-
ertheless true,  that this operative  process, applied to the tendons
of the neck, had hardly attracted attention at the period M'hen M.
Guerin proposed it as a new method, sustaining himself upon facts
and reasonings that produced entire conviction.
  The text of the authors who have first spoken of this operation
is not sufficiently clear to authorize us to maintain that Dupuytren
confined himself to a single puncture.   The narration of  MM.
Coster and Froriep (Ibid., p. 590) would admit of the belief, that,
after having inserted the point of the bistoury upon one side, he had
also perforated (traverse) the skin with  it  on the other side.  M.
Guerin,  (Exper., t. i.,  p. 589 to 592,)  M'ho  strongly insists  that we
should confine ourselves to a single puncture, has, moreover, modi-
fied the operation in two  other  points.  In place of incising the
tendon from  behind  forward, like Dupuytren and his imitators,
he divides it from before backward, or from the  skin  toM'ards the
deep-seated parts. In fact, he first makes the puncture  on the outer
side of the tendon, in order  to penetrate under the skin from with-
out inward.  In  reality, this discussion  is a matter of very little
importance;  although the  process  of M. Guerin, in fact, is prefer-
able to  the others, when  the  teguments are sufficiently pliant to
permit of its employment, it cannot be denied that in operating like
Dupuytren, or M. Dieffenbach, or M. Syme, that is, in  perforating
the skin on both sides, (qu'en traversant la peau des deux cdtes) and,
in dividing the tendon from behind forward, we should obtain a
result almost fully as advantageous.  I should add, that there must
be cases where each  one  of these  processes would be found more
particularly applicable, and that it would be absurd to wish to adopt
one to the exclusion of all the rest.   Who does  not, also, see that
these modifications in the  operative process, for tenotomy of the
neck, resolve themselves into a simple repetition  of what has been
done and said upon the occasion  of  the tenotomy of  the leg, and
more especially of the section of  the tendo-Achillis ?
  In conclusion, the  sterno-mastoid muscle, like the tendo-Achillis,
ought to  bfe  divided whenever by its  retraction it produces an
abnormal deviation.   When we are to divide it, it is  advisable to
ascertain if it is retracted by one of its  portions, or by both  at the
same time.  On the supposition that in the vicinity of the clavicle
there should be adhesions, morbid cicatrices, or  any circumstance
whatever that might interfere with its section in this place, it would
be advisable, as  M. Dieffenbach informs  us was done  in a case
operated unsuccessfully upon by M. Graeffe some time previous, to
divide the body of the muscle itself: but I do not think it would be
proper to divide this  muscle in its upper  part, as M.  Bouvier has
recommended, nor to make a previous  incision  in the skin which
covers it, either after the Dutch method, or in adopting the  mode
of Sartorius, as M. Magendie still did in 1838, at the Hotel-Dieu.
Nor has the  process  of Delpech any greater claim to be adopted
for tenotomy of the neck.
   As to the processes by puncture, I have already said that that 
ALTERATIONS  OF THE TENDONS OR MUSCLES.
469
of Dupuytren could be adopted, if it should appear impracticable
to divide the whole breadth of the retracted muscle without pene-
trating (atteindre)  the skin  on the  opposite side.   Otherwise the
process by simple puncture, in the  manner MM.  Stoess, Bouvier,
and V. Duval, have  for a  long  time employed it for the tendo-
Achillis,  would be preferable.  For myself, I should also, unless
there were particular difficulties in the way, adopt the improve-
ment made in this process by M. Guerin; that is  to say, I should
prefer to make the bistoury pass under the  skin  than along the
deep surface of the tendon.  Also, I regard as a decided improve-
ment, the precaution of dividing sometimes the sternal branch only,
and sometimes the clavicular branch, and in other  cases both these
two branches at one  stroke, according as the retraction comprises
a part only, or the whole of the  muscle.  We see, indeed, that M.
Strohmeyer (Arch. Gen. de Med., 1838,  t. ii., p. 94) found himself
obliged to perform, successively, the  section of the sterno-mastoid
muscle, then  that of the clavicular  bundle, (faisceau) and finally
that  of the clavicular portion of the trapezius muscle, and, in addi-
tion  to all these, a cellular bridle, which extended from the sterno-
mastoid to the scalenus muscle.
   As to the question, whether  if after the operation it is proper to
employ the apparatus or bandages, either to adjust the head or
prevent a  new retraction, and which appears, in fact, to have oc-
curred in some patients of M. Dieffenbach, and as has doubtless
happened also with others, I do not think it can be decided upon with
absolute certainty. A young girl operated upon by M. Fleury, (Ibid.,
p. 78,) and M'hom I saw, was  not subjected to that treatment, and
yet recovered promptly.  If the reunion of a divided tendon should
in consequence of a suppuration  result in the formation  of an
inodular bridle, these mechanical means would be indispensable.
not only to carry on the cure, but,  as M. Guerin  recommends, to
complete it.   Should the deviation  of the cervical portion of the
spine prove  an impediment to the perfect  straightening of the
head, mechanical expedients  in this case, also, should be had re-
course to, after the operation.
   In short, the operation having been performed, those mechanical
contrivances should  be made  use of as often  as it should seem
difficult for the head to  sustain, itself in a proper position by the
spontaneous action of the muscles.   In  the contrary case, we may
dispense with them Mdthout any risk, and even with advantage.
   C. Operative Process.   The  sterno-mastoid muscle, in  its whole
length, is surrounded with  organs  which we could not avoid the
danger of wounding. In its upper half we could not divide it, with-
out implicating many branches  of  nerves of the  cervical plexus.
On its middle third there would be danger of wounding the exter-
nal jugular vein, and some filaments of the same plexus.  Its lower
fifth is in the neighborhood of  some small veins, which there  cross
its insertion as they course  under the skin; then, deeper still, it  is
approached by the sub-clavian and  internal jugular veins, without
taking into account that the carotid and sub-clavian arteries, also, 
470
NEW  ELEMENTS OF OPERATIVE SURGERY.
are not far distant.  It is not, therefore, a matter of indifference to
perform its section on this or that point of its length. In selecting the
lower portion, we have not only the advantage of being enabled to
cut its two roots separately, but of also  easily ascertaining through
the skin the condition of that portion of it which M'e M'ish to divide.
We have, besides, a kind of hollow, or void, which  separates it from
the large vessels M'hich I have spoken of, and which in depth corre-
sponds to the entire thickness of the clavicle.   Without, hoM'ever,
participating in all the fears of M.  Bouvier, (Exper., 1838, t. ii., p.
275,) M'e ought not to be ignorant of the fact, that the arrangement of
the veins of the shoulder or neck which  come to this region, to open
either into the internal jugular or into  the sub-clavian, is liable to
very great modifications, so that it is impossible to say at first that
we shall not wound any of them.   In this point of view, therefore,
the section  of the  sterno-mastoid muscle is  an operation of rather
more difficult character than that of the tendo-Achillis.
  We begin by causing the patient to  lie down, unless we should
prefer to seat him on a chair,  taking care  to  keep his chest in a
state of semi-flexion.   The surgeon, placed  in front, or on one side,
makes wiih  the  right  hand for the  left side, and the left hand  for
the right side, if he adopts the  process of M. Guerin, a puncture on
the outer border of the sternal tendon of the muscle, at the distance
of six or eight lines above the  sternum.  Then, gliding the instru-
ment flatwise under the skin,  as far as to  the inner border of the
muscle, he  turns its cutting edge backward, and thus divides the
tendon  from the teguments toM'ards the  deep-seated  parts.   If
it is useful to relax the muscle  a little while gliding the instrument
under the skin, it is advisable  to extend  and stretch it at the mo-
ment of making the section of the tendon itself. As the bistoury acts
on a firmly-stretched fibrous tissue,  the  cessation of resistance soon
informs us when there is nothing farther to  divide, and thus guards
us from inclining the cutting  edge of  the  tenotome too far in the
direction of the deep-seated vessels  of the neck.
  For  the  clavicular portion, it Mould  be  necessary to make the
puncture at an  inch to  an inch  and a half farther to the outside,
and rather close to the clavicle, than  at a distance from  it.   As
this portion is wider (plus large) than the other, it would be neces-
sary, also, to insert the bistoury farther in, from without inwards.
This tendon, M'hich should be divided as thoroughly upon its inner
as upon its outer border, upon its cutaneous as upon its deep-seated
surface, is surrounded, but at a greater distance  than the  sternal
portion, by the veins and large arteries.
   If, in place of thus dividing the muscle by beginning  on its sub-
cutaneous surface, we should  prefer dividing it  from  behind for-
ward, it Mould be more convenient,  but not indispensable, to make
the puncture of the tegments on the inner side of  each tendon, and
the puncture being made, I should  consider it a matter of great
prudence to substitute the  blunt-pointed tenotome or bistoury,  for
every kind of sharp-pointed instrument,  in order that we might with
greater certainty avoid the veins in that  region. Afterwards, cutting 
ALTERATIONS  OF  THE TENDONS OR MUSCLES.
471
from behind forwards, with gentle saM'-like movements, we should
have to watch the successive separation of the divided tendinous
bundles, in order to run no risk of coming through the skin itself.
  This precaution, also,it would be well to take,even when we adopt
the method of passing the instrument from the outer to the inner bor-
der.  We may also perceive, that in dividing this muscle from before
backward, there M'ould be but little inconvenience in inserting the
instrument from its inner  to its outer border.  The best course in
all this, is first to make a puncture with a lancet, then* to introduce
into this puncture a tenotome, or a narrow blunt-pointed  bistoury,
and which could  glide flatwise between the  skin and the tendon,
or between the tendon and deep-seated tissues, without incurring
the risk of perforating the vessels or the skin itself.
  As  soon as the tendon is cut, it leaves a void on a line with the
separation which takes place  between its  two extremities.  The
head  may then  be straightened  Mdthout difficulty.  Among  the
accidents  mentioned as consequences of tenotomy in  the neck, is
ecchymosis, which exists sometimes to a considerable extent, but
which, in  the patients treated by M. Guerin, was always promptly
relieved.  M. Dieffenbach, (Exper., Aout, 1838, t. ii., p. 276,) M'ho
says  he has performed this operation thirty-seven times, has failed
in only one single case. The young girl, of whom M. Fleury speaks,
fell into a state of nervous delirium, of a very peculiar character,
which lasted three days, but from which  she afterM'ards very rap-
idly recovered.   We see, also, that the voung man  operated upon
December 2d, 1837, by M. Guerin, (Gaz'. Med. "de Paris, 1838, p.
529,)  experienced some of the symptoms which appeared to in-
dicate the introduction of air  into the veins, but Mdthout any un-
pleasant consequences resulting from them.  The small M'ound has
always cicatrized in the course of a few days.   Up to the present
time,  there has been no mention  made that it has  suppurated or
caused  inflammation  underneath.  The  effusion and  fluctuation
which M. Dieffenbach speaks of,  (Exper., t. ii., p. 276; Gaz. Med.
de Berlin, 1838,) and M'hich he  overcomes or prevents by compres-
sion, is no cause for any alarm.
  As  to the mechanical means to be employed, if these should be
necessary, I should advise  the simple dividing bandage of the neck
to begin with, and would not proceed to an apparatus, properly so
called, until after being convinced of its being indispensably ne-
cessary.
  [Dr. Mott divides the sterno-cleido-mastoid at the junction of the
two roots. It is narrowest there.—71.]
  [Torticollis.  The sub-cutaneous section of  the  sterno-cleido-
mastoid muscle, whose retraction is the almost exclusive source of
this well-known  deformity, has yet been but seldom practised in
America.   But few have had the courage or experienced tact of a
Guerin to operate by the  sub-cutaneous  section  in  the dark, in a
region so  dangerous;  and although Dr. J. M. Warren, of Boston,
and Dr. N. R. Smith, of Baltimore, have performed  it in  several
cases, Dr. Mott of New York, notwithstanding the now general con- 
472
NEW  ELEMENTS OF OPERATIVE SURGERY
demnation of the  old method, or open transverse incision through
the integuments, and after all that he has been  an eye-witness to
at Paris, of the admirable skill of Guerin in the sub-cutaneous sec-
tion, still adheres to that ancient, and, as he deems  it for the gene-
rality of practitioners, safer practice.   As a  professor of surgery,
Dr. Mott believes  it  to be his conscientious  duty, not so much to
teach M'hat can be done by  adroit manipulation, as M'hat may be
done by ordinary operators to extend the usefulness of their profes-
sion.  He hasdivided the sterno-cleido-mastoid muscle twelve times
for torticollis, incising cautiously the whole breadth of the retracted
parts from without  inward,  and  keeping the lips of the  wound
carefully apart by  lint, and by the position of the head moderately
inclined to the opposite  side, until the  wedge-shaped fissure is filled
up with  granulations.   This  mode has certainly one great advan-
tage over  the sub-cutaneous, viz., that it never  or very rarely re-
quires to be repeated,  as the sub-cutaneous often does, from  the
tendency, in this  last  process, of the extremities  of the  divided
muscles to reagglutinate.
  Professor Syme  of Edinburgh has recently published some very
interesting observations upon  this subject.  The first case of sub-cu-
taneous section of the sterno-mastoid in Great Britain for wry-neck,
was performed by that  gentleman M'ith  perfect  success, on a boy
aged six, at Edinburgh, Nov., 1832.  (See Braithwaite's Retrospect, No.
7.)   The tenotome was inserted on the tracheal margin of the ster-
nal portion, an inch above the clavicle, and the hard cord instantly
divided with a loud snap, and perfect and  immediate restoration
of the head to its place.   M. Syme justly remarks, that lateral  de-
viations  of the  spine  are produced  by  wry-neck  from  muscular
retraction of the sterno-mastoid,  the  dorsal vertebrae on  the  re-
tracted  side assuming  a corresponding convexity, and the lumbar
bending in an opposite lateral direction to preserve the balance of
the trunk.   The operation for the torticollis readjusts the column,
unless the  disease has  continued so  long as to alter the shape of
the bones, which alteration generally consists in a compression of the
bodies of the vertebrae  and  projection of the  sternum.   In these
cases, however, the division of the sterno-mastoid gives great relief,
and the spine may recover its natural condition in  time, if the  pa-
tient is not arrived at maturity.   Professor  Syme  gives a  recent
instance of this kind in a young lady  upon whom he had operated
in 1841, and where the back and ribs were much  distorted, and  the
constitution so much affected that he scarcely hoped for success.
In two years, however, she became, from being a  pale, sallow,
and crooked looking girl, a hale, ruddy, healthy  looking  young
woman.
  There is another case he mentions  of wry-neck and lateral cur-
vature of the spine,  where the sterno-mastoid appeared soft and
relaxed until the  patient attempted  to straighten his head.  The
division was effected, and the next day the patient's back was com-
paratively straight.
   Thirdly, caries  at the occipito-vertebral  articulation, that is, 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         473

between the occiput and atlas, generally a fatal disease, must not
be mistaken for wry-neck.  (London and Edinburgh Monthly Jour-
nal of Science, April, 1843.)
  M. Liston, on the other hand, (Vid. his Elements of Surgery, Lon-
don,) imputes most cases of wry-neck (erroneously, as we conceive)
to some  vice in the bones, as curvature from softening, attended
with deformity of the trunk or of the limbs, the twist in such cases
being generally to the right side, the ear approaching the shoulder.
He therefore in such cases recommends the use of apparatus, to
restore the perpendicularity of the vertebral column, before, as we
understand him, as well as after the sub-cutaneous section of the
sterno-mastoid.—7T.]

h. Section of some  other Muscles of the Neck, in  cases of Deviation
                          of the Head.
  There is no doubt that most of the muscles on the sides of the
neck may become the cause of a permanent retraction, and con-
tribute in this manner to son:e of the deviations  of the head.  Up
to the present time, however, the trapezius and platysma-myoides
are the only ones besides the sterno-mastoid, which in this respect
have attracted the attention of surgeons.
  In becoming indurated, and in retracting itself, the clavicular por-
tion  of the trapezius muscle would draw  the head  towards  the
corresponding shoulder.   Thus M. Strohmeyer (Arch. Gen. de. Med.,
1838, t. ii., p. 96)  perceived  that  he could  carry the bistoury by
puncture under the anterior border of this muscle, and divide it from
the deep-seated parts towards the skin, in a  young girl  in whom
the torticollis had been but imperfectly removed by the section suc-
cessively of the two branches of the sterno-cleido-mastoid muscle.
As the object of the operator in such a case would not be to cut the
whole breadth (largeur) of the muscle, the ordinary narrow bistoury
inserted by puncture would be preferable to the blunt-pointed bis-
toury, and to the different kinds of tenotomes ; and I do not see that
it would be very important whether we made it cut rather from
the skin towards the deep-seated parts, or in the contrary direction.
It is an operation, moreover, whose utility it would at the present
time be difficult to  appreciate, as it does not yet appear to have
been put in practice but in one single case.
   The Platysma-Myoides, (Peaucier)  The platysma-myoides, ex-
panding (s'epanouissant) upon the lower part of the face in one
direction, and upon the apex of the thorax and shoulder in  the
other, might, if it should  be retracted, produce  a deformity of a
sufficiently complex character.  The lower lip and the correspond-
ing commissure would necessarily be drawn downward and out-
ward by means of the risorius muscle.  We may conceive, also,
that the lower jaw would have a constant tendency to be depressed,
and consequently that the mouth of the patient might remain per-
manently open; the whole head, in fact, would be drawn forM'ard,
and to one side. It is a species of deformity which Gooch says he
has met with.  Perhaps in the patient mentioned by this surgeon, as
                              60 
474
NEW ELEMENTS OF OPERATIVE SURGERY.
well as in the one that  M. Lelong (Thise, No. 179, Paris, 1819)
speaks of, there Mere sub-cutaneous fibro-cellular bridles, and cer-
tain inodular cicatrices of the skin, rather  than actual retraction
of the platysma-myoides.  Be that  as  it may,  Gooch divided the
abnormal cord transversely, was then  enabled to straighten the
head, and ultimately, he says, cured his patient.
  If such  a deformity should  be  met with at the present time, it
would be advisable, above all, to  ascertain M'hether it arose from a
muscular  retraction rather than from cutaneous  bridles.   In this
last case, in fact,  we  should have recourse to transverse  and re-
peated incisions,  or to the extirpation of the bridle itself, after the
manner I have pointed out in another chapter.
  If the deformity in reality depended either upon a cellulo-fibrous
bridle, or upon the platysma-myoides, and the skin above remained
free from  adhesions, the processes of tenotomy should be  had re-
course to.  It would be advisable, especially, to raise up the integu-
ments, in  order to separate them as  much as possible from the
bridle, and that, the puncture  being made, the bistoury might glide
in the sub-cutaneous tissue to beyond the cord to be divided.   This
manner of proceeding would evidently be  preferable  to the pro-
cesses of M. Strohmeyer, or those of MM. Stoess and Bouvier.  The
only part which could run any risk in this operation, M'ould be the
external jugular vein ; but it is sufficient to recollect this, to enable
us to avoid it  with certainty.  The section of the bridle having
been effected in one or several places, it Mould at  least be  quite as
necessary here as after the section of the sterno-mastoid muscle, to
call to our aid an apparatus or bandages to complete the cure, and
restore to the head as straight a position as would be desirable.
                        CHAPTER IV.

DEFORMITIES IN CONSEQUENCE  OF ALTERATIONS OF THE  LIGA
            MENTS OR DEEP-SEATED APONEUROSES.

  It having been  remarked  that certain deviations, independent
of diseases of the  articular surfaces, or of alterations in the direc-
tion of the bones, could not in any manner be explained by morbid
cicatrices, sub-cutaneous bridles, or the retraction of the muscles,
practitioners asked themselves the question, if the cafuse might not
be in the shortening or rigidity of the ligaments.  This is a ques-
tion altogether new in operative surgery. MM. Ghidella and Fro-
riep, who appear to have been the first who have given considera-
tion to this subject, have not accompanied their descriptions with
details sufficiently precise to know exactly to what kind of lesions
they in reality directed the treatment of which I am about to speak.
Nevertheless, as we do  in fact sometimes  meet with  tetractions 
         DEFORMITIES FROM ALTERATIONS OF LIGAMENTS, ETC.      475

which it is utterly impossible to explain, otherwise than by the rigid-
ity of certain ligaments, and the shortening of certain aponeurotic
bridles; and as it is now impossible, after one of the observations
communicated to me by M. Champion,  and after that published
by M. Froriep, to call in doubt the power that the aponeuroses have
of retracting themselves, I think we should  not, in  too absolute a
manner, reject the practice of the surgeons of whom I have spoken.
I ought  also  to  add,  that  each of  the  three  surgeons  who as
yet have endeavored to  call attention to this  point of  surgical
pathology,  extols a different method.  M.  Ghidella, (Bulletin de
Ferussac, t. xiii., p. 67,) for example,  recommends that we should
divide all the retracted bands  (rubans) by means of large (large)
and  numerous  incisions.  He gives many  cases of rigidity,  and
one of a very ancient semi-anchylose state of the lower jaw, which
were cured by this  kind of operation.   On the  contrary, in  the
process of M. Froriep,  (Encyclog. des  Sciences Medic, t. i., p. 252,
ou Gaz. Med. de Berlin, No. 12, 1836,)  we are advised to rely upon
mechanical  means, when the simple incisions  after the  method
of Dupuytren do  not appear to be practicable.  In fine, M'e per-
ceive, by the researches of M. Nanzio, (Bullet, de VAcad.  Roy. de
Med. t. L, p. 60, et t. ii., p.  135, et suiv.,) professor of hippiatrique
at Naples, that in horses, where this kind of retraction appears to
be very frequent, the operation should consist of deep (large) inci-
sions, which should penetrate to near the joint, and of the iron
heated to whiteness, which should  be applied directly to the cap-
sule or the  ligaments.
  The authors who have, proposed these  operations are men that
are known and esteemed; they relate facts  and successes  in sup-
port of their practice ; we should, therefore, act discourteously to
reject their recommendations  without examination.  It seems to
me, however, that the  method of M. Nanzio, transferred from the
veterinary art to  surgery, properly so called, would incur  the risk
of serious dangers, without authorizing us to expect from it any spe-
cial  efficacy; that of  M. Froriep  would hardly have any more
chances of  success  in the deviations produced by retraction of  the
ligaments,  than in  those caused by  retraction of  the muscles;
on the other hand,  it  would scarcely be allowable to  apply the
method of Ghidella, except upon the ligaments situated superficial-
ly."  Nevertheless, simplified as this method has been for tenotomy,
it might be made  trial of without great danger, upon the articula-
tions of the fingers and toes, the wrist and instep, the knee  and el-
bow, as well as upon the temporo-maxillary  articulation.

                             §1-

  In the fingers, this method, which had already been proposed in
some cases of luxations of the phalanges difficult to be reduced, and
which Bell performed  with a cataract needle, might be effected
with the point  of a very narrow bistoury, or, better still,  with  a
strong arrow-headed needle.  Passed  from one of the surfaces of 
476
NEW  ELEMENTS OF OPERATIVE SURGERY
the finger to the other, as it grazes along the deep-seated surface
of the skin, so as to avoid the lateral vessels and nerves, the in-
strument, whose cutting edge should  be  soon turned crosswise,
would, Mithout any great difficulty, divide the lateral-ligaments of
each of the phalangeal articulations, or those of the  articulation
of the fingers M'ith the hand.

                             §11.

  At the wrist, where the operation would be a little more danger-
ous, because of the  ulnar and radial arteries,  it Mould be better,
after the puncture has been made below, and upon the cubital side
of, the styloid process of the radius, to cut  the ligament  from the
deep-seated parts toM'ards the exterior, rather than from the skin
towards  the articulation.  It would  be the same for the internal
lateral ligament, although it  may not  be quite so near the  ulnar
artery as the preceding one is to the radial artery.

                             §111.

  The lateral  ligaments of the elbow would be very easy  to divide
by this method.   Nothing would prevent us from passing the nee-
dle or the bistoury between the skin  and the other tissues, in order
to cut the ligament from without inwards.  We must, nevertheless,
remember, that, in proceeding thus  with the external lateral liga-
ment, we should run the risk  of partially dividing the supinator
radii brevis, while, in cutting  from the deep-seated parts towards
the exterior, we could avoid  this muscle with  greater ease.   The
instrument, moreover, should be introduced at the distance of three
or four lines below  the external  condyle.  We could  render this
separation of the ligament more easy, if M'e could possibly keep the
forearm in a state of semi-flexion during the operation.  The  inter-
nal lateral ligament would be difficult of division under the ante-
rior origin of the flexor carpi ulnaris;  we should, moreover, recol-
lect that the ulnar nerve passes between the inner condyle and the
olecranon.
  As to the anterior ligament of the humero-cubital articulation, I
do not think that any surgeon would have the boldness to  attack it
in such cases.           *

                             §rv.

   The section of the  ligaments of the toes, should it ever become
necessary, ought to be made like those of the fingers.

                             §V.

   At the tibio-tarsal articulation, it would be easy to divide the in-
ternal lateral ligament by passing a bistoury under the skin, and
from before backwards, then turning its cutting edge soon after in 
        DEFORMITIES  FROM ALTERATIONS OF LIGAMENTS, ETC.      477
                    ♦
the direction towards the astragalus, in order to divide the ligament
transversely at the distance of some  lines below the apex of the
malleolus.   ,
  The external lateral  ligaments could be reached in the same
way; there  would be no other  risk incurred in such cases than
that  of wounding either the tendons of the peroneus longus  and
brevis, or those of the tibiales; but it is yet doubtful if the indica-
tion for such an operation could present itself in the  feet.

                             §VI.

  It is especially to the articulation of the knee that the remarks of
M. Froriep apply.  It is true, that bridles of the fascia lata some-
times take on  in this neighborhood a thickness and hardness alto-
gether abnormal, and that the necessity of dividing them has sug-
gested itself to the mind. It is also true, that both the internal and
external  ligaments  of the knee are situated quite superficially
enough to enable us to divide them without difficulty, if they were
in reality retracted.  Thus, with a lancet to make the  puncture, and
a blunt-pointed tenotome introduced under the skin from before back-
wards, commencing at the distance of two fingers' width inside the
apex of the patella, and extending to a level M'ith the anterior border
of the pes anserinus, and then brought opposite to the articular inter-
stice, we could divide without difficulty the whole breadth of the in-
ternal lateral ligament.  Carried in the same manner outwardly, the
bistoury M'ould have difficulty in dividing the ligament without di-
viding also the tendon of the biceps, since those  parts are, so to
speak, enclosed one  within  the other ; but the division of both
might be rather beneficial than  injurious, for how are we sure at
first that the ligament only is retracted 1
   As to the aponeurotic  bands, their section does not require that
we should trace out  rules for them, since it must vary according to
the form, seat, or degree of elevation of the bridle to be divided. It
is unnecessary to say, that the ligaments of the shoulder and of the
hip will probably always remain exempt from any attempt of this
kind.

                             §VII.

  It remains to speak of the articulation of the jaw.  I do not know
to what extent the rigidity or shortening of the temporo-maxillary
ligament might produce an anchylosis of the jaw.   In all cases, a
cataract-needle, introduced by puncture from before  backwards, or
from behind forwards, would without difficulty effect its division;
but I ought to repeat, in terminating this article, that such opera-
tions do not offer any special remedial benefits, and we may be al-
lowed to doubt if they will continue in practice. 
478
NEM  ELEMENTS OF OPERATIVE SURGERY.
                        CHAPTER V.

     DEFORMITIES FROM ALTERATIONS IN THE SKELETON.

  I shall divide the deformities to be examined in this chapter into
two orders—those which result from an anchylosis (soudure) of the
articulations, and those which depend  upon a deformity (defoima-
tion) in the body (du corps) of the bones.

                    Article I.—Anchylosis.

  Three kinds of operations—the fracturing of the anchyloses, the
excision of one of the neighboring bones, and the establishment of
a false joint—might, strictly speaking, be undertaken to remedy the
anchylosis of the joints.

                § I.—Fracturing the Anchylosis.

  When, in consequence of any disease  whatever, the joints become
anchylosed, there results from it an infirmity which is* generally in-
curable ; the idea, then, of breaking the anchylosis in such cases is
altogether  natural.   Thus have there existed in  all times surgeons
who, in accordance with the vulgar opinion, have recommended
destroying in this manner the different kinds of articular rigidities.
Some ancient observations, also, Mould seem to encourage this prac-
tice.  Fabricius of Hildanus relates the case of an anchylosis of
the fingers and of the wrist, which was cured by a fracture of the
forearm produced by a fall.  We see, on the other hand, in  Meck-
ren, that a stiffness in the elbow, caused by an abscess, disappeared
in consequence of a fracture of the  forearm from  a fall.  Bartholine
(Trad, de Bonnet, t.  iv., p. 410) mentions the case of a patient M'ho,
having had his forearm dislocated, was  seized with gangrene at the
elbow to such extent as to prevent any attempt at reduction, and who,
by a fall from a horse in the succeeding year, had the movements of
the articulation re-established; but, supposing that in these cases
there was in reality an anchylosis, we should have  to oppose to
them facts of a totally opposite character, and well  calculated to
discourage practitioners.   A woman (Arch. Gen. de Med., t. xxv.,
p. 569) had the femoro-tibial articulation anchylosed for a year, in
consequence of a white swelling, (tumeur blanche) It was thought
advisable to endeavor to break the anchylosis; but this rupture
was succeeded by an inflammation so violent, and symptoms so se-
rious, that death took place at the end of a few days.
   The question relative to the rupture of anchyloses will always
be difficult to solve in a definite manner.  If, in some cases, every 
         DEFORMITIES FROM ALTERATIONS IN THE  SKELETON.      479

thing indicates that the mobility of the joint might thus be re-estab-
lished,  it is also  certain, that, in performing it, we are exposed to
an inflammation  which might seriously endanger the life of the
patient, or at least compel us to amputate the limb. As an anchy-
losis, moreover, in no way prevents the patient  from enjoying good
health, it appears to  me that, in a general point of view, the prac-
tice of which I have just spoken ought, from prudential considera-
tions, to be proscribed.

                  § II.—Excision of the Bone.

  If  the anchylosis should be accompanied by a deviation too fa-
tiguing for the diseased limb, perhaps it would be practicable to
apply to it an operation which has not hitherto been proposed, ex-
cept  by M. R. Barton, (American Jour, of Med. Sciences, Feb., 1838,)
and of which I wish to say only a few words.   I will suppose an
anchylosis of the knee, with deviation of the leg; would it not then
be allowable to lay bare the point of the femur  nearest to the skin,
and  to  remove from it by two cuts of the saw a fragment, which
should have the form of a wedge, or of a slice  of melon ?  After-
wards bending  the leg  in an opposite direction from  the articula-
tion, we should obtain the consolidation in this position by means
of an immoveable dressing.  The leg, thus adjusted, would permit
the foot to come in contact with the ground, (de regarder le sol.) It
is true that the limb  would, in that  case, take, to  a certain extent,
the form of a Z ;  but, besides that this double curvature would be
but little noticed, if it was made very near the knee, it would not
deprive the patient of the use of his foot. We see, also, that in place
of selecting the thigh, we could operate on the  tibia itself, directly
under the knee.
  I do not disguise from myself the inconveniences of such an opera-
tion ; but I have tried it upon the dead body, and it does not appear
to me to be of very difficult execution.   I therefore believe it prac-
ticable in certain deviations of the foot, and those of the knee, wrist,
and also of the elbow.

                         A. The Foot.

  If  a pes-equinus, for example, arose from a  tibio-tarsal anchy-
losis, I do  not  see why we should  not  attempt the removal of a
wedge from the tibia and fibula.   For that purpose there would be
required a longitudinal incision extended from the anterior edge of
the internal malleolus to three inches above.   After having isolated
the bone from all the soft parts, we should shove the latter apart
on each side by means of a blunt hook, which an assistant should
at the same time force backward or outward.  A half-circular (en
crete de coq) saw, directed transversely, would divide the bone per-
pendicularly for the upper cut, obliquely from below upwards for the
lower cut, to the  distance of some lines from its posterior surface,
and  in  such manner  as to circumscribe a wedge, whose  base, of 
480
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
greater or less width, according  to the degree of deviation in the
foot, Mould be turned forward.   After  having repeated the same
operation on the fibula, we should succeed in breaking the bones of
the leg by acting  on the foot.   This latter  being then raised up,
M'ould  put the two surfaces of the section into contact, and give a
horizontal direction  to the  plantar  surface  of the  distorted  foot.
The dextrine dressing, as in fractures of the leg, should be imme-
diately applied, and we should, moreover, attempt  the immediate re-
union of the wounds.  As this operation has nothing to do with re-
establishing the  mobility of the joint, we may without any actual
danger include the tendons of the region in the flap  of the soft
parts.
  B. At the Knee, the section of the tibia would give every possible
prospect of success: a semilunar  incision, with the convexity down-
wards, and extending from  the lower part of one of the condyles
of the tibia to the other, M'ould allow of circumscribing a large flap
of integuments which would  include in  its base  the extremity of
the ligament of the patella.  This flap being raised up by an as-
sistant, the surgeon would saw perpendicularly through the head of
the tibia, a little above the tuberosity, until he  reached near the
neighborhood of the ham.  Bringing back the saw to an inch or an
inch and a half underneath, he would direct  it obliquely from be-
low upwards, in order to strike the posterior terminus (le fond)  of
the first section, and thus separate  a wedge  from the  bone.  We
should thus avoid wounding  the  anterior tibial artery, and the ne-
cessity of operating upon the fibula.  The fracture would be easily
completed by making tractions upon the leg.   The void created  in
this manner would enable us to restore to the limb a great portion
of  its  natural perpendicularity,  without either shortening or de-
forming it to any considerable extent.
  The immoveable dressing for complicated fractures, and the ap-
proximation of the lips of  the wound  by means of the suture  or
strips merely of adhesive plaster, would be immediately had re-
course to.   The recurrent artery of the knee is the only one which
runs any risk of being wounded  when we operate in this manner,
and upon this a  ligature may become necessary.
  In the event that it would  be  required to saw the femur rather
than the tibia, we should have to  select that part of the thigh where
the operation would  offer the greatest number of advantages and
the fewest dangers.
  The most suitable place in that case, would be immediately above
the knee.  A  semilunar incision, with  its  convexity  downwards,
and the free border of which should come  down to half an  inch
above the  patella, would allow of cutting a flap which should  be
raised from below upwards, and which would lay bare the anterior
surface of the bone.  The saw would then separate  from it a frag-
ment shaped like that which I have described  in the preceding ar-
ticle. Then adjusting the leg, the  notch in the bone would be made to
disappear by approximating the  lower plane of the cut of the saw
to its superior plane.  The flap of the soft parts, then brought down 
         DEFORMITIES FROM ALTERATIONS IN THE SKELETON.      481

and retained  in its place by means of the suture or agglutinative
bandages, would immediately cover all the parts ; and there would
remain nothing more to do than to surround the limb with an im-
moveable dressing.
  M. Barton (Arch. Gen. de Med., Juin, 1838, p. 357)  has recently
made an application  of this method to the lower part of the thigh
for an anchylosis of  the knee.   M. S. Deaz, the  young physician
who submitted to it, May 27, 1835, wrote on the 6th of November,
1837: "I have the satisfaction of4saying that  the operation which
you performed on my leg has completely succeeded.  I  walk well,
attend  to my affairs, mount my horse, and sometimes travel from
thirty to fifty miles a day without any fatigue ; the entire sole of
my foot touches the ground, and I scarcely limp any."
  The author cut upon the soft parts a triangular flap, the apex of
which corresponded to the antero-internal part of the  ham, and ter-
minated at its base on the outer part of the same region.  Having
thus laid bare the anterior surface of  the femur, he exsected from
it, by two cuts of the saw, a cuneiform fragment, as in the cases
of straightening which I have supposed above.  M. Barton (Southern
Med. atid Surg. Journal, vol. ii.,  p. 471, March, 1838)  proceeded
also in the manner I have described, as relates to  the  reunion of
the wound.  For myself, I should prefer  in this case the semilunar
flap, described in the preceding  paragraph, to the  triangular flap
of M. Barton; I will also add, that the immoveable dressings used
with us, would render the subsequent treatment and success of this
operation infinitely more simple.
  We could, it  is true, lay bare  the femur on another  part of its
length ; but at a greater distance from the knee, the  straightening
of the leg would make too projecting an angle upon the thigh, and
a considerable shortening of the limb ; whilst immediately above
or under the condyles, the straightening is effected to a  certain ex-
tent without a new deviation.
  C. If the thigh only M'as anchylosed, and at the same time in-
clined forward or inward, perhaps it would also be possible to at-
tempt its readjustment.  It would in that case be immediately be-
low the quadratus femoris, that I should advise the operation to be
performed.  The semilunar flap, mentioned in the two preceding
cases, should  have its base on a level with the root of the great
trochanter, and the middle of its free border at two inches below.
[Dr. Mott suggests a straight incision on the outside of the thigh.—
T.~\  This flap should be extended transversely from the outer side
of the great trochanter, to  a level with the tuberosity of the ischi-
um ; but in making  it, we should  carefully avoid wounding the
great sciatic  nerve.  The bone, once  laid bare,  should be sawed
upon its outer and posterior part, if the limb was in a state of ad-
duction as well as flexion.
  If there was only a simple flexion, without any deviation  in-
wards, it might be useful to detach the fibres of the triceps adduc-
tor muscle, then to crowd all  the soft  parts inwards and forwards
by means of a plate (plaque) of horn,  pliant wood, or tin, in order 
482
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
to remove the wedge directly from the posterior surface of the fe-
mur.   We Mould complete the fracture of the bone by drawing the
thigh backward, the flap of the soft parts would be brought down,
and supported as in the preceding case, and the whole  limb be im-
mediately placed in an immoveable dressing.
   The advantages of the operation I describe are not as obvious in
the upper as in the loM'er limbs.
   D.  In the fingers, for example, it could hardly be practicable, ex-
cept on the dorsal surface.  But I do not know which is the most
annoying, flexion or  extension, when there  is an anchylosis  of the
phalanges; and M'e should also  recollect, that the straightening
of a finger is not a  restoration of its movements.  If, however, it
.should happen that one or more of the fingers are bent like  hooks,
(en crochet) so as to destroy the functions of the hand, there might,
I think, be some utility in practising on the dorsum of the angular
(coudee) phalange the kind of exsection which I have proposed to
apply to the tibia and femur, since it might be possible in this way
to bring the deformed fingers into an intermediate position between
flexion and extension.                                  %
   E.  For an anchylosis with extreme flexion  of  the hand, the ope-
ration should be performed at three fingers' width above the wrist.
The radius would be laid bare in this place, immediately above
the deep-seated muscles of the region, by an incision of two inches
in length, and parallel to  the direction of the bone.  The two lips
of the wound being  properly separated,  and each protected by a
piece of pasteboard, would allow of the surgeon removing a cu-
neiform fragment from the radius, by means of the  semicircular
saw, as I have said in speaking of anchylosis of the foot.
   We should proceed in the same manner with the exsection of the
ulna. We should afterwards adopt, in respect to the straightening of
the limb, the union of the  wounds, and the consolidation of the frac-
ture, the same mode which I have described above.  A semicircu-
lar incision, to form a flap, which should include all the soft parts
on the dorsum of the region, 'would render the operation more sim-
ple, and ought to have the preference, if the tendons have lost their
mobility.
   F.  The anchylosis of the elbow  is not of  a nature to require this
species of excision of the bones.   If the forearm is in flexion, it is
the least inconvenient position that it can take ; if it were found
in extension, we could not remedy it but  by dividing either the hu-
merus or the bones  of the forearm in front; M'hich doubtless no
person would have the hardihood (courage) to do for a simple de-
formity.   Nor do I see any contingency that could require the cu-
neiform excision of the bones in the neighborhood of the scapulo-
humeral articulation.
   In  conclusion, the  cuneiform excision is not, as it appears to me,
suitable as a remedy in anchylosis, but for re-establishing the flexion
or extension of some part of the limbs.
   G.  In  place of attacking the body of the bones, we  may carry
the saw  upon the articulation itself, and remove  from it a semi- 
          DEFORMITIES FROM  ALTERATIONS IN THE SKELETON.      483

 lunar or cuneiform fragment.  This process, which might be appli-
 cable to the knee, and even to the fingers, where it would have the
 advantage of not producing any new deformity, M'hile it Mould
 happily admit of correcting the old  one, would  not, however, be
 always suitable.  The soft parts, besides being generally altered in
 this point, are  almost always unfavorable in such places to the
 formation of flaps.  If suppuration should take place at the bottom
 of the wound, the dangers would be manifestly greater in the articu-
 lation than on the continuity of the bones.
   I would not like, moreover, to practise such operations, unless all
 irritation and every trace of inflammation had, for a long period
 before,  disappeared from the  anchylosed joint;  also, it would be
 necessary that the curvature  should be excessively annoying, and
 that the patient himself should have a strong desire to be partially-
 relieved of it.

                § III.—Supplementary Articulations.

   Another operation, which has been suggested to my mind by that
 of which I have been speaking, would consist in establishing artifi-
 cially an articulation above or below that which is anchylosed.  It
 would be no longer, then, for the purpose of straightening a distort-
 ed limb, but for  restoring  the movements of the part. We perceive,
 therefore, that its object then  is the relief of anchylosis, even when
 the direction of  the limb is as little disturbed as possible.
   To perform this operation, it is necessary to lay bare the bone in
 such  manner as to interrupt its continuity.  In order to prevent its
 consolidation afterwards, we should take care, from time to time, to
 impart to it gentle movements, arid to employ all those means which
 could contribute to  the production of a false  articulation.  In the
 course of time the two ends of the bone partially mould themselves
 to each other; the moveable  end is rounded and  blunted, and the
 other, as it enlarges, becomes  slightly excavated;  the muscles soon
 adapt themselves to  this new joint, which ultimately alloM's the pa-
 tient to use it to some extent in the manner of the old one.
   At  the  first glance, nevertheless, the operation will be rejected,
 both because it  seems dangerous, and because we  do not see that
 it could produce the result which the surgeon would desire.   Do
 not false joints,  the  consequences  of ununited fractures, it Mdll.be
 said, put it in the power of practitioners to estimate their value
 and to justify their rejection ?   Nevertheless, if M'e reflect, that un-
 united fractures  are composed of pieces whose ends are  uneven
 and  slide over  each  other obliquely, M'hilst here  the bone is
 divided transversely, we soon  perceive that we ought not to judge
 of one of  these  cases by the other.   Then, also, do there not exist
 examples of accidental articulations, which have ultimately ended
 in re-establishing a great  part of the functions of the limb ?   M.
Larrey (Caron, Thise, No. 83,  Paris, 1826) mentions a patient who
had a false joint of the thigh, the  result of a fracture, but M'ho,
nevertheless, walked with it without crutches.   M. Sanson told me 
484           NEW ELEMENTS OF OPERATIVE SURGERY.

he had met with a similar case ;  and I have myself seen a woman,
who walked M'ith a cane only, though she had had for fifteen years
a false joint near the middle of the femur.  [Dr. Mott has operated
for ununited fractures in  the femur, by the seton, in three or four
cases:  in one, the false joint had existed for more than a year, and
was cured.—T.]  A tailor, whom Saltzmann (Reissessen, De Articul.
Analog., chap, ii., § 5)  makes  mention of, and who easily  moved
the foot backward and forward, limped only in consequence of the
shortening,  though he had a false joint (pseudarthrose) in the mid-
dle of  the  thigh.  Sue (Sur quelques  Mal.desOs, 1803) says the
same of a patient  in M'hom he  had not been enabled to effect the
consolidation of a fracture in the femur.
  As to the  dangers, they would be infinitely less  than those of
amputation or exsection of the bones.   At the present day,  the es-
tablishment of an artificial joint, with the view of remedying an
anchylosis, is  no longer a  mere speculation; two examples of it, at
least, have  already been performed upon man.
  There are, however, only certain portions of the limbs  which
might require it.  I do not think, for example, that it is suitable for
the foot or the toes ; I doubt, also, if it could be of any great utility
for the shoulder;  but  there are some  anchyloses  of the  fingers
and of the elbow, of the knee and the hip, which might sensibly be
benefitted by  it.

                   A.  The Upper Extremities.

  If the phalangeal articulation was anchylosed, without the  neigh-
boring tendons  having lost theic. mobility, nothing would prevent
our laying the bone bare  on its dorsal  surface, sawing transversely
through it near its middle, afterwards uniting the wound by three
stitches of  suture, which should include both the skin and the ex-
tensor tendon, then leaving this wound sufficient time to become
cicatrized, and not commencing the artificial movements of the two
fragments of the phalanx until at the end of eight or ten days.
  If the movements of the fingers were not  destroyed by the an-
chylosis of  the wrist, we  might also endeavor to establish  a new
articulation at some lines above the styloid  processes of the fore-
arm.  An opening on the  radius, and another on the ulna, would, in
fact, allow  of their being divided by passing the chain-saw around
them.
   For  the  elbow,  the  operation should be  performed by  prefer-
ence immediately above  the joint.   We should make an incision
from two to three inches  long on the external border of the hume-
rus, and  then, after having  separated by a  proper dissection the
brachialis-anticus and the triceps, we should pass around the bone
the chain-saw,  which, being well guarded and carefully directed,
would easily effect its section.  I do not know that I deceive myself,
but it  seems  to  me that  this operation would be neither very dif-
ficult nor very dangerous, and  that it presents real chances of
success. 
DEFORMITIES FROM ALTERATIONS IN THE SKELETON.      485
                   B.  The Lower Extremity.

  It was for the abdominal limb, and, so to  speak, for that exclu-
sively, that  the  idea of an  artificial articulation  first  suggested
itself.  An American  surgeon, Mr. R. Barton, (Western Med. and
Phys. Journal, vol. i., p.  108,) is the true inventor of it;  it was on
the 22d of November, 1826, that he performed it for the first time.
On his patient, the young Coyle, aged twenty-one  years, M. Bar-
ton incised and detached all the soft parts which surround the great
trochanter;  he afterwards effected the division of the femur by
means of a small saw.  The wound being brought together by suture,
the limb was placed in the extension apparatus of Desault.  The
cicatrization of the soft parts required two months to be completed;
and the boy died nine years afterwards from pulmonary disease,
after having made use of  his limb for five or six years.  This boy,
abandoned to drunkenness, and giving himself up, says M. Barton,
(Amer. Journal of Med. and  Surg. Sciences, February, 1838,) to all
kinds of excesses, was attacked with a pain in the thigh, and with
an  anchylosis in the new articulation, two years before  his death.
The examination of the dead body afforded an opportunity of proving
that there had taken place the anatomical  arrangement which I
have spoken of above.
  A surgeon of New York, M. Rodgers, performed the same ope-
ration, November 24th, 1830, in presence  of Doctors  Mott and
Stevens.  At the end  of six  or eight  days, some serious  symptoms
supervened; but six weeks later the wound  cicatrized, and the
patient left the hospital, completely cured, four months after the
operation.  This man, whom, from some incorrect information, I had
in the first edition of this  treatise represented as having died, M'as
still in  very good health  in June, 1833, the epoch at which M.
Rodgers had the goodness  to transmit to me the history of the case.
In that part, therefore, where it M'ould seem  the most difficult and
the least  capable of succeeding, the  operation for an artificial ar-
ticulation has been attempted, and in both cases with success.
  [Dr. Gibson of Philadelphia (See North Amer. Med. and  Surg.
Journ., July, 1842) performed a similar operation to that  of Dr.
Barton, in a case of angular anchylosis of the knee joint, and with
equal success.—T.]
  I ought not, however, to conclude this article without making the
remark, that in the lower extremity such operations should be per-
formed but seldom.  An anchylosis of the knee, even an anchylosis
of the hip, if the limb preserves its  rectilinear position, inconvenien-
ces the patients,  but does not actually prevent them from walking,
and gives them no suffering.  The establishment of a new articu-
lation may, on the contrary, endanger their life.  Supposing even
that the  operation has every possible success, the artificial joint
would not probably in many cases afford any great security, either
in standing (la station) or walking.  Such articulations, also, must
have a great tendency to become reconsolidated.  The case of M. 
486
NEW  ELEMENTS  Or  OPEI.ATIVE SURGERY.
Barton is conclusive proof of it.  While admitting, therefore, that
it should be retained, we should guard ourselves against adopting,
M'ith too much enthusiasm, this new conquest in surgery.

 Article II.—Deformities from Deviation in the Body of the Bones.

  It is not the  place in this work to treat of torsions and deformities
in the body of the bones, developed under the influence of mollifies
ossium or rachitis. It is from orthopedy, and not from operative sur-
gery,  that such  diseases demand relief; but it may happen, that
in consequence of fractures badly consolidated, the limb remains
deformed, either by being too much  shortened, or by deviation
from its axis, or  from the arrangement of the callus.  Hence ope-
rations have been proposed and put  in practice to remedy this kind
of deformity.  Among the operations  suggested for this purpose,
there are two  whose merits it appears  to me I ought to  examine:
the one  consists  in breaking the deformed bone aneM-, in order to
restore to it  a d>etter direction ;  in the  other, we confine  ourselves
to excising a portion of  the angular bone, in order to straighten it,
and afterwards  effect its consolidation by means of the ordinary
dressings.

                  § I.—Breaking of the Callus.

  The breaking of the callus  in fractures badly consolidated is
a very ancient practice,  which has long divided the opinions of sur-
geons.  Though, after the recommendatipn of Hippocrates, we find
that it was,  to a certain extent, adopted by Celsus, (lib. viii., cap.
10,) we  soon after see  that Galen,  Paul of JEgina, and Avicenna,
scarcely venture to sanction it.  Guy of Chauliac, who  advises
it, does not appear to  have  been satisfied of its advantages, nor
Vigo, Pare,  nor  Fabricius ab Aquapendente, who  consent to its
trial only in the first months of the  fracture.   Fabricius  of Hilda-
nus also formally proscribes it; and M'hatever Munnick may have
thought proper to say of it, Petit and Heister so strongly objected
to it, in  the  beginning of the last century, that Hevin, and after-
wards Boyer  and  Callisen, easily succeeded  in causing it to be
generally proscribed.  There is scarcely any other person than M.
Richerand, among modern writers, who believes in its utility;  even
this practitioner also confines it to cases in which the deformity is
excessive, and to those in which it is urgently demanded by the pa-
tients. It seems, then, that it  is an operation definitively  adjudged.
So that, in spite  of what MM.  Jacquemin  (These, No. 140, Paris,
1822) and Torchet (Thise, No. 271, Paris, 1830) have,  upon the
authority of Dupuytren, felt themselves warranted in saying  in its
favor, M. H. Berard, nevertheless, concludes, in the words of Fabri-
cius of Hildanus: Ergo  non diffrigendumcallumhabemus,(Reforman-
dum-ne  Callum Vitiosum ? Paris, 1827.)
  If with us a verdict like this has been without appeal,  it has not
been so in Germany.  A  surgeon of that country, M. Oesterlen, (Rup- 
         deformities from alterations  in the skeleton.      487

ture du Cal, trad, par Maurer, Strasbourg, 1828,) in his endeavor
to demonstrate the advantages  of the  rupture  of the callus, has
collected in his book more than forty examples of it, derived from
his own practice, or from that of surgeons in neighboring cantons.
In analyzing the observations of  M. Oesterlen,  relatively to the
adjustment (redressement) of the callus, I have found that there are
eighteen for the femur, seven for  the leg, three  for the arm, one
for the forearm, and one for the clavicle. In every case, we see that
the operation, M'hich, according to the author, is quite easy to per-
form, and one which the famous  Ignatius Loyola was  not afraid
of submitting  to, M'as  unattended with danger,  and  almost con-
stantly succeeded.  M.  Jacquemin, who borrows  similar  facts from
De la Motte, Guillon, and Desgranges, and who takes four of them
from the practice of Dupuytren, proves on his side that the dangers
of these kinds  of operations had been singularly exaggerated.
   M. Riecke (Journ. Analitique de Med., Septembre, 1828, p. 466)
goes still farther.  An incision, which extends from the great tro-
chanter to  the external condyle  of the  femur, enabled him to lay
bare a callus of the size of the head. The saM', gouge, (gouge) and
mallet, (maillet) were then put into requisition. There was a short-
ening of eight inches, and yet the dressing by permanent extension,
nevertheless, succeeded afterwards in restoring to the limb its natu-
ral length.
   In supposing a callus which had not existed over three  months,
the breaking of it would not in reality be either very difficult or
very painful.  The ends of the  bones,  by means of the  fracture
bandages newly introduced into  practice, being adjusted, and their
extremities placed in  coaptation  with  each other, would almost %
inevitably  become consolidated, without exposing to more dangers
than a simple  fracture.   If the morbid callus was of much longer
duration, we should, without doubt, experience greater  difficulties
in breaking it, and the consolidation, moreover, would have fewer
chances of success, than in the preceding case.
   It is important on this subject to divide the deformities into two
classes, according  as they are merely a shortening of the limb, or
where the bone is consolidated with an angular deformity.  The
rupture of the  callus in the first case, should not be attempted after
the third month of the  fracture.  At a later period we should  have
to fear the  fracture of the bone  in a sound  portion as  M-ell  as in
the diseased part, and we may well conceive that there would then
result no advantage from it.  Supposing even we  should succeed in
separating the two fragments, so as to be able to destroy their lap-
ping over, (le chevauchement) we should at least have to fear that
their extremities  formerly cicatrized would  be  incapable of be-
coming cemented (.se cotter) together, and of reuniting by a  genuine
consolidation.  In such a case, hoM'ever, at the present time, when
we have the improved immoveable dressings, I should not  hesitate
to break the callus.
  When the callus is angular, to  the degree of interfering to a con-
siderable extent  with the functions of  the limb, I  see  no reason 
488           NEW ELEMENTS  OF  OPERATIVE SURGERY.

why we should object to breaking it, hoM'ever ancient  the  con-
solidation may be.  For  this  kind of deformities, in fact, we are
always in time for breaking  the bone, and ahvays  have it in our
power to fracture it at its most angular point.  Numerous appara-
tus and various processes have  been contrived to arrive at this
result.  M. Oesterlen has given a figure of one  of them, which
would fulfil the indication very M-ell; but it is too  complicated.
It  almost always answers, in such cases, to fix the deformed limb
on its concave part to a solid plane, while we suddenly press down
upon  it with the knee or the two hands placed upon  its convex
part.   Having effected the rupture, we must extend the  part as
much as possible, or until it has acquired its natural  length.  The
limb should afterwards be kept in a dextrine dressing until it has
consolidated anew.  In conclusion, this rupture of the callus, which
has originated rather from pathology than from operative surgery,
does not, as it appears to  me, expose in reality to but very little
danger.  The  skin not being divided, there results a fracture in
every respect  analogous  to simple fractures;  and it  is  certain,
whatever may be said of  it, that the bones newly consolidated are
much more easy to break where the callus is, than on either side
of it.  It is also proved that these new fractures in general  consoli-
date more easily and more promptly  than the primitive fractures.
In a patient whom I had  had  for two months under dressing for a
simple fracture in  the body of the femur, and who in a fall broke
the thigh afresh eight days after, a month longer only was required
to obtain a  new consolidation.   Another individual, who  left one
of the hospitals of Paris with a shortening of five inches from  a
very oblique fracture in the femur, broke his limb a second time in
his  efforts to walk.  Admitted into La Charite, ten  months after
this accident, he was submitted to a readjustment and re-extension
of the limb by means of  a bandage  saturated with  dextrine, and
required but two months only to obtain a perfect consolidation, with
only an inch of shortening.

             § II.—Excision of the Angular Callus.

  It may happen that the  bones, during the consolidation of a frac-
ture, become cemented together at a  very acute angle.   The kind
of deformity which results from it, is  sometimes of such extent as
to give  the patient considerable  trouble.  Up to the present time,
no one had suggested a remedy for it; but a distinguished surgeon
of Rochefort, M. Clemot,  has  made known an ingenious method,
which it appears to me  ought  to be preserved in  practice,  and
which promises another  triumph for modern surgery.   M. Cle-
mot's operation  was performed the  first time on a  young child,
and the second time on an adult.  In both cases it was  a femur
bent into an angle in consequence of former fractures badly treated.
The surgeon laid bare the osseous  projection by an incision suffi-
cietly extended, removed by  two cuts of the saw a wedge from
the femur, as I have said in the article on anchylosis, completed 
          DEFORMITIES  from alterations IN THE SKELETON./     489

 the breaking of the bones by tractions, readjusted the limb, reuni
 ted the wound, and afterwards applied the ordinary dressings for
 fractures  of the thigh.  The two patients recovered perfectly, (Ar-
 chiv. Gen. de Med., 2e serie, t. xi., p. 235.)  In such cases, no doubt,
 the method of M. Clemot should be adopted; this operation appears
 to me to be a valuable resource, in every respect worthy of being
 adopted in general practice, more especially now,  since the im-
 moveable dressings have been  simplified in such manner as to as-
 sume any form or direction we may require.
   [It must not be left out of sight, however, that this operation of
 M. Clemot is, in strict truth and in principle, nothing more nor
 less than  a close  imitation of that devised and originated, and first
 performed by our countryman, Dr. Rhea Barton, of Philadelphia, to
 whom, in fact, as M'ill be seen in the preceding  pages, the author
 had previously, with  his accustomed ingenuousness, frankly con-
 ceded  all  the honor and importance which this.rich conquest for
 surgery is entitled  to.   The wedge principle is precisely the same,
 whether to remedy  a permanently angular or flexed position of the
 limb from an anchylosed joint or badly-treated fracture.—T.]

                    Article III.—Appendix.

   Should  I not say,  in conclusion, that this long chapter on deformi-
 ties—a chapter which modern surgery has the right to claim entire-
 ly as its own—might allow at the present day of our grouping and
 classifying a crowd of isolated  facts, which, up to this time, have
 remained without any connection or explanation in science.
   Valleriola (Obs. Med., lib. ii., obs. 4;  et Saucerotte, Mel. de Chir.,
 t.  i., p. 225) speaks  of a permanent flexion produced by convulsions,
 and M'hich resisted for six years all remedies applied  to it, but
 of which the patient was one day cured by leaping from his bed in
 a fit of anger.
   In an invalid, says Wurtz, (Chirurgie, fyc, p. 368,) the limb re-
 mained flexed, in consequence of a wound in the knee ;  but being
 suddenly under the necessity of running, the patient was  cured
 of it immediately.  One of  the women of the calif Haroun-al-
 Raschid had, it is said, a retracted  arm, which she could not use.
 A  physician offered to cure  her.  Having caused the woman to
 make her  appearance in the court of the  calif,  he stooped down
 as if in the act of lifting up her dress, in a manner that shocked her
 modesty;  the patient threw  out her arm violently, to prevent this
 outrage, and the cure was complete !  Might we not attribute cures
 thus obtained, to  the rupture of certain tendons or retracted liga-
 ments,  or of imperfect anchyloses ?
  My intention was to avoid all discussion of priority,  in speak-
 ing of  the section of  tendons, and to  confine myself  to  the
pure and  simple  narration  of  dates ;  but  I see, in a journal in
which  M.  Little gives an account of four cases of section of the
tendo-Achillis, and one of section of the flexor tendons of the leg,
 (The Lancet, January 27, March 13 and 31, May 19 and 26, 1838,) 
490
NEW ELEMENTS OF OPERATIVE SURGERY.
that he claims, in opposition to the French  surgeons, the totality
of sub-cutaneous tenotomy for M. Strohmeyer.   M. Dieffenbach,
(Lettre a I'Academic des Sciences. 10 Septembre, 1838,) who had at
first generously ascribed it to its true source, has also changed his
mind, and at present claims the invention for himself.  Now the
progress of this operation ought to be understood, as  follows:—
1. Bell divides the ligaments of the fingers through a puncture in
the skin;  2. A. Cooper does the same for bridles in the palm of the
hands ; 3. Brodie operates in this manner for varicose veins ;  4. Du-
puytren applies  this process to the tendon of the sterno-mastoid;
5. M. Strohmeyer transfers it to the tendo-Achillis;  6. From thence
it is applied to  other tendons by  MM. Strohmeyer, Dieffenbach,
Stoess, Duval, Bouvier, and Guerin.  That is its history.
     APPENDIX ON TENOTOMY TO THIS AMERICAN EDITION.

[A Critical Examination of the late Discussion in Paris on Tenotomy.

  Professor Velpeau has transmitted for our consideration, for this
American edition of  his work, a learned brochure  on this subject
by M. Vidal, (de Cassis) published during the past year (1843) at Pa-
ris, in the Annals  of French and Foreign Surgery, vol. vii., edited
by MM.. Begin, Marchal, (de Calvi) Velpeau, and Vidal, (de Cassis.)
Though a treatise  upon this subject of a purely controversial cha-
racter would not properly enter into a practical work on operative
surgery, there is in this  so  much valuable historic matter apper-
taining  to the progress of the now brilliant discoveries in tenotomy,
and so much other new and practical material bearing directly on
the present  actual state of that  department of operative surgery,
and the  most approved processes now adopted, that we consider it a
duty to the medical student, as well as to the profession at large, to
avail ourselves largely of these very interesting and recent details.

                    Etiology of Deformities.

  M. Vidal, in stating that the causes of deformities are exceed-
ingly numerous, says the  ultra (absolus) partisans of tenotomy have
attached too  much  importance to muscular retraction as one of
them.   M. Gerdy,  in his  discourse on the etiology of deformities,
makes fifteen orders,  which he has afterwards grouped under four
heads:  1. Primitive vicious formation of the  bones; 2. Ulterior
alterations in the formation  of these textures ; 3. Fibrous or  fibro-
cellular indurations ; 4. Muscular retractions.
  M. Vidal agrees in the opinion  that muscular retractions are  co-
incident with the greatest number of deformities, especially those
that are congenital.  In allusion to a recent discourse of Professor
Velpeau, M. Vidal says he has shown himself a perfect master of
the subject,  and enabled  us  to put a proper estimate upon illegiti-
mate pretensions when compared with unerring dates and facts. 
APPENDIX  TO TENOTOMY.
491
  In allusion  to passages  in the discourse of M. Bouvier, on the
doctrine of muscular retractions, especially in relation to club-foot,
as broached in publications in 1821, 23, 32, and 34, by MM. Ru-
dolphi, Strohmeyer, and Dieffenbach, we have in M. Vidal's article
a quotation on this subject from Delpech, wherein he claims pri-
ority in point of time for Bsclard.   This illustrious French patho-
logist in a long memoir endeavored to prove that monstrosities and
deformities, including  club-foot, were imputable to  diseases and
lesions of the cerebro-spinal system.  He expressly points out (Bul-
letin de la Faculte, t. v., p. 517) the  club-foot among these deform-
ities, and all his investigations show that he considered the nervous
centres the point of departure for the numerous deformities  of the
human body.
  Before MM. Strohmeyer  and  Dieffenbach; (says M. Vidal,) M.
Lafond, in a great work published in 1827-29; endeavored to show
the connection between deformities and the perverted action of
muscles, especially in curvatures of the spine.  In these  latter he
considered the extensors the most powerful cause, and he advises,
where there is the least deviation of the spine from the right line,
to search diligently for some local affection of the muscles on one
side, from whatever cause arising, and by which this deviation in
front  or behind, or on one  or the other side, is temporarily pro-
duced, (Recherches sur  les Principales Difformites du Corps Humain,
p. 36, 1827.)
  The same author, M. Lafond, (at p. 177,)  speaking of torticollis,
says: " We have never perceived that this  disease was caused by
the bones; the muscles are always its first cause.  It is especially
the sterno-mastoid which we must charge with this deformity."
  To explain the spontaneous luxation of the femur during intra-
uterine life, " it is sufficient," says M. Lafond, " to  recollect that
the most powerful of the muscles  surrounding the upper articula-
tion of the femurs, tend constantly to carry the  head of this bone
upM'ards," (p.  203.)
  He also says permanent  flexion of the thigh upon the abdomen
is caused by the muscles, (p. 260.)
  So  in torsions  of the legs, when the knee is  turned inward,
the cause is the  biceps muscle, and when outward, it  is chiefly
the semi-membranosus.   Other muscles  concur  a little,  (pages
271, 272.)   So also  he remarks  that  the muscles are always
the first  organs affected  in permanent flexion of the  leg  upon
the thigh.   So in club-foot, says M. Lafond, the muscles  alone,
and especially the gastrocnemii, (jumeaux) with  their common
tendon, are  the determining cause of the  disease,  (page  283.)
but that it  is not  to  be denied that this  shortening sometimes
affects also the plantaris,  tibialis posticus, and peroneus longus.
That  the  shortening or retraction (racourcissement) of  the  mus-
cles may commence with  the embryo, (p. 284,) and that "facts
authorize us to believe that the convulsions experienced by the foetus
in utero may give rise  to the congenital production of club-foot,"
(p. 300.) 
492          NEW ELEMENTS OF OPERATIVE SURGERY.

  In 1836, before M. Guerin had made known his doctrine on de-
formities, and M'hen he had in this same year reflected so little
upon special tenotomy that he addressed to the Academy remarks
on a new manner of treating club-foot, (Gazette Medicate, 1836, p.
268, 620,) we have a thesis supported June 20, 1836, at Stras-
bourg by M. Held, M'ho, after  referring to  Duverney and M. La-
fond on club-foot, says, " the turning of the foot inM-ard is evidently
caused  by muscular contraction," " that in the pes equinus  the
inequality of force  exists from the beginning, and the inequality
of length is  consecutive;" in other M'ords, that the  disease is at
first dynamic, and at a later period organic.  That, although club-
foot is the product of inequality of the  antagonist muscular forces
originally, and that it may possibly originate in enervation at some
point in the spinal marrow, or a dynamic or organic affection of this
substance, it frequently happens  that while the cause disappears,
the effect remains.  In cases of shortening of the limb from frac-
ture, luxation, or congenital  defect of length, the club-foot arises
from voluntary muscular contraction,  whereas in the preceding
cases it is convulsive.   So in  club-foot the consequence of various
wounds, ulcerations, abscesses, and burns, situated in the foot, leg,
thigh, &c.  To prevent the pain, the patient at first avoids putting
the heel or the points of the toes on the ground, but, as in the prece-
ding cases, this retraction of the muscles soon becomes permanent,
and the inflammation of the muscles themselves is  generally ac-
companied with a contraction which  may remain after the cessa-
tion of  the phlogosis, or lead to suppuration, adhesion, and conse-
cutive  atrophy of the inflamed muscle, and thus cause olub-foot in
two ways (d'une double  maniire)   That  which the contraction
(contracture) of certain groups of muscles effects, may in like man-
ner be  produced by the paralysis or  debility of certain  other
muscles.  In ordinary cases this paralysis  is imputable to affec-
tions of the spine, and the  club-foot  may exist though the para-
lysis ceases.  " Thus,  therefore,  the  causes which produce an
interruption  to the equilibrium of the antagonist muscular forces,
whether by  augmenting  their contractility and determining the
contraction  of the  muscles, or by  paralyzing the  action of their
antagonists,  and abandoning  them  to an organic  contractility,
by virtue of which they constantly tend to an  approximation of
their extremities, are capable  of finally producing the shortening
of the muscles, and therefore club-foot," (Held, p. 26.)  Such gen-
erally  are the causes which give  rise to accidental club-foot.  In
speaking of the causes before birth, he asks (p. 29)  if the muscular
action which keeps the feet in a state  of torsion during intra-ute-
rine life, is not the same which produces spontaneous  club-foot
during  that  period.  A fact which confirms this  is, that  at the
moment of  birth, when the muscles are neither  extended nor atro-
phied, the. foot is restored with the  greatest ease to its natural
position.  M. Velpeau therefore concludes, that whatever may be
the apparent contradictions in some  parts of M. Held's thesis, he 
APPENDIX TO TENOTOMY.
493
has distinctly stated muscular  contraction as a determining cause
of club-foot.
  M. Held, in speaking in  more general terms of tenotomy, says:
" We  are of the opinion that an operation so simple and trifling
will be generalized, and applied to all cases of deformity dependent
upon the contraction or shortening of the muscles, and that it will
ultimately become one of the most important conquests of modern
surgery."   M. Velpeau asks if any thing published since  1838 can
be more clear or explicit than  this.
  In another passage (p. 62) M.  Held speaks of tenotomy  for  va-
rious deformities analogous to that of club-foot, as naturally sug-
gested by the brilliant operation  for the tendo-Achillis.   He there
particularizes the cases of sections of the various other tendons of
the leg.  Finally, he concludes (p. 65) in general terms, " not only
do we believe it (tenotomy) applicable to all the muscles, but we
ask also, if, in a great number of deformities, it is not preferable
to the employment of mechanical apparatus, (des appareils meca-
niques")
  Besides what has already been given from Beclard, in proof that
he recognised the character of club-foot and other deformities, M.
Velpeau cites other  passages wherein, speaking  of  acephalous
monsters, he considers  that some  accidental  disease which  they
have experienced during the period of intra-uterine life has caused
the atrophy or destruction of  the medulla oblongata, (de la mo'elle
allongee) and of the upper part  of the spinal marrow, and that all
the apparent irregularities which it presents  are the natural and
more  or less direct result  of this  accident, (p. 516 and 517.)  To
show that this subject was long since appreciated, M. Velpeau also
quotes  a passage  to this  effect from  Benj. Bell:—The  limbs are
deformed in various ways.   The causes of this accident are nume-
rous.   The bones  may be diseased, or the muscles in a state of
contraction, or the bones and muscles may  be both affected. Nev-
ertheless, the most frequent cause of  the vicious conformation of
the limbs is the contraction of the  flexor muscles of the leg and
fore-arm.
  M.  Velpeau goes  still farther back, and cites a passage from
Morgagni, (his 27th  letter, art. 33,) wherein, speaking of the doc-
trines of Glisson and Mayow, he says:  " As to the second, (that of
Mayow,)  you will understand it if you admit that  the muscles
which are found on  the left  side increase less than the bones, or
contract more than the muscles on the right side;  whether this con-
traction depends upon convulsions or upon a greater degree of
force, which enables  the muscles of the  left side to preponderate
over those of the right; a  state of things which exists from birth,
or which results from the diminution of force in the muscles of the
right  side from paralysis, or any other  cause whatever.
  " Also, though I  do not deny that the first cause may sometimes
exist of itself and produce the  gibbosity, I think, however, that this
latter is more frequently the effect of the second, that is  to say, of
the contraction of  the muscles." 
494
NEW ELEMENTS OF OPERATIVE SURGERY.
  M. Velpeau then cites an author still more ancient, viz., Miry,
in the Memoirs of the Academy of Sciences, 1706.  The substance
of these citations is, that though it might be thought quite easy
to explain the curvature of the spine from the vertebrae being a
little thicker  on  its convex than  on its concave  part, this thick-
ness, hoM'ever, is not sufficient to cause a curvature in  an oppo-
site  direction; and the shortening of the  muscles of this column
can  alone explain it, for both the relaxation of  the extended or
elongated muscles, and the greater or less degree of thickness of
the vertebrae, can be caused only by the muscles that are shortened.
When the muscles act equally, the spine  bends only in a straight
line  backwards; but if all the muscles on the right side are in con-
traction and those of the left relaxed, the spine is bent to the right
side, and vice versd,.  So that the irregularities of the spine, and the
extension of its relaxed muscles, and the thickness of the  vertebra
on one  side more than on the  other, " are all solely the effect  of
the contraction of its shortened muscles." The shortened muscles of
the spine, by their permanent contraction holding  it inflexibly bent
to one side, retain the opposite muscles in  a state  of  perpetual ex-
tension.  Repeating the  same idea, M. Mery  says:  " The perma-
nent  and involuntary contraction of these muscles  is  therefore the
sole efficient cause of the extraordinary  curvature of the spine."
  In respect to curvatures of the limbs,'  M.  Mery says that the
weight of the body and the softness of the  bones can  only be occa-
sional causes, and that it is only the contraction of the muscles of
the thighs and legs to a greater degree  in one direction than in
another, M'hich can determine the femur, tibia, or fibula to become
bent backward rather than forward.  Lie  adds, M'ith much force:
" The curvature of the bones of the arm, in which it is evident that
the weight of the body can have no part, is a clear proof of this
truth; whence, in fine, I conclude, that the more forcible contraction
of the muscles upon one side than upon the  other,* is the onlu efficient
cause of the curvature of the bones."  On the contrary, " when the
antagonist muscles (says he) of a  p*art act with equal force, they
maintain the bones in their natural shape,  in spite of their softness
and the M'eight of the body."
  In thus grouping together authorities from those  epochs in which
M. Guerin contends that  tenotomy Mas exclusively empirical, and
not an etiological or rational science, JM. Vidal cites  above all  of
them the great surgeon Delpech, as having pointed out the source
and recognised and  generalized the effects of these  contractions.
M. Vidal quotes also a remark of M. Bonnet,  (a friend of M. Gue-
rin,)  in his treatise on tendinous  and muscular affections, (p. xvi.,)
wherein he says of Delpech, that the moderns  have only confirmed
or developed many valuable opinions of that great surgeon in his
work on orthomorphy, and adds  that Delpech also insisted  on  the
part  which the spinal marrow and nerves had  in the production  of
deformities of the bones  through the intervention of the muscles,
and  that thus an  irritative action in a principal nervous trunk and
its branches may be transmitted to the muscles  it supplies, and, 
APPENDIX TO  TENOTOMY.
495
causing in these latter a permanent shortening, change the mutual
relation and  inclination of the bones, (Orthomorphie, p. 84.)  So,
says Delpech, may an affection not only of the nerves, but of the
spinal marrow at the origin of those nerves, produce the same ef-
fects on the muscles of the trunk as on those of the limbs to M'hich
they are distributed.  Delpech also remarks, that such morbid con-
ditions would produce still more serious deformities when occur-
ring in  infancy, exemplifying this by convulsions so common in
infancy, and which he considers may have important relations with
some lesion of the spinal  marroM', or of the origins of the dorsal
nerves, or of  the arachnoid membrane or pi a mater, producing ul-
timately a contraction of certain muscles  and a deformity of the
spine.  The same author (Orthomorphie,  t. i., p. 99) says it is diffi-
cult for  him to separate the idea of these deformities from that of
a preceding abnormal condition of one of the great vital centres, as,
for example, the spinal marrow.
  M. Vidal, using the expression of Delpech  himself, where that
author illustrates his views by the contracted state of the muscles
of the calf as they appear on dissection in club-foot, accords to
him the honor of having discovered the key  of the whole doctrine of
tenotomy.
  M. Gerdy had also  established a crowd of articular deformities
that do not arise from muscular retractions, to  wit, those from sub-
cutaneous bridles, and certain alterations of the ligaments.
  In relation to the remark of M. Guerin, "that  tenotomy is destined
to be applied to retraction in all the muscles wherever it presents
itself," M. Velpeau refers  to  those passages in this present work
of his upon operative surgery, where it  will be found that he (M.
V.) says the  same thing under  a great variety of forms, and in a
number of different chapters, and had, in fact, generalized the sub-
ject of  muscular retraction  and  tenotomy  before  M. Guerin had
treated  of it.
              Characters of  sub-cutaneous Wounds.

  M. Vidal proceeds  to show that the  great  principle which has
given birth to the most rational processes of tenotomy, that is, the
sub-cutaneous section, had been well understood by John Hunter,
who pointed out the true source of the healing  up of" wounds with-
out inflammation to be the exemption of such lesions from exposure
to air.   Hunter showed that this adhesion by first intention would
take place, not only in most  internal  lesions that had no commu-
nication externally, but also in many  that had such communi-
cation.
  M. Vidal denies emphatically the assertion of those who pretend
that sub-cutaneous wounds are always exempt from inflammation.
He cites Hunter's Lessons on Surgery to show M'here this author
distinctly states, that to produce adhesion in two surfaces, coagula-
ble lymph may be poured out in sufficient quantity to make  it un-
necessary for either to be in a state of inflammation. In the repa-
ration, therefore, Hunter notes the agency not only of inflammation, 
496
NEW ELEMENTS OF OPERATIVE SURGERY.
but of another act which  is not inflammation, nor a morbid pro-
cess, but  a phenomenon purely  physiological.   So M. Est or, the
skilful translator of J. Bell into French, says: " What J. Bell says,
(of the consolidation of recent divisions by a  process absolutely
analogous to that of the growth of parts,) is applicable especially
to divided parts still  covered with their  natural integuments, and
which become united together while protected from contact with the ah-,
and without any of the ordinary symptoms of inflammation."  Mr.
Estor even foreshadoM'ed in another note  the idea, that the process
here, too,  was analogous to that of nutrition.
  From all these facts, and the well-known popularity of Hunter's
doctrines at Montpellier, and the admiration which Delpech enter-
tained for them, M. Vidal  comes very naturally to the great his-
toric event, that Delpech was the first in France who  proposed and
performed the  section of  the  tendo-Achillis,  in leaving the skin
which covers it entire.

                      Tenotomy in general.

  M. Vidal ingeniously and very naturally traces  from the above
recited facts and  sound principles of pathology, the  source of the
zeal of M. Serre, successor of Delpech at Montpellier, in behalf of
immediate reunion  of wounds as the necessary result of the princi-
ple of dressing by occlusion, as it was called by Dupuytren. Hence
arose the  scrupulous  care to  make the  external Mound of the
smallest dimensions possible, and  as far  as possible  from the part
M'hose inflammation was to be dreaded, in order  to prevent the
air from  traversing such  part.   Dupuytren  did injustice to the
school of  Hunter,  but  nevertheless perfectly understood its princi-
ples, his reputation in  fact  being associated (vid. text of this work)
with the sub-cutaneous method.   From  the doctrines entertained
by the school of Hunter, it is easily explained why he divided the
tendo-Achillis with a  cataract needle, and  Bell, in  certain  irre-
ducible luxations  of the fingers, advised the lateral  ligaments of
the fingers to be  divided with a cataract or spear-pointed needle,
(en fer de lance) and by a  simple puncture of the skin ;  why Bro-
die, so long as  tM'enty to  thirty years since, and after Bell's ope-
ration, (just named,) adopted  the sub-cutaneous method for the
division of varicose veins; why  Delpech avoided Mounding the
skin which covers the  posterior part of the tendo-Achillis, and why
Boyer proposed and practised the well-known process for the open-
ing of abscesses by congestion.
  According also to M. Goyrand, Sir Astley Cooper, in 1835, adopt-
ed the Hunterian plan for  the tendo-Achillis, in dividing sub-cuta-
neous bridles in the palm of the hand.  (See a note, infra, from Pro-
fessor Fergusson's Surgery, confirming this.)
  Delpech distinctly says, (Maladies reputees Chirurg., t. ii., p. 170,)
that the section of the tendons is not dangerous, if it is practised
under the skin and excluded from the air.
  M. Gagnebe, a young physician, in 1830, (see Thesis, No. 5,)  with 
APPENDIX TO TENOTOMY.                 497
the same view describes the sub-cutaneous operation for ligature
of varicose veins.
  M. Bonnet, a friend (says M. Vidal) of M. Guerin, thus classifies
the persons who made the first steps in tenotomy:—

  1816—Delpech divides the tendo-Achillis by two  lateral  inci-
sions, leaving untouched the skin behind the tendon.
  1831—Strohmeyer substitutes two narrow punctures for the in-
cisions of Delpech.
  1836—The second puncture (that is, on the point opposite to the
entrance of the tenotome) is dispensed with simultaneously by seve-
ral surgeons.
  That there was an interval of fifteen years after Delpech, and that
it  then  became, after being  revived by Strohmeyer, universally
adopted.
  It still became necessary to give confidence to the timid by prov-
ing the safety of such wounds, and this  M.  Guerin has unquestion-
ably greatly contributed to do by his experiments on living animals
and on man; having carried the sub-cutaneous section farther, and
performed it  a greater  number of times,  and that on the same
person, than any other individual: (vide a note infra  on this sub-
ject.)   M. Vidal, however, inveighs  against the abuse  of a  good
remedy, and seems to think the day may come when the evils pro-
duced by incisions too numerous, deep, and extensive, will cause a
reaction against tenotomy.
  As a farther proof that the importance of excluding the air was
long since well known, M. Vidal mentions the fact which had  been
noticed of the cure, almost Mdthout marked symptoms of inflam-
mation, of severe comminuted fractures by the immoveable appa-
ratus of Larrey, that for occlusion of the air by Dupuytren, and the
dextrine bandage of M.  Velpeau.  He  mentions also a successful
case of his own which he treated at La Pitie.   He  thinks, how-
ever, that this treatment  of the  above-named  surgeons, and  of
Seutin and others, may be too often followed by fatal  gangrene of
the deep-seated  parts, confirming the observation of Hunter, that
such fractures may  produce  such consequences, especially when
the mischief is  deep-seated.  This, however, is  far from being
a parallel  case to the slight superficial wounds of tenotomy.  But
these, even in the most skilful hands, may produce dangerous con-
sequences.  M. Vidal calls for a frank avowal and description of
these.
  On the  other hand, he thinks there are many errors that have
retarded the progress of tenotomy:
  1. The exaggerated danger of punctured wounds, notM'ithstand-
ing the innocence of the severe puncture made in depressing cat-
aract had been so familiar to every one.
  2. The supposed danger  of wounding tendons, as the ancients
also had thought, from their confounding them with nerves.   This
notion prevailed also universally among the moderns, though Hun-
                             63 
498
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
ter had shown that most eases of ruptured  tendons healed kindly
when not exposed to the air.
  3.  A third error grew out of the above, and the  tardy progress
of pathological anatomy, which, not making a distinction betM'een
wounds exposed and not exposed to the  air, supposed that the
functions of the tendon M'ere destroyed, and the  cicatrix necessa-
rily deformed,  adherent, &c.
  M. Vidal then resumes his quotations from the  discourse of M.
Velpeau, M'hich latter on this subject says:  Up to the present  time
almost all physiologists and surgeons considered that a divided or
ruptured tendon thereby forever lost its functions, and that these
wounds M'ere exceedingly dangerous.  Tenotomy advanced slowly
against such obstacles, though Lorcns in 1782, Ant. Petit in 1799,
and Michaelis and Sartorius in 1809 and 1812, endeavored to dis-
sipate  this prejudice.  Delpech  in 1816, and again in 1823, still
cautions that the tendons should  be cut under the  skin, M'hen Du-
puytren, in 1822, giving a new blow  to the  ancient doctrines, laid,
as M.  Velpeau conceives, the foundations of modern tenotomy.
But it was by  the facts established by Strohmeyer, between  1831
and 1834, that those ancient errors M'ere definitively annihilated.
Thus escaping from its imprisonment, tenotomy at once became
generalized in France and in Germany, England, Belgium,  and
America, by the operations of MM. Stoess,  Duval, and Bouvier,
and  by almost all  the surgeons  of French hospitals, before (says
M. Velpeau) M. Guerin had spoken a M'ord of it.
  Naturally tenotomy began M'ith  the tendo-Achillis,  as the  most
prominent and important distortion to be relieved, and for the  rup-
ture  of which such endless combinations of complex apparatus had
been devised in  all  times.  M. Velpeau had shown in 1833, and
since proved,  how  little  dangerous  this rupture  M'as. and  how
easily it could  be cured by resting the limb for some ten days in an
immoveable dressing, and afterwards by not allowing the patient to
walk without this dressing for the space of  a month.   The princi-
pal apparatus  formerly employed had in fact  contributed to give a
dangerous character tothese wounds. The success of tenotomy on
the tendo-Achillis being established, the transition was easy enough
to the ham, neck, &c.; and M. Velpeau sees no particular merit
as to any  fundamental claims of discovery, in cutting  here  or
there additional tendons that have heretofore not yet happened to
have fallen under the, action of the tenotome.
   M. Vidal, quoting from the pathological portion of M. Velpeau's
discourse, alludes to  an important practical observation of the lat-
ter, deducible from what takes place in the formation of the  new
tendon:  (see text of this work, supra.)  It is this: that the sub-sec-
tion M-ill be more successful in proportion as the  neighboring parts
are  more abundantly supplied by cellular tissue.  " If  (says M.
Velpeau) the reproduction of a divided tendon is  effected as I  have
described it, that is to say, by means  of a cellular sheath, lamellae,
filaments, and cellulo-vascular tissues, which serve, so to speak, as
the atmosphere of the divided organ : that all these tissues, imbi- 
APPENDIX  TO  TENOTOMY.                  499
bing a liquid  at first, and becoming the  seat of an abnormal af-
flux, thicken, approximate, and vascularize in a blended mass, and
by degrees harden and solidify, it is easy to comprehend where te-
notomy will be more or  less efficacious, or not succeed at all."
  In regard to the opposite opinion, entertained by MM. Ascher,
Held, Duval, and Guerin, that  all that is necessary (after the ideas
of Hunter) is  an effusion of plastic lymph, either pure or slightly
mingled with a little blood, M. Velpeau says they do not take into
consideration that wherever this plastic matter is effused it must
contract adhesions with something, and that in  the fibro-synovial
sheaths of the fingers, the  ends of the tendon, lost in this matter,
and  which must necessarily adhere to inflexible parts, would no
longer have any relation to each other; and that if these ends were
brought in contact by flexion of the fingers, reunion would not take
place.   Hence, wherever tendons are surrounded by sheaths or
tissues, either purely cellular or fibro-cellular, tenotomy would have
the greatest chances of success; but, in  regions where the  ten-
dons are surrounded only by synovial net-works, or fibro-synovial
sheaths, the chances would be less.  In these respects the tendo-
Achillis is most favorably situated ;  then  come the tendons of the
ham, the biceps flexor cubiti, the  two branches of the sterno-mas-
toid, the peronei, tibiales, extensors of the toes,  above and below
the malleoli, &c.
  The tendons most unfavorably situated, are the tendons of the
flexor longus digitorum  pedis  at  the  point of the foot, the tibialis
posticus, the flexor longus pollicis pedis, the peronei laterales at
their passage behind the malleoli, the flexor sublimis and profundus
in the palm of the hand, and more particularly on the palmar surface
of the phalanges.   In the palmar  face of the hand, in fact, betM'een
the aponeurosis and interossei muscles, there is nothing around
the tendons but synovial, or rather exceedingly dense and slightly
vascular fibro-synovial net-works.   As, however, the neighborhood
of the lumbrici muscles, and of the filaments which traverse the
palmar aponeurosis of  the  interosseous muscles, may furnish, by
the attenuation of  those various parts, a sort of new riband  going
from one end of the tendon to the other, there i^ reason to believe
that certain movements  of the  fingers would be re-established after
the section of the tendons of the flexor, or of the profundus in the
palm of the hand.  On the fore-part of the phalanges, success
would be  much more problematical; the fibro-synovial or osteo-
fibrous sheath  which exists there, represents an encasement (etui)
formed behind by the phalanges themselves, and in front by  trans-
verse or longitudinal fibres, closely condensed together, and of a
completely fibrous character.  As the interior of this sheath repre-
sents rather a simple synovial surface, than a membrane susceptible
of being flattened out, (solee) it follows that M'hen the tendon is once
cut it finds nothing which can  re-establish its continuity, and that
its action on the finger runs great risk of being destroyed.
  The doctrine of M. Velpeau exacts that the greatest possible
care should be taken in the sub-cutaneous section, to avoid making 
500            NEW ELEMENTS OF OPERATIVE SURGERY.

too great a Mound of the sheath or tissues  nearest to the tendon.
We thereby have the best chances of a reparation more nearly ap-
proaching to the normal condition of the parts.  While, on the other
hand, too extensive a division of the tendinous sheath, and with it
lesion of the tissues which are connected with it, produce an irreg-
ular, M'ide  cicatrix, adherent to  the neighboring organs, and con-
sequently incapable of giving actual continuity to the tendon, and
of propagating the movements of the muscle belonging to it; for, in
order to effect that, the tendon requires a certain degree of freedom,
which it has lost.  These movements do not, in that case, go be-
yond the upper end, and every thing in relation to the lower end
is as it were paralyzed.
  The  tenotome, therefore, (continues M. Vidal,) should  act more
by pressing than sawing,  so that  a combined movement may re-
sult, in which the tenotome acts  on the tendon and  the tendon on
the tenotome ; in fact, that the cutting edge and the parts to be cut
should  act  upon each other, and that these parts should be more
stretched in proportion  to the force with which the instrument is
applied to their deep-seated  surface.
  M. Guerin challenged M. Velpeau to show him, in any work, the
principle of a voluntary physiological  contraction as a means of
favoring tenotomy.   M. Velpeau says, if he means to deny thereby
that, this extension should be made to increase the stiffness and
prominence of the part to be divided, whether it be by the will of
the patient or otherwise, he  denies what is considered requisite in
every operation of tenotomy.
  M. Gerdy, also, in reply to M. Guerin, says  that  it would have
been a truism  too trite not to have drawn down ridicule, to have
enjoined this preliminary proceeding, which is acknowledged by
M. Guerin  himself to be absolutely indispensable to the  division
of a tendon or muscle.  Strohmeyer (says M. Gerdy) never spoke
of it, nor looked upon it as a discovery.   M. Vidal, furthermore,
puts the question to M. Guerin, if the retracted muscles, especially
those for a long time retracted, or paralyzed, and fibrous bundles
which  are  not muscles, possess this voluntary physiological con-
traction ?
  M. Gerdy (in conformity  also to the opinion  of  M. Vidal, and
contrary to the  now prevailing opinion of MM. Dieffenbach, Gue-
rin, and most English surgeons) is in favor of making two or more
stages to the operation ; that is, that in order to  avoid making un-
necessary or uncalled-for  divisions, we should  cut  the  different
retracted tendons successively at different epochs, according as the
first sections do not appear sufficient.
  M. Vidal approves, however, of M. Guerin's method, borrowed,
he says, from M. Scoutetten; that is to say, when there are many
tendons  to  cut, that  they should  be  cut at different  points and
distances, as the simultaneous concentration of many sections upon
one point would make  too large a cicatrix, and blend the cords
together, or incur more risk of exciting inflammation, and each
tendon, moreover, being deprived of its appropriate connections, 
APPENDIX TO  TENOTOMY.
501
could not preserve its independent movements, while its functions
would be executed with less precision, or be entirely abolished.  He
urges, also, the use of apparatus afterwards, as we may thus, after
certain sections have been made,  economize our operations, and
dispense with any more of them.

           Tenotomy of the Wrist, Hand, and Fingers.

  M. Vidal quotes from a late treatise by M. Bonnet, wherein the
latter says, that up to the present time, in all the sub-sections for the
fingers, these organs, though they have been-straightened, have lost
their movements of flexion.  M. Doubovitsky judiciously observes of
the two extremities, upper and lower, that tenotomy is equally ap-
plicable to each;  but that in the lower, the form of the limb is the
principal point  aimed at, for in regaining that, we generally re-
establish the use of the limb; while in the upper, form is secondary,
and use the principal object.  In the hand, he adds, use should not
be lost sight of, in restoring  the form, (Annales de Chirurgie, Fe-
vrier, 1841.)
  MM. Bouvier and Velpeau  have expressed the same idea, both
as to the flexions of the hand  and the foot, and that in this last, the
important point is to bring the sole in close  apposition with the
ground, even  though the  toes should remain immoveable.  It fol-
lows, therefore, in their judgment, that the section of the flexor longus
digitorum pedis, M'hether on the plantar surface of the phalanges, on
the sole of  the foot, or in  the  groove of the os calcis, should not be
neglected, if  any  deviation whatever  of the foot should seem to
require it.
  M. Bonnet, in his  late work, to which we have just alluded, fur-
thermore remarks, that failures in the  section of the flexors of the
fingers are imputable to  the  presence  of synovial sheaths, in the
interior of which  the ends of the tendon cannot reunite.  Hence,
says he, the failure of the operation in  dividing the flexors of the
fingers on the phalanges, which happened twice to Strohmeyer and
Dieffenbach, and once to M. Guerin, in the case of M. Doubovitsky
himself.  M. Bonnet, also, in thus dividing the  four tendons of the
common flexors on  a line  with the first phalanx, found  that he
could straighten the fingers, but their flexion was to a great degree
destroyed, even for grasping  small bodies.  M. Larrey, junior, he
says, failed in the same way, in dividing the flexor muscles in the
palm of the  hand,  though there are there  no  synovial sheaths.
Therefore, says M. Bonnet, in  order to preserve to the flexor mus-
cles of the  fingers their normal action, they should be divided at
the forearm ; but other reasons prevent  this from being done, as we
incur, at the lower part of the forearm, the riskv of wounding the
median nerve, while at the upper  no  good result could ensue on
account of their numerous adhesions with the  surrounding parts,
and the extent of their insertions on the bones.
  M. Bonnet comes to the conclusion, therefore, that the section of
the flexor muscles and tendons of the  fingers is useless, and that 
502
NEW  ELEMENTS OF OPERATIVE Sl'RGERY.
the only case in which  it could be useful, would be  where  the
retracted finger, by its abnormal position, had interfered with  the
motions of the others.   In this case, he  has  divided the retracted
tendon on  a line with the second phalanx.  The finger remained
extended, and incapable of flexion, M'hile the others thus regained
their liberty.  When, however, the flexors only of the hand are re-
tracted,  tenotomy is  indicated.  So also  for retracted toes,  the
division is often of the utmost importance and benefit, for the rea-
sons just given.               »
  On the 3d of October, 1842, and immediately subsequent to  the
publication of the above treatise of M. Bonnet, M. Bouvier read a
discourse to  the Academy of Medicine,  giving  the results of  his
orthopedic experiments on dogs.  They are as follows:
  1. The section of the flexor carpi radialis, flexor carpi ulnaris,
and flexor digitorum sublimis, in the  foreleg, was followed by  ad-
hesion of these muscles to one another, and the loss of their indi-
vidual action, without  the  flexor profundus participating in either
effect.
  2. After the section of the same muscles, and also of the  flexor
profundus, there was formed a common  cicatrix, adherent to the
ulna, whereby the toes lost their movement of flexion.
  3. By dividing the tendons of the flexor  sublimis and flexor pro-
fundus, on the metacarpus, there were produced adherent cicatrices
between them and with the bones, causing almost total loss of flexion
of the toes.
  4. After  the section of the flexor profundus, on the second pha-
lanx, there  was in one case no trace of reunion of the tM'o ends,
but adhesion of the lower end with the  flexor sublimis, and loss
of motion in the third phalanx.
  From these facts, M. Bouvier concludes that:
  1. The cicatrices of tendons are isolated  and exempt from adhe-
sions only in those cases" where they can be divided separately, and
where there continues to remain around  them, and between  them
and the  organs in  closest vicinity  to  them,  a sufficient quantity
(epaisseur) of cellular tissue which has  not been disturbed.
  2. That as the greater separation of the muscles at the wrist in
man, permits those conditions to be fulfilled better than in  dogs,
the  results  of his experiments cannot  be applied without restric-
tions-to man, particularly in what concerns the flexor carpi ulnaris,
and the palmaris longus and palmaris brevis.
  3. That the section of the sublimis and profundus, on the meta-
carpus, ought to involve, as in dogs, a greater or less degree of de-
struction of the movement of the second  and third phalanges.
  4. That after the section of one  only  of these muscles at the
same  place,  the  Cicatrix of the divided  tendon would  without
doubt become adherent to the unwounded tendon.
  5. That the division of the tendons in their fibrous  sheaths, on
the  phalanges, would cause the loss of their action from the failure
of their reunion or  from their adhesions.
  6. That if, therefore, there should be an indication to divide the 
APPENDIX TO TENOTOMY.                  503
flexor carpi ulnaris and  the palmaris longus and  palmaris bre-
vis, or though M'e might  attempt even the section of the subli-
mis at the forearm, still  the simultaneous "section of the subli-
mis and  profundus,  in  the palm of the hand and  opposite to
the phalanges, from the loss of  motion which  follows this sec-
tion, would make the employment  of mechanical means gene
rally preferable  in this case to tenotomy;  which  latter should
be  restricted in  its  application  to  the  cases  where, from  or-
thopedy having failed, the hand  or the fingers were  left  in such
a state of deformity or feebleness, that the  patient might derive
advantage  in regaining a regular conformation by means of the
operation, notwithstanding the loss of motion which would result
from it.
■  At a subsequent sitting of the Academy, these  conclusions were
vigorously  attacked by  M. Guerin, who objected that tendinous
sections in man afforded different results from those of dogs;  and
exhibited a statistical table of operations on the forearm, hand, and
fingers, to show  that  these  were sometimes followed by the de-
struction, and at other times by the preservation, of the functions
of motion of the divided muscles.   He imputes the loss of motion
in M. Bouvier's experiments to  some defect in his process, which
had alike been the cause of failure also with other surgeons ; that
success could, on  the contrary, be generally attained by following
the rules which he traced out, of which the case of M. Doubovitsky
was an example,  motion having been re-established from three to
eight days  after the operation.
  M. Bouvier replied that he had always acknowledged from the
beginning,  that his  results from sections on  the forearm were not
rigorously applicable to man, and  that he had only rejected, in the
majority of cases, the section of the flexors of the fingers at the
hand.  M. Bouvier went on to establish proof of failures, by textual
quotations  from the works of MM. Strohmeyer, Dieffenbach, Phil-
lips, and  Bonnet, and a statement of the case of M.  Hipp. Larrey.
He went on to show that there was a perfect identity in the results
of the cases on man, and his experiments on dogs, so far as related
to the hand and fingers; and that the rules which the surgeons
whom he had named  had followed, did not differ from those that
M.  Guerin had traced for the hand, or from those that  he (M. Bou-
vier) had also followed, and which M. Guerin himself had prac-
tised in the very cases even wherein he had failed; that they were
incapable of preventing the loss of motion; that by dividing sepa-
rately the sublimis in the palm  of the hand, and the profundus on
the second phalanx, we might prevent the osseous adhesions of the
first-named muscle, but not its adhesion with the profundus; that
the separation of  the ends, to which the non-union of  divided ten-
dons in  their sheath had been attributed, was  not greater in dogs
than in man ; in fine, that the case of M. Doubovitsky, published by
himself in the Annales de  Chirur., (torn, i., 1841,) could not be in-
terpreted as it had been, since the author himself, (M. Doubovitsky,)
who had  watched over his case with the  greatest care, made no 
504
NEW ELEMENTS OF OPERATIVE SURGERY.
mention of this alleged occasional re-establishment of the motions,
and even repudiates with warmth the supposition of the temporary
existence and subsequent rupture of the cicatrix in  the ununited
tendons.
  M. Guerin contended, nevertheless, that the flexor tendons at the
wrist, hand, and first and second phalanges, could be cut and their
motion preserved.   Among other members M.  Velpeau, the most
formidable opponent of M. Guerin, and who had disputed his claims
to the establishment of any new principle whatever  in  tenotomy,
did not deny the possibility of success to a certain extent in the te-
notomy of the hand and the fingers ; but as he  could not conscien-
tiously say that the patients exhibited by M. Guerin afforded satis-
factory conclusions, he desired that  there might be a new investi-
gation.
  M. Gerdy denied nothing a priori, but wished to have broad day-
light upon the subject.   Among other objections, however, he said
that  the tendons of the sublimis and profundus were not, as  was
generally supposed, tM'o flattened cords which slide upon  one an-
other by two  uniform plane surfaces.  The tendon of the sublimis,
at the upper part of the first phalanx, is bent into a groove  con-
vex in front, (se courbe en gouttiire convexe en avant) and concave be-
hind, so that it embraces at first the tendon of the profundus.  To-
wards the middle of  the phalanx, it is divided into two  tonguelets,
(languettes) which curve outwardly and backwards, forming by
their reunion behind the  tendon of the profundus, a fibrous tube,
which this  last-named  tendon traverses.  It results  from  this ar-
rangement, that at the lower part of the first phalanx, the tendon
of the profundus becomes anterior to the lateral reunited languettes
of the sublimis, (superficiel)   The consequence of this remarkable
arrangement  is, that if M'e cut perpendicularly from before back-
wards, at the lower part or lower third of the phalanx, we first di-
vide the tendon of the profundus, here more superficial  than  that
of the sublimis; that if we cut in the same manner at  the middle
of the length  of the phalanx, we cut at  once both the languettes of
the sublimis, and also the tendon of the profundus; that if we cut
still higher, we divide at  first the middle of the convexity of the
tendon of the  sublimis, and that we reach that of the profundus be-
fore having completed the transverse section of the half-tube which
the sublimis forms in front of the profundus.
  M. Velpeau replied in substance :
  That when the fingers are  retracted, if the tendon of the subli-
mis is alone contracted, it raises, chafes, and separates impercepti-
bly the sheath which envelops it, and  is  thus removed from  the
phalanx, to which  it becomes to a greater or less  degree  perpen-
dicular, and completely abandons the flexor profundus, which in its
normal condition it encases.   This latter, moreover, is retained by
means of a solid bridle and a most  ingenious  contrivance, on  the
anterior surface of the first phalanx.  In the patient whom I oper-
ated upon, the finger was so powerfully retracted that its extremity
rested against the root of the thenar eminence, and the tendon of 
APPENDIX TO TENOTOMY.
505
the flexor sublimis formed there a cord so straight and so perfectly
isolated, that its section was unattended with the least difficulty.
Whatever M. Gerdy may think, this section of the sublimis would
be easy, and would present yet more chances of success at the root
of the finger near the palm of the hand, than near the anterior ex-
tremity of the phalanx.
  I would say,  then,  that on the palmaris  longus and brevis,
and on  the  flexor carpi ulnaris, tenotomy offers every desirable
prospect of success;  that  it  is nearly the  same with  all the
extensor tendons, beyond the point where they traverse the fibro-
synovial sheaths of the head  of the radius;  that in the palm of
the hand  it will also  frequently succeed, though in a less per-
fect manner, and that the  palmar face  of the fingers is the re-
gion which  presents the fewest advantages for it.   I will add,
however,  that it may even still render some service there, un-
der the circumstances pointed  out.  Moreover, are.there not cases
where the deformity is  such,  that its removal  should be  para-
mount to  every other consideration ?  When a finger is  glued to
the hand, for example, it is not only an  inconvenience because it
is of no service, but  also because it deprives us of the power of
grasping any instrument or foreign body, and thus abolishes the
functions of the entire hand.  In straightening a finger of this kind,
though  it were  to remain completely incapable  of motion  after-
wards, we should still render  a service  to the patient.   Nothing,
at least, prevents our straightening it to the extent of three-fourths
or half the distance, so that, representing an arc of a circle, it may,
if required, sustain a body or give some support to it.
   Thus, in the case of a gentleman whom I have recently had un-
der my care, and who  for many years past has been annoyed by a
very painful retraction of the fingers of one of his hands ; if tenoto-
my was performed in this case, the patient might certainly be re-
lieved of an inconvenience which may ultimately make life almost
burdensome.  This patient, who is troubled  with an almost con-
stant tremor, and whose spinal marrow appears to be diseased, has
the fingers so strongly drawn back, that two of them have ulcera-
ted the palm of his hand.  Is  it not evident that we ought  to de-
sire, above all,  to deliver him  from such  suffering, though it were
even  impossible  to attack the cause of his  general tremor ?  And
can any one deny the utility of tenotomy in such  a case 1
   M. Guerin replied to M. Gerdy as follows :
   1. A  question having arisen incidentally, on the subject of the
section of the flexor sublimis in front  of the first phalanx, and M.
Gerdy, pretending that I had laid down this process as a principle,
has persuaded himself and asserted that on this point he had redu-
ced me  to silence. He has entirely deceived himself.  There is an
omission which I made in my first reply: the reasons which I gave
him then have lost nothing of  their value to-day   In giving in my
last  reply, (Bulletin,  p. 132,) the recapitulation  of the operations
which I had  performed on the hand, I mentioned that I had made
the section of the sublimis in front of the first phalanx four times,
                              64 
506
NEW  ELEMENTS  OF OPERATIVE SURGERY.
without explaining myself any farther.  Nom-, these four operations
Mere those M'hich I performed on M. Doubovitsky; but they Mere not
made as M. Gerdy has supposed, and as he has stated  to you;  but
they Mere made elsewhere, otherwise, and in other conditions.  Being
perfectly aware, and haying long since taught, that the two tendons
traverse each other at a certain point of the first  phalanx, 1 per-
formed, as I have said to you, the section of the sublimis, elsewhere,
otherwise, and in  other conditions, than has been supposed by M.
Gerdy.  Thus, elsewhere: I have not divided it at the  point where
the tendon of the sublimis is traversed by the profundus, but higher
up, and on a line M'ith the upper portion of the first phalanx.  But
the profundus only traverses the sublimis farther doM'n, at the mid-
dle of the phalanx.   At the point, therefore, M'here I have divided
it, I have been  enabled  to reach it  Mdthout necessarily coming at
first in contact M'ith the  profundus.  I have performed  this section
otherwise, and in other conditions, than has been stated to  you.   In
fact, in  M. Doubovitsky I had previously divided the flexor profun-
dus in front of  the  second phalanges; this  tendon was  not then
prominent, it  was at that time shrivelled, (affaisse) and separated
from the sublimis, which latter remained raised up and stretched.
I Mas then enabled  to feel the tendon of the sublimis, isolated and
stretched under the skin; I had it  therefore in my power to reach
it without cutting tqe profundus, which would have escaped before
the instrument; in fine, I thus avoided the danger which M. Gerdy
had supposed inevitable.
  To enable the Academy to convince themselves of the justness
of the  remarks which I have just made to them, I have brought a
prepared hand, upon which I am going to divide, under their eyes,
the two orders of tendons as I divided them on M. Doubovitsky.  It
is to be remarked, that the point where the  two tendons traverse
each other corresponds nearly to the middle of the  phalanx ; there
is then between this point and the apex (sommet) of this  last, (the
phalanx,) a space of about two centimetres.  I first divide the ten-
don of the profundus in front of the second phalanx; there, you
see, it is relaxed, while  I stretch the tendon of the sublimis.   Fi-
nally, I shall  now divide this last,  and you will observe that  the
profundus is  in no  M'ay implicated.   (At  this moment, M. Gerdy,
seated behind M. Guerin, denies  that he has divided the tendon of
the sublimis at  the point where he said he had: he had divided it
higher up.)   You see, gentlemen, that  in the second, as in the first
experiment, there exists still a very perceptible stump  (moignon) in
front of the point where the sublimis gives passage to the profun-
dus ; also that the profundus, in the two cases, has been completely
avoided, (menage) and that ought to*be so, for if the blade of the
instrument had been carried  upon it, the state of relaxation in
M'hich it was, would necessarily have impeded  the action of the
cutting edge.   [Among  others who were present at the operations
upon Professor Doubovitsky of St.  Petersburgh by M. Guerin was
Dr. Mott, who  vouches  for the skill and elegance with which they
were performed.—T.] 
APPENDIX TO TENOTOMY.
507
  M. Gerdy does not absolutely reject, he says, the section of the
sublimis and profundus flexors above the wrist  and at the palm of
the hand, because he is far from participating in the fears  of M.
Bouvier in relation to their reciprocal adhesion; but he asserts that
he M'ould have extreme repugnance to attempting  the tenotomy
of the sublimis at the first phalanx, according to the process of M.
Guerin, because it is impracticable.  As a better method, M. Gerdy
proposes  gliding the tenotome, at the  lower part  of the first pha-
lanx, behind the tendon  of the profundus, and in front  of the re-
united languettes of the sublimis ; then in turning the cutting edge
backward to divide the reunited languettes of the sublimis upon
the phalanx.   M. Gerdy says he has  sometimes succeeded by this
method.
  In thirty-four cases in which M. Guerin performed the section of
the flexor tendons  in front of the fingers and  in the palm  of the
hand, he  failed, by his own acknoM'ledgment, either wholly or par-
tially, in sixteen instances.  M. Vidal, from all the facts on this
subject, conies to the conclusion that tenotomy in the palm  of the
hand, is  far from possessing the same efficacy that it has in other
regions of the body.
   M. Velpeau, also, felt  authorized  in saying, that tenotomy on
the flexor tendons of the fingers has, in the operations of  M. Guerin,
failed in  more than half the cases.
   M. Bouvier admitted that one single case of actual  reparation
of the flexor tendons of the fingers m ould satisfy him.
   M. Guerin then presented two patients  operated upon by him,
and  which he thought should remove all doubts on the subject.
   M. Bouvier then proposed a commission to examine these two
cases,  and to report to the Academy.   M. Guerin having objected,
M. Bouvier alone  soon made  an examination of the state of the
two children,  and thus reported:
   The young girl,  Clemence Delamain, aged from fourteen  to fif-
teen years, who has undergone the section of the flexor longus
pollicis,  and of all the  tendons  of  the sublimis and  profundus,
has entirely lost, not only the flexion of the second phalanx of the
fore-finger, which M. Guerin has spoken of, but every movement of
flexion of the second phalanx of the thumb, of the second phalanx
of, the little finger, and the third also of this finger and of the mid-
dle  and  ring finger.  These two last alone  have retained the
movement of the second phalanx.  This patient had lost the third
phalanx  of the  fore-finger.  The little finger  appeared to  derive
the flexion of  its second  phalanx merely from being drawn by the
ring finger under which it was situated.
   The right hand was the part afflicted, and though the patient
could sew with difficulty before  the sections, she could now no
longer do so, being obliged for that purpose to use the left.   The
thumb and fore-finger having flexion only at their base, can no
longer be applied together so as to hold the needle.  The immobil-
ity of the three third phalanges disables the patient from handling
the wheelbarrow.   M. Bouvier considers the operation in this case 
508
NEW ELEMENTS OF OPERATIVE SURGERY.
a new misfortune, less complete, but not less real than that of
M. Doubovitsky, and then depicts what it would have  been in this
poor peasant girl, if she had been an artist, painter, musician, &c.
He censures the omission of the previous use of proper orthopedic
mechanical  means, especially as the case was not of long stand-
ing.  It is true a very imperfect one had been used before she ap-
plied to M. Guerin, but without effect.
  The  other child, Clementine Mouchy, aged nine to ten  years, in
whom there were no other sections made but those of the tendons
of the  sublimis and  of the tendon of the profundus  of  the fore-
finger,  and of the flexor  longus pollicis, preserved the flexion of
the second phalanges, except to a little less extent of motion in the
second phalanx of the fore-finger.  The flexion of the third pha-
lanx was very feeble in the little finger, a little less restricted in the
ring  finger, and still a little more extended in the middle finger,
though  perceptibly less than  in the normal state.   The third pha-
lanx of the fore-finger was entirely incapable of motion; M. Gue-
rin had recognised it, and explained it by the unintentional section
of the  tM'o flexors in the palm of the hand.  The use of  the hand
was  greatly restricted in part by the effect of the sections, and in
part by a paralysis which had existed previously.
  M. Bouvier then contends :
  1.  That the section of the sublimis and profundus  of the fore-
finger in the palm of the  hand, in C. Delamain, produced  the same
loss of motion observed in the experiments on dogs, and in the case
of M. H. Larrey. \
  2.  That the section of the profundus opposite to the second pha-
lanx, also had the same effect on the  three fingers, the destruction
of motion in the small phalanges,  (phalangettes) as in the experi-
ments in question.
  3.  The division of three tendons  of  the  sublimis only, in the
palm of the hand, in C. Mouchy, was followed by the  adhesion of
this muscle to the profundus, as had been predicted by M. Bouvier
would  take  place under  such circumstances.  The adhesion  was
shown by the little extent of motion in the three phalanges, &c.
  4.  The same section joined to that of the profundus in  the other
patient, has left undisturbed on two fingers  the flexion of the sec-
ond  phalanx, and abolished it  on the third.  The flexion of the
third phalanges had been destroyed by the section of the profun-
dus.  Thus two movements out of six have been preserved, whereas
in the cases previously known of the  section of the two  tendons,
nearly all were destroyed.
  5. The flexor longus pollicis, divided in the two patients, reac-
quired its movement in one case, but not in the other.
  In conclusion,  M. Bouvier  thinks the  condition  of the  two pa-
tients  confirms the deductions which had been made  from other
cases, and he shows that the section at  the hand of the flexors of
the fingers,  is an  operation which must be put in the second class,
not to  be resorted to until after having exhausted the resources of
orthopedic mechanism—and  then  not to be decided upon till the 
APPENDIX TO TENOTOMY.
509
advantages of restoration of form are well considered in connec-
tion with loss of motions, &c.
  M. Guerin now felt himself obliged to submit to a commission,
and was allowed the privilege to name the members himself—his
friends, of course, says M. Vidal.
  The commission, composed of MM. Amussat, Blandin, Bousquet,
Paul Dubois, and Ribes,  reported unanimously on the two cases as
follows:
  Clementine Mouchy.—1. Appearances of pre-existing paralysis
in the hand, especially on the muscles of the thenar and hypothenar
eminences, which were almost completely atrophied, and exhibited
no prominence  under the efforts of contraction.  Temperature of
the hand reduced.
  2.  Motions of flexion  in all the articulations of the fingers and
thumb, as  follows:
  A. Movements of the Thumb.  Flexion on the hand remains, but
very limited, owing to the paralysis and atrophy of the flexor polli-
cis brevis and other muscles which move this articulation. Flexion
of the phalangette  on the phalanx, normal.
  B. The  Fore-Finger.   Flexion in the three articulations—com-
plete at the metacarpo-phalangeal and phalango-phalangeal—very
limited at  the articulation of the second with the third phalanx.
  C. Middle Finger.  Flexion of the finger on the metacarpus, nor-
mal ; second phalanx on the first, the same ; third on second, the
same.
  D. Ring Finger. Flexion  of the finger on the metacarpus, nor-
mal.  Second phalanx on first, same ;  and third on second, near-
ly so.
  E. Little Finger.  Flexion  of  the finger on the metacarpus,
normal;  second phalanx  on first, normal;  third  on  the second,
nearly so.
  3. Besides the paralysis, she has some retractions  of the  exten-
sors, which interfere more or less with all the movements of flexion
of the fingers and phalanges.  This retraction is especially observ-
able in the extensor secundi  internodii pollicis, and the correspond-
ing head of the middle finger.
  Use of the Hand.  Used the hand with difficulty  before the ope-
ration ; could not hold her spoon and carry it to her mouth; could
not cut bread, &c.  Now uses it much better; holds her spoon, car-
ries it to her mouth, and cuts bread ; but the ordinary uses  of the
hand are limited by the paralysis.  Although there  are no means of
ascertaining now M'hat, under the influence of the paralysis, was the
state of the movements of the hand not examined in this note, every
thing induces to the belief that these movements have been pre-
served such as they were before the operation.

  Clemence Delamain.—1. Appearance of the hand, regular. The
third phalanx of the fore-finger is wanting, and that  of the ring
finger has been shortened one-half by the destruction of its free
extremity. 
510
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
  2. Movements of flexion exist in all the articulations of the fin-
gers, and of the thumb, but in very different degrees in some.
  A. Movements of the Thumb. Its flexion on the hand, very exten-
sive :  that  of the  phalangette on  the phalanx, very limited, but
very appreciable.
  B. Fore-Finger.  The third phalanx wanting.  Flexion  of the
phalanx on the metacarpus is about tM'o-thirds its normal extent.
Second on the first, very limited, but manifest.
  C. Middle Finger.  Fiexion  of the finger on the hand, normal; of
the second phalanx on the first, the same ; the third on the second,
difficult and limited, but manifest.
  D.  Ring Finger. Flexion of the fingers on the hand, normal:
of the second phalanx on the first, the same ; of the third on the
second, a little difficult, but manifest,  and reaching almost to the
normal degree, in spite of the mutilation.
  E. Little Finger.  Flexion of the finger on the hand, normal;  of
the second phalanx on the first, very obscure and very limited, but
appreciable ; of the third on  the second, the same as at the pre-
ceding articulation of the same finger.
   Use of the  Hand.  Before the sections, the use of the hand was
very imperfect and very limited.  She seM-ed M'ith great difficulty
with the right hand; she  now does  it very well.   After having
sewn in our presence, she was enabled to take the scissors and rip
out the stitches, M'hich  she could not  have done before.   She had
been obliged to learn to sew  M'ith  the left  hand ; she sews since
with the right hand: she had  become for the most part left-handed;
she is now  again become right-handed : she drew the bafrow M'ith
difficulty, as the labor gave her pain in the  retracted  muscles ; she
does it now more easily, for a longer time, and M'ith much less fatigue
to those muscles.  She could not use her hand to dress or  comb her-
self, or pick greens, or sweep, or make her bed; she now performs
all those exercises.  She  can now do most kinds of housework.
There is especially one kind of occupation  M'hich she can now do,
that she could not before the  operations.  The parents deal in turf;
she could not in any way assist them in this occupation, M'hich con-
sists in selecting, digging out, and  piling up lumps of sward.  At
present she performs all those exercises very well.
   Paris, December 2, 1812.
         (Signed)           Paul  Dubois,  Ribes,     Amussat,
         ^  "               BousauET,     F. Blandin.

   M. Vidal, after passing some few censures both on M. Bouvier
and M. Guerin, comes to the conclusion, from the above report, that
the facts are very difficult to appreciate, especially in the heat of
an academic discussion.   He admits, however, that, after these
sections, a species of reunion may take place.  But  for practical
purposes, we ought always to know—1. What was the state  of the
parts before the operation, and how  far their forms  were altered,
and their functions perverted or lost, and what were the services
that these  parts could still render; 2. If mechanical means, well 
NOTE ON TENOTOMY AND  MYOTOMY.             511
directed and for a long time applied, had produced no good results;
3.  Whether, on examination, and after being perfectly assured of
the insufficiency of these means, the  operation might not do more
harm than good.
  M. Bouillaud vehemently urged  a  new commission,  which M.
Guerin peremptorily objected to.   All the details of this discussion
may be found in the Bulletin of the Academie Royale de Medecine,
t. viii.—T.]
  [NEW OPERATIONS IN TENOTOMY AND MYOTOME
                        IN EUROPE.


Extensive and Simultaneous Division of Numerous Important Mus
                cles and Tendons by M. Guerin.

  Myotomy of  the Muscles of the Back in lateral Curvature of the
                           Spine.

  As early  as July, 1840, (Gaz. Med. de Paris, and Med. Chir. Rev.,
July, 1840,) M. Guerin of Paris says he had, in nearly fifty cases,
divided, more or less completely, most of the muscles of the back and
spine for lateral curvatures of the spine.  The muscles divided were
the trapezius,  rhomboideus, levator anguli scapulae,  sacro-lumba-
lis, and longissimus dorsi.  In each the M'ound of the muscles was
from three  to four inches in length, and sometimes from one and a
half to  two and a  half in depth, as M'hen the sacro-lumbalis and
latissimus dorsi were completely divided; in those cases where the
trapezius and  rhomboideus were  entirely cut across, the bistoury
traversed at least  from four  to  five inches  or more under the
skin.  In almost every one, no local inflammation or constitutional
feverishness supervened, and by the third day many of the patients
were able to get up and walk  without support.  He  had at that
time divided successively, also, the sterno and the cleido mastoid
muscles, separately or together, twenty-five times for  wry-neck by
the sub-cutaneous section, and the tendo-Achillis two hundred times
for club-foot.  In the former sections  there was occasionally con-
siderable sub-cutaneous effusion of blood, M'hich was usually ab-
sorbed in about twenty-four hours.  The total amount at that time
of M. Guerin's successful sub-cutaneous sections of various tendons
and muscles amounted to five hundred cases.   The rapid success
in all, M. Guerin imputes to the exclusion of air by the immediate
closing of the  small external punctures, which thus promotes first
intention. 
512
NEW  ELEMENTS OF OPERATIVE SURGERY.
   In the year 1840, Dr. Laycock of York, and Mr. G. B. Childs, also
 both divided the trapezius and rhomboid muscles in lateral curva-
 ture of the spine.

            Division of forty-two Muscles and Tendons.

   The most remarkable achievement in tenotomy on record was
 that of M. Guerin in 1840. In a case of most extensive deformities
 of the  trunk and limbs, he divided forty-two muscles by only twenty-
 eight punctures.   The results were as follows:—
   On the trunk, the pectoralis major.
   At  each elbow,  the biceps  flexor  cubiti, the pronator radii teres,
 the flexor carpi  radialis, the  flexor  sublimis, and  the  palmaris
 brevis.
   In each fore-arm, the isolated tendons of the flexor carpi ulna-
 ris, the palmaris longus and brevis, and the abductor longus pol-
 licis.
   At each knee, the sartorius, the biceps flexor cruris, the semi-mem-
 branosus, the semi-tendinosus, the rectus femoris, the external late-
 ral ligament, and the fascia lata.
   On each foot, the tendo-Achillis, the tibialis anticus, the extensor
 digitorum communis, the extensor longus pollicis pedis,  and the
 peroneus tertius.
   The  operation lasted an hour, and caused very little pain.  The
 inflammatory action supervened, and on the third day the external
 openings cicatrized.  This universal deformity in  the patient arose
 from a fall and shock  on  the nervous system during his infancy.
 (Med. Times, Sept. 19,  1840.)
   Dr. Mott was present  at  this operation, which was performed
by M.  Guerin at  his  orthopedic establishment of La Muette at
Passy.  Dr. M. saw the patient several times afterwards, and found
him much improved.—TV]

[Tenotomy for old Luxations of the Muscles at the Shoulder and Foot.

  Professor Dieffenbach of Berlin, to whom new surgery, as tenoto-
my and anaplasty may be called, owes such  priceless obligations,
so long ago as in the year 1839, (see Medicinische  Zeitung, Dec. 18,
 1839, and British and Foreign Review,  April, 1840,) when tenotomy
at least was in its very infancy, performed the following important
operation for an old dislocation of the humerus: Thomas Herr, aged
over thirty, dislocated his right shoulder tM'o years before by a fall
from his horse.  This shoulder was an inch higher than the left;
the acromion formed a sharp angle, and on the outside, the shoul-
der was deeply hollowed, while the  scapula lay flat.  The head of
the humerus lay on the anterior side of the chest, close to the clav-
icle, and  two inches from the upper portion of the sternum.   The
arm stood out far from  the body, and was useless, except for some
motion in the hand.  He complained of  a  sensation of cold in the
limb, and the arterial pulsation at the wrist was feeble. The head 
NOTE ON TENOTOMY AND MYOTOMY.
513
of the bone lay buried in a dense wall of ligament,  which it  had
made, and motion gave great pain.   Sheets were tied around the
hand and upper part of the humerus and under the axilla, with nu-
merous assistants at each. Those at the axilla and  hand making
gradual and firm extension and then stopping, the professor passed
a small scythe-shaped knife through the skin, and divided the most
tense portion of the pectoralis major close to its tendon.  Then in-
troducing the knife at the posterior border of the axilla, he succes-
sively divided the latissimus dorsi,  teres major, and teres minor.
The usual crackling  noise was heard in all.  He next passed the
knife into three places by the head of the humerus, and divided, un-
der the skin, the dense and hard false ligaments which formed the
new joint, and now lessening the extension, loosened  the head by a
few rotations.  Powerful extension being again'made, the professor
easily slipped the head into its place. There were only a feM' drops
of blood from the punctures.  The  shoulder, breast, and arm, were
enveloped with bandages, soaked with paste, which soon dried and
rendered the parts immoveable.   In nine days the dressings were
removed, and the  natural appearance and motions perfectly  re-
stored, sooner,  in fact,  than in old luxations, as there were  no
contracted muscles now to contend with.   M. Dieffenbach  has
also successfully reduced, in the same manner, a luxation of the
foot backwards of  a year's  standing, by dividing  the tendo-
Achillis.
  Dr. Mott, in  his lectures, recommends, but  has not yet had an
opportunity of  trying, the section of the triceps extensor cubiti, in
recent dislocations of the ulna backwards, accompanied with frac-
ture of the coronoid process.—T7.]

  [The Sub-Cutaneous Section for Synovial Tumors, Ganglions, fyc.

  To M. Barthelemey, of the hospital of Grand Caillou at Paris, are
we  indebted for a new and most important application of tenotomy,
viz., to the destruction of synovial tumors.   He slides  a  longish,
narrow-bladed  scalpel under the integuments, and cuts the tumor
fairly across in the middle, so that  all its contents shall be extrava-
sated  into the  surrounding cellular tissue ;  the knife is then with-
drawn by the  small puncture, and compression made for a few
days.  This practice  was pursued  in three cases with perfect suc-
cess, (Gaz. Med., and Medico-Chir. Rev., July, 1840.) M. Malgaigne
has tried this process successfully, also, in one case in ganglions,
or synovial swellings over different joints.   He suggests its appli-
cability to some cases of  hydrocele, (lb)
  In 1841, (see  Dublin Medical Rep., April 21, 1841,) we find  the
above practice of M. Barthelemey was successfully repeated at
Dublin by Professor Williams, on  several  chronic tumors of the
bursa? mucosae and synovial sheaths of tendons.  In one, over the
knee, the cataract needle was passed into the tumor, and the entire
thickness of the sac  divided by several  parallel and longitudinal
incisions.   A portion  of the fluid escaped into the cellular tissue,
                              65 
514           NEW  ELEMENTS OF  OPERATIVE SURGERY.
 but the greater portion found an exit externally on the withdrawal
 of the needle.  The knee M'as then strapped M'ith adhesive plaster,
 and the limb kept at rest. Dr. Llouston of Dublin has repeated the
 same operation M'ith equal success, though, from accidentally hav-
 ing a needle too short for the size of the tumor, he Mas obliged to
 introduce it by five or six different Incisions, (Ib.)
   A most ingenious and important application (if  it succeed per-
t fectly) of the ideas of M. Barthelemey, is the thought which seems
 to have suggested itself simultaneously to M. Goyrand of Aix, and
 Mr. Syme of Edinburgh, without either being aware  of it, (see
 British and Foreign Medical Review, April, 1841.)   It was the ap-
 plication  of the process  to  the  dislodgment  of foreign bodies in
 joints.  The loose body in the  knee joint was pushed by M. Goy-
 rand into the synovial pouch above, and  to  the outer side of the
 patella, beneath the vastus externus muscle, and, while  an assist-
 ant held it fixed there, he passed a narrow knife through the skin,
 at some distance above the joint, and through all the intermediate
 tissue down to the foreign body.   Without enlarging the opening
 in the skin, the synovial membrane and adjacent tissues over  the
 loose substance  were then freely divided, till, by the pressure on the
 latter, it slipped out of the joint through the wound, and lodged it-
 self in the  sub-cutaneous cellular tissue, or in some of the other
 tissues between the skin and joint.  Sticking plaster was applied
 to the small external puncture, and rest  enjoined for several days,
 till  all  chance  of inflammation  had passed away.  The foreign
 body, dislodged  from the joint, forms a cyst for itself, and  may be
 allowed  to  remain  there, and, after a  time, extracted by cutting
 down to it.  In this case, there were two loose cartilages dislodged,
 one of which was  subsequently removed.   The relief obtained to
 the joint was complete.  Mr. Syme has performed a similar opera-
 tion with entire success.
   Why could not  the sub-cutaneous principle be thus extended to
 a great number of chronic incysted tumors, or, perhaps, to others
 also ?  What are to be the limits to useful applications of this dis-
 covery ?
   The application of the sub-cutaneous section to bursal tumors
 has more recently been again followed up with further  successes
 at the Dublin Hospital.   In a  female  with a large patellar bursd,
 an incision of an eighth of an inch was made along the outer mar-
 gin of the tumor,  and a  very  small bistoury introduced obliquely
 into the cyst, at such a distance from the superficial cutaneous in-
 cision as to prevent the escape of the fluid.  The sac was then cut
 in several places, chiefly on the anterior surface, until all the fluid
 had been evacuated.  A small compress was then applied, and sev-
 eral straps of adhesive plaster, and a roller, from the toes to the
 knee.  A splint was also applied, which extended from the middle
 of the back part of the thigh to the same point of the leg.
   On the 10th day the dressings Mere removed ; considerable dimi-
 nution had taken place in the size of the swelling.  On the 17th day
 the natural appearance of the joint was restored. 
NOTE ON TENOTOMY AND MYOTOMY.
515
  The puncture into the sac should be made with care, and the in-
ternal surface of the cyst  then cautiously scored, and  the  fluid
evacuated by firm  pressure, so as to prevent the ingress of air.
The operation might fail, perhaps, where the sac is much thicken-
ed, its interior loculated, and the cells filled with a thick gelatinous
substance. (Dublin Medical Press, Oct. 26, 1842.)
  Dr. Mott has also recently performed this operation several times.
with entire success,  on bursal tumors.—71.]
  The rationale of this treatment is explained by what takes place
under the ancient and hitherto most perfect process  of cure, and
where there is no opening whatever made, viz., that of suddenly
bursting the  cyst by striking upon it with a smooth heavy body, as
a large book,  while the  limb is stretched out  firm on some solid
support, and the patient unaware of your intention.   The rupture
of the cyst,  and the diffusion of the contained fluid into the sur-
rounding cellular tissues, are in these cases instantaneous.  I have
thus instantly made permanent  cures of bursas on the dorsum of
the carpus ;  also, of one  of the size of a pigeon's egg at the olecra-
non, which had caused much pain, and M'hich the patient supposed
would require amputation of the arm ; also,  of another, three
inches in diameter, of oval  shape, and covering the whole pa-
tella.  Since the preceding part of this paragraph was written, I
have, in the  same manner, cured another bursa of large size on the
side of the olecranon.—T.]

         [The Sub-Cutaneous Section in Inguinal Hernia.

  M. Guerin has applied tenotomy to a case of old inguinal hernia,
after reduction.  He raised up a transverse fold of the skin of the
groin, pubis, and root of the scrotum, and drew it from below up-
wards to a level with the orifice of the  inguinal canal.   He then
plunged in a small bistoury at the base of this fold, up to the entry
of the canal  above, and to the interior of the spermatic cord, M'hich
latter an  assistant held aside.  Through this opening he then pass-
ed a blunt-pointed convex myotome, having a portion of the blade
not cutting.   He  then cut with this from behind  forwards, and
from within  outwards; afterwards turned  the  blade  and incised
successively  from above  downwards, and about the angle of the
pubis, the two divisions of Poupart's ligament, and the  fibres of the
obliquus externus, which  terminate there. Lastly, he made several
scarifications in the  intermediate points.
  The operation lasted ten minutes, no fever or reaction folloM'ed,
and the cicatrization of the puncture took place immediately.  On
the fourteenth day the effused  structures  had  become hardened,
and were able to resist  the expulsion of the hernia.   At the end
of a month, the patient resumed his work without a truss; no her-
nial protrusion took place  upon coughing, nor  from any exertion
he now made.—(Bulletin  of the Academy of Medicine, Paris, Sept.
1841.)
  M. Bouchut  goes farther, and proposes the sub-cutaneous opera- 
516           NEW ELEMENTS OF OPERATIVE SURGERY.

tion in cases of strangulated hernia itself, M-hether the strangula-
tion be owing to the contracted  and indurated neck of the sac, or
to the aponeurotic rings.  The first operation  he calls intra-perito-
neal kelotomy, and is to be made into the sac,  with a masked (con-
cealed) kelotome, a kind of  lengthened flat trochar in its canule.
The other operation he  calls extra-peritoneal kelotomy.  The word
kelotomy is here rather inappropriate, as the kelotome makes  in
this case the division of the aponeurotic rings.  He  has  not yet
tested his process on the living subject.—(Vid. Journal  des Con-
naissances Med., Paris, Nov.  1841.)

                    Tenotony in Dislocations.

  In that particular displacement sometimes met with in the pha-
langes of the second toe, from tight shoes, where at  the  junction
of the first and second phalanges an acute angle upwards is formed
by the joint action of the extensors on the distal extremity of the
first phalanx, and of the flexors on the other extremity of the toe.
Professor Fergusson has obtained a perfect cure by the subcutanc
ous section of the flexor tendons, and then splinting the toe under-
neath and keeping' it fixed, by adhesive  plasters, to the great toe.
He states that Sir Astley Cooper refers to a case of a similar kind.
—(Pract. Surg., loc. cit.)

                     Myotomy in Entropion.

  M. Petrequin, of the Hotel Dieu, Lyons, having been  satisfied
that certain cases of entropion, as the blepherospasm of scrofulous
ophthalmia, are caused by a permanent contraction of the orbicula-
ris muscle, effected a cure in a case of this kind by the subcutane-
ous section, thus :—The lid being held extended, he placed the in-
strument on a level with the floor of the orbit, passed  it under the
skin and the orbicularis  up to the free edge of the eyelid, taking
care  that no fibres above  escaped division ;  the instrument Mas
then carefully withdrawn, assisting the division by pressing on the
eyelid with the finger.—(Gaz. Medicale)

              Sub-Cutaneous Section in Entropion.

  Dr. Neumann had complete success with the sub-cutaneous longi-
tudinal division of the muscles of the lids, where all the lids  were
in a state  of entropion from repeated attacks of strumous  ophthal-
mia, and where  the irritation of the  eyelashes had rendered the
right cornea quite opaque, and the left nearly so.  Sight was almost
entirely destroyed.  A small  tenotome was introduced at  half an
inch from the external angle of each eye, and carried flatwise to
the internal angle, when its cutting edge was turned  downwards
and the levator palpebrae and other tissues divided.   To  prevent
the globe from being injured, a thin plate of horn was placed be-
tween it and the eyelid.  The lower lids were treated  in the  same 
          TENOTOMY, MYOTOMY, AND ANAPLASTY, IN AMERICA.       517

way, the tenotome being introduced into the same puncture in the
temple which had been used for the upper.  The eyelashes regain-
ed the normal direction.  In the left eye the operation was com-
pletely successful, but had  to be  repeated in the  right after the
lapse of three weeks.  The sight of the left eye was completely re-
stored.—(Lond. and Edinb. Monthly Journ. of Med. Sc, September,
1842.)—T]
    [TENOTOMY,  MYOTOMY, AND ANAPLASTY,  IN
                         AMERICA.

  Although scarcely four years have elapsed  since those brilliant
conquests of modern surgery,  the various processes of anaplasty
and tenotomy, came  into general use  in Europe, they are already
become operations of almost  every day practice in the principal
cities of the United States.  Both, for their parentage, go back to a
remote period of time, anaplasty owing its birth to Hindoo rhino-
plasty, and tenotomy tracing  its first  essays to orthopedy, or club
foot, at an epoch not perhaps quite as distant.  Both, it may be
said, owe their existence, like  so many other valuable discoveries
and improvements in all sciences, not so much to the  progress of
philosophical inquiry and anatomical or physiological investigations
by learned professional men, as to the  accidental or contingent cir-
cumstances  which concurred  in producing  incentives to supply a
want  or void that was severely felt among the masses of popula-
tion, and in the common walks of society.  As the not unfrequent
and serious deformity of club-foot early suggested some mode of
relieving so distressing an impediment to locomotion, so did the
more  hideous disfigurations of the face, common  in some  parts of
Asia from the ancient cruel and barbarous punishment of cutting
off the nose, thus incidentally  create a yet more pressing necessity
for the ingenious process of rhinoplasty.   •
  The incidental occurrence,  at a later period, of frequent mutila-
tions or loss of the nose in the  south of Europe, from the imperfect
modes of treatment in syphilitic affections, led the surgeons of that
time, and especially Tagliacotius, to direct their  attention  to the
restoration of that important  organ, and consequently to the im-
provement and adoption of the Indian operation.
  Rhinoplasty, thus known for many ages past in Asia, and seve-
ral centuries ago introduced into and adopted  and improved in
Europe, more particularly by Tagliacotius and 'other Italian sur-
geons, was at a still  more recent period  revived again, by the at-
tention drawn to it by English army surgeons, who had M'itnessed
it  in  India.   But this also, as it seems, did  not afford sufficient
occasion  or motives for  its  more  general  adoption, until an- 
518           NEW ELEMENTS OF OPERATIVE  SURGERY.

other purelv incidental  concurrence of circumstances,  growing
out of the  frequent  mutilations of the  features among respecta-
ble classes  in certain parts of Germany, by their peculiar modes of
duelling, gave to anaplasty an impulse among the surgeons of that
country, M'hich soon spread in all its applications to every part of
Europe.  Though far fewer occasions present in Europe or in this
country, (except in fights which end  in biting off the nose or ear,
now happily proscribed,) for such  applications of the processes of
rhinoplasty, anaplasty in general has had a far more extended and
useful appropriation, by its employment in all the infinite variety
of cases  of mutilations, fistulas, and  other losses of substance in
every part of the body.  This has now given it universal currency;
notM'ithstanding which, it is yet far more  imperfect in its results,
and  consequently infinitely more  restricted in its usefulness, than
the more brilliant and emphatic triumphs of tenotomy and myoto-
my, in all their forms; these latter creating of themselves  almost a
revolution,  and an eclat and  prestige for surgery unexampled in
the history  of the  science, and that too, it may be said, M'ithin so
late  a period as the last three years.  Dr. Mott, during his residence
at Paris and his visit to Berlin, Dresden, etc., had carefully studied
the rapid and almost magic progress of this department of surgery,
to whose very birth, as it were, and almost masculine (if not too
precocious) maturity, it may be said he was an eye-witness, at the
great orthopedic  establishments  of Guerin,  Bouvier,  and others.
And to him belongs, in great part, the credit of having immediately
on his return to America, in 1841, by his publicly expressed appro-
bation of these processes, and his repeated practical exemplifica-
tions of their utility at the clinique established by him at  the Uni-
versity of New York, (the first in the United States.) infused among
our practitioners a general knowledge and  desire not to lag behind
their brethren of Europe ; and thus, in fact, may be said to have
been most  instrumental  in domiciliating in our country this most
important  branch  of surgery.  Anaplasty and tenotomy require
some general remarks in respect to the claims of those M'ho were
the first to lead the way in these operations in America.
  The earliest case of tenotomy performed in America, is that of
the section of the tendo-,Achillis, by Dr. Dickson of North Carolina,
in the year  1835.   As  this case of pes-equinus by Dr. James H.
Dickson, of Fayetteville, North Carolina, was the first operation for
club-foot in America by the subcutaneous section, and the first opera-
tion, probably, of any kind ever attempted on this continent, it is
proper to give a brief abstract of  it  from the operator's own ac-
count, as published in the American Journal of the Medical Sci-
ences^ (Philadelphia,) for November, 1838.   R---- D----, a lad
aged fourteen, of delicate make, M'as born with his limbs  and feet
apparently perfect—but when he first began to creep,  was observ-
ed to drag  the right leg after him in a very awkward and peculiar
manner.  He was late  in learning to walk, and had never been
able to get more than the toes and corresponding metatarso-pha-
langeal articulation to the ground.  The left side of the body, and 
          TENOTOMY, MYOTOMY, AND ANAPLASTY, IN AMERICA.       519

left leg and foot, were well developed;  the right arm and leg per-
ceptibly smaller than the left, and the right leg half an inch shorter
than the left.   The  heel M'as drawn up to full three and a half
inches from  the ground.  The tarsal bones of the right  foot were
very prominent, and M'hen the patient stood erect, their dorsal sur-
face was nearly in a line M'ith the anterior surface of the leg.  The
patient's mode of progression partook at once of a hop and a walk.
There was but little  motion  in the ankle joint, and  the power of
the limbs over the flexor muscles seemed entirely lost.   The heel
was small and narrow, and  its skin, from never having come in
contact  with the ground, was delicate and tender.
  The operation was performed at Fayetteville, (N. C.,) January
10th, 1835, in  presence of Dr. Benjamin Robinson of that place.
Dr. Dickson inserted  a sharp-pointed narrow bistoury two and a
half inehes above the insertion of the tendo-Achillis and underneath
this tendon, and divided  the fibres from  within outwards, merely
cutting  through  the tendon, without wounding the skin  except at
the point where the bistoury was introduced—following the process
of Strohmeyer.   The foot almost immediately came down to a right
angle nearly with  the leg, the only dressing  consisting of a bit of
adhesive plaster on the small  wound, a compress  on each side of
the divided  tendon, secured by a roller, while the foot was kept in
its  position by a splint to  the front of the leg  and foot. There was
so little pain produced, that an anodyne administered  once or twice
M'as all that Mas required during the treatment.  Five days after
the operation, Strohmeyer's apparatus was applied, and  extension
very cautiously and  gradually made from day to day until the ex-
piration of the fourth week, when the  foot was found to be at a
right angle with the leg.  A laced boot was now substituted for
the apparatus during the day, and  the latter worn only at night.
This was continued  for a week.  Dr. Dickson says he applied ex-
tension  sooner in this case than he should have done, from having
seen, in the Medico-Chirurgical Review, that Strohmeyer  attributed
his failure in one of his cases to delaying it too long.  At the end
of the second month, the patient could  walk  with very little  limp-
ing, the deficiency in the  length of the leg being in a good degree
remedied  by a high-heeled boot.  The  deformity was entirely re-
moved,  and  the  flexor muscles now became  obedient to  the will.
When Dr. Dickson saw the patient again, in May, 1837, he walked
with ease, and with scarcely any perceptible  limp.  The  limb had
become  much more  developed, and its  muscular power greatly
increased.   This surgeon has informed  me, if I  recollect right,
that he has since  repeated  this operation with success in  other
cases.—T.~\
  The next  cases  in  America were that of Dr.  N. R. Smith, of
Baltimore, in 1836, and that  by  Dr. William Detmold, formerly
of Hanover, Germany, now  of New York,  who  has  since that
time, as  he states, performed this operation  more frequently, and
as it would seem  has had  more  experience  in  these sections,
than any other surgeon in this country—the number of his  cases 
520
NEW ELEMENTS  OF OPERATIVE SURGERY.
(see Reese's American Edition Cooper's Surgical  Dictionary, 1842)
amounting, November, 1842, to four hundred,  and the number
of the tendons divided, to twelve hundred.   He has. shown that
the intermediary uniting substance is  always formed, however
far apart  may  be  the divided ends of  the  tendons; also,  he
has demonstrated the  importance of dividing  other tendons con-
cerned in club foot, besides  the tendo-Achillis.   He makes-use of
subsequent mechanical apparatus when required.   He never has
seen the operation followed  by trismus, or other unpleasant symp-
toms.
  Among the  prominent names in American tenotomy, or rather
myotomy, we must  here mention that of Dr. John W. Schmidt, "of
New York, to whom  is to be accorded the distinction of having
been the first, in any country, to perform the complete section of
a most important muscle, (the masseter,) with entire success, in a
case of immobility in the lower jaw, which we shall give in detail
in its proper place.
  Myotomy, properly so called, as distinguished from tenotomy, was
first  performed in America, (according to Dr. Reese,  in his last
American edition of Cooper's Surgical Dictionary, New York, 1812,)
by Professor Paul F. Eve, of Augusta, Georgia.  The case (as re-
ported in the Southern Medical and Surgical Journal, for 1838) con-
sisted in the successful division  of the adductor longus femoris, for
deformity and consequent loss of motion in the thigh.  The incision,
five inches in length, extended from  the pubis along the  inner edge
of the muscle, the latter being divided about three inches below its
origin from the pubis.  The success Mras complete.
   Dr. Mutter, of Philadelphia, has also lately divided the adductor
and the pectineus muscles, in a lady who had been deformed and
crippled by their contraction for nine years.

          [Sub- Cutaneous Section of the Masseter Muscle.

   To Dr.  John W. Schmidt,  Jr., of New York, as we have  already
said, belongs the credit of having been the first, in  any  country, to
divide the entire masseter  muscle  by the sub-cutaneous  section,
Oct. 8, 1841.
   We transcribe with much pleasure his own account of this oper-
ation, as we find it in the Boston Medical and Surgical Journal for
July, 1842:
   " Miss S. had labored for more than twelve years under the very
serious inconvenience of not being able to open her mouth, owing
to a contraction and rigidity of one of the masseter muscles, which
was caused by an extensively ulcerated throat when a child.  The
jaw was not only so closed  that the end  of the little finger could
not be inserted between  the incisors, but was also  much drawn to
one side.   Frequent attempts had been made to open the jaws by
means of an instrument, which I have seen succeed in cases of im-
mobility of the jaw,  produced  from the use of mercury, and de-
scribed by Professor Mott in the fifth volume of the  American Jour- 
          TENOTOMY, MYOTOMY, AND ANAPLASTY, IN AMERICA.       521

nal of Medical Sciences for  November; but no permanent  good
resulted from this instrument, for after its use  the contractility of
the masseter seemed only aggravated, and the jaw rendered  more
firmly resistant.
  " The young lady being very desirous to have this inconvenience
and deformity removed, after  some examination of the case I deter-
mined on the following operation.  On the 8th of October, 1841, in
the presence of my friends Professor Mott and Dr. C. A. Porter, I
passed a narrow bistoury through the mucous  membrane of the
mouth, immediately in front of the anterior edge of the masseter
muscle, about on a line with the alveolar processes of the lower
jaw.   Holding the integument up from the muscle with one hand,,
the bistoury was passed over the masseter, between it and the in-
teguments, and the muscle completely divided  to the bone.  The
mouth M'as immediately opened to near the usual size, and the lat-
eral distortion of the jaw much improved.  Considerable hemor-
rhage followed, and some extravasation into the cellular substance,
which gradually subsided, and  the case succeeded M-ell.   To pre-
vent  union of the muscle, pieces of soft wood, wedge-shaped,  M'ere
kept  in the mouth  during the  night,  and occasionally during the
day.
  "I  am not  aware that the entire division of  the masseter, on
the sub-cutaneous  principle, has  before  been  performed.   Pro-
fessor Mott, who witnessed  a great  many  orthopedic operations
by M. Guerin,  has never  seen him divide this muscle.  I M-as in-
formed, by a practitioner in this city, that the  masseter had  been
divided by Dr. Mutter, of Philadelphia ; but  on referring to his pa-
per, published in the  American Journal of Medical  Sciences for
May, 1840,  I  find  that he only divided the  anterior  fibres of the
muscle, with an instrument  resembling a gum lancet.  The knife
being introduced within  the mouth, had the great advantage of
leaving no scar."
  In a note upon  this  operation, which Dr.  Schmidt  has had the
kindness to communicate, he has called attention more particularly
to the manner in which this section was and should be made, and
of the precautions necessary to  be taken, to avoid  wounding the
numerous important organs  in the immediate vicinity of the  mas-
seter.
  Anatomy of the Parts.  The  masseter is  a  thick quadrilateral-
shaped muscle, composed of  two planes of fibres, superficial and
deep.   The superficial arises, by a strong aponeurosis, from the tu-
berosity of the superior maxillary bone, and from the lower border
of the malar bone and zygoma, and passes backwards to be insert-
ed into the ramus and angle of the inferior maxilla.  The  deep
layer  arises from the posterior part of  the zygoma, and passes for-
wards to be inserted into the  upper half of the ramus.  The  mus-
cle has, upon dissection, a tendinous or glossy appearance. •
  The muscle  is connected, by its external surface, M'ith the zygo-
maticus major and risorius Santorini muscle, the parotid gland and
Stenon's duct, the transverse facial artery, the pes anserinus, and the
                              66 
522
NEW  ELEMENTS OF OPERATIVE SURGERY.
integument.  By its internal surface, with the buccinator, from
which it is separated  by a  large mass of fat, and with  the  ra-
mus of the lower jaw.  By its posterior border, with the  parotid
gland ;  and by the anterior border, with the facial artery and
vein.
  The points to be carefully attended to in the operation, says Dr.
Schmidt, are the danger of wounding the facial artery and vein,
and the parotid duct and gland.   The best method of avoiding the
parotid  gland  is to direct an assistant to embrace it  with  his fin-
gers, and to press it directly backwards, the assistant placing him-
self behind the  patient.
  It  must be obvious to any person  acquainted with the anatomy
of the parts, that a slight deviation of the knife from the proper di-
rection, might be attended with serious consequences.
  It  is worthy of remark, says Dr. Schmidt, that in the case oper-
ated upon by him, the rigidity and contraction were confined only
to the masseter muscle of one side, viz., the one divided; and that
the jaws, at times, were so firmly closed together that it was im-
possible to introduce between the teeth a body of greater thickness
than a dollar.  The immobility had existed about sixteen years.
—(See accompanying plate, illustrating these  parts.)


      Division of the Muscles of the Face for Chronic Spasms.

  Dieffenbach has  performed this operation  in four cases, where
the disease had existed  some time.   The orbicularis palpebrarum 
STRABISMUS.
523
was divided, also the muscles of the cheek, from the ala of the nose
to  the anterior border of the masseter, and lastly, the muscles at the
angle of the mouth.  A perfect cure ensued,  (British and Foreign
Med. Rev., Jan., 1842.)  It will be noticed that the masseter itself
was not divided, the claim of priority for the  division of that mus-
cle resting with Dr. Schmidt. No other persons, so early as Drs.
Schmidt and  Mutter, or so extensively as Dieffenbach, had before
this time undertaken  the sub-cutaneous  section of the muscles of
the face.
  The masseter, however, was afterwards again completely divided,
in 1842, by Professor Fergusson, of King's College, London, for  a
permanent closure of the jaws which had existed five years.  The
man, in this case, could not  open his mouth wider than a quarter
of an inch between the incisors.  About five years before, a swelling
had appeared near the place of the attachment of the masseter to
the lower jaw.  In about two years, it burst and discharged matter
for six weeks.  A swelling  about half the size of a walnut  con-
tinued on the spot, and the patient could  not open his mouth.   Af-
ter various unsuccessful treatment, including iodine externally and
internally, Mr. Fergusson determined on  the transverse division of
the masseter.  He first tried partial division, by cutting through
half an inch of the anterior  margin of the muscle.  " The point of
the knife was passed from  the mouth  through  the mucous mem-
brane and buccinator muscle, a little below the parotid duct, and
having been pushed between the  skin and the masseter, the fibres
of the muscle were divided  by carrying the edge from within out-
wards."  In about fourteen  days, Mr. Fergusson  cut  through the
rest of the muscle in a similar way, being convinced, from the result
of the first operation, that a  permanently good result would follow
The cure was complete.—(Load, and Edinb. Monthly Journ. of Med
ical Science, April, 1842.)
  It appears, therefore, that Dr. Mutter had divided only the ante-
rior edge of the muscle, and that Professor Fergusson also only di-
vided the muscle partially  at first,  and the remainder not until
fourteen days after ; so that the entire section of the muscle at one
cut, has never  yet been performed but by Dr. Schmidt, who first
proposed and first put it into practice.—T.]
                       [STRABISMUS.

  When this present and last edition of Professor Velpeau's work on
operative surgery M'as published at Paris, in 1839, the operation for
squinting, or strabismus, whose extraordinary and successful results
have naturally attracted such universal attention, and reflected so
much lustre upon  surgery, was, it may be said, utterly unknown.
In 1842, therefore, M. Velpeau published a  small octavo of near 
524           NEW  ELEMENTS OF OPERATIVE SURGERY.

two hundred pages, devoted entirely to the history of this opera-
tion, and of those well-known and common deviations in the posi
tion of the eye which it is designed  to remedy.  As appears upon
the title, this work is intended as a supplement to complete M'hat
was M'anting upon  this subject in this great elementary  treatise.
We have, therefore, deemed  it no more than just to M. Velpeau,
to give in this place an abrege of all the most useful and essential
portions  of this supplement, to which  will be added M'hatever in
the rapid march of surgical  discovery at  the present time (M'hen
a few years only furnish more matured results and more surgical
triumphs than long  centuries had hitherto achieved) is justly enti-
tled to be deemed new acquisitions in this brilliant department of
(as it may be called) Myo-Tenotomy.  The copy  from which M'e
abridge,  is one recently transmitted to us  by the learned author.—
P. S.  T]
  All that has been hitherto done to relieve strabismus, by various
mechanical contrivances of glasses and spectacles of different de-
grees of opacity, and by forced positions  given to the direction of
the axis of vision,  has proved, with very few exceptions, totally
unavailing.  Now, however,  surgery can remove this  disease
as it  does cataract or fistula-lachrymalis, by an  easy operation,
unaccompanied by any danger, and  which consists in  the sec-
tion of the muscle  or muscles which  give to the eye a morbid di-
rection.
  Those who M'ish  to consult what  ancient authors  have written
upon the varieties, causes, nature, and treatment of strabismus, may
refer  to the treatises of  MM. Verhaege (on  Strabisme,  Bruges,
1841,) Florent Cunier, (Myolom. Appliq.  au Strab.,  fyc, Brussels,
1840,) Dufresse, (Strab.  el Begaiem., 1841,) and  especially to the
work of M. Bonnet, (Sections Tend, et Muscul., fyc, Lyon, 1841,)
and that  of M. Boinet, (Journal Medico- Chirurgical, Jan v., Fevr.,
Mars, 1842.)

                      Article I.—History.

  Though this operation is unquestionably a modern invention,
some surgeons of the last century made special mention and recom-
mendation of it, and to all appearance it had already been several
times performed before the present epoch.  The famous charlatan
and empiric, Taylor, frequently had recourse to it, as Hewermann
in his Surgery expressly says that Taylor professed to cure strabis-
mus by the section of the tendon of the superior oblique muscle.  Le-
cat, also, in the Transactions  of the Academic Society of Rouen,
says,  " the charlatan Taylor pierced  the conjunctiva with  a needle
threaded with  silk,  and divided with a cut of the scissors, the mem-
branous  fold included in the noose  of the silk thread ; the sound
eye was then covered with a plaster, the diseased eye was restored,
and it was pronounced a  miracle."  Taylor, when 'asked for his
reasons for the operation, replied, that  strabismus was caused only 
STRABISMUS.
525
by the inequality of the  muscles, and that to cure it one of them
must be weakened.
  Taylor, in  fact, according to  M. Giraldes, came to Paris, and
everywhere  announced his intention to  cure strabismus by a sur-
gical  operation.  He called himself oculist to  the king of Great
Britain, and  in his advertisements claims that  he had discovered
the mode of restoring the direction of squint-eyes (les yeux des louches)
by a prompt operation, almost without pain, and without the fear of any
acccident, (Mercure de France,  1737, Juin, page  1180.)
  M. Cunier (1st Supplement  to the Ann. d'Oculist., p.  258) also
points  out, in  the Dissertation of Verheyden, supported in* 1767,
this surgical phrase : strabones permultos ferro sanatos apud anglicos
vidi.
  Whether Taylor really cured  strabismus  and divided  the mus-
cle, or not, it  is certain  that  he indicated this operation for the
cure, in the middle of the last century.
  The operation, however, M'as forgotten until M. Strohmeyer pro-
posed it as one that was absolutely new.   Sammels of Courtray,
however,  (see Memoir of Verhaege) claims to  have performed it
twice in  1824 or 1825, and M. Carron du Villards says it  was sug-
gested to him by a hunter having accidentally been cured of an
old strabismus from a leaden shot detaching the  pulley of the great
oblique.
  M.  Cunier (op. cit., p. 126) says  M. Gensoul  of Lyon  had pro-
posed the section of the muscles of the eye before M. Strohmeyer.
But all this is mere assertion, and of no  importance, and the labors
of M.  Strohmeyer are those alone  which have really awakened
attention to this subject.
  In 1838 h*e described his operation, which until then he had only
performed on the dead body.  In the beginning of 1839  M. Pauli
attempted it on a young girl, (Schmidt's Jahrbiicher, 1839, vol. xxiv.,
n. 3, p. 351, or Verhaege, p. 39,) but it was unsuccessful.  On the
29th of October, 1839, it  was performed on living man, by M. Flo-
rent Cunier, (Supplement, fyc, p. 264.)
  Though M.  Verhaege assigns the date of M.  Dieffenbach's first
operations to December, and M. Phillips (Strabisme et Begaiement, p.
8 ; De la Tenotomie sous-cutanee, Paris,  1841, p. 223) places them
at October 26, 1839, they were undoubtedly the first that were
known and that drew attention.  In fine, this operation was defini-
tively created  by M. Strohmeyer, and made practically useful by
M. Dieffenbach.
  Before this remedy, which had been so long thought of, could be
brought into use, it was necessary to establish completely the suc-
cess of the section of the muscles, as for club-foot, wry-neck, &c,
which was not triumphantly effected until the year 1830.
  This operation M'as then naturally suggested to remedy the de-
formity in question.
  Such doubts, however, still existed, that even the first letter of M.
Dieffenbach (Gazette Medicate, 1840, p. 107) produced but a slight
sensation in France.  At a later period, M. Guerin having been sue- 
526
NEW  ELEMENTS OF OPERATIVE SURGERY.
cessful but in four cases, (Gaz. Med., 1840, p. 424.) M. Roux having
failed in his two first  essays, (same journal, p. 494,) and I myself
having had but little success, we looked upon  the  announcement
of constant successes by the surgeon of Berlin as  somoM'hat strange.
The inexactness of certain details confirmed this, as in the relation
made at the Academy of Sciences, Paris, June 29, (vid. Gaz.  Med.,
p. 424,) where  a practitioner speaks of having made four cures,
and immediately after confesses that three of the patients continued
to squint.
  M. Phillips, who had affirmed that the operation ahvays succeeded,
who at least did not mention a single failure in a hundred opera-
tions performed by him in Russia, and M'ho has published  that in
over four  hundred  cases, the  operation  has  ahvays been suc-
cessful in  the hands of M. Dieffenbach, finds a decided opponent
in M. Melchior, (De Myotomia  Oculi, fyc, Hafnice, Mars, 1841,)
and some incredulous  persons also in the Medico-Chirurgical Re-
view.
  The residence of this young surgeon at Paris seemed to  change
his views,  as in his last  work,  (Tenotomie sous-cutanee, p.  321,)
he  relates  one  hundred cases as performed upon by him, and
attended by M.  Bouvier, out  of which twenty-five  proved unsuc-
cessful.
  M. Baumgarten, also, (Operative Behandlung,  etc.,  Leipzig, 1841,)
had admitted that of fifty-two cases, only thirty-three were  cured;
and of these last, ten had to be twice operated upon.  Of the seventy-
two operations, also, performed at Dresden by MM. Ammon, Zeis,
Warnatz,  and  Baumgarten,  forty-five only M'ere successful.  M.
Guthrie, also, who in his Annals of Surgery, vol. i., p. 492, mentions
his having had  only two or three failures in three hundred, and forty
cases, afterwards speaks with less confidence of the final  results
of his practice.
  In Belgium M. Dumont, in fact, says (Cunier, Myot. Ocul., 1840)
the frequent failures discouraged operators themselves;  and M.
Blariau declared, before the Society of Medicine  at  Gand, that
he  had  never seen a single  squint-eyed person cured, (Cunier, p.
42, 44.)
  Finally,  the  authors  of the  exaggerated accounts  themselves
commenced handling each other M'ith  no little severity, as was
seen in the remarks of M.  Phillips  (De la Tenotomie, p. 318) on
one of  his rivals,  who professed   not  to have  failed once  in
eight  hundred  cases !   M. Phillips himself declares these  asser-
tions lies.
  M.  Cunier writes  to M. Velpeau  in  December,  1840, that out
of twenty-nine  operated upon, he had seen tM'enty-one relapses, in
periods varying from fifteen days to five months, and that he knew
of only six perfect cures.  Since that, he states (Ann. d'Oculiste,
Fevrier, 1841) that the deviation was reproduced in forty-seven cases
out of one hundred and sixty-nine, and that he failed twelve times
in  seventy-one  cases.   In June of the  same year, he announces
that he had succeeded  two hundred and thirteen times  out  of two 
STRABISMUS.                       527
hundred and eighty-six; and M. Fleussu (Ann. d'Oculiste, 1° suppl.,
p. 308, 309) maintains, that out of six hundred cases M. Cunier ob-
tained constant success.  Out of one thousand four hundred opera-
tions, (SuppL, etc., p. 288 and 312,) our confrere of Brussels scarcely
admits of any reverses.
  M. Dufresse, also, while calling in  question the results of others,
avers himself, that he partially failed only in a few cases, and that
the disease returned but in three cases out  of forty-seven.  The
same language appears in  the treatise  of M. Josse, (Considerat.
sur t'Oper. du Strabism., 1841,) and in that of M. Kup, (Ann. d'Ocul-
ist., t. vii., p. 44.)
  In recommending caution in pronouncing upon success immedi-
ately after the operation, M. Velpeau complains that his language
was improperly interpreted by M. Guerin, in the Gazette Medicale,
as meaning opposition to the operation.   M.  Velpeau, in 1840, Oc-
tober 14, (Gaz. Med., p. 87,) estimating the proportion of failures to
cures, etc., lays down two important principles on this subject: to
determine accurately the existence and nature of the strabismus
before the operation, and to exhibit  the patients as cured at the
end of three months.   Pompous announcements of success in po-
litical journals the  day after the operation, discredit our profession
and  favor the extension of charlatanism.  In this light, also, M.
Velpeau views the asseverations of those who, in attempting  to
give plausibility to  their exaggerations, declare that their successes
depend  upon the peculiar perfection  of their modes of operating,
and, vice versa, the failures  of others, on their awkward or vicious
processes.
  M. Velpeau is exceedingly severe on these  self-puffing, ambula-
ting operators.  He declares that he has seen at Paris some of those
who had been operated upon by these pretenders, squint outwardly
after having squinted inwardly; some who  squinted  even after
being twice  operated  upon, and others who were disfigured by
enormous denudations of the eye, &c.
  These things at Paris have brought odium upon the operation,
so that its intrinsic value, after unexampled popularity, begins to be
mistrusted.
  Experience  taught  the  crowds,  who, misled by the reports  of
never-failing  success, thronged the operative chambers, that they
had been deceived, and that the deformity in many instances  only
becomes changed from  one  side to another.  Thus, from one ex-
treme of confidence, they have passed to the  other of distrust, and
the real  efficacy of the operation for certain  cases is overlooked,
and the  patient prefers  his deformity to the hazard  of an  opera-
tion.
  M. Velpeau  excepts M. Guersant fils, M. Jobert and M. Bouvier,
and others at Paris, as  among those who have spoken and acted
with frankness; also, the essay of M. Boinet, (Du Strabisme et  de
son Traitement, 1842,) and  that of M. Bonnet of Lyon.  After all
that may be said of the inconveniences that may attend ocular my- 
528           NEW ELEMENTS OF OPERATIVE SURGERY.

otomy as well as any other operation, M. V., in conclusion, says, that
it Mill be.  preserved in practice, and not only does honor to human
genius, but is one from which the organ of vision will derive great
advantage in future time.


                     Article II.—Anatomy.

  To appreciate  the  respective processes, we must examine  the
tissues M'hich fill the orbit, viz., the conjunctiva, globe  of the eye,
its muscles, and the cellulo-fibrous tissue M'hich forms a more or
less perfect sheath to each ball.
  Before  strabismus attracted  notice, surgeons rarely noticed  the
aponeuroses of the orbit.   Since that, however, the researches on
this subject have been extensive.  Layers  (toiles) and  sheaths of
various form, density, thickness, and number, have been described
with  a care  and minuteness which  leave  nothing apparently to
desire.
  It is found that the ancients M'ere aware of the fibro-cellular  tis-
sues in the orbit.  Galen was acquainted M'ith the layers or cellular
coverings  of the muscles of the eye, and Zinn described them M'ith
some care in the last century, after Colomb, Casserius, and Riolan,
(Helie, Thise, Paris, 1841.)  It is, however, to Tenon to whom we OM'e
the first extended article  on the aponeuroses of the eye, (Mcmoire
sur VAnatomie, la Pathologie, et  la Chirurgie, etc., Paris, 1806, t. i., }>.
193.)   Since this memoir, M'hich was  read to the Academy of Sci-
ences, there has been  such a total silence upon the subject among
anatomists as well as surgeons, that up to 1839, in spite  of  the
essay of M. Briggs, published  in 1835,  (Boinet, Journal des Con-
naissances Medico-Chirurgicales, Janvier,  1842,  p. 9.)  it Mas  no
longer spoken of.
  Since strabismus has occupied public attention, we have seen  the
description of the aponeuroses of the  orbit resumed in all its bear-
ings, by M. Lucas of London,  (On Strabismus, London, 1840,)  M.
Bonnet of Lyon, (Des  Sections  Tendineuses, etc., Lyon, 1841, p. 1,)
M. Guerin, (Gazette Medicate, 1842, p. 12,  97,) M. Dufresse, (Trea-
tise cited,  pages 32,  40,)  M. Helie, (TJiise,  Paris, 1841,) and  M.
Boinet.
  M.  Velpeau thinks it not surprising that in former times so little
was known apparently of the lamellar coverings of the eye, inas-
much as  they had no special relation to operations performed on
the ball, or in the orbitar cavity, or to the  diseases that may exist
there.
  These fibro-cellular sheaths, which  surround the muscles of  the
eye, and the lamellae which unite or separate them, present in their
mechanism and  distribution  in the orbit much greater simplicity
than some think.
  [To the late  Professor Hosack of New York, (see his Obser-
vations on Vision, read before the Royal Society of London, May 1, 
STRABISMUS.
529
1794,) are we indebted for the first clear and distinct notions that
we possess upon the important functions of the muscles of the eye ;
he alone having first  pointed  out, in the scientific paper here re-
ferred to, not only the well-known uses of these muscles in turning
the globe in almost  every possible direction, but also  the more im-
portant function, M'hich he discovered belonged to them, of elonga-
ting [if  not also of shortening] the axis of the eye to the different
distances of objects, and thus,  by means of increasing the convex-
ity of the cornea and by pressure on the humors, increasing the dis-
tance between  the  cornea and retina, and aiding most  materially
in all the operations of vision.
  To this physician, therefore, are we probably under more obli-
gations  than would at  first appear, for the attention  which  in
after years Mas bestowed  upon the subject of  the muscles of
the eye, and  their diseased   condition,  retraction, &c,  which
finally  resulted in the triumphant  surgical operation for strabis-
mus.
  Dr. Hosack states that he was first led to this investigation  (being
then at London) by observing that the common opinion, that the eye
was enabled to see objects  at different  distances by the different
quantities of light admitted  to it by different degrees of contrac-
tion of the pupil, was altogether  erroneous.   As it was manifest
upon a  moment's reflection, that the pupil, for example, became
greatly dilated when the same object in the same degree of light
\vas brought too close for the image to converge on the retina, and,
on the  contrary, in viewing an object so  remote and emitting  so
strong a light as the sun, the pupil contracted  to its utmost degree
of constrictive power; so also, he observes, does the pupil possess
its ordinary powers of contraction  and dilatation in myopes and
squint-eyed persons.
  Dr. Hosack proceeds to show, furthermore, the more obvious and
natural  function of the  pupil  and  iris to be, to regulate merely,
by dilatation or contraction, where  objects are viewed, for  exam-
ple, in the same field of light or vision, the greater or less quantitv
of light required, according as the object is farther off  or nearer
by.   But that the iris manifestly  has nothing to do with  the direc-
tion of the rays, which, as he fully explains in his learned memoir,
is by far the most important optical principle involved  in the fa-
culty of vision.
  Thus, other things being equal or unchanged as to the shape of
the globe,  and to the condition  of its humors, the rays of light from
an object fall upon the cornea  at a less or greater angle in a direct
ratio to their greater or less  distance, and that consequently their
power of convergence upon the retina, after  passing through the
cornea,  pupil, lens,  and  vitreous humor, must  be in an inverse
ratio to that distance: that is, the rays  forming the image  of the
object will  converge  sooner when  that object is more distant,
and not at all, or even behind the retina, when  that object  is too
near.
                              67 
530           NEW ELEMENTS  OF  OPERATIVE  SURGERY.

  Dr. Hosack then takes up  and ably refutes the theory of vision
by Dr. Thomas Young, predicated upon the supposed muscular con-
struction of the crystalline lens, which, if true  in references to the
great number  of concentric  laminae which  LeMcnhoeck shows
that lens to possess, (2000 coats,) Mould, according to Dr. Young,
have no less than 12,000 minute radiating muscles and membra-
nous tendons in constant operation—a conclusion M'hich  involves
an absurdity.
  Couching also, he says, shows that the crystalline lens is far from
being indispensable to good vision.
  With like ability the Professor demonstrates the futility of the
idea once maintained, that the ciliary processes possess any mus-
cular power to change the shape and situation of the  lens, and to
adapt it to vision by making it more  or less convex.   This opinion
falls to the ground with  the preceding.
  He then comes naturally to the situation, structure, and action of
the external muscles, which he illustrates by some  very excellent
anatomical  dissections in the accompanying plates.
  Dr. Hosack remarks as follows : " The use ascribed to these dif-
ferent muscles is that of changing the direction of the eye, to turn
it upward, downward, laterally, or in any of the intermediate di-
rections, accommodated  either to the different situations of objects,
or to express the different passions of the mind, for which they are
peculiarly adapted.  But, (asks Dr. II. with much emphasis,) is it
inconsistent  with the general laws of nature, or even with the animal
economy, that from their combination they should have a  different ac-
tion  and thus an additional use ?  To illustrate this, M'e need only
witness the action of almost  any set of muscles  in  the body;  for
example: in lifting  a weight, the combined  action of the muscles
of the arm, shoulder,  and chest, is  different from the individual
action of either set, or of any individual muscle."
  Dr. Hosack explains this action by the very simple experiment
of directing the eye, for  example, upon a succession of objects sit-
uated on the same line, and in the same horizontal plane.  Some
important change is immediately perceived to have taken place in
the visual power of the  eye, for  after looking at an  object at the
distance of  six feet, and  then  fixing the eye on one at the distance
of six inches, the image  of the former is no  longer felt on the re-
tina, though its rays of light fall as before on the cornea, while the
image of the nearer  object upon which  the  visual orb is  concen-
trated, is perfectly distinct.  So vice versa.  But it had been shown
that the rays from the  more distant object  converge sooner than
the  nearer  object; therefore, in  the  first case the picture of the
object at six  feet falls before, while that of the other forms upon
the retina, " but (he proceeds) as my eye is still in the same place as
at first,  the retina has, by some means or other, been removed  to a
greater distance from the forepart of the eye, to receive the picture
of the nearer object," [as before explained.]  " From which it is evi-
dent, that to see the less  distant object, either the retina should be re- 
STRABISMUS.
531
moved to a greater distance, or the refracting power of the  media
should be increased."
  The lens which has the greatest refracting medium being shown
to be incapable of changing itself, Dr. Hosack, by a very natural
process of inductive reasoning, founded upon the soundest mathe-
matical principles in the science of optics, comes then to the ex-
ternal muscles as the true and legitimate means of explaining the
phenomena of vision, so far as the important and essential principle
of the  distance  of objects and the direction of  the rays is  con-
cerned.   " Let us (he says) next inquire if the external  muscles, the
only remaining power the eye possesses, are capable of producing
those changes.   With respect  to  the  anterior part of the eye, M'e
have seen the situation of those muscles ; the recti strong,  broad.
and flat, arising from  the back  part of the  orbit, passing over the
ball as over a pulley, and inserted by broad flat tendons, at the ante-
rior part of the  eye ; the oblique inserted towards the posterior
part, also by  broad flat  tendons; when they act  jointly, the  eye
being in its horizontal position, it is obvious,  as  every muscle in
action contracts itself, the four recti,  by their combination, must ne-
cessarily make a compression upon  the different parts of the eye, and
thus elongate its axis, while the oblique muscles serve to keep the eye
in its proper direction and situation.   [M. Velpeau, it  will  after-
wards  be seen, doubtless without being  aware  of this  beautiful
application  of the antagonist  action of the  two different sets of
muscles, recti and  oblique, alludes to it in explaining certain  con-
ditions of the eye in squinting, and  the section of muscles  for its
relief.—T.]   For my  own  part, I have no  more  difficulty in  con-
ceiving of this combination of those  muscles,  than I have  of the
different flexors of my fingers in holding my pen.  But other cor-
responding effects are also produced by this action;  not only the dis-
tance between the  anterior and posterior parts of the eye is increased,
but of consequence the convexity of the cornea, from its great elasticity,
is also increased,  and that in proportion to the degree of pressure, by
which the rays of light passing through it are thence necessarily more
converged.  But another effect, and one not inconsiderable, is, that by
this elongation of the eye, the media, viz., the aqueous, crystalline, and
vitreous humors, through which the rays pass, are also lengthened, of
consequence  their powers of refraction are proportionally increased,
all  which correspond with the general principle.  It may, however,
be said, that as the four recti muscles are  larger and stronger than
the two oblique, the action of the  former  would overcome that of
the latter, and thus draw  back  the  whole globe  of the eye;  but
does not the fat, at the posterior part of  the orbit,  also  afford
a resistance  to the too great  action of the recti muscles, especially as
it is of a, firm consistence, and the eye rests immediately upon it 1"
  With the  common speculum oculi,  Dr. Hosack made different
degrees of pressure upon the globe of his own eye, by which means
he could alter the local distance at pleasure, and in fact, by greatly
elongating the ball  by a greater  pressure, could  plainly see  and 
532
NEW  ELEMENTS OF OPERATIVE SURGERY
distinguish the lines and letters of a printed book at only two inches
from the eye, though  without that pressure  they M'ere not at all
distinguishable.  In the next paragraphs it M'ould almost seem that
the author was about to stumble immediately upon the great dis-
covery M'hich, m ith the foregoing lucid exposition and deductions,
and M'ith our present knoM'ledge, it would have appeared impossible
for him to have avoided.   At least  he  almost foreshadowed, we
may say, the section of the retracted muscle  in strabismus, by
opening" up his  argument  directly to this point, and,  as  it were,
forcing  himself to the necessity of hitting upon this key, and this
only, as the  natural one, and the only one  to unravel the whole
mystery, and give the power of mathematical demonstration to the
whole chain of his reasonings.
  " Such, then, (says Dr. Hosack,) I conceive to  be  the action and
effects of the external muscles, and  which,  I apprehend, will  also
apply in explaining many other  phenomena of vision."
  He thus explains the diminution of the poM'er of vision in old
age, by  the absorption of the fat in the orbit, [he might  have added
the flattening of the cornea,] the diminution of the humors, and the
irregularity and debility of the external muscles, no longer capable
of remedying the  difficulties.  So also he shows the influence of
habit upon the conformation of the  eye; as long sight in sailors
and sportsmen—short sight, as  in watchmakers, seal-cutters, &c.
Then he asks—"Secondly, how are we to account for  the Meaker
action of one eye in  the case of squinting ?  That  this is the fact
has been well ascertained;  [see this  subject touched upon by M.
Velpeau in this treatise farther  on, but where the defect of vision
is explained by him as owing to disuse of the eye.]  Dr. Reid,
(Inquiry into the Human Mind, p.  132,) upon  this subject observes,
that he  has examined above twenty persons that squinted, and found
in all of them a defect in the sight of one eye.   Porterfield and Jurin
have made the same observation.   The distorted position  of the
eye has, I  believe, been generally attributed to  the external mus-
cles, but no  satisfactory reason  has ever been given why the  eye,
directed towards an object, does not  see it distinctly at the same
distance as with the other.  The state of the iris here cannot ex-
plain it, as it contracts and dilates in common with  the other; nor
can we  suppose any muscles the lens  might possess could have any
effect, as  they are not at all connected with the nature of this dis-
ease.  But the action of the external muscles, I apprehend, will
afford us a satisfactory explanation.   When the eye is turned from
its natural direction, for example, towards the inner canthus, it is obvious
that the adductor muscle is  shortened, and its antagonist the abduc-
tor lengthened; consequently, as  the abductor has not the same
power of contracting itself with the adductor, when the eye is di-
rected towards an object, their  power of action being different and
 irregular,  the compression made upon the eye and its humors must
also be  equally irregular, and therefore insufficient to produce the reg-
ular changes, in the refraction and shape of the eye, we have shown to 
STRABISMUS.
533
be necessary, in adapting it to the different distances of objects.  The
effects produced by making  a partial pressure upon the eye with
the finger or  speculum oculi, before noticed, would also appear to
favor this explanation.
  " Thirdly, may it not in part be owing to the loss  of this combined
action of the external muscles, and  the  difficulty of recovering it,
that the operation of couching is  sometimes unsuccessful, especially
when the cataract has been of long standing ?  This cannot be at-
tributed to the iris,  for it, perhaps, dilates and contracts as before ;
nor to the  muscles of the lens, for they are removed;  nor to the
state of the nerve, for it  is still sensible to the light; and yet the
patient cannot see objects distinctly; and  it is not an uncommon
circumstance,  even when the  operation succeeds, that the sight is
slowly and gradually recovered.
  " Instances  have  occurred, Mr. Bell (see his System of Surgery)
observes, of the sight becoming gradually better for several months
after the operation."
  Dr. Hosack  thus, as we see, justly attaches much importance to
the difficulty the eye has in recovering any  certain combination
of muscular actions which had  ceased to be in exercise after it
had been long habituated to them.  The same as in muscles else-
where, as in playing upon  a musical instrument, and then laying
it aside.
  In conclusion, he thus sums up:
  " I have thus endeavored, first, to point out the limited action of
the iris, and of consequence the insufficiency of this action for ex-
plaining vision.  Secondly: to prove that the lens possesses no power
of changing its form to  the  different distances of objects.  Third-
ly:  that  to see objects at  different distances, corresponding changes
of distance should be produced between the retina and the anterior
part of the eye, as also in the refracting powers of the  medium through
which the rays of light are  to pass.  And fourthly:  that  the  com-
bined action of the external muscles is not only capable of  produ-
ding these effects, but that, from their situation and structure, they
are also peculiarly  adapted to produce them."
  " If (says Dr. Hosack) I should be so fortunate as  to succeed in
establishing the principle I have proposed for explaining the phe-
nomena dependent  upon this more important organ of our body,
(if any part possesses a pre-eminence in nature,) I also hope  it may,
in abler hands, admit of some  practical application  in  alleviating
the  diseases to which its  delicate  organization so particularly ex-
poses it."
  [Was not this desired  practical  application,  so  prophetically
foreshadowed  by this illustrious physician, (whose memory I ought
not less to revere  as my preceptor, than as one of the most pro-
found and clear-sighted practitioners that ever  adorned the pro-
fession,)  happily verified in the  section  of the  retracted muscle
or muscles, restoring the  equilibrium  and .regularity of  muscular
pressure ?—P. S. 7VJ 
534
NEW ELEMENTS OF  OPERATIVE SURGERY.
   In a note Dr. Hosack remarks, that he finds the effects of the ex-
ternal muscles noticed by some of the earlier writers.   He therefore
says he claims  no originality for this thought, though he  was not
aware of it till  after he had  made his investigations.   " If, there-
fore, (he says,) I have succeeded  in pointing out  the precise action
of these muscles,  and its application to the general principles of vision,
IN WHICH,  I BELIEVE, I HAVE NEVER BEEN ANTICIPATED,  it will be the
height of my wishes."*]

                     § I.—Muscles of the Orbit.

  Of the  seven muscles  contained in  the orbit, there  are but six
which serve for  the movement of the eye; these alone, therefore, can
be  concerned  in the  subject of  strabismus.   Six of them, being
attached to the bottom  of the bony cavity, where  they are  con-
founded with the periosteum  around the optic foramen, and on one
of the borders of the sphenoidal fissure, terminate in front by a true
tendon,  expanded (rubane) on the sclerotica, which  they assist in
forming.  Four  of them—the four  straight muscles—extend to
wilhin about  the one  twenty-fifth or one twenty-sixth  part of an
inch (cinq ou six millimetres^) of the cornea on their anterior sur-
face ; but their  deep-seated surface terminates at three or four mil-
limetres behind, so that this  extremity appears a  little curved and
thickened like  a leech, M'hich attaches  itself to  the skin by its
posterior extremity.
  The   superior oblique  behind  the  upper eyelid, parses with-
in the  supra-orbitar foramen,  through a fibro-cartilaginous  ring,
before it passes from before backward, and  from within outward,
under the levator muscle of  the  eyelid, in order to attach itself to
the posterior and upper part  of the globe of the eye. The inferior
oblique  muscle  passes from the  external  side  of the nasal canal,
outwards, backM'ards, and upwards,  between  the floor  (plancher)
of the orbit and  the inferior rectus muscle, to terminate at the outer
and posterior part of the sclerotica.
  It follows from this arrangement:
  1.  That the four straight muscles, (the recti,) M'hen too  short or
  * [It is to be hoped that these original, ingenious, if not sound and philosophical views
upon vision, and which singularly enough appear to  have escaped notice in the very
active investigations now going on in EuTope upon the section of the muscles of the eye
for strabismus and other diseases of that organ, will be turned to useful advantage in thoBe
important operations, and serve as a sound basis and guide for a correct diagnosis of
some of those diseases, and of the curative results that may be anticipated.  In cataract,
for example, if the sight is not restored after the operation, and the eye remains to all
appearance sound, but for the loss of the crystalline, might it  not be well to inquire how
far a division of some one or more of the muscles, recti or oblique, might be adcantageous
to lessen the perhaps too powerfully elongating or compressing action upon the globe
which all those muscles must possess, after the eye in its vertical diameter or axis, that is,
its breadth, has been, as it would seem it  necessarily must be, weakened by depriving it
in that direction of the support of so firm a substance as the lens is ?—P. S. T.]
  t [A metre (French measuijp) is 39.37 inches; a centimetre is 0.393 inches ; and a
millimetre is 0.039 inches.—T.] 
STRABISMUS.
535
too contracted, tend to shorten the transverse and vertical diame-
ters of the sclerotica, and at the same time to  give prominence to
the cornea, from whence we have one cause of short-sightedness,
(myopie) and the idea of dividing these muscles to elongate the field
of vision.    •
   [This does not directly militate against the theory of Professor
Hosack, (supra,) inasmuch as that theory implies a normal condi-
tion of the muscles,  and, therefore, an elongation of the globe of
the eye by their healthy contraction, and consequently a shortening
of the vertical axis.—7'.]
   2. The inferior oblique, in contracting itself singly or dispropor-
tionately, (avec preponderance) turns the eye outward and upward,
which  gives it a certain influence in the production or continuance
of external strabismus.
   3. The superior oblique turns the eye inward and downward;  at
other times it aids rather the action of the external rectus muscle,
and the inferior oblique, in external strabismus.
   4. By  their simultaneous retraction,  the two  oblique muscles
draw the globe of the eye forward.  Becoming in this manner
antagonists  of the four straight muscles,  they may also cause the
cornea to protrude, (faire bomber la cor nee) and  produce myopie,
from whence proceeded the  suggestion of their division to remedy
this deformity.
   [It is here observable,  that Professor Velpeau makes the oblique
muscles not only antagonist to  the recti, and a point d'appui for
them, as Dr. Hosack does, but also co-operating with them in pro-
truding or giving  convexity to  the cornea.  It is clear, that the
same physiological idea existed in the  minds of both  those au-
thors.— T]

                     § II.—Globe of the Eye.

   It is  to be remarked:
   1. That the optic nerve, inserted within the antero-posterior axis
of the sclerotica, is much less removed from the cornea within  than
outward ; one of the reasons, perhaps, why internal strabismus is
more frequent as  compared  with external.
  2. That this organ, being  composed of a fibrous shell, (coque)
almost inert, of very  little sensibility, extremely difficult to become
inflamed,  and of several millimetres in thickness,  allows of our
acting  with  instruments  upon its external surface with the  most
perfect liberty, and without incurring any serious risk.

                      § III—The Nerves.

  Of the nerves of the orbit, the sixth pair and the third only re-
quire notice.  The pathetic, that of Willis, and the ciliary nerves,
are not specially concerned in strabismus.  The  optic  nerve  is to
be recollected as representing  the axis of  the orbit behind the eye, 
536           NEW ELEMENTS OF OPERATIVE  SURGERY.

that M-e may not divide it, as was done by an orthopedist of Paris,
in the operation of strabismus.  The nerve of the sixth pair, sup-
plying only the external straight muscle, would, if paralyzed, cause
an internal  strabismus.  The patient, though he could then turn
the  eye upward,  doMiuvard, and  inward,  could not,  though the
other eye was shut, turn the pupil towards the temple.
  The other muscles of the  eye. being  supplied by the nerves of
the  third pair, shoM' how, when this nerve is diseased, it is folloM'ed
by an external strabismus.   In this case the  eye, fixed outwardly,
can neither be moved imvard,  upward, nor  downward, and the
strabismus is complicated often with a more or less marked depres-
sion of the upper eyelid.
  Thus, as all  these nerves are appropriate  to the different muscles,
and as those of the globe of the eye come from another source, it
may readily be conceived that the operation for strabismus ought
not  to cause any nervous disturbance in the ocular functions.

                      § W.—Tlie Vessels.

  The vessels of the orbit  are of  greater volume in proportion to
their distance from the globe ; the arteries all arising from the oph-
thalmic trunk, and  being situated posteriorly, and encircling the
optic nerve, are so small M'hen they arrive in the neighborhood of
the  conjunctiva, or the anterior extremity of the muscles, that their
section at  the place where the instruments should be applied in the
operation  for strabismus, incurs no risk of any serious hemorrhage,
and is generally attended M'ith but a very slight discharge of blood.
The case of threatening  hemorrhage mentioned in England, (see
Phillips, 1841,  <fcc.,) must have been  an  exception,  and  from  a
hemorrhagic predisposition.
  The large veins M'hich proceed  from  the internal angle of the
eye, and from  the  eyelids and  root of the nose, and which pass
along the internal wall  of the  orbit, into the  cranium, must  be
avoided, as must  also the  ethmoid bone,  in convergent  stra-
bismus.

                      § V.—Aponeuroses.

  The nerves, vessels, muscles, the eye itself, and the conjunctiva,
and superincumbent layers of the eyelids, are all enclosed and
lined with lamellae and layers foreign to their appropriate structure :
all known under the name of the cellulo-adipose tissue of the  orbit.
and apparently complicated, but in reality simple.
  I have established, in my Surgical Anatomy:
  1. That the fibrous tissue is  but  a transformation of the cel-
lular.
  2. That all the membranous and fasciculated parts are formed
in their place, and nol; contiguously, (de proche en proche) as many 
STRABISMUS.
537
authors still seem to believe, in conformity with the figurative lan-
guage of Bichat.
  3. That all the moveable organs are  enveloped or lined with a
cellular, fibrous, or fibro-cellular layer.
  4. That the interval of all the parts thus sheathed, is filled with
fatty pelotons, or cellular, lamellar, or filamentous tissue.
  In conformity M'ith a great laM-  of the organization, all the ves-
sels and nerves have a kind of cellular sheath, independent of their
own coat;  there is no muscle  or  tendon which is not surrounded
by a sheath or encasement, either of purely fibrous  plates, simply
cellular, or cellulo-fibrous; the  same as M'ith all the glandular or
other viscera, and all the  organs contained in the splanchnic cavi-
ties, and in the mouth and the orbit.
  The ball of the eye, nerves,  muscles, vessels, even the internal
surface  of the conjunctiva, and the deep-seated surface of the pal-
pebral ligament, are all enclosed  in this duplicature or pocket of
slightly  condensed cellular tissue, M'hich,  moulded  upon the eye
and optic nerve, and forming  a flattened  sheath on the recti and
oblique  muscles, and on the levator of  the eyelid, and each of the
nerves  and vessels,  becomes, from  the  constant motions of the
parts upon each other, in every direction, more and  more isolated
and hardened, until it has acquired the  character of true fibrous
tissue, or simple cellular lamellae, of greater or less density.  These
lamellae are thus much more cellular than fibrous in early life, and
much more fibrous than cellular  in adult  age.   There is thus an
aponeurosis for each part.

           A.  Aponeurosis of the Eye,  Proper or Globe.

  This, commencing at the cornea, is a simple, somewhat dense
lining, enveloping the M'hole sclerotica and optic nerve.  In front
it is continuous with the aponeurosis of the conjunctiva, and be-
hind M'ith the internal layer of the sheaths of the  muscles.   It is
interrupted by the required number of openings for the passage  of
the oblique and straight muscles.   Its mobility, and the fine texture
of the cellular tissue of its inner surface, admit of its being detached
from the eye, either from behind forward, or from before backward,
in the manner of a purse

                B. Aponeurosis of the Conjunctiva.

  This is also a dense cellular tissue, which strengthens this mem-
brane as the fascia-propria strengthens the adherent surface of the
serous membranes.  Setting out from  the periphery (pourtour)  of
the  cornea,  where it is continuous  (se continue) at a very acute
angle with the aponeurosis of the eye, it proceeds backward to the
conjunctival border, (crite) which corresponds to'the oculo-palpe-
bral groove.   It is then reflected from behind  forward, to follow
the  palpebral conjunctiva, and to contract adhesions with the con-
                              68 
538
NEW  ELEMENTS OF OPERATfVE SURGERY.
vex border of the tarsal cartilage, or  to  terminate between this
cartilage and the conjunctiva, upon the meibomian glands.

                  C. Aponeurosis of the Orbit.

  This lamella, seemingly continuous  with the preceding, or the
upper expansion of it, passes upward at the base of the orbit, as if to
line the posterior face of the palpebral ligament, and to bend from
before backward, to serve  as an inner layer to the  periosteum,
which it covers in its M'hole extent, so as to convert the orbit into a
cavity completely closed before and behind, in which latter position
the,aponeurosis of M'hich I  speak is  continuous with that of the
muscles.

                D.  Aponeurosis of the  Muscles.

  The fibrous, or rather cellular and somewhat dense and lamella-
ted encasements of the muscular system of the orbit, are composed
of small, unequal, flattened sheaths, which are adherent to the mus-
cles,  and extend between them, under the form of membranes, that
spread out from one muscle to  another.  All these sheaths, com-
posed of an external and internal layer, reach to the sclerotica, and
are continuous with the aponeurosis of  the eye, where it has united
itself with the aponeurosis of the conjunctiva in front, and M'ith the
aponeurosis of the same  organ, as it passes backM'ard  towards the
optic nerve ; that of the oblique muscles, also, loses itself in the
aponeurosis of the  eye.   There results from this  arrangement, as
M. Guerin has noticed, (Gaz. Med., 1842, p. 84,) a kind of compart-
ment, (loge) formed  by the  funnel-like expansion of each one of
those sheaths for the insertion of each tendon of the muscles  in
question.
  As to the sheath  of the levator  muscle of the upper  eyelid, it
is blended in front, and above and downwards,  with the palpe-
bral  aponeurosis, rather than with the aponeurosis  of  the con-
junctiva.
  It  results from this, that  the oblique muscles seem to  have
wrought  out the aponeurotic net-works, which extend from one
border to the other of the  straight muscles, and that they have
lent to these last a part of their own proper sheath at their point of
contact or crossing.
  Upon the entire white of the eye, the aponeurosis of the conjunc-
tiva  rests in contact, when we look at it in front, with the anterior
portion of the aponeurosis of the globe and a certain extent of the
aponeurosis of the  muscles.   But according as  the eye is turned
more or less in one  direction or in another, this contact diminishes
or totally disappears on one  side, while it proportionately increases
on the opposite side. Between the aponeurosis of the globe and the
straight muscles there is nothing posteriorly but fat, cellular fila-
ments, vessels, and nerves.  It is the same between the oblique and 
STRABISMUS.
539
the straight muscles, between the levator (elivateur) muscle and all
the others, between the M'hole muscular system of the eye and the
aponeurosis of the orbit.    y
  In no part, moreover, is the fibro-cellular system of the orbitar
cavity as dense and complete as at the place where the tendons of
the straight muscles abandon their fleshy tissue  to be inserted in
the sclerotica, under the oculo-palpebral circle of the conjunctiva,
which latter seems to be retained there by the aperture of  a large
purse, analogous  to that which holds  the peritoneal cul-de-sac of
the lower (petit) pelvis  to the aponeuroses of the  perinaeum or the
prostate.

               Article III.—Operative Methods.

                   § I.—Method of Strohmeyer.

  In convergent  strabismus of a spasmodic character, M. Stroh-
meyer, guided by his  operations on the dead body,  advises the
sound eye to be  covered,  and the patient to keep the squint one
turned out as far as possible.   The operator then inserts into the
conjunctiva, near the  inner  limit of the protuberant part of the
eye,  (bulbe)  a small double hook, M'hich he immediately passes to
the assistant, in order to hold the eye outM-ard.  The surgeon then
raises the conjunctiva with  a forceps, and with  a cataract  knife
makes a vertical incision through it, so as to open into the orbit on
the inner side of  the bulb or  globe.  The assistant now draws the
globe more outwardly, which immediately brings into view the
rectus-internus muscle.  Having  passed a small probe (petite son)
underneath  this  muscle, it is divided  with  the curved scissors, or
with the same knife with which the  incision was made into the
conjunctiva.
   Cold fomentations and an anodyne are then used, and the sound
eye  afterwards kept occasionally closed, that the motions of the
other may become  re-established by exercise.  The operation of
M. Strohmeyer  is the trunk  or  base  from which all the others
branch off.

                   A. Process of Dieffenbach.

   M. Verhaeghe, who M'as one of the first cases of strabismus ope-
rated upon by M. Dieffenbach, says the latter in his first essay,
December, 1839, in following out Strohmeyer's directions, encoun-
tered much  difficulty in exposing the rectus-internus muscle, as
well as in seizing it. The operation, however, was completely suc-
cessful.  The process of M. Dieffenbach, as described by M. Ver-
haeghe, (Mem. sur  le Strab., fyc, Bruges,  1841,  p. 41,)  is as fol-
lows :—
   The instruments are composed of the elevator of Pellier, a double
blunt hook, (supported by a slender handle,) in order to depress the 
 540            NEM' ELEMENTS  OF OPERATIVE SURGERY.

 loM'er eyelid, tM'o small sharp-pointed  hooks to seize (harponner)
 the conjunctiva, scissors curved on their flat.sides for the incision
 of this membrane, and a blunt hook to pass underneath the muscle,
 M'hich is cut M'ith the curved scissors ;  finally, a small, sharp-pointed
 double hook, reserved  by the operator  for cases M'here  the  eye is
 turned convulsively imvard, to such degree as to endanger tearing
 the conjunctiva.  The hook in that case  is inserted into the scleroti-
 ca, to control the eye. A sponge and hot Mater complete the articles
 required.
  The surgeon, being  seated in front, and a little higher than the
 patient, places under the upper eyelid the elevator of Pellier, M'hich
 the assistant M'ho supports the head then takes charge of. Another
 assistant in front holds the depressor  of the loM'er lid.  The pa-
 tient having turned his eye outward as  much as possible, the small
 sharp-pointed hook is inserted into the conjunctiva near  the carun-
 cula-lachrymalis; the other hook he inserts in the conjunctiva near
 the cornea, and holds it in his left hand. While the conjunctiva is
thus raised up in a fold, the operator, armed M'ith a curved scissors,
makes an incision into it, and successively divides the other tissues
 until the muscle is laid bare.
  Then passing the blunt hook  betM'een the sclerotica and the mus-
 cle, he divides this latter with the scissors.
  The eyes are examined to see if they are straight.
  The only difference of Dieffenbach's  process from Strohmeyer's,
is that the former, instead of seizing hold of the conjunctiva M'ith
a forceps near the lachrymal caruncle, in order to stretch the mem-
brane, as M. Strohmeyer does, employs  a second hook,  (erigne)

B. Process of M. Cunier, (Myotomie Appliquee  au  Traitement du
   Strabisme, etc., Bruxelles, 1840, et Ann. d'Oculist, Juin, 1840.)

  In Belgium, MM. Van Rosbrooeck, de  Meyer. Claeysens, and
most  of the surgeons, adopt the process  of M. Strohmeyer.  M.
Cunier, hoM'ever, one of the first, if not the first  who operated for
strabismus, makes some slight modifications, using the  speculum
 of Lusardi, as well as the elevator of Pellier, and making a semi-
lunar incision into the conjunctiva of the breadth of the muscle,
which latter he divides at one stroke M'ith  the  small blunt-pointed
scissors, curved on their flat  sides.   He uses, also, blunt hooks, to
keep apart the eyelids at the angle on the  diseased side.
  M. Velpeau sees no preference in this process over the German
 modes, and M. Cunier himself has substituted for it that of M. Phil-
 lips, using likewise M. Velpeau's blephareirgon and the suture of
 the conjunctiva.  (Annul. d'Oculist., ler Supplem., etc., p. 271.)

                    C. English Processes.

  England was  the first after Germany to adopt  the processes pro
 posed for strabismus, as seen in the numerous operations by MM. 
STRABISMUS.
541
Lucas, Ferrall, Liston, &c, before M. Verhaeghe, in the beginning
of 1841, gave vogue to it in Belgium.
  M. Guthrie, junior, claims three hundred and sixteen cases before
April,  1841,  (Ann.  de  la Chir. Frangaise, t. I, p. 492.) and MM.
Hall, Grant,  Eliot,  and Duffin, had already published instructive
treatises upon this subject.  All operate differently, but by modifi-
cations so slight, that they cannot be separated in reality from the
method of Strohmeyer.

     D. Process of M. Lucas, (Cure of Strabismus, fyc., 1840.)

  M. Lucas,  after separating  the lids, at once seizes the conjunc-
tiva with  a forceps, and dividing  it, inserts through the opening
the double hook into the sclerotica to hold the eye, and then divides
the muscle with a curved scissors.

                    E. Process of M. Ferrall.

  M. Ferrall seizes the caruncle with a sort  of double hook, (erigne
double) and pushes it inward.
  After having seized  with  the forceps a portion  of the  conjunc-
tiva near the cornea, and divided it with a small pair of angular
scissors, he lets the eye repose for a few moments.
  He afterwards raises the tendon of the muscle with a blunt hook,
and divides it very near the sclerotica with  the angular scissors.
   M. Ferrall, by applying his forceps  outside, while Strohmeyer
uses his on the inside,  has made the operation somewhat more dif-
ficult,  by thus dispensing (deplacer) with two of its instruments.
Nor is there  any advantage in the angular scissors.

                    F. Process of M. Liston.

  M. Liston, using  one assistant only, who raises the  upper lid
with his fingers or  Pellier's  elevator, seizes a large fold of the con-
junctiva,  in  the oculo-palpebral groove, with  a  spring forceps,
whose M'eight alone, left to itself, depresses the  lower lid.   This
method, M'e shall see, is exceedingly defective and objectionable

                      G.  French Processes.

  The operation was first attempted in France in June or July, 1840,
and first performed by M. Huard  and others at Havre, the particu-
lars of which M. Velpeau is  not in possession of.  After that, it was
performed by MM. Guerin, (Lettre a. VAcademie des Sciences, 29 Juin,
1840,)  Roux,  (Communication a VInstitut., 20 Juillet,) and Amussat,
by methods which completely failed, and which have not been pub-
lished.  Finally, in the hands of M. Simonin, at Nancy, it proved,
for  the first time, perfectly successful. 
542
NEW ELEMENTS OF OPERATIVE SURGERY.
H. Process of M. Simonin, (Du Strabisme, fyc, Nancy, 1841, in 8vo.)

  This does not  differ materially from  that of Strohmeyer and
Dieffenbach, only in adopting the best parts of each.

                     I. Process of M. Roux.

  After M. Simonin and M. Guerin, it was  M. Roux, according to
M. Velpeau, M'ho M'as the first, he thinks, to perform this operation
publicly in France ; viz., at the Hotel Dieu in July, 1840, on two
patients, M'ho, hoM'ever, continued to remain squint-eyed afterwards.
His operation differed from  the German, only in having the blunt
hook for raising the muscle, grooved for  the direction of the small
bistoury that divided it.

                   J. Process of M. Sedillot.

  M. Sedillot performed the operation of strabismus, at the Val de
Grace, Paris, a few days after it had been performed by M. Vel-
peau.  In order to hold the eye, he  inserted into the sclerotica a
hook with three prongs, instead of the double hook of M. Cunier,
and the simple one  of Strohmeyer, (see Gazette des Hopitaux, 1841,
Sept. 15.)

                   K. Process pf M. Phillips.

  Up to November, 1840,  there still  prevailed great doubt as to
the utility of the operation for strabismus.  Notwithstanding  the
constant successes announced at Berlin, Petersburgh, and London, it
was seen that many failures occurred among the practitioners of
Belgium, while in France no one obtained results entirely satisfac-
tory.   But a young physician, M. Phillips, M'ho had acted  as an
assistant to M. Dieffenbach, and had himself performed the  opera-
tion a number of  times in Russia,  having arrived  in Paris,  M.
Velpeau interrogated him as to the cures made at Berlin, and if the
failures in France  were to be imputed rather to the processes  fol-
loM'ed  there, than to the operation itself.   He ascertained from M.
Phillips that he used an erigne  in the conjunctiva, not only to hold
the eye outward, and  which erigne was passed to an assistant,  but
another erigne to secure the fold in  the conjunctiva near the ca-
runcula, dividing with a bistoury betM'een the  tM'o erignes,  en-
larging the wound up and doM'n  M'ith  a small pair .>f curved
scissors, then  separating the muscle from the globe by a small
probe, (curette) and substituting for this last the blunt hook, and
lastly, dividing with the small  scissors already mentioned.   He is
in the  practice also  of excising the anterior end of the divided
muscle, to be more certain of preventing  its reunion, which Dief-
fenbach was also in the habit of doing, but has now abandoned, (De
la Tbnotomie Sous-Cutanee, p. 245.) 
STRABISMUS.
543
  Emboldened by the safety which they saw in the dissections of
M. Phillips, the Paris surgeons obtained the same results with the
German practitioners.

         L. Process of MM. Amussat and Lucien Boyer.

  They use a toothed forceps instead of the erigne to fix the eye.
Two of these being held in their place by an assistant, the ope-
rator incised the conjunctiva with a bistoury, raised up the mus-
cle by a  separated hook, (crochet  a ecartement) (the  one, accord-
ing to M. Phillips,  invented and afterwards discarded by Dieffen-
bach—see Du Strabisme, p. 27,) and divided it by a straight pair of
scissors.

                   M.  Process of M. Baudens.

  M. Baudens performed the operation at the close of December,
1840, and imagined he was  the first, though he was only the fiftieth.
His operation is the same as Dieffenbach's.

                      N. Other Processes.

  It  remains  to. speak only of the  modifications  made by M. Du-
fresse, (Du Strabisme et du Begaiement, Paris, 1841;) by M. Boinet,
(Journ. des Conn.  Med. Chir., Mars,  1842;)  and by  M. Bonnet,
(Des Sections Tend, et Muse, fyc, Lyons, 1841.)   M. Dufresse raised
the muscle M'ith a  flat and slightly-cutting hook.  He seized the
conjunctiva and muscle together by a  forceps,  and  divided  the
whole of  the  tissues included  between the two forceps, and
then  removed  a portion of the tissues thus divided.  This part
of the process  he  borrowed from  M. Velpeau himself, as adopted
by him in Dec.  1840. M. Bonnet holds the eye with  the  forceps,
and cuts the muscle with a small scalpel, (Sect. Tend, et Muse, fyc,
p. 97-100.)

                 0. First Process of the Author.

  The failures met with by some of the Paris surgeons, caused the
operation to be generally laid aside, till revived by  M.  Velpeau in
August and September, 1840, atLaCharite, (see his lectures there,
Sept.  11 and 12,) of which  the Gazette  des Hopitaux gave  (Sept.
17, 1840) but a  very imperfect description.
  The eyelids were separated  by  the elevator of Pellier and  a
triple blunt hook,  the  patient being directed to turn his eye  as
much outward as possible.  A small double erigne was inserted in
the sclerotica, and held by an assistant if it M'as the left eye; and
with another similar erigne, a little less curved and  more blunt, he
seized the muscle  through  the  conjunctiva as deeply as possible,
bringing  it forward with the  right  hand in the manner of a cord, 
544
NEW ELEMENTS OF OPERATIVE SURGERY.
and M'ith a small curved knife divided the whole at one stroke, viz.,
retracted muscle, fibro-cellular envelope, and conjunctiva.
  The advantages of the operation are—its rapidity, the dispensing
of any dissection M'hatever, and the very small opening it leaves
in the conjunctiva, besides that of the cure being speedily  effected
Mdthout any inflammatory reaction in the eyes.  Of ten patients,
however, upon whom he  thus operated in  September, October,
and November,  only  three had their eyes  continue perfectly
straight.   In four others the disease was reproduced as severely
as before.

                  P.  Process of M. Andrieux.

  M. Andrieux (Gaz. des Hdp., 1840, Sept.) proposed to change M.
Velpeau's erigne into a cutting-hook, to divide the tissues  while it
raised  and secured them: the  eye was held by a double erigne
M'ith cutting points.

                 Q,.  Second Process of the Author.

  Having seen M. Phillips operate on the dead body, M. Velpeau
immediately conceived that, in  imitating him, success  might be
hoped for where there had hitherto been complete failure.  In re-
flecting upon the free and bold dissections of M. Phillips in denuding
the  sclerotica, and which had hitherto appeared formidable to M.
Velpeau, he perceived that  by  his  own operation, numerous  la-
mellae might be left remaining undivided in the eye.  M.  Phillips
soon having an  opportunity to prove on the  living subject that
there was no  danger to  be apprehended, greater confidence M'as
produced, and the question assumed a new aspect;  (Du Begai. et
du Strab., Paris, 1841.)
  M. Velpeau now modified his process by seizing with  a claw
forceps, (pince a griflfe)  a large fold of the conjunctiva, and the
attachment itself of  the. muscle  at the  sclerotica, in  order to hold
the  eye and turn it outward.  If it is  the right eye, he holds this
first forceps in his  left hand.  Then with a similar forceps, but
stronger, he proceeded to embrace  deeper still the  body  of the
muscle  and the conjunctiva, in  order  to raise it and stretch it.
This last forceps was immediately confided to an assistant.   With
a small blunt-pointed scissors, straight, or slightly curved on their
flat sides, and  held  in  the  right hand, he divided the whole bridle
comprised  betM'een the two forceps.  After making the division,
M.  Velpeau inserts one of the  blades of the scissors betM'een the
sclerotica and ocular aponeurosis, and freely  cuts away  all the
adhesions there,  to  the extent of about four fifth's of an inch,
(deux centimitres)—the two ends  of the  divided muscle, &c, being
still held tense by the two forceps while this detachment is being
made.  He terminates the operation by excising  a portion of the
tissues, to wit, that  portion of the conjunctiva and of the  tendon 
STRABISMUS.
545
of the retracted muscle  held  by the  first  forceps, having  first,
with  the  beak  of the blunt scissors shut, cleared away all the
remaining adhesions on  the globe of the eye, till a denuded space
is made on the sclerotica, which is recognised by its smooth shining
surface.

                  R.  Variations of the Process.

  The above process  was  put into practice by M. Velpeau in
December, 1840, since M'hich period he has employed  it in two
hundred cases.  The instrument with which the eyelids are kept
asunder during  the operation, is termed  the blephareirgon.   It is
the invention of M. K. Snowden, as modified by M. Velpeau, and
the latter gentleman prefers it to all others—the speculum of Lu-
sardi, the  elevators and depressors of Dieffenbach,  M. Pellier, and
others, the flat  forceps  of  M.  Liston, the dilatators of M. Cu-
nier, &c.  It  is made of iron wire.   The two forceps he uses are
preferable, he thinks, to the  erignes.  Llis are strong and short, and
have  two small hooks at the extremity of one branch, and one on
the other, which hooks catch into each  other.  Those of the ante-
rior forceps  converge  a  little, so that the}' may not catch into the
sclerotica.   Erignes expose  to lacerations.  On  the left eye he in-
serts the first forceps with his right  hand, and hands it  to an as-
sistant, and then holds himself the posterior or deep-seated forceps
with his left  hand.  Generally M. Velpeau excises the portion or
fold of the conjunctiva, and  of' the termination of the muscle in the
sclerotica, which are grasped by the first forceps.   He does this to
prevent consecutive engorgement there.   The  scissors should be
straight and  blunt; they cut better than the curved.  The first for-
ceps are directed upon the point where the tendon  of each muscle
is inserted into  the sclerotica, and the parts grasped in it are the
conjunctiva,  conjunctival aponeurosis, muscular aponeurosis, and
the tendon itself.  This gives  the operator  full control over the
ball.  The second forceps, which should be  a little stronger and
longer than the first, and are directed upon the bottom of the oculo-
palpebral  groove, beyond the transverse axis of  the eye, and  gra-
zing the sclerotica, embrace the rectus  muscle in all its thickness,
M-ith the different mucous and  cellulo-fibrous layers which natu-
rally envelop it,  while pressing the lachrymal caruncle towards the
nose.   These forceps have this advantage,  that their firm pressure
on the vessels prevents  hemorrhage when the section is  made.
The grasp of the tissues  with  the first forceps should rather be
made  below  than above the transverse axis of the  eye, for  it is
easier afterwards to dissect  with the scissors the adhesions from
below upward, than in the opposite direction.  The whole portion
of the  tissues included between the two  forceps,  or, what is the
same, a portion of the  extremities of these tissues,  after the divis-
ion, may be excised whenever judged advisable, as was the prac-
tice of Dieffenbach.
                              69   ' 
546           NEW ELEMENTS OF OPERATIVE SUEGERV.

  Another modification which M. Velpeau proposes in his method is,
to make at first a partial incision only into the bridle be! ween the
two forceps;  then he separates the conjunctiva from the aponeuro-
sis and muscle with a  blunt hook, or the blunt scissors shut;  then
detaches the  ocular aponeurosis from the sclerotica, and raises up
the muscle, in order to divide all the fibro-cellular or muscular tis-
sues which separate the globe from the conjunctiva, doing this Mdth-
out enlarging the incision just made.

                   S. Process of M. Daviers.

  M. Daviers, of Angers, uses what  he calls  an  erigne-forceps,
with four hooks at the points to fix the eye, taking care to embrace
in the  fold the sub-conjunctival and muscular aponeuroses, and
even some of the tendinous fibres.  This fold is raised up as much
as possible, and divided perpendicularly to the direction of the mus-
cle, and in such manner, that the erigne-forceps  remains implanted
in the anterior or corneal lip of the division, and thus serves to keep
the eye  firmly fixed. ' The blunt hook is then immediately passed
under the muscle, and the forceps is removed.  The division of the
muscle is then made with scissors of short and blunt  blades, and
either straight or  curved on  their flat.

                  § II.—Process of M. Guerin.

  M.  Jules Guerin, who denominates this operation  the  sub con-
junctival (sous-conjonctivale) method, has two processes :

                 A. First Process of M. Guerin.

  At the close of October, 1840, M. Guerin had operated five times
in the following manner:—The patient lying in bed or on a table,
and the  lids  being kept separate by proper instruments, a small
erigne, single or double, was inserted into the conjunctiva near the
cornea, and an aid, taking  charge  of this, drew the eye outward.
Then, with a large forceps seizing the conjunctiva near the carun-
cle, he incises this  membrane, dissects a flap and turns it inward,
and thus exposes the  muscle.  Raised up by another forceps, the
muscle  is then immediately divided by a blunt scissors.  The con-
junctival  flap is now replaced  on the wound, and the  operation is
thus terminated.
  M. Velpeau perceives disadvantages in this method; says it dif-
fers but little from those of MM. Ferral, Lucas, and Simonin;  that
in two of the five cases only M'as it successful; and finally, as M.
Boinet remarks, that none of the other methods require a greater
denudation of the muscle, or larger incision into the conjunctiva,
than this does, (see Boinet, Du  Strab., p. 39.) 
STRABISMUS.
547
                  B.  M. Guerin's Second Process.

   Not satisfied with the difficulties by the last process, of detach
 ing the tissues under the conjunctiva, M. Guerin, to date from Oct.
 26, 1840, (see  his letter to the Academy of Sciences,) proposed a
 new modification, the germ of which M. Velpeau finds  in that of,
 his own, or of M. Andrieux or M. Lucas, and the first idea of which
 may, M. Velpeau thinks, be traced to the sub-cutaneous method of
 M. Ammon, (vide Cunier, Myot. Ocul., p. 107;  1840.)
   The  modification consists in puncturing with a lancet the con-
 junctiva,  below  the muscle  to  be divided.   A  small  scalpel,
 shaped like a Z, with its cutting edge convex,  is then  introduced,
 to detach from the  eye both the ocular  aponeurosis and the
 shortened  muscle.   In the  next, or third  stage  of the  operation,
 the cutting edge of this knife is  pressed forward and outward
 against the internal  surface of the  muscle, which latter is made
 more tense, by drawing  upon the conjunctiva  with the erigne in
 the opposite direction.  Withdrawing the knife through the punc-
 ture in the conjunctiva, there remains, says M. Guerin, scarcely
 any perceptible wound between the eyelids, (Gazette Medicate, 1842,
 p. 148.)

   Article IV.—Comparative Value of the Operative Processes.

   Under the title of methods, M. Velpeau compares only the usual
 method, viz., that by dissection, or Strohmeyer's, with the sub-con-
 junctival.

                   § I.—The Sub-Conjunctival.

   Besides objecting to the name of this method, which  M. Guerin
 has given to it in following out the principle of sub-cutaneous  sec-
 tions, M. Velpeau says it does not  exclude the  air. and besides,
 sometimes  involves serious  infiltration, or  ecchymosis and tume-
 faction,  both of the  conjunctiva  and the entire thickness of the
 eyelids ; that it is also more difficult and painful, and that it is  less
 certain than the other process, as the divisions are made in the
 dark and out of sight.
  M. Guerin,  on the other  hand, considers its advantages to lie
 m these  particulars:  that it  prevents  a return of the disease,
 or a strabismus in an opposite direction, also an abnormal separa-
 tion of the lids, and that  protuberance of the eye known as exoph-
 thalmia.  M. Guerin also esteems it the most  easy and rapid process.
 M. Velpeau says, however, that the same accidents occur after M.
Guerin's as after other methods, and that so far from his (M. Vel-
peau's) oM'n method, or most of the others, exacting ten  to fifteen
minutes, they are generally terminated in less than a minute ;  be-
sides that,  the  formidable inflammations,  loss of  the  eye, &c,
which M. Guerin charges upon other methods, all  resolve them- 
548
NEM' ELEMENTS OF OPERATIVE  SURGERY.
selves  into a very  trifling degree of inflammatory reaction.  " If
(says M. Velpeau)  I did not know  M. Guerin as M'ell as  I do, I
would in truth believe that his intention, in charging other methods
with so  many  imaginary imperfections, was in reality  to mask
those that are inseparable from his own.   Ardently desiring, as he
does, that sub-cutaneous surgery, and the sub-cutaneous section of
tendons  in particular, should take  their  birth from  his  peculiar
ideas about muscular retraction, [see long note on the Paris Dis-
cussion upon Tenotomy, supra,] he has extended his theory also to
strabismus, in  a round of illusions  upon which he uselessly ex-
pends his logic  and  talent."
  The  only real advantage of the sub-conjunctival method is, says
M. Velpeau, that it generally prevents the  small  reddish vegeta-
tion, or species of ocular  polypus, which  is frequently formed at
the bottom of the wound, at the expiration of from fifteen to thirty
days after the  processes of Strohmeyer's method.   But  this is  a
trifling inconvenience, and easily  removed: besides, M.  Guerin's
method is not  entirely exempt from it.  It is a method, moreover.
which  is followed only by himself and a  few other surgeons.  M
Velpeau, however, does not declare that M. Guerin's method is pos-
itively  bad;  only that it is not in reality better, but at  least as
dangerous, and certainly more difficult, than the usual method.

          § II.—Method of Strohmeyer, or by Dissection.

  Though it must be confessed, that there is no one of the  methods
yet devised  which  in  the strict sense of the words  may not be
both practicable  and  successful,  and that the pure process of
M. Strohmeyer, having as yet been performed only on the dead
body, is  incomplete and but  imperfectly described, still  the im-
provement upon this by M. Dieffenbach is now the  fundamental
process.

  A. Whether  the erignes and the forceps should be applied in this
or that place, or manner, either according to M. Lucas, Strohmeyer.
or M. Ferral, is a matter of little importance.
  B. Whether  the  erigne should be single or double, placed near
the cornea or the caruncle, is equally unimportant.
  C. Those who, like MM. Verhaeghe, Cunier, Simonin, Andrieux.
and others, fix the crotchets (hooks) of the erigne  into the sclero-
tica, have, M. Velpeau thinks, the  advantage, while producing no
serious wound, of  holding the  globe more steadily,  than  when
the anterior erigne  is inserted into the conjunctiva only.
  D.  M. Liston's forceps to depress the loM'er eyelid, is only appli-
cable where assistants or a convenient dilatator are wanting.
  E. In a very docile patient, the fingers of the assistants are suffi-
cient to  keep the eyelids apart.   The two-branched depressor of
Dieffenbach, the elevator of Pellier, and some other instruments of
the cutler Charriere,  (at Paris,) are, however, less embarrassing,
and enable us to act with more freedom and certainty. The hooks 
STRABISMUS.
549
extolled by M. Cunier,  for separating the lids at the angle where
the operation is to be performed, might sometimes be of advantage.
The  specula both of Lusardi and M. Cunier are no longer in use.
M. Velpeau again gives a decided preference to the blephareirgon
of M. Snpwden, but  says  the mode of applying it upon, or outside
of the lids, is not as secure, or attended with as little pain, as under
the lids.
  F.  M. Velpeau sees no advantage in the recumbent posture of
the patient, as  enjoined by  MM. Guerin and Sedillot; and thinks
also, in opposition to M. Guerin, that the operator should stand up,
and not be  seated.
  G.  M. Velpeau prefers the  toothed forceps of M. Lucien Boyer
to the erignes, because  they fix the eye and tissues, &c. more stead-
fastly, and expose less to a laceration of the parts.
  H.  M. Velpeau, being desirous of embracing in one grasp both the
conjunctiva and tendon of the muscle with one forceps, and the con-
junctiva and body of the muscle itself with the other, found that he
required forceps almost as strong as a dissecting forceps, and having
one or two solid teeth at their points.  He has no  doubt that they
will one day entirely supersede the erignes. MM. Bonnet, Dufresse,
Boinet, and Daviers, have already adopted them.
  •I.  The incision of the conjunctiva  may be made with a cataract-
knife, as is done by Strohmeyer and Dieffenbach, and the English
surgeons, or by any small scalpel or bistoury that is at hand.  But
the blunt scissors are best for this, and also for the ulterior dissec-
tion of the tissues.
  J.  The isolation of the muscle  is as practicable with a small blunt-
pointed knife, the extremity  of a pair of small scissors, or  a curved
probe, as  with Dieffenbach's hook. M. Boyer's forceps to raise  the
muscle  first before cutting it, is superfluous.
  K.  The division of the muscle may be readily made with a cata-
ract  needle, any kind of bistoury, small  concave knives, the little
rondache of M. Bonnet, the  crotchet of M. Andrieux, the cutting-
probe, the bistoury of Dieffenbach, or the small serpette M'hich I used
in the beginning, with a  button to it  like that  of M. Van Steen-
kiste, revived by  M. Doubovitski.   The small  blunt-pointed scis-
sors is, however, most secure and most handy.
  L. The erigne slightly blunted, to grasp the muscle through the
conjunctiva, and bring it  forward like a loop, causes more blood
than the claw-forceps,  (pince d,  griffe.)
  M.  The erigne-bistoury  proposed  by M. Andrieux, and having a
sort of cutting-hook  on its concavity, though it might sometimes
divide the  conjunctiva and muscle  with one  stroke, exposes to
the risk of wounding  the eye, is  moved with less freedom in
destroying  the bridles,  and may leave  some of the fleshy fasciculi
undivided.
  N. From all this discussion it follows:
  1.  That a surgeon should  follow his own taste and practice.
  2.  That the whole matter in  this business is reduced to a trifling
consideration, either way. 
550           NEW  ELEMENTS OF OPERATIVE  SURGERY.

  3. That the choice of the mode, among so great a variety, is a
matter more of taste than necessity.
  4. That, in fine, the process of M. Velpeau is, as he conceives,
the most simple, easy, and sure.

          Article V.—Treatment after the Operation.

  In this we must prevent or  subdue the accidents,, and endeavor
to establish a sound direction to the eye.
  Practitioners have gone to two extremes; either totally abandon-
ing their patients, or pursuing too rigid a regimen.
  In the great majority of cases, the mildest kind of precautions
are all that is necessary.
  For the first two days, lotions with cold or warm water, accord-
ing to the season, &c, are all that is requisite.  They may be made
more emollient with lettuce, plantain, &c, if desired.  Alum water,
as advised by M. Dufresse, may do at a later period.  Linen kept on
the eye, and wet every few minutes, as M. Yerhaeghe advises, is
useless.  Foot-baths nightly, and made  stimulating or not, as  M.
Simonin advises, are  unnecessary,  except  there  should be severe
cephalalgia, or symptoms of congestion in  the head.  Tepid emol-
lient lotions  are properly substituted for  plain water, after the
second  day.  Leeches to the  temples, behind the ears, or to the
anus, or general bleeding, are rarely required.   So of laxatives,
purgatives, injections, and debilitating diet and regimen.   The  in-
flammation  at  the  wound  is a simple conjunctivitis, extending to
the cellular tissue there, but rarely to the cornea.
   The swelling,  engorgement, and inflammation of the wounded
tissues, are  generally at their height on  the  third or fourth day.
Resolvents are then better than emollients.   Lead water, a weak
solution of nitrate of silver, &c, are, in  the opinion of M. Velpeau,
of less efficacy than a collyrium made with a weak solution of sul-
phate of zinc in lettuce-water  and  mucilage ; thus:—

           Eau de  laitue  )             „_
           ----de  bleuet  j...... aa'  60 grammes-
           Sulfate  de zinc............20 centigrammes.
           Mucilage de psyllium...... 3 grammes.

   The eye being frequently cleansed during the day with warm
water, some few drops of the above are let to fall into its angle,
morning and evening.   In ten to twenty days all further treatment
may generally  be dispensed with.
   In most patients  the eyes should  be left uncovered, and exposed to
the air.  The patient, however, should not use them until after
three or four days, and then with  caution.  He should also avoid
every imprudence, all fatigue, &c.  In many cases no precaution is
required, and the patient resumes his usual pursuits.  Covering  the
diseased eye, or hindering its movements, would be apt to irritate
and inflame the wound.   Motion has also the advantage of main- 
STRABISMUS.                       551
taining the pliancy of the tissues, and of preventing too close an
adhesion of the divided lamellae to the sclerotica.
   The covering of the sound eye is useful only where the one ope-
rated upon still slightly deviates.  In forcing the latter alone to re-
ceive the impressions of light, it is compelled to maintain its proper
position in the centre of the orbit, and  is much more comfortable
under the  action of the  three muscles  remaining, than  under the
pressure of compresses and bandage.

          Article VI.—Consequences of the Operation,

   The consequences are either immediate or remote.  Among the
first are: the incomplete restoration of the eye to its natural posi-
tion, or its  deviation to an opposite direction, immediately, after the
section of  the muscle ;  chemosis, and symptoms  of phlegmonous
inflammation in the  orbit, or the lids; a vegetation, to  greater or
less extent, at the  bottom of the wound; fever, and certain distur-
bances in the gastro-intestinal functions.   Among the consecutive
accidents, are:  the return of the disease ; a strabismus the reverse
of that which has been removed; deviation of the eye upward or
downward; exophthalmia; the separation, or flaring open (erail-
lure)  of the eyelids; the unequal motion of the  eyes; diplopy, (or
double vision,) &c.

                   § I.—Incomplete Restoration.

   This occurs more frequently in divergent than  convergent stra-
bismus.  M. Phillips  is in error in saying that this  is always owing
to an incomplete  division of the retracted muscle.   The smallest
bridle, fibrous, cellular, or muscular, will effectually retain the  eye
in a morbid direction, which M. Velpeau believes to  have been the
cause of the great proportion of failures in the first trials at Paris;
but, even since the practice of freely incising the tissues has come
into use, and the prpof has been given that the aponeurotic lamel-
lae, which go from one muscle to another, are sufficient to keep up
the strabismus, he has, nevertheless, seen this accident supervene,
and that,  too, though he had convinced himself, by  means of  the
blunt hook and the blunt point of a small scissors,  that every thing
had been divided  on  the strabismus side  of the eye, and though
more  than  one-third of the sclerotica had been perfectly denuded
back to the optic nerve.
   As  to the question now of dividing another muscle, the great ob-
lique, for example, in convergent strabismus, M.  Velpeau is pos-
sessed of no authentic evidence in favor of this section, and on this
subject inclines  more to  the opinion of  MM. Bonnet and Phillips,
than to that of MM. Verhaeghe, Kuh, (Ann. d'Ocul., t. vii., p. 44,)
and Gairal, (Mem.  sur le Sfrab., 1840,) and certain itinerant opera-
tors.  M. Velpeau, where he has deemed  it advisable to proceed
farther with the operation, has confined himself to  dividing the
border of the superior and inferior recti muscles. 
552            NEW ELEMENTS  OF OPERATIVE SURGERV.

  The difficulty he explains in two ways:—
  1. By the fact that the superior and inferior recti muscles each
form a small riband of about two fifths of an inch (un centimetre) in
breadth.   Two millimetres (deux millimetres)  only of this width,
represent the antero-posterior axis of tfie eye.  The remainder ne-
cessarily exists outside and  inside of this median part.  Is  it not
probable that the inner bundle of fibres, (le faisceau interne) having
become identified (congenire) with  the rectus [internus] muscle,
may be sometimes found contracted  in that part, to the degree, in
that case, of partially keeping up the deformity, though the muscle
which has been the essential source of the deviation, has been com-
pletely divided ?
  In support of this, he adduces  a considerable number of cases, in
which the eye was not effectually restored to its straight direction,
until after the division of the inner third or half of the superior and
inferior recti muscles.
  2. A circumstance  which has hitherto been overlooked, is the
smallness of the space M'hich  separates the root of the optic  nerve
from the cornea on the inner side. It is, in fact, easy to shoM', (vide
Cunier, Myot.  Ocul., etc., p. 49, fig. A.,) that a line M'hich would di-
rectly prolong the optic nerve, through the globe of the eye in front,
would leave much more of the sclerotica outside than upon the side
towards the nose.  May it not therefore result from this, that this
space  being naturally less,  may be still further  diminished  from
imperfect development, in individuals M'hose strabismus has been
of long standing ?  The external rectus muscle, in such cases, being
necessarily much longer than the internal, M'ould exhaust its power
of retraction before having brought the cornea  to the centre of the
orbit, and would be  incapable  of bringing the  eye freely to the
outer commissure of  the lids.   (M. Marehal communicated  to M.
Velpeau an explanation of the persistence of the deviation, founded
on the nature  of strabismus itself, namely, that it is the result of a
spasmodic contraction, and not that of a contraction M'ith shorten-
ing.   Thus, in most of the cases, the division of the muscle modifies
the nervous condition, and the spasm ceases.   In others, the spasm
remains, and reproduces its effect as  soon as  the adhesion of the
posterior end to the sclerotica has taken place.  This explanation
is deserving of attention.)
  But M. Velpeau remarks, that in some cases  (in convergent stra-
bismus) the eye M'ill  still continue  to be  turned slightly inward,
even after the above divisions he has recommended have been su-
peradded to the others—excepting from this remark, unnatural ad-
hesions, cicatrices, and paralysis.
  M. Velpeau cautions practitioners  in these cases  against too
extensive a denudation of the eye at  first; they would incur the
risk of a divergent strabismus, flaring of the eyelids, or an exoph-
thalmia, to remedy an inconvenience which sometimes disappears
of itself, and which may be attacked  in another manner.  In five
cases,  he saw the eye, M'hich obstinately retained a degree of con-
vergence during the operation or the  next day, perfectly restored 
STRABISMUS.
553
to a correct position in four or five days.  He explains this, in some
cases, by a certain spasmodic action in the muscles, excited by the
operation itself; in others, the rectification has been unquestiona-
bly caused by the tumefaction of the cellular tissue and conjunctiva,
in pressing from within outward and against the globe of the eye,
in consequence of the resistance opposed to this tumefaction on the
side of the orbit.
  M. Velpeau advises, therefore, to keep  the sound eye perfectly
covered and at rest, and to have the inner half of the glass of the
spectacles to be used over the diseased eye, made opaque.  A cer-
tain species of compression, hoM'ever, and certain kinds of perma-
nent tractions exercised upon the eye, are the most efficacious.

                       A. Compression.

  To effect this  he uses small  balls of lint, or pieces of agaric or
mild plaster, collected together in form of a cone, and made to  press
directly on the extremity of the eyelids, at the inner angle of the
eye, M'here they are firmly fastened by diagonal arcs of diachylon
plaster, or turns of bandage properly applied.   This dressing, M'hen
properly arranged, produces a compression M'hich prevents the eye
from turning towards the root of the nose.   To do this, it is not ne-
cessary to compress the eye itself, M'hich in fact it is important to
guard  against.   We must make of the dressing a sort of dike, in
the form of a fixed body, making resistance against the inner side
of the orbit.
  M. Velpeau speaks  in complimentary terms of the neat manner
of applying this dressing, by a young pupil of medicine, M. Gourain-
court.   It may be left on for eight days, and need not be changed,
unless it becomes displaced or  produces inconvenience.   If badly
put on, it may cause tumefaction and inflammation of the conjunc-
tiva and lids, and of the vascular tissues of the orbit. In one case, it
thus produced phlegmonous erysipelas of the face, a most violent
conjunctivitis with chemosis, and finally, purulent suppuration of
the cornea.  In this patient, too, the strabismus M'as divergent, with
partial paralysis of the upper lid, and incipient paralysis of the three
remaining recti muscles.
  B. A noose of thread passing  through the conjunctiva, or the root
of the  divided muscle, naturally suggested itself to effect tractions
upon the globe.   This mode, which originated with M. Dieffenbach,
and was brought to Paris by M. Phillips, has  been used by M. Vel-
peau with success.  Thus, in internal strabismus:
  1. He  seizes M'ith his claw-forceps a fold of the conjunctiva, and
of its cellulo-fibrous lining, near the cornea, and passes through it a
fine needle armed with a double  thread, M'hich he  immediately
forms into a noose.  This is attached to the cap, or elsewhere near
the  ear, in such manner as to keep the eye fixed as near to the tem-
poral angle of the orbit as may be desirable.
  2. Or, having in the same manner passed the thread through the
root of the divided tendon or as many of the  lamella? of the tissues
                              70 
554           NEM' ELEMENTS OF OPERATIVE  SURGERY.

remaining on the sclerotica as possible, the noose is fastened under
and outside of the chin, or to the eyebrow above.   If it  Mere
made to pass over the  surface of the cornea, it Mould chafe it, or
ultimately render it opaque.   To avoid this, we must place small
pieces of linen or agaric, or a rouleau of lint or  diachylon, on  some
point  of the circumference of the orbit, to  serve as a fixed pulley,
(poulie de renvoi.)
  With care, the difficulty of maintaining an equal degree of trac-
tion all the time, is overcome, and this need not be continued over
two to five days, as the thread usually, by that period, cuts through
the included tissues.
  The same rules apply, in  a converse sense, to divergent strabis-
mus.  If this mode prove unsuccessful in either  form of the disease,
all other treatment must be renounced, and then the question arises
as to a second operation.

            § II.—The Eye turned too much Outward.

  Because the eye, upon the day after the operation for convergent
strabismus, may slightly diverge  outwardly, this is no reason  for
the immediate division of the rectus  externus. In  some cases, I
have seen this soon disappear without  any treatment:  nor is com-
pression, though applicable  in divergent strabismus, as efficacious
here as for preventing the  convergence of the eye; but, on the
other hand, the application of the thread is more easy and effectual,
and the opposite side of the bridge of the nose furnishes an excellent
point  of attachment for the noose.

            § III.—Other Accidents from the Operation.

  The laceration of the eye by erignes and hooks, and plunging a
knife by mistake into the globe, with other  mal-practices of opera-
tors, are no argument against the use of the proper remedies.  rLhus
therefore these, and also wounds of the cornea, perforation of the
sclerotica, hemorrhages, neuralgia, (Dufresse,  p. 65,) etc., do not
properly constitute any of the accidents of the operation  for stra-
bismus.

                     § IV.—Inflammation.

  The inflammation is  generally  slight, or is  characterized by a
tumefaction which is confined to the inner half of the eye and to
the lips of the wound; and, though it may take on the appearance
of an irregular grayish and then red mammellated fungous plate at
the inner commissure of the lids, is of little consequence, causes but
little pain, and seldom any general reaction.  This projection soon
disappears, and  cicatrizes under the proper treatment  already re-
commended.
  When the patient has committed imprudences, the inflammation
may proceed to the formation of a complete chemosis, with cepha- 
STRABISMUS.
555
lalgia, febrile reaction, intestinal disturbance, etc.  As the cornea
may become implicated, bleedings, leeches,  purgatives, etc., may
then be required.

                § V.—Polypus in the Inner Angle.

  This is the reddish tumor at the bottom of the wound, as describ-
ed by M. Verhaeghe, (p. 53,) and since, by  all others who have
adopted the method of dissection of the tissues.  This, which at
first is a simple vegetation of the character of fungosities, assumes
afterwards the appearance and consistence of a small mucous po-
lypus, similar to those sometimes seen, under other circumstances,
on the inner surface of the lids, or at the internal angle of the eye.
It is rarely observable until after the  eighth or  twelfth day, and
does not become isolated from  the sclerotica, and pediculated at
its root, till at a later period.
  It has no other inconvenience than keeping up a slight degree of
purulent discharge, conjunctivitis, and blepharitis, which  blear the
eye and prevent it from assuming its natural color and normal
movements.  It varies from the size of a currant-seed, to that of a
pea or small nut, and has the appearance of a cherry, or straM'berry,
in the corner of  the eye.   It took place  in tM'o thirds of the cases
upon  M'hich M. Velpeau had  operated.   It is rare after the opera-
tion for external strabismus, or the section of the superior and in-
ferior rectus and oblique  muscles.  The section of the internal rec-
tus is the only one, almost, that produces it.   It does not originate
from the anterior extremity of the divided muscle, nor from the con-
junctiva, because  it has been formed in some, where M. Velpeau
has with the greatest care excised  the  conjunctiva close up to the
cornea; and in others, where, after the division of the rectus mus-
cle, and after scraping  the sclerotica as much as possible, he has
removed the tendon of the muscle.  In fact, the pedicle of the vege-
tation is farther back than the cut end of the muscle  in question,
or than the conjunctiva.
  The process by  which this polypous  vegetation is formed, he ex-
plains thus:—The lamellar cellular tissue which lines the sclerotica,
vascularizes and softens a little,  at the same time that the divided
edges of the conjunctiva and aponeuroses are becoming tumefied.
The cicatrization proceeds from the circumference towards the cen-
tre of the traumatic surface.   The contact of the lids, which makes
permanent compression on a  great portion of this wound, leaves
the vicinity of the caruncula lachrymalis intact.  The continual
movements of the  eye thus crowd all the vascularizable portion of
the cellular tissues behind the straight portion of the free border
of the lids, and thus form the polypus.
  This tumor, though frequently observed in the cases operated
upon  by MM. Dieffenbach, Verhaeghe, Phillips, Dufresse, and all
others, who practise the method of dissection, is, however, a circum-
stance of little importance.   Even if left  to itself, it will disappear
sometimes without any treatment, only that  it may then last for 
556
NEW  ELEMENTS OF OPERATIVE  SURGERY.
several months.   It maybe arrested and destroyed even before it is
pediculated, by touching it lightly with the nitrate of silver crayon
three or four times a day for the space of ten days.  The better
M'ay is to let it pediculate perfectly, and not to touch it under three
weeks or a month.   It is then removed M'ith the greatest ease, and
without pain, by a pair of blunt scissors, the patient turning his
eye outward.  Nothing more is necessary.   In the first cases, it re-
turned tMo or three times, because they undertook its excision before
it was properly pediculated. To retard its growth, all that is neces-
sary in the first eight or ten days, especially M'here it is  in the form
of a small cone, is to touch it with the lapis infernalis ;  or M'ith as-
tringent collyria,  if the patient is intractable or  timid ; finally, to
excise it with the scissors, from the fifteenth to the  thirtieth day.
There is no need of a hook or erigne, to raise it up first, as the blade
of the scissors suffices for that.   Cauterizing the root afterwards, is
also unnecessary.

         Article VII.—Inconveniences of the  Operation.

  Besides diplopy, an abnormal separation of the lids, exophthalmia,
and alterations in  the mobility of the eye, as already mentioned,
the operation may also cause a shrinking or absorption of the ca-
runcula lachrymalis.

                  § I.—Diplopy, (Double Vision.)

  Double vision is readily accounted for in those who squint, because
the axes of  the  globes cross each other  at  an angle more or less
acute, instead of being parallel; but why this should continue  to
exist, immediately and for some time after the operation, and when
the eye has been righted in its position, has not  been explained.
Some impute it to the eye being yet unaccustomed to its new func-
tions.  Most frequently, it lasts during  the first eight to fifteen days,
and entirely disappears before  the end of  a month.  In one case
only, of a man aged fifty, in whom the rectus internus and externus
were divided in both eyes, and the internus again  for the return
of convergent strabismus in the right eye, the double vision obsti-
nately continued, though the strabismus was removed.

                 § II.—Separation of the Eyelids.

  Though mentioned by MM. Phillips, Lenoir, and  Dufresse, this
flaring open of the lids has not been seen by M. Velpeau, in his own
cases, except as connected with exophthalmia.  In those of others,
he has seen it.  Where it exists in both eyes, where both have been
operated  upon, it is of no consequence ; but if in one  eye only, it
makes a deformity, and the cause always is too extensive a dissec-
tion of the sub-conjunctival aponeuroses,  and different  lamellae
which unite the  lids to the eye.   M. Velpeau suggests, that the
reason why he has not observed it in his cases, may be because  he 
STRABISMUS.
557
is  in  the  habit of incising the conjunctiva much nearer the cornea
than the caruncula, whereas the reverse is the practice of M. Phil-
lips and others.  The treatment of compression on the whole front
of the orbit, as recommended by Dufresse, is of no use ; and the su-
ture, as some suggest, makes a worse deformity.

                     § III.—Exophthalmia.

  The projection of the globe is a serious deformity.   In  a young
man operated upon some months before, by M. Baudens, it seemed
to M.  Velpeau as if the ball was double its natural  size, and had
started out of the  head.  A sort of buphthalmia, he says, is thus
sometimes produced.
  He  has  seen it  in  his own cases, only in those where several of
the muscles had to be divided;  as in a  woman aged fifty-two, with
convergent strabismus in both  eyes from infancy, and in whom  the
internal, superior  and inferior recti muscles in both eyes had  to be
divided, before the eyes were restored to their position.  However,
the appearance of both eyes is uniform, which is one thing gained
over their  previous condition.   So in two other similar cases, in one
of which,  a fat subject, the eyes, naturally protuberant, were made
excessively disagreeable by the operation.   He never saw it on
one side only, but in two or three cases.  In no case of his was this
exophthalmia ever perceptible, where only one muscle was divided,
or the neighboring fibro-cellular tissues also with it, except in a very
slight degree.
   Unfortunately, it is without a remedy.  In some cases, perhaps,
early compression, and before the divided ends of the muscles have
formed adhesions, might possibly succeed.   He haS great doubts of
any advantage from the kind of palpebral suture advised by MM.
Rognetta, Guerin, (Cunier, Premier Suppl, 4-nnal. d'Ocul, p.  310,)
and others, or as practised by M. Cunier, after excision of the con-
junctiva at the angle of the eye, (Suppl,  p. 311.)

    § IV.—Immobility and Fixity of the Eye, (Fixite de V02U)

   The eyes are often affected, after the  operation, with a certain
restraint, irregularity, and inequality in their  movements.  How-
ever strange, as remarked by M. Velpeau, it might seem, a priori,
yet he has established, that in some cases an obliquity still continues
inwards, (in convergent strabismus,) even where the rectus inter-
nus, and the fibro-cellular tissues uniting it to the superior and in-
ferior recti muscles, have been thoroughly divided.   This he  no-
ticed especially in very old cases, and he  considers the cause to be
this: that  the inner portions of the superior and inferior recti muscles,
participating in the retraction of the rectus internus, act in such man-
ner as  to take the place of the divided muscle, and  thus keep up  the
deviation.   It is, however, rare in cases of but a few years standing,
and in some cases it is impossible. 
558
NEW  ELEMENTS OF OPERATIVE SURGERY.
  In some cases, where it is not observable immediately after the
operation, the divided muscle will ultimately regain its power upon
the globe, through the intervention of the fibro-cellular tissues, and
Mill not fail to establish it.  After a month  or two, he has seen al-
most all his patients enabled to move the eye  in all directions  as
before the operation, but this complete mobility of  the eye is, nev-
ertheless, often wanting.
  Where M. Velpeau has been compelled  to cut several muscles,
and to make extensive denudation of the globe, the eye has  some-
times become steadily fixed in the middle of tlu- orbit, without the
possibility of making it pass within  the antero-posterior line.   And
in some, in whom he divided the internal and  external recti mus-
cles, this position in the centre of the orbit was immoveable, and
could not be altered either inward or outward.
  Where it is excessive in both eyes, it gives a haggard look  to the
visage, and the patient has to turn his head like a statue, or image,
to see sideM'ise.   Though it be in one eye only, it is  still a repulsive
deformity to have  one ball turning freely and naturally, M'hile the
other is fixed.   This last  deformity, to a certain  degree, is almost
inseparable from the  operation ; as the new attachments  must be
more or less  approximated to the  cornea, or  deviated  more  or
less upward or  downward, owing  to  the different  degrees of
movement in the  eye, the volume, force  of  retraction, and special
contractility of the divided muscle, and the degree of relaxation
or  inflammation  of the cellulo-fibrous  lamellae  M'hich reconnect
them with the cornea;  all M'hich  are  beyond the control of the
surgeon.
  In most cases this deformity is not perceptible.  Where one muscle
only is divided, it is generally slight, and almost always disappears
entirely.  After the section of tM'o or three muscles, on the contra-
ry,  it is  in general very marked; and often complicated with ex-
ophthalmia, flaring open of the eyelids, and neM' deviations of the
organ.
  To attempt  to reach and detach  the divided muscle, in order  to
attach it on another part of the sclerotica, as has been proposed,
M'ould  be too difficult and dangerous, and probably do more  harm
than good.
  Preventive measures, therefore, during the operation, are all that
can be relied upon, and those M. Velpeau has been in the habit of
employing, are :  1. Not to liberate or detach the aponeurosis above
and below the divided muscle, but to the extent absolutely required;
2. To allow only slight movements to the eye during the first days,
and should  immobility be apprehended, to  prevent it, by covering
it, from  moving in the direction opposite  to  that  of the  divided
muscle.
  Time will often do much, in these patients, in restoring the organ
to its natural state. 
BTRABISMUS.
559
         § V.—Alteration of the Caruncula Lachrymalis.

  When  the caruncula disappears after the operation, the eye ap-
pears much larger on one side  than the other, and is extensively
denuded of the conjunctiva in one direction, and covered  entirely
by it in the other.  The internal angle of one of the orbits, is thus
also  made  much deeper than  the  other, causing a hideous de-
formity.
  M. Velpeau thinks he has noticed it at Paris, more frequently in
patients that  had been operated upon  by MM. Phillips, Amussat,
and  L. Boyer ; and more  frequently still, in those  who had  been
under the hands  of M. Baudens.  Having seen it but very seldom
in his own cases, he imputes it to  the  process of  Strohmeyer, as
adopted by MM.  Phillips, Amussat, and others.  While M. Simonin,
and the English surgeons who adopt M. Velpeau's mode of incising
the conjunctiva, at a very considerable distance forward of the
caruncula, make no mention of it.
  M. L. Boyer proposes, as a preventive, to incise the conjunctiva
both above and below the muscle, and  to divide this latter behind
the tegumentary membrane, as  under a bridge, so as to leave this
bridge or bridle untouched in its whole  extent, from the root of the
nose to the neighborhood of the  circumference of the cornea.
  M. Guerin ascribes the absence of all deformity of the caruncula,
in his cases, to his process of operating.
  M. Velpeau, in conclusion, says,  that when the conjunctiva is
grasped over the tendon of the muscle by one of the forceps, while
we take  care  to force this membrane inwardly with the other for-
ceps, it  is divided at a point so remote  that the caruncula is not
touched by the operation, and there  remains afterwards but a  very
trifling depression in the angle  of- the orbit.  He therefore thinks,
that  the  suture of M. Cunier, and the precautions of MM. Guerin
and Boyer, are alike unnecessary.


     Article VIII.—State of the Parts after the Operation.

  Three  opinions have been entertained on this subject:  1. That
the body of the shortened muscle being approximated  to  its  deep
attachment, became fixed and contracted new adhesions, and  was
transformed, at  its free  portion, into a new tendon, M'hich M'ould
attach itself to a part of the sclerotica more or less distant;  2. That
a new tissue would  be formed between the two ends of the  divi-
sion, so as to re-establish the continuity, at the same time giving it
a greater length ;  3.  M. Phillips, among others, (Tenotomie  sous-
cutanee, etc.,)  adopting the idea  of M. Strohmeyer, maintains  that
after the  operation, the muscle, no longer undergoing retraction by
the spasm, is enabled, by a kind of elongation, to become fixed  near
its former attachments.   None of these opinions are positively  true, 
560
NEW ELEMENTS OF OPERATIVE SURGERY.
and that of M. Strohmeyer (Verhaeghe, p. 49 and 50) must be pro-
nounced from inadvertence.
  An examination of the orbit after death, has  shown  that each
muscle, when once divided, retracts more and  more backM-ard for
a week or two ;  that the  cellulo-fibrous  laminae  or  aponeuroses
which line its surfaces, approximating and hardening as they become
thicker, assume by degrees the form of a riband  or small flattened
tendon, which, inserting itself upon the sclerotica near the extrem-
ity of the transverse diameter of the eye, is  continuous in front M'ith
the sub-conjunctival  aponeurosis, that ultimately becomes par-
tially re-established, and behind M'ith the aponeurosis of the eye,
properly so called.  This kind of new tendon does not reach to the
situation of the former one, but the lamellae M'hich compose it, in
other respects are arranged at a short distance from the cornea, in
the same manner as M'ere the aponeurotic  layers of the primitive
muscular sheath.   This is what M. Velpeau saw in three subjects,
also in  the  cases that M.  Bouvier exhibited to the Academy, as
M'ell as in some others M'hose details have been published in Eng-
land.
  We have thus the explanation of the variety, force, and re-estab-
lishment of  the motions of the eye, where the operation  has  not
been followed by  any unpleasant consequences.  ■
  It sometimes, however, happens  otherwise.  Where the inflam-
mation has been very active, and the muscle has become too quick-
ly reattached to the globe of the eye, it is possible that an imme-
diate reunion may take place between its recently divided fleshy
extremity, and the  cellular tissue  which belongs to the  sclerotica.
M. Velpeau had two patients, in whom the wound completely re-
united in twenty-four hours, and whom he operated upon a second
time at the end of  eight days. In a case of M. Lenoir, dissected
two months afjter the operation, the rectus internus muscle which
had been divided, adhered to  the sclerotica by  its fleshy substance.
and  not b}' a flattened tendon, in the manner the three other recti
and the two oblique muscles were  attached to it.  There had also
been, in this case, a return of the disease.  The nerves, vessels, and
other connections of the eye, undergo no change.

               Article IX.—Counter-Indications.

  Some of these  appear to me not well founded.   M. Cunier, for
example, who at  first approved of the  operation only in permanent
strabismus, (Myot. Ocul, etc., p. 39,) has abandoned this opinion.

                    § I.—Optical Strabismus.

  A natural, though not a real distinction, has been  proposed, of
muscular and optical strabismus.   There are persons in whom  the
eye deviates, because the rays of light cannot any longer reach the
retina on  their natural  axis;  as happens  from spots or cicatrices 
STRABISMUS.
56 J
upon the cornea masking the sight, and obliging the eye to deviate'
in the direction of the blemish, in order to bring the pupil as much
as possible in a line with the light;  so also, M'hen from disease or
lesion of some kind, the pupil is approximated to the circumference
of the iris.  To these forms M'e may apply the title M'hich  M. Gue-
rin gives them, of optical strabismus.
  For these, it was contended, no operation should be performed—
1. Because the deviation is an advantage; 2. Because  the eye
Mould reassume this deviation after the operation.   It is false, that
strabismus must necessarily be produced by the above causes.  I
have seen hundreds of persons, as all physicians can  daily attest
of their  own, M'ho have for years had albugo, leucoma, and various
kinds of opacity of the  cornea, covering a quarter, a  third, two-
thirds, and even four-fifths of the pupil, and M'hose eyes, neverthe-
less, were perfectly straight.  So with those who  have the pupil
on one side, M'hether from  the operation of cataract, or artificial
pupil, or from accident or disease.  I have operated upon a consid-
erable number of subjects, in whom the cornea M'as in the condition
I have described, and the restoration of the eye has been as perfect
as in others.  The operation, in them, has  been attended with  no
particular difficulty or embarrassments, or any serious consequence
or tendency to a return, that I have not met with in others.
  The only question that could arise in such cases, is whether the
improvement of the sight, from the deviation of the eye, compen-
sates for the  inconvenience of the strabismus ?, This must be de-
cided by the patient.  The deviations, in fact, are  but  a slight ad-
vantage,  while  the  strabismus  is a serious deformity.  Optical
strabismus, therefore, should not be  considered a counter-indica-
tion.

                    § II.—Fixed Strabismus.

  In many cases, where the eye would appear  to be permanently
fixed in its morbid position,  it is found to possess all its motions on
closing  the sound eye.  There are,  however, some in which the
globe is steadfastly maintained in its false direction, and in which
even mechanical  means of traction cannot force it into a central
position between the lids.   Cases of this kind may arise from pa-
ralysis of some of the muscles, and  unnatural adhesions between
the  sclerotica and corresponding wall of the orbit.

                § III.—Strabismus with Adhesion.

  Strabismus complicated with adhesion, by M. Cunier denomina-
ted  strabisme ankylose,  is not unfrequent.   M.  Velpeau has seen
five cases of it.  It is caused, chiefly, by former inflammations,
wounds, and various lesions of greater or less depth in the  corre-
sponding angle of the  eye.   In one  case,  an abscess  which had
been for a long time suppurating, was the cause; in  another, it
was produced by a wound  from a ram-rod, between the eye and 
562           NEW ELEMENTS OF OPERATIVE SURGERY.

the caruncula lachrymalis; in a third, by a wound from the point
of a knife, in  the same place; in a fourth case, from shot lodged
there by  a musket ;  and in the  fifth,  it was ascertained that
there had been an acute  inflammation in that  part  tM'enty years
before.
  Although these  are the only cases which, according to a rigid
interpretation of M. Cunier's principle, should  be  operated upon,
they are precisely those M'hich, in that respect, often present se-
rious inconveniences.   M. Velpeau operated  upon all the above
five  cases, and in  three  of them  the normal  direction  and mo-
bility of the eye were almost  perfectly restored.   In the  other
two  the deformity  was re-established.  In such cases, the mus-
cles, fasciae, and even conjunctiva, are sometimes so blended togeth-
er, and so intimately and  extensively united to  the sclerotica, that
their dissection becomes  very difficult, and their isolation, in  the
manner it is effected in ordinary cases, out of  the question.  We
must expect, therefore, under these circumstances, great difficulties
and tedious painful dissections, besides the tendency of the parts to
become readherent.  The cure is almost as uncertain  as that of the
attempt to relieve deformities produced by cicatrices from burns in
other parts of the body.  It is these cases that are adapted to such
remedies as compression in the angle of the eye, and other orthoph-
thalmic means. Yet fixed strabismus, by adhesion, is not absolutely
a counter-indication

                § IV.—Strabismus with Paralysis.

  When the eyes are  deviated by defect of innervation,  it M'ould
naturally  seem impossible to remedy the deformity by an opera-
tion.  But there are many kinds of paralysis.   Sometimes it is in
the brain,  M'hen nothing can be  done : at other times, in one of
the nerves going to the orbit.  It may be the sixth  pair, producing
then convergent strabismus.   If it is the third, or common motive
of the eye at its  source, the strabismus is  external, with com
plete immobility of the eye.  If only one of  the branches of this
latter, the eye, though turned  outward, may still move  upward
and doM'nward, or inward, according to the muscles that remain
unaffected.
  For the  most part, strabismus with paralysis is  a  counter indi-
cation.  However, there  may be  established two  classes of this
deformity : 1. Complete paralysis from some lesion of a part of the
brain, or of the body of the nerve, and which lesion  is  still existing,
in which case there  can be no operation.   The treatment for the
paralysis  is the only indication.   2. When the paralysis is only
partial, unaccompanied M'ith any lesion of the brain, and is ancient,
and  appears to  be permanent, and to have  not varied for,many
years;  and where  the eye still retains  certain movements  and
oscillations in a direction opposite to that of  the deviation.  The
operation may then be performed,  if the patient  consents; and it is
proper to  inform him of the slight amendment  only  that he may 
STRABISMUS.
563
derive  from it.  One of the first patients M. Velpeau operated
upon, (viz., in September, 1840,) had a convergent strabismus from
paralysis of the rectus-externus.   The eye was straightened, and
could perform slight movements outward and inward, and preserved
its normal power of elevation and depression. He explains this result
by the division  of the rectus-internus muscle, the only one which
could give  equilibrium to the externus, while the oblique muscles,
acting in concert, direct the eye a little outward, and the inner fibres
of the superior and  inferior recti muscles come to the relief of the
divided muscle, as their  outer fibres  do to the paralyzed muscle.
It was, no doubt, M. Velpeau says, from not taking into considera-
tion  this arrangement, that M. Cunier (Myot. dans le Strab., etc.,
p.  87) censured  the operation for strabismus in any case of para-
lysis.
  M. Velpeau made trial of it again, in two patients affected with
divergent strabismus.  In one, the eye had lost its movement of ad-
duction only; the  section of the  rectus-externus restored the eye
to the centre of the orbit.   The movements on the inner side were
not restored, and there resulted from this a kind of fixity in the or-
gan.  Nevertheless, the strabismus was destroyed, and the second
deformity was infinitely less repulsive than the first.
  The other case, though unfortunate in the end, was not the less
conclusive.  The patient was fifty-nine years of age, and had been
troubled with distressing pains in the head for eight years, and
with divergent  strabismus for four years, M'ith a depression of the
upper eyelid from  the commencement, and an almost entire para-
lysis of the rectus-internus, and of the superior and inferior recti
muscles, the eye, however, retaining still some slight motions upward,
and  downward, and in the direction of the axis of vision.  Anxious to
be operated upon, M. Velpeau, doubtful of the result, as he told him,
nevertheless assented.   On the  division of the rectus-externus, the
eye regained its straight position without difficulty; but for fear of
the deviation returning, the compressing bandage already mentioned
was  applied.  This was made by a pupil  of the hospital with so
much force, and so directly upon the eye, that  acute pains on
the same day  attacked the entire cavity of the  orbit.  On the
morning after that,  the upper eyelid was found to be swollen, and
affected with a diffused ophthalmia.  The inflammation  reached
the cellular tissue, and a severe chemosis supervened ; a simple
erysipelas now extended over the entire  face, invaded the head
and neck, and in ten days returned to the face, and aggravated the
suppuration of the lid and the inflammation of the  eye, which lat-'
ter also suppurated at the expiration of the third week.  As to the
restoration of the position of the organ, it continued perfect through-
out ; and it is not probable the deviation  would have been repro-
duced, if the accidents mentioned had not  supervened.   In strabis-
mus  M'ith paralysis, therefore, the operation is not absolutely  con-
tra-indicated but in certain cases.  It allows, however, in general,
only of a partial restoration of the position of the eye, and a dimi- 
564
NEW  ELEMENTS OK OPERATIVE SURGERY.
nution of the deformity, but not a  perfect re-establishment of the
motions of this organ.

                       § V.—Amaurosis.

  Many cases of strabismus have been mistaken for amaurosis.  In
closing the sound eye. it is observed that the patient sees badly, or
with  difficulty, M'ith the one  deviated, and that the pupil of this
latter  is  more  or less dilated.  At present  it is well known that
this is owing to defective action in  the affected eye. Nevertheless,
true amaurosis does sometimes exist in cases of strabismus. But
in cases of strabismus M'ith amaurosis, either true or apparent, the
operation is as likely to succeed as  in those who have not lost their
power of vision, because  amaurosis does  not affect the muscular
action of the eye.  But though the amaurosis M'ill not be relieved,
there  is  no reason, if one  eye  is  sound,  why the mere deformity
itself in  the other should not be removed.   It would not, however,
be prudent, if the amaurosis  proceeds from disease in the brain or
optic nerve, compromises the life  of the patient,  or  is attended
with an organic lesion still present.  Therefore, with these excep-
tions, amaurosis is not a contra-indication, but in truth is frequently
followed, after the straightening of the eye, by an  improvement of
the faculty of vision.

          § VI.—General Diseases—Tumors in the  Orbit.

   Where there are  bony, fibrous, or cancerous tumors in the inte-
rior of the orbit, and the muscle is not concerned in the  strabis-
mus, the operation for this latter is  contra-indicated, or should be
deferred.  So also M'here there exists acute inflammation  of the
brain  or in the face, some serious affection of the nose, mouth, or
pharynx, erysipelas, an affection of the respiratory organs, or cir-
culating or digestive system.   So also in pregnant women, and, in
short,  in every case  where an accession of febrile symptoms is ap-
prehended.   But an affection purely local,  upon  the extremities,
would not be a counter-indication.

                    § VII.—Ag e of the Patient.

   Though infants and old persons ought, in the  opinion of some, to
be considered exempt from the operation,  it often succeeds as well
in them  as in adults.  In  infancy there is room  to hope the disease
may disappear, and after sixty the  operation scarcely compensates
for the pain, and there is  also required a more extensive dissection
of the tissues; whereas, in infants, as there is  less of this  neces-
sary, it succeeds better than  in adults ;  and in  fact it may be laid
down as a rule, that the younger the person is, the more successful
the operation.   Convenience, therefore, and not necessity, may in-
duce us  not to operate at either extreme of life, though  we  should 
STRABISMUS.
565
do so, even in patients far advanced in age, if they desire it.  In
them the chance of success would be as great as in young subjects,
if we took the precaution of freely liberating the connections'of
the retracted muscle.  M. Velpeau  has  operated with  entire suc-
cess in patients of fifty-tM'o, fifty-five, and fifty-eight years of age.
In children he does not operate previous to the age of three or four
years.   In the first years of life, the causes of strabismus so often
appear and disappear at intervals of some months, that  the deform-
ity might, with  the  same  facility, recur after an operation.  But
after the fourth year, though the operation may be more  trouble-
some than at a later period, the child may be then mastered, and
delay would incur the risk of giving a greater degree of perma-
nency to the deformity.

                  § VIII.—Double  Strabismus.

  Sometimes, both in convergent and divergent strabismus, both
eyes appear to  squint, and the question arises whether both should
be operated upon, and at the same sitting; while some contend that
an operation  on one  eye  is in such cases often  sufficient,  others,
with some degree of hardihood, advise both to be  operated upon,
even when one only is the seat of the deformity.
  Where both eyes are affected  alike, and to the same degree, M.
Velpeau strongly recommends that both should be operated upon
on the same day.  The operation then does not require so exten-
sive a dissection of the tissues as for one  eye, and the  patient re-
covers in half the time.
  Where there is a marked difference in degree, and  the patient
has his doubts if one eye is actually affected, the operation should
be  confined  to the eye most  deformed.   The other eye may  be
operated upon  immediately  afterwards, if  the  deformity  of the
first is not at all changed; if it is,  however, we  should wait from
eight to ten or fifteen days before operating on the other.  M. Vel-
peau  has cured many cases of apparently double strabismus,  by
operating only on the most deformed eye.  The other soon begins
to act in harmony M'ith the one that has been restored.
  He  proscribes operating on the two eyes when one  only is
affected, though that course, it would seem, is recommended by M.
Elliot, (British Medical and Chirurgical Foreign Review, 1841,) M.
Guerin, &c.

          Article X.—Advantages of the Operation.

  These consist in restoring the position of the eyes, and improving
the vision.

             A. Restoring the Position of the Eyes.

  M. Velpeau alludes to  the heated controversy and discourteous
language which characterized the schools of Paris in the first epoch 
566           NEW elements of operative surgerv.

of strabismus, inasmuch as the immediate restoration ol the eye to
its normal position did not always ensure success, and that the de-
formity often returned M'ithin a few weeks or months, (as in the
twenty cases out of thirty operated upon by M- Cunier.) Those who
M'ere cautious and prudent in making up their minds as to the real
benefits of the operation, have been too often rudely denounced by
its more violent and unscrupulous partisans.
  M. Burggrave mentions a case of his, in point, (Cunier, Mxjot.
Ocul,  p. 43,)  of a young girl, mherein he Mas  M'armly compli-
mented for his brilliant success, for eight days after the operation,
but in whom the disease returned on the ninth as bad as ever!  So
in a lady of rank, six months after being operated upon (1810) by
M. Dieffenbach.  So in a case referred to by M. Velpeau, who, in
six months  after he had  been operated upon on both eyes by M.
Guerin, (January, 1841,) squinted as much as before.   M. Velpeau
having  also observed,  that in many persons whom he himself had
operated upon in  September,  October, and November, 1840, the
strabismus,  though the restoration for eight, fifteen, twenty,  and
even thirty days, appeared perfect, returned as before, saw the ne-
cessity of further experience before he  could make  up his mind
as to the value of  the operation.
  Eighteen months, and some thousands of cases, have afforded posi-
tive results.  The cases  of return of the  disease are now only
exceptions.  Three explanatory circumstances may here  be men-
tioned.

                  § I.—Illusion of the  Operator.

  One cause of deception in strabismic cases is  this: that when
the sound eye is closed, the other often  regains as it were a perfect
command of its functions, reassumes its normal position, and moves
freely and correctly under  the guidance of the will in all directions,
and even sometimes as it were unconsciously.  It is a mistake to
suppose that there is any parallelism in strabismus in this respect to
club-foot, for example, where the retracted or atrophied muscles and
tendons present a physical impossibility to extension by the will, or
even by tractions.   M. Velpeau has seen in strabismus cases in the
dead subject where there had been no operation, that the deformed
eye exhibited no perceptible alteration, either in the length or thick-
ness of the fleshy or tendinous portions of the muscles, in comparing
them with those of other subjects in whom the eyes had always been
sound.  One of these was a man of thirty, who had had convergent
strabismus in both  eyes, from birth.  M. Simonin (Du Strab., p. 10)
thinks the  muscles thicker,  but others find them thinner.  So in
a  case of  a female  subject  aged over  eighty,  who  had  had
strabismus from infancy,  and in whose orbit, as exhibited by M.
Bouvier, it would  have been impossible to have distinguished the
rectus-internus of the  squint eye  from the corresponding muscle
of the sound eye. 
STRABISMUS.
567
  Many cases of apparent  or supposed return of the disease,  M.
Velpeau  thinks, have  arisen from the practice of covering the
sound eye during the operation, when, as has been before remarked,
the deformed eye would, immediately after the operation, appear
to have recovered all its  motions perfectly, whereas the muscle
had not in reality, perhaps, been entirely liberated.   So also the
practice of covering  the sound eye  after  the operation, which M.
Velpeau  says he himself was at first in the habit of, for the same
reason prolonged the deception; though  in fact in this, as in the
other  case, the disease  had not in the beginning been effectually
operated upon.
  Taylor, the empiric, (mentioned in the first part of this treatise,)
appears to have availed himself of this, as Lecat distinctly says that
oculist was in the habit of covering the sound eye instantly after
the operation, and that the multitude thereupon cried out miracle !

             § II.—Incomplete Division of the Parts.

   An imperfect or partial section only of the muscles, or too re-
stricted a liberation of the neighboring fibro-cellular lamellae, were,
says M. Velpeau, the principal causes  of the return of the disease
in the first cases  of MM. Roux, Sedillot, Amussat, Guerin, and
himself.  Confining myself, says M. Velpeau, to seizing the muscle,
and to stretching  and dividing it with the  serpette by one stroke, I
studiously avoided directing  the instrument to the bottom of the
wound, and afterwards dividing the bridles which might have re-
mained upon the  sclerotica, and enlarging, both above and below
the incision of the aponeuroses, so much fear had I of large wounds
and extensive dissections in the orbit.  It is certain, he thinks, that
in acting in this manner he must have  often left portions of muscle
and resisting bridles, that M'ere  quite sufficient to  reproduce the
deviation.
   To the  discovery of  this error he imputes the recommendation
of large  denudations, and the excision even of a part of the mus-
cle by MM. Dieffenbach and Phillips.

             § III.—Circumstances Difficult to Control.

   M.  Velpeau differs from M. Bonnet in the opinion  that the stra-
bismus, when the eye is once  fairly straightened, never returns.  M.
Velpeau  particularly specifies two  cases where it returned twice,
and even after he had carefully divided and even scraped and
cleansed off from the entire inner side of the sclerotica all muscular,
tendinous, aponeurotic, or cellular bridles, from the inferior up to
the superior rectus.
   In some, the deviation has been so obstinate  that, after all this
dissection, the eye was not restored but  to one half the distance
from  its  true position.   Thus, in  a case of a young man aged
twenty, at La Charite, (April, 1842,) where M. Velpeau had thus in 
568
NEW  ELEMENTS OF OPERATIVE SURGERY.
the second operation denuded the sclerotica as far back as the optio
nerve, and M'here the patient moved his eye freely in all directions;
it turned imvard again towards the nose, tM'enty days after the ope-
ration.   M. Bonnet errs, also, in saying  that the deformity will not
return where the eye has remained straight for three weeks, for M.
Velpeau has  seen cases, though rare, where it returned, either to
the inward or outward direction, two to four months after the ope-
ration.
  If it is true that a new intermediate tissue is formed between
the divided ends, it holds the place of tendon, and  must consolidate,
retract, and shorten, and contract more  or less extensive adhesions
with the neighboring tissues for several months.
  M. Velpeau sees no reason  M'hy the process of reorganization
between the eye  and its connections should not be kept up at the
bottom of the  orbit, in some persons, a long time after the external
cicatrization  is complete;  although M. Bonnet may or  may  not
admit (p. 157, 158) that this result can be possible.
  If one of the causes of the return of convergent strabismus, that
already mentioned, in very old cases,  of  the  short space on the
sclerotica upon the same side  as  the internal rectus, even where
that and its  fibro-cellular dependencies  have all been divided,
could be ascertained beforehand,  it would be better  not to  ope-
rate.
  This condition may also exist, perhaps,  M'here the difficulty ap-
pears to arise  from the bandelettes of the superior and inferior recti
muscles, whose division, however, may prevent a return.   But such
dissections should not be undertaken without cause, as they might
favor the projection of the eye, exophthalmia,  and the fixity of the
organ.
  M. Velpeau says he has operated upon a number of persons,
who, whether from primary or accidental  causes, have had a sin-
gularly abnormal arrangement of the muscles.  After having divi-
ded the conjunctiva opposite the lower edge of the rectus-internus,
,for example, he has  found that the scissors glided with  difficulty
there upon the sclerotica.  Using then the blunt hook, he has found
the  muscle adherent  to the sclerotica as far back as the  posterior
part of the eye, in place of being  separated by the  usual lamellae
of that  region, so that it has  been impossible to isolate it, com-
pelling him to divide the fibres, bundle by bundle, from the neighbor-
hood of the conjunctiva to as far back as the optic nerve, and from
the inferior up to the superior rectus.  Once he found a muscle with
three anterior divisions, (languettes,) as M. Phillips mentions to
have seen frequently.   As before remarked, these close adhesions
seem to have  been occasioned by previous purulent inflammations,
though in two cases they had the characters of primitive organiza-
tion. Failure in cases of this  kind ought not to surprise  us.  For
however free the division of the fleshy bundles, they will recombine
with the intervening tissues, readily readhere to the sclerotica, and
re-establish the deformity. 
STRABISMUS.
569
  It may also happen, that from fear of pain, or ignorance, the eye
will be kept immoveable for several days, or the patient may persist
in retaining it in its morbid direction.  The divided tissues then
speedily reunite by first intention.
  In a young girl, aged nine years, with strongly convergent stra-
bismus, and whom M. Velpeau operated upon with apparent per-
fect success, the disease returned in three days, the reunion of
the  divided tissues having been so complete, that there were no
visible traces in the angle  of the eye  either of inflammation or
wound.  Two days  after he repeated the operation, kept a band-
age over the other eye  for a week, and the  cure this time was com-
plete.
  In some  cases the inflammation, after the operation, being too
intense, produces in the tissues, which contract new adhesions
with the eye, too great a degree of induration, then imperceptibly
a retraction, which reproduces the primitive deformity to a greater
or less extent.

                § IV.—Return of the Deformity.

  Rigidly speaking, it is almost absolutely certain that a return of
the disease may be prevented; for where the surgeon is skilful and
the patient resolute, a failure is rare.  If the section of one muscle
does not suffice, we may proceed to the  others, from one of the
recti or both to the oblique; or where the division  of the inter-
nal rectus causes divergent strabismus, we can attack the external
rectus, and repeat the operations. M. Velpeau, however, is adverse
to this repetition of the operation, for such a course must favor the
production of exophthalmia,  the flaring open of the lids, the absorp-
tion of the caruncula,  the fixity of the eye, or some other unusual
alteration in its appearance.
  M. Velpeau then  makes two divisions of cases: one, of complete
success after the operation;  the other, where there is still some de-
fect left.

                   Cases of Complete Success.

  1.  Those in which the restoration is so perfect, that, unless they
are examined very near, no evidence is apparent that the individual
has ever had strabismus.
  2.  Where the eye  preserves its  mobility, and acts in  harmony
with the other;  where it is neither more projecting nor  flaring
than the other*; and where the caruncula remains, and the look of
the eye has nothing peculiar.

                 Cases where a Defect Remains

  1.  Where the  eye is usually straight, but at certain  moments
                             72 
570
NEW ELEMENTS OF OPERATIVE  SURGERY.
slightly deviates in one direction  or  another, especially when the
patient is excited.
  2. Where the eye can only be partially turned in the direction
of its former deviation.
  3. Where the caruncle is flattened, the commissure of the eyelids
slightly separated, and the eye a  little more  prominent than  the
other, and its look not perfectly steady.
  None of these discordances, however, are perceptible but upon
close examination, and are nothing compared to the deformity be-
fore the operation.
  Out  of three hundred cases operated upon by M. Velpeau, [by
his  last computation when this brochure on strabismus was pub-
lished,] half of those who have followed the necessary precautions
have been perfectly restored in every respect.  A third part of the
other half came under the second class just mentioned, that is, there
continued to be a slight deviation above, downward, outward, or
inward, or a slight degree of fixity or projection, or discordance in
the axis, or movements of the two eyes, or a perceptible alteration
of the caruncle, or a certain undefinable awkwardness in the open-
ing or  appearance of the tM'o lids.  The two other thirds of this
last  half comprise the cases of  actual failures—namely, where
the deviation M'as in a direction opposite to the first;  M'here the
primitive  deformity  was completely  or  partially  re-established;
where  the eye, in place of turning itself outM'ard or inward, devia-
ted upward or downM'ard ; where there was exophthalmia, or immo-
bility, or fixity  in the look of the  eye, or irregularity in its move-
ments ; and where  all of these   defects  were  apparent to any
observer.  The deformity was changed, but still unpleasant and
noticeable by every person.
  Had they rigidly observed the  precautions  directed, the results,
doubtless, would have been more favorable ;  but so much had been
said in the journals of the trivial nature of the operation, and that
it was  of no more importance than a simple  bleeding, that most of
the patients  came to the hospital in the morning, and being opera-
ted upon, returned  to their homes, to resume their usual occupa-
tions and mode of living, as if the eye had not been touched.  M.
Velpeau, therefore, does not Mash that the absolute  success of the
operation should be judged  of by  the cases under his care, or by
others that have been related.
  It will require, he thinks, some  years, to come to  a definitive
solution of the question; and when the operation shall no longer
be attempted  but  by conscientious surgeons, who will carefully
weigh  all the necessary precautions.
  M. Bonnet also gives (pp.  162, 163)  only fifty-four cases of com-
plete success out of three  hundred operations which he had per-
formed for strabismus, though he  says there were  many of them
whom  he never saw again.  M. Velpeau doubts if he would have
found in the whole number of three hundred  more than one hun-
dred and fifty perfect cures.  M. Velpeau justly remarks, that it is 
STRABISMUS.
571
a difficult thing to furnish correct statistics in this matter, and that
he should not  feel  authorized to speak  with  certainty of more
than one hundred  and fifty of his three  hundred and more cases.
A very great number from the environs of Paris, from a distance,
or from the provinces, neglected to come back, he says, to the hos-
pital, either from indifference, or unwillingness to put themselves
to the trouble, or from  not conceiving any possible utility in doing
so, &c.
  Prepared for these difficulties, this surgeon took the precaution
of obtaining, the address of the out-door patients, and to keep an eye
upon the cases during  the  space of two,  three, or four months, in
the event of their not returning to the hospital to show him their
eyes at the  times  appointed.   M.  Gouraincourt,  whose zeal, he
says, he has  greatly to praise in this  matter, visited them every
eight or fifteen days, and took a minute of all that passed.
  M. Velpeau  then proceeds  to  give  a resume of the details of
about one hundred and fifty cases, which, as they have been pro-
miscuously taken,  he  thinks may be  received  as a fair  sample
of a close approximation  to the  proportions of success,  partial
success, and  failures, among those also  where no minutes could
be obtained.   He doubts if the marvellous  narrations of the suc-
cess  of others would in reality present any thing more favorable
than this list.
  There  is  an instructive  table of the cases of M.  Boinet in
the  Journal  des  Connaissances Medico- Chirurgicales.   Out  of
sixty-eight also operated upon by M. Peyre, (Traite  du Strab.,
Sf-c,  1842,) he admits  only eight to ten failures.   M. Proske  al-
lows of  only  twelve  failures in  fifty-five  cases operated upon by
M. Kuh.

             The Cases Operated upon by M. Velpeau.

  Out of 128 cases minuted by M. Gouraincourt, there were—

     Convergent...................................  Ill

  Of these there were—

      Double.................................  17
      Right eye...............................  07
      Left eye................................  27

    Divergent....................................    17

  Of these there were—

      Right eye...............................  10
      Left eye................................   7
Total........................   129 
572
NEW  ELEMENTS OF OPERATIVE SURGERY.
  Out of 138 cases, as examined by INI. Velpeau—

     Convergent...................................   123

  Of these there were—

      Double ................................. 20
      Right eye............................... 52
      Left eye................................ 51

     Divergent....................................    15

  Of these there Mere—

      Double .................................  2
     •Right eye...............................  8
      Left eye................................  '5

                      Total........................   138


              Cases Operated upon by M. Bouvier.

  The number was 45, and all on one eye.  The  muscles divided,
were the rectus internus and rectus externus, and in one  case only
the inferior oblique Math the rectus externus.   In no case M'ere the
superior or inferior recti, or the superior oblique, divided.

  Of the above 45 cases, there were—

      Females...................................... 29
      Males'........................................ 16
      From  8  to 10 years of age.................   5
      From 11  to 20 years of age.................  16
      From 21  to 30 years of age.................  16
      From 31  to 47 years of age.................   8

  There were in this number—

35 cases of convergent strabismus,
10 cases of divergent, (including one case which followed an ope-
     ration for convergent strabismus.)

22 cases affected the right eye, either exclusively or principally.
23 the left eye.

  The definitive results of the operations, ascertained a  month or
several months afterwards, were as follows :—

  1. Convergent  Strabismus, 35 cases:  the eye entirely restored in
25 cases ; the strabismus partially remained, or appeared occasion-
ally, in 8; the restoration failed entirely, or nearly so, in 2. 
STRABISMUS.
573
   Out of 25 cases of complete restoration, there M'ere 8 in M'hich
 the position and movements of the eye were altogether normal;
 16 in M'hich the eye Mas too much in the middle, between the open-
 ing of the ej'elids, and its movement of adduction more or less en-
 feebled, or almost entirely abolished ;  1 in which there occurred a
 strabismus outward, M'hich continued in spite of the section of the
 rectus externus.
   Among the  16 cases (above)  where  the eye  was  too much
 straightened, (trop redressee) is to be reckoned the case in which
 the operation had been  already performed without success.
   2. Divergent Strabismus, 10 cases. The  eye was entirely restored
 in 7 cases;  it preserved in all these cases its position and norma!
 movements.
   The operation failed, or nearly so, in 3 ;  and of these three*cases,
 one was the case of consecutive strabismus, following an opera-
 tion for convergent strabismus performed by another surgeon, and
 should not in reality be included M'ith the other cases.  A second
 of these three cases is that of a man aged  47, affected with paraly-
 sis of the rectus internus, from a cerebral  affection; this, therefore,
 is a case,  also, which  had nothing in common with the others.
 There were, therefore, but 8 cases of failure.

    Section II.—Amelioration of Vision by the Operation of
                          Strabismus.

   A fact, which had  hitherto almost escaped notice, has been as-
 certained from the  operation of strabismus, viz., that almost all
 squint-eyed persons see badly m ith the deformed eye.  With some
 the strabismus is complicated with ambliopie, or a species of amau-
 rosis ; others have the sight double, (dyplopie)  or short,  (myopie.)
 In some  the eyes soon become fatigued, and in others these organs
 have a constant trembling.  Not that  the vision is  altered in all
 cases of strabismus ; M. Velpeau  has, on the contrary, remarked
 that, in 25 out of 100 cases, the  patients see as far with the dis-
 torted eye as M'ith the sound one.
   It has been found that  the defect of vision in question was not
 the cause, but the effect of the strabismus.

                        § I.—Amblyopy.

  One of the most  common defects in persons with strabismus is
 amblyopy, or a sort of confused vision.   M. Velpeau has noticed it
 in various degrees in about half his cases.  M. Phillips is in error,
 in saying that the operation always removes it; for M. Velpeau
 has seen  it in a great number of patients as late as a month or two
 after the operation.  In some it disappears  immediately, but it can-
 not be determined beforehand whether  the operation will relieve it
 or not.  The operator is often  deceived on this subject, from pa-
tients crying out, immediately after the operation, that their sight 
574
NEW ELEMENTS OF OPERATIVE  SURGERY.
 is vastly improved, M'hen, in fact, there has been, as yet, no change
 effected in this respect.

                         § II.—Diplopy.

   Some squint-eyed persons see double, wnen they attempt to use
 both eyes ; which  is a very natural result of the crossing of the
 axes of vision, and the double image which is the result of it, as
 has been  before mentioned.  There are scarcely any other strabis-
 mic patients that retain their vision natural, except those who can
 scarcely see M'ith the distorted eye ; but these last are most nu-
 merous ; and among the others, there are some M'ho, in fact, make
 use only of the sound eye, though the visual faculty may exist un-
 changed in the distorted eye.  Diplopy is almost always cured by
 the operation ; but M. Velpeau mentions a case where it continued
 after the division of the rectus internus and perfect restoration of
 the position of the eye.

                         §  III.—Myopy.

   A considerable number of strabismics  are short-sighted in the
 eye that squints.  M. Velpeau doubts if this can be imputed to the
 compression of the recti muscles, through and from above downward
 upon the  sclerotica, or to the action of the oblique muscles from
 behind forward and from before backward, having the recti mus-
 cles for their antagonists.  The operation, however, often removes
 the myopy.
   [It was,  as  we have  seen, (supra,) the opinion of Dr. Hosack,
 that short-sightedness arose from the too energetic contraction of
 the  recti,  compressing and thus actually elongating the globe, and
 at the same time giving greater convexity to the cornea—the ob-
 lique muscles  merely serving as antagonists to keep the eye in
 place.  Then a permanent contraction of one or more of the recti
 must favor the production of short-sightedness;  and as this is seen
 to accompany strabismic cases, it is so far, in our opinion, a striking
 corroboration of Dr. Hosack's theory.— T.]

                     , § IV.—Amaurosis.

  The alleged  cure of amaurosis by the  operation appears to be
 unfounded.   This disease is generally the result of lesions inde-
pendent of  the  globe  and its  appendages.  No one, M. A'elpeau
thinks, would hope to cure amaurosis caused by remote lesions in
the digestive passages, interior of the mouth, or cranium, or in the
 optic nerve or retina, by means of the section of one or more mus-
 cles of the orbit. Physicians have, no doubt, erroneously diagnosed
 confusion  of vision (amblyopy) for amaurosis: but the cure of the
first by the operation is a very different thing from that of an idio-
pathic or  symptomatic paralysis of the retina.  The almost total 
STRABISMUS.
375
abolition of vision in the diseased eye is, nevertheless, not a coun-
ter-indication for the operation.

             § V.—Kopiopy, or Fatigue of the Eyes.

  The fatigue which the unsound eye experiences when attempted
to be used alone, has been noticed by M. Petrequin, M'ho  gives it
the  name of Kopiopie, (Annal.  d'Ocul,  1841.) and  by  M. Bonnet
and most other surgeons.  M. Velpeau rationally  explains it by
the  diminished power of  the diseased eye and its habitual repose.
Therefore, as he justly remarks, when, after the operation, this eye
is restored to its position, and begins to act in concert with the
other, and to become, as it were, disciplined and habituated to ex-
ercise, this feebleness gradually disappears.  In many, however, it
continues for some time.

         § VI.—Nystagmus, or Trembling of the Eyes.

  Nystagmus, or continual oscillations or vibrations of the eyes, is
seen in some strabismics, and  also in some  persons who are not
affected with squinting.  The cause is unexplained, and the re-
markable part of it is, that the sight in such persons is sometimes
as regular and perfect as in others.  M. Selle, a physician of Paris,
has it in an extreme degree.
  Whatever  others  have anticipated or related of cures of nys-
tagmus in strabismic patients by section of the  muscles, from the
very natural supposition that it must originate in some derange-
ment of the motive functions, M. Velpeau considers it very doubtful
if the operation will give relief.  In four or five of these  cases,
which he operated upon, not one was radically cured  of the nys-
tagmus.  One was a child of seven years, with double convergent
strabismus,  and  perpetual  oscillation  in both  eyes, which was
slight when he was at rest, but vehemently agitated, into irregular
movements downM'ard, upward, inward, and  outward, whenever
any one attempted to approach or examine his eyes, and especially
if one eye M'as, at the same time, kept shut.
  After the operation on each eye successively, the trembling
subsided for a few M'eeks, but returned  in two months  as strongly
as ever, though the  strabismus in both  eyes was perfectly cured.
The brother of this child, aged eleven,  had, in a less  degree, the
same singular affection complicated with strabismus from infancy,
and the results of the operation in both were precisely the  same.
  In most cases, however, the operation has the  effect to diminish
the oscillations.

                      §  VII.—Conclusion.

  The operation for strabismus may, in  general, favorably affect,
but will not always completely restore, all the functions of the eye,
where the sight has undergone a certain change. 
576           NEM' ELEMENTS OF OPERATIVE SURGERY.

  In strabismus,  the  sight may be confused, or almost abolished,
uncertain, short, or fatiguing, in two Mays—1. By defect of use of
the organ ; 2. By some organic alteration in the tissues M'hich com-
pose it.
  In the first, the eye, once restored to its natural  position, grad-
ually recovers from the prolonged repose of the organ, and regains
its functions.
  In the second,  M'here the defect in the vision in strabismus is
complicated with actual lesion, as of the  optic or some other nerve
of the orbit, lesion of  the choroid coat or retina, the section of  the
muscle will have little or no avail.  Nevertheless, even  in a stra-
bismic patient, M'ith amaurosis or myopy, the operation is not to be
proscribed, for the restoration alone of the position of the eye is a
matter of some importance, though other complications may  not
be remedied by it.

Article XII.—Section of Different Muscles of the Eye to Remedy
                other Diseases than Strabismus.

  The alleged results obtained in the  amelioration of certain com-
plications of strabismus, have led to the proposition to apply  the
operation to these affections, even where there is no strabismus.

                         § I.—Myopy.

  This has been the first disease upon which this practice has been
attempted, and it has given birth to three opinions as to the origin
of the disease.
  In one, it Mas  maintained that the myopy was caused by the
shortening, active  or passive, of the recti muscles.   Hence the pro-
position to make the section of  one or more of them.
  M. Guerin makes two kinds of myopy, viz., mechanical or mus-
cular, and optical or ocular, (Annul. d'Ocul, Avril, 1841, p. 31,) and
gives examples of successful treatment by the operation.
  M. Cunier relates cures of myopy by the simultaneous section
of the internal and external recti muscles, (Ann. cVOc, Juin, 1841.)
  M. Kuh of Breslau, who about the same time published in the
Journal of Casper  (1841—No. 15) a successful case of myopy, from
section of the four recti muscles, and one of presbyopic (Proske in
Ann. cVOc., t. vii., p. 44: Sach's Allgemeine Zeitung) admits that he
obtained no success from the section of the internal and external
rectus in another case.
  M. Phillips, representing the opinions and  practice of Dieffen-
bach, contends that it is the superior oblique  muscle which is  the
cause of myopy, while M. Bonnet (Des Sect. Muse.) maintains that
it is the small oblique.
  M. Velpeau thinks, if the cause lies in the  muscles, that all may
be equally concerned in the production of myopy, the globe, during
the retraction of the  recti muscles, finding a point  d'appui behind
by the reaction of the oblique muscles, and these last again, when 
STRABISMUS.
577
 retracting or shortening, finding antagonists  at the cornea  in the
 recti muscles.
   M. Velpeau says, that having long since maintained at his cli-
 nique, that transparent staphyloma of the cornea, and staphyloma in
 general, was a mechanical effect from the action of the muscles on the
 globe of the eye, he M'as naturally strongly disposed to adopt the
 new theories of  myopy, and even went so far as to operate on the
 muscles for it in one case—a man aged about forty-six, from the
 provinces, who had had myopy and nystagmus from infancy.   M.
 Velpeau first divided the rectus internus on one side, and, in twelve
 days after, the external  rectus in  the same eye, not only to relieve
 a divergent strabismus M'hich was beginning to form,  and also an
 unpleasant diplopy, but  in order to complete the operation. (
   M. Velpeau ascertained, by careful attention to this patient, that
 his myopy was benefited to the extent of seeing to one-half greater
 distance than before the operation.  But the double vision still an-
 noyed him; and as this might arise from the  two organs acting in
 different fields of vision, he operated upon  the other eye with the
 same precautions as upon  the first.  The myopy at  first appeared
 to subside in  this eye as it had done in the other, but the sight re-
 mained uncertain (vague) and confused, and the diplopy, which had
 ceased for some  time, soon became re-established.  One of the eyes
 finally deviated inward.  He considered that  he should re-operate
 upon it as for a convergent strabismus;  but the external rectus
 having  been already divided, the eye  could not  be  completely
 straightened  but by methodical compression in  the  inner angle of
 the lids.
   The eyes being now straightened, he  found they could not  be
 turned outward  or inM'ard but imperfectly.  The double vision had
 diminished, and  he M'ent home, but returned  in six months to the
 hospital, M-ith this last-mentioned  disease strongly marked, and also
 decided amblyopy, and slight  convergent strabismus in both eyes.
 M. Velpeau now thought an operation for this M'ould  destroy the
 diplopy, and the  rectus internus of the right and left eye was again
 detached.   The eyes M'ere completely straightened, but the double
 vision continued.   The patient  now resolutely  proposed,  as  is
 recommended by M. Phillips and  M. Bonnet, that one of the  ob-
 lique muscles should be cut.  M. Velpeau  declined, believing the
 eyes already too  restricted in their movements to justify the section
 of any more of their muscular bands.
  M. Velpeau thinks that  the section of the muscles in sound eyes
 exposes  to  more unpleasant results  than after  strabismus.  For
 who can say that the section of  the internal and  external recti
 muscles will not  be followed by a  deviation inward or outward, or
 that a section of one of the oblique muscles will not cause any de-
 viation of the eye ?  What can secure us  in these sections against
 fixity and immobility of the eye,  in  various  degrees ?   With the
possibility  of  such results, the remedy  would be M'orse than the
disease; and  as  myopy itself, moreover, does  not  always yield  to
                             73 
578           NEW ELEMENTS OF OPERATIVE SURGERY.

myotomy, the operations hitherto made trial of in these cases will
not, he conceives, be adopted in practice.

                        § II.—Amaurosis.

  M. Adams, an English oculist, proposed myotomy for amauro-
sis.  After division of one of the recti muscles, in a girl aged 22,
the vision M'as partially re-established; but, as the diplopy super-
vened, he cut the rectus muscle opposite.   The diplopy ceased im-
mediately, and  the  sight continued  to  improve,  (Prov. Mrd. and
Surgical Journ., April, 1841.)  But  M. Fleussu remarks with jus-
tice, that this was rather a case of  kopiopy, or fatigue of the eyes,
than of amaurosis, (ler Supplement aux Ann. d'Ocul, p. 319.)
  The two cases of M.  Ruete of Gottingen, reported as cures of
amaurosis, by myotomy, are considered by M. Fleussu to have been
only partial paralysis of the third  pair, with strabismus and my-
driasis.
  M.  Petrequin of Lyons, who "contends that  certain  forms  of
amamrosis may be produced by a spasmodic state of one  or several
muscles of the eye, (Revue Medicate, 1842, t. i., p. 207,) is also much
in favor of ocular myotomy in gutta serena.  Two such cases, ope-
rated  upon by  him in 1841, experienced, he says, decided  benefit,
(ler Supplement, Annates d'Oculiste, p. 321 ;)  but M. Velpeau, in re-
ference to these cases, as M'ell as to what has been said on this
subject by M. Kuh, and M.  Peyre, (Traite du Strabisme, p.  174,)
feels constrained to entertain some doubts as to the amaurotic na-
ture of the disease in question, and concludes in expressing it as
his opinion, that the operation would  for this disease be still more
unjustifiable than for myopy.

                       § III.—Nystagmus.

  Among the cases of myotomy for nystagmus proper, M. Velpeau
remarks, that the patient of M. Phillips appears to have been  com-
pletely cured by this means, (Tenotomie Sous-Cutanec, Paris, 1841, p.
317;)  but M. Bonnet confesses that he failed in three cases where
he made trial of it, (p. 302.)  If it be true that M. Roux of Mex-
mieux has cured a person both of myopy and nystagmus, by the
division of the two inferior oblique, (Bonnet, Ouvrage Cite, p. 305;)
it is equally true that M. Bonnet himself has failed, both in dividing
the inferior oblique as M-ell  as recti muscles, (p. 303.)  Moreover,
M. Velpeau says with great candor, that his own  cases are totally
adverse to the anticipations of MM. Phillips and Peyre, (Traite du
Strab., p. 163, 1842.)  oince the strabismics operated upon by M.
Velpeau retained their  trembling movements of the eye, he could
not rationally conclude that the operation could be depended upon
for this affection, where there was no strabismus.
   M.  Velpeau deems it  a feeble resource in  nystagmus; but be-
lieves, M'ith M. Bonnet, that this disease may often be complicated
with,  or the effect  of, various alterations in the eyes.   Thus it may 
STRABISMUS.
579
 originate from a myopy, amblyopy, diplopy, a spot on the cornea, or
 from a cataract from infancy.   It seems that in all these circum-
 stances, the uncertainty of vision induces the eye to carry itself
 instinctively and continually in every possible  direction, as if in
 search of the rays of light that it required.  In these, therefore, the
 cause must be first removed before thinking of myotomy.  M. Vel-
 peau deems  it  doubtful, even where the convulsive trembling and
 strabismus are unaccompanied with  any defect  of vision, (pertur-
 tion visuetle) (as in the  tM'o children above  related,) and has
 his doubts of the reported success of M. Kuh, (Sach's Allgemeine
 Zeitung, and Annales d'Oc, t. vii., p.  44.)

                     § IV.—Artificial Pupil.

   Sometimes  the spots on the  cornea cover only one half or two
 thirds of it.  Nature, to accommodate the pupil, turns (as has been
 already explained) the eye in such manner forward, as to bring the
 transparent part of the cornea more directly in a line with the pu-
 pil and axis of  vision.  This is, at least, as good as an artificial
 pupil.
   M. Cunier, therefore, proposed making an artificial strabismus
 in patients with leucoma, or cicatrices of the  cornea.  This, he
 says, he does by dividing one or more of the muscles of the eye*
 (Lettre a  VAcademic des Sciences, 1841.)   M. Cunier has given one
 successful case, and M.  Petrequin,  in a letter to the  Academy,
 (Bonnet, Ouv. Cit., p. 312,) relates another.   M. Proske (Ann. d'Oc,
 t. vii., p.  44) has also treated of this subject.
   M. Velpeau remarks, that this new application of myotomy can
 only be practicable in cases where the pupil remains  sound behind
 the cornea, and  that  the  opacity does not go  beyond the circum-
 ference of the pupil.  The  operator should hold the  eye steadily
 with  the  forceps  or  erignes, for some  seconds, in the position in
 which the globe should  be turned, [to enable the light to strike
 through the cornea and pupil upon the retina,] so as to be assured
 that this can be  effected before he divides the muscle  or muscles.
  We should also weigh well M'hether one of the numerous opera-
 tions  for  artificial pupil,  as these do not require  division of  the
 muscles and  deviation  of the eye, would not still be advisable.
 This artificial strabismus, it must be  recollected, is the  establish-
 ment of a permanent deformity, to remedy a simple  imperfection
 of the sight, and but few persons, probably,  M'ould desire to squint
 for the sake of seeing with both eyes.
  The facts on the subject are still too limited to give a definitive
 opinion.
  The muscles to be  divided are always  those that correspond to
 the point of the  cornea nearest  to the  pupil.  Thus  the internal
 rectus for  divergent strabismus, if the pupil, could  be seen better,
 and the patient could see  better on the nasal  than any other part
 of the cornea, and vice versa with the external rectus.  If the trans-
parent point on  the cornea was below, we should divide the infe- 
580           NEW ELEMENTS OF OPERATIVE SURGERY.

rior rectus to produce a frontaL strabismus, and for the reverse the
superior rectus.

  Article XIII.—New Varieties of the Operation of Strabismus.

  Less severe means than  myotomy have been proposed for stra-
bismus.

§ I.—Destrudtion of a portion (plaque) of the Conjunctiva to remedy
                           Strabismus.

  Some suggestions upon this subject from M. Dieffenbach, are to
be found  in the Journal of Casper, 1841, No. 36, and in the small
volume just published by M. Cunier, (Revue Ophthalmologique. 4/c.,
ou Suppl. aux Ann. d'Oc, p. 297.)
  When the strabismus is slight, in order to avoid an inverse stra-
bismus after the section of  the retracted muscle, the operator of
Berlin advises an excision of a portion of the conjunctiva and of
the tissues  which  line it, near the tendon  of  the corresponding
muscle.  In the progress of cicatrization, the borders of the divided
conjunctiva gradually approximate, so as to shorten it considerably,
and thus straighten the eye.
  M. Dieffenbach professes to have obtained the same  result by
cauterizing with nitrate of  silver.   M.  Velpeau, M'ith every confi-
dence in M. Dieffenbach, cannot but express his doubts that all the
cures he  has spoken of were  in reality cases of pure strabismus.
The conjunctiva, says M. Velpeau, is too moveable and pliant, and
is too easily displaced, for  an  operation of this kind to restore in
reality the natural position to  a  deviated eye.   Moreover, if the
straightening should take place, there would result from it a mani-
fest impediment to the movements of the eye in the other direction,
and consequently a new deformity.
  M. Cunier (in the Mork quoted) says, if this operation should be
adopted, it would be much  better to reunite the wound of the con-
junctiva by first intention,  by means of the suture, than  to leave
it to  suppurate.   But this, says M. Velpeau, would probably de-
prive M.  Dieffenbach's  operation of the only chance for success
which it  has ;  viz., that of forming an inodular cicatrix, which
would slightly draw the eye in that direction.

       § LI.—Section of the  Muscles of the Eye by a Thread.

   M. Velpeau has for a long time, he says, reflected upon the proba-
ble utility of operating for strabismus by embracing the tendon of
the retracted muscle, previously raised up by the forceps, in a noose
of  silk;  then to twist the two threads of this noose together, and
fasten it on the other side of the nose  in external strabismus, and
on the temple in the internal variety.  The straightening of the
 eye could be thus carried as far as we  judged necessary, and even
beyond the central line, and this organ could be kept there, until the 
STRABISMUS,
581
thread had completely divided the tissues comprised in the noose.
As I  foresee (says M. Velpeau) the theoretic objections which
might be advanced against this proposition, and which I do not look
upon myself m ith  any great degree of confidence, I have not yet
made  trial of it.
 [STRABISMUS IN  GREAT  BRITAIN,  AND  ON  THE  CON-
                    TINENT  OF EUROPE.

                        General Remarks.
   Mr. B. Lucas, says Mr. Braitlrwaite, (in his invaluable Journal, en-
 titled Retrospect of Practical Medicine and Surgery, July to January,
 1840,) M-as, he believes, the first to introduce the operation for stra-
 bismus into Great Britain.  He uses a sharp hook for the conjunc-
 tiva, a blunt hook for the tendon of the muscle, and a pair of sharp-
 pointed scissors.  The eyelids are secured by the fore-fingers of the
 assistant, M'hich are less  irritating to the  orbicularis muscle  than
 any instrument,  such as a speculum, forceps, etc.  To accustom the
 eye to the manipulations, the assistant raises and holds up the upper
 lid M'ith his finger  three or four times, before the operation is be-
 gun ; and  the surgeon should, for the same reason, thus touch also
 several times, M'ith his blunt hook, the part of the conjunctiva he
 is about to divide.  The sharp hook should have a light cedar han-
 dle, that its M-eight may irritate less  when, in the struggles of the
 patient, the operator designedly relinquishes his hold upon it.   The
 hook is inserted into the conjunctiva at about two lines from the
 cornea, on a line M'ith the tranverse axis of the latter.   Mr. Lucas
 makes a semicircular incision into the conjunctiva, from below up-
 M'ards, to four or six lines, or more if required.  The sharp-pointed
 hook is now withdrawn, and  the eyelids are permitted to close for
 a few moments.   The blunt hook is then inserted through the open-
 ing of the conjunctiva, underneath the muscle, and between it and
 the sclerotica.
  The sub-conjunctival cellular tissues  and fasciae, and the  sub-
 muscular fascia, especially the  last, often make some resistance to
 the progress of the hook.  The tendon of the muscle, being brought
 into vieM% is to be divided as close to the sclerotica as it can be,
 with propriety.   If, by trying the vision, it is found that any fila-
 ments  remain, the blunt hook is to be reintroduced.   Still there
 may, and will be, says Mr. Lucas, after the most careful division,
 and after even a portion of the muscle itself has  been excised, an
 inversion of the globe; which, he says, he has ascertained beyond
 all doubt to be owing to the condition of the sub-muscular and'sub-
 conjunctival fasciae.  They will be found tense, and must be divided
 freely upward and downward, M'ith a  forceps and pair of scissors,
 and in most cases the eye will become perfectly straight.   The ex-
 ceptions are, when these fasciae are intimately adherent to the scle-
rotic coat, from which they must be  carefully dissected off, until 
582
NEW  ELEMENTS OF OPERATIVE SURCERY.
the latter is completely bare.  In such cases it will be seen, that
in dividing the conjunctiva, it is found not connected loosely to the
subjacent parts, as in the natural state, but that it  is thicker than
usual, and cannot be freely raised with the sharp hook. (Vide Prov
Med. and Surg. Journ., Oct. 3, 18-10.)
  Dr. Franz (see Med. Gaz., July 24, 1840) has sometimes found it
necessary to divide the tendon of the superior oblique, as well  as
that of the internal rectus.  Mr. Liston is  also reported to have fre-
quently divided the inferior rectus, completely or  partially, when
the eye retained some obliquity inward,  after the division of the
internal rectus; and Dieffenbach has occasionally divided the tro-
chlearis also, when shortened, as well as the rectus.  Mr. Duffin
thinks, however, the remedy will generally be found in the division
of some few tendinous fibres, or bands of adventitious cellular at-
tachments, remaining above the tendon of the muscle ; so small is
the degree of fibrous adhesion that may mar the beauty and finish
of the operation.   These fibrous bands,  or digitations, are some-
times posterior to the  largest  diameter of  the  ball,  and  they
appear to be a condensation of the cellular tissue, connecting the
muscle with  the sclerotic coat,  and gradually adapting itself  to
the shortened state of that muscle.  This condensation may arise,
in childhood, from inflammation, and thus produce permanent stra-
bismus.  It is most observable, he thinks, in persons who squint most.
The free division of these attachments will, Mr. Duffin says, succeed
in ninety-nine  cases out  of  a hundred, in removing the slight ab-
normal  direction of the  ball after the section of the muscle.
  Mr. Charles  Guthrie agrees with MM. Lucas and Duffin, that it
is only necessary, in the convergent strabismus, to divide the inter-
nal rectus, and the cellular and tendinous attachments mentioned.
These generally, Mr. Guthrie thinks, should be liberated, especially
from all remaining connection with  the  superior or inferior recti
muscles, by a free division every M'ay to  three eighths of an in';h,
leaving the sclerotic coat in that part bare.  (Vid. Medico-Ch. Rev.,
Oct., 1840.)
  Mr. Charles Clay, of Manchester, has invented a very ingenious
speculum, as a substitute for the sharp hooks.  It  is spoon-shaped,
and has a semilunar notch  anteriorly, to leave the inner  canthus
exposed, while  the edges of the speculum are thick, in order to keep
the lids apart.  If this does  in reality answer, it would indeed be a
great point gained, as no part of the operation is so painful and
unpleasant to the patient, as the insertion of  the sharp hooks into
the conjunctiva, and keeping them  there, as is done, by a certain
degree of force and traction. (See London Lancet, Sep. 12, 1840.)
  Mr. James Adams has invented an improved hook, viz.: by ma-
king the short  points turn back on the stem  at an acute angle,  so
that it is not necessary to thrust them into the sclerotica, as is done
M'ith the hooks which have the  points at  right angles, but it is re-
quired only to make use  of  a drawing motion gently, and in a line
with the stem,  by which means they enter obliquely, and make no
disagreeable pressure.  (Vid. Med. Gaz., Aug. 21, 1840.) [This mod- 
STRABISMUS.
583
ification of the erignes or hooks, to avoid penetrating the sclerotica,
is justly due, we believe, to Professor Velpeau, and not to Mr. Ad-
ams.  Vide the extended supplement, which we have given above,
from Professor Velpeau's brochure on strabismus, transmitted to us
by him, for this American edition of his Operative Surgery.—T.]
  Dieffenbach relies on hooking into the conjunctiva only.  He and
an  assistant stretch the conjunctiva upward and outward,  into a
tense fold, by two fine sharp  hooks  inserted near each other, and
which, as soon as the scissors make the incision, and the blunt hook
is passed under the muscle, are withdrawn.  While the blunt hook
commands the eye, and draws it out of the inner angle of the orbit,
a flat probe detaches  the  cellular tissue between the  muscle and
sclerotica, and the division of the muscle is made anterior or poste-
rior to  the hook.  The upper eyelid  is held up by an assistant be-
hind, with one  of Pellier's  hooks, and the lower held  down by a
double hook, by another assistant who kneels in front.  Dieffenbach
thinks  the operation is more complete, the farther back  the division
of the muscle is made; and that slight cases of strabismus require
only the division of the anterior fibres.   In these latter, M'hen con-
vergent, the opening into the conjunctiva should be very small, and
the tendon divided  close to the eye only, without separating the
muscle from the  globe.  After some M'eeks, the eye acquires the
normal position.  On  the contrary, where, for example, the cornea
itself is sunk and hidden into  the inner angle, an extensive incision
of the  conjunctiva, and equally free division of the muscle and all
the connecting cellular tissues, as far back as possible, are impera-
tively  required.  (Vid. Casper's Wochenschrift, July, 1840, and Brit-
ish and Foreign Med.  Review, Oct., 1840.)
   Mr.  French, of the St. James' Infirmary, and Mr. Edwards, of Chel-
sea, operate in this simple manner:  An assistant behind covers the
sound  eye M'ith one hand, and M'ith his other hand raises the upper
lid.  The patient then directing his eye upward and outward, the
conjunctiva is snipped at the  under edge of the rectus, M'hich latter
is immediately secured by a curved probe, the  point of which, by
another cut of the scissors, is then made to appear.  The muscle is
divided on the probe.  The  curved hook or probe  used, has  two
parallel stems  between which  the point of the  scissors passes, in
dividing the muscle.   It should, when  under the muscle, be held
loosely, for fear,  in spasmodic  movements of the globe, it  might
plunge back and bruise.  When held loosely, it  produces no pain.
(Vid. Med. Gazette, Sep. 4, 1840.)
  M. Guerin places the patient on his back.   He uses the hook for
the ball, and then, with a small convex bistoury, pierces first the con-
junctiva, and then, by a semi-rotation, passes it behind the muscle,
and divides that from  within outwards.  By drawing the eyeball a
little forward  and sidewise, the muscle is made tense. This pro-
cess may  be called the sub-cutaneous,  in  its principle, or, as M.
Guerin says, sub-conjunctival, both in relation to the small opening
into the conjunctiva, and the mode of  dividing the muscle.  (Vide
Provincial Med. and Surg. Jour., Nov. 14, 1840.) 
584
NEW  ELEMENTS OF OPERATIVE SURGERY.
  Mr. Charles Brooke has invented an efficient instrument, which is
a small curved  bistoury blade,  sliding in a small curved  director.
The blade and director are accurate portions of a circular are. com-
prising rather more than one sixth of a circle, the diameter of M'hich
is one inch and a quarter.   The groove gradually deepens from the
point to the handle, so as to  conceal the taper-pointed blade M'hen
withdraMn a little; and is continued through the solid part of the
handle, to give steadiness to the motion of the blade.  Mr. Brooke
says he has used this instrument, M'ith complete  success, in more
than a dozen cases, without  the aid of any accessory instruments.
for fixing the eye or eyelids.   He makes  in the conjunctiva a very
small opening, M'ith a pair of probe-pointed scissors, through M'hich
the director is introduced, and  passed under the tendon  to be di-
vided ; the blade being passed  forward M'ith  the point of  the fore-
finger,  completes the operation.  The instrument  is made by Mr.
Fergusson, London. (Vid. Lond.  Lancet. Nov. 14, 1840.)
  Mr. Hocken justly, as we conceive, considers the pathology and
the cure to be founded  upon the same principles as those of talipes.
Thus, the  unequal  contraction being removed, the  normal position
is maintained by the antagonist muscle,  while the divided muscle,
by becoming  attached further back, is thus virtually elongated, and
becomes equally balanced, in its muscular energies, M'ith  the atro-
phied but  now reinvigorated antagonist  muscle. (Vide Med. Gaz.,
Sept. 11, 1840.)
  M. Bonnet, of Paris, imputes  the continuance of strabismus after
an operation, to  a fibrous capsule at the bottom of  the orbit, which
surrounds, without being in contact with, two-thirds of the poste-
rior part of the globe.  The recti and oblique muscles pierce it to
reach the  eye, and  it is their attachment to the capsule at the point
where  they emerge, that produces the subsequent  difficulty. (Vid.
Gaz. Medicate, Feb. 13, 1841.)—TV]
                [STRABISMUS IX AMERICA.
  This last, latest, and most brilliant conquest of tenotomy, has
spread, as it Mere, like a contagion over both continents ; for, though
but three years only have yet elapsed, since it obtained admission
or was even named in standard surgical M'orks, and but four years
since it made its debut in distinct treatises, it is an operation in its
nature so simple, easy, and prompt of execution, that it has now
become almost of universal adoption.  It has, moreover, been justly
remarked, that  the facility M'ith which the mere mechanical ma-
nipulation of the operation may be performed, has often embolden-
ed adventurers  in the profession, persons ignorant of the anatomy
of the parts, and  even empirics, to undertake to practise it, that
they might thereby obtain a temporary notoriety, before those who
were M'itness to the sudden  and natural  righting of the eye in  its
position, immediately after the  section of the retracted muscle was
made. 
STRABISMUS.
585
  It  is to be hoped, and, in truth, this hope has already been par-
tially realized, that professed  and expert surgeons will take and
keep this subject in their own hands, and devise, as they no doubt
will  be enabled to do by extended experience, a great number of
improvements, and  especially  precautions, which are still required
in the processes now so much  in vogue, and M'hich, in fact, are  al-
ready much perfected, since this bold and beautiful discovery was
finst  made by the illustrious Dieffenbach.
  Professor Gibson, of Philadelphia, claims the merit of having  di-
vided the recti muscles of the  eye, some tM'enty  years since, at
Baltimore, Math the vieM' of curing strabismus;  but the operation
did not succeed. (See Reese's  edition of Cooper's Surg. Diet., New
York, 1842, art. Strabismus—Appendix.)
  It  is difficult to say to M'hom the credit is justly  due, of having
first performed this operation successfully in America.  Dr. Willard
Parker, of New York, claims to have performed it first in this city,
in August,  1840 ; and Dr. Detmold, of New Yrork, Dr. Goulding, of
Arkansas, and Dr. Gross, of Kentucky, are also stated to have soon
after repeated it, (Reese, toe. cit)   And Dr. Mott also performed it
a very few months after  his  return from Europe, which  was in
May, 1841, and since that it has  become generalized in all parts of
the country.  Dr. Mott is inclined to give a preference to a rather
free  incision through the conjunctiva, that not only the muscle, but
its lateral attachments and tendinous expansions on each side, may
be thoroughly  divided, and thus remove the disease  effectually.
Dr. Dix, of Boston,  on the other hand, prefers a smaller opening in
the conjunctiva, as he  thinks too free a division of  it is one cause
of a disagreeable projection or protuberance of the globe, and of
the  gap at  the inner canthus, not un frequently  noticed after the
operation of convergent strabismus more especially.
  It  is due to Strohmeyer to say, that  he first suggested the divi-
sion of the  muscles of the eye for strabismus, immediately before
Dieffenbach put it into execution.
  So great is the preponderance of convergent strabismus (the turn-
ing of the eye inM'ard) over all  other kinds, that a M-riter in the Phil-
adelphia Medical Examiner found that in five hundred and thirty-
six cases of the disease, five hundred and six Mere of this variety.
There is also, in the convergent form, according to Professor Gross,
of Louisville, almost constantly  an accompanying inclination slightly
upward, rather than downM'ard.  The writer quoted  in the Medical
Examiner remarks, that in eight hundred and sixty-six cases  of
strabismus, only forty-four  were divergent, that is, the eye turned
outward; but in these the upward obliquity is less than in the con-
vergent variety.  In the same  article it is stated, that in four hun-
dred and fifty-nine cases, the distortion was  in one eye only, and
only forty-seven had it in  both.   Professor Gross denies this pro-
portion, in respect to convergent strabismus, in which, he says, both
organs are almost always implicated, though not to the same de-
gree ; which opinion he considers conformable to the known and
intimate organic sympathy existing between the two eves, in health
                             74 
586           NEW ELEMENTS  OF OPERATrVE  SURGERY.

and disease.   The one  that squints the least, and that  the patient
consequently uses most, he usually calls his  best eye ; and this, says
Professor Gross, Mill be found to be in most cases the right, the left
being the one M'hich is generally most affected.  This opinion would
seem questionable, when it is recollected that the greatest develop-
ment of muscular energy is usually on the right side of the median
line of  the organization.  Dr. Phillips, of Liege, confirms  this re-
mark ;  though Mr. Lucas  thinks the proportion of cases of squint,
in the left to the right, is as three to two.  Professor Gross imputes,
and no  doubt M'ith truth, many cases of squinting to imitation ; and
says our school-rooms, from the propensity of boys to imitate, for
example, one of their cross-eyed companions, are a fruitful  source
of this distortion.  We differ from  the Professor in one point—that
the disease is not hereditary; as there can  be no question, as com-
mon and familiar observation ever}' day shoM's, that it is very often
hereditary, running through  a M'hole family where both the pa-
rents, or even one only, is strongly marked M'ith it.   Prof. Gross
thinks this too is explicable, by the child imitating the  parent or
parents. He gives a striking example against the hereditary notion,
which is this : that of three brothers, M'ith perfectly sound eyes, one
had  three children M'ith s! rabismus, another tM'o, and a third, one.
The uncles and  aunts of these children, too, all  of them except one,
have all sound eyes.   To decide this point, hoM'ever. the Professor
should  have pushed this inquiry farther back,  that is, to the third
or fourth generations;  for the action of the hereditary principle in
the organization, in other  matters  as well  as  in this, is familiarly
known  to lie dormant for  a time, in one or tM'o intermediate gene-
rations.  Thus, in the mixture of the African and white blood, some
strong and characteristic  features of the negro, as the thick lip,
curly hair, dirty, discolored, or brassy tint  and  appearance of the
skin, especially  about the  temples  and around  the eyes,  ears, nose
and mouth, etc., M'ill be suppressed often for four, five, or six gen-
erations, and then suddenly peep out, in characters too  legible to
be mistaken ;  while, perhaps, in a  twin sister,  (as I have seen in
the West Indies,) there will be every trait of a pure white.
  Professor Gross remarks, that the more  frequent occurrence of
convergent strabismus, is doubtless owing  to the internal straight
muscle  being not only naturally larger than the others, but inserted
nearer the cornea.  He thinks the earlier the operation is perform-
ed the better, if it be after  the age of one year.   We are somewhat
surprised, hoM'ever, that after all the cautions given by some of the
ablest European surgeons,  who have had such immense  opportuni-
ties, against too much M'ounding of the sclerotica, or even penetra-
ting it at all, if it be possible to avoid it, that Professor Gross should
distinctly, unequivocally, and  even  emphatically, recommend (vid.
his American edition of Liston's Elements of Surgery, Philadelphia,
1842, p. 297) "inserting the sharp hook  into  the sclerotic coat;"  and
that "the points of the  hook (a double one too)  should be fairly im-
planted into the substance of the sclerotic tunic, but no more." Indeed;
we think that quite  far enough.  He, however, justifies this by 
STAMMERING.
587
saying, that he thinks it impossible to steady the eye if the hook
penetrates no deeper than through the  conjunctiva; and besides
that, there  would then be  danger of lacerating that membrane.
Moreover, Professor Gross divides the fold of the conjunctiva very
far forward, viz., about three lines from the cornea, just behind the
sharp hooks, which he directs to be inserted at only one line from
the cornea.  This recommendation  appears to  proceed from an
opinion  he  entertains, of the possibly troublesome nature of the
hemorrhage, if the division should be farther back.   In further evi-
dence of the necessity of avoiding the sclerotic coat, if possible, M'e
may mention his own admission, that a wound there may be fol-
lowed by suppuration, or abscess of the ball, and the escape of the
humors.
  He entirely disapproves of the practice of endeavoring  to keep
the eye, as  soon  as the operation is performed, in a natural  direc-
tion and normal  position.  When the eye is made straight by the
operation, and yef does not move in concert M'ith the  other eye, he
invariably divides the corresponding muscle of the opposite side,
for the reason which he had already given, that the distortion gen-
erally involves both organs.
  The most general cause of the failure of  the operation, and one
which has  been, in the opinion of Professor Gross, too much over-
looked, is the co-existence of strabismus in both eyes, and  the fact
that the operation is usually confined to one  eye, which  he deci-
dedly disapproves of.  He always, therefore, if  possible, operates
on both.  He  doubts if the oblique muscles have any agency in
strabismus.—T]
                       [STAMMERING.

  The relief of this unfortunate infirmity, a legitimate object, as has
hitherto been supposed, of the curative processes of tenotomy or
myotomy, remains as much a mystery to-day as in the earliest pe-
riods of time.  The dangerous process proposed and practised by
Dieffenbach, of exsecting a triangular-shaped wedge from the  base
of the tongue, having been followed too often by alarming hemor-
rhage, and even, it is said, by death in some instances, and in no
case, that  we are aware of, effecting a perfect cure, has been  gen-
erally proscribed.
  The division of the genio-hyo-glossi muscles, close  to  the sym-
physis of the chin, has been  practised for two or three years past
to great extent in New Y'ork, and other parts of the United States;
but though affording manifest and palpable temporary relief, npt
to say miraculous  restoration of  the  powers of articulation and
speech, at the moment, has  effected  no well-attested, permanent
cures.  The same  may be said of horizontal acupuncture of the
tongue, through the entire thickness of its tissues, transversely;  also,
of electro-puncture. 
588           NEW ELEMENTS OF OPKHAT1VE SURGERY.

  In those cases only m here the genio-hyo-glossi, or the frenum,
have been abnormally contracted, has their section proved of de-
cided advantage.
  Nevertheless,  the rational hope exists, with Dr. Mott and others,
who have given the above section of the  muscles at  the chin and
acupuncture  a full trial,  that  farther advances in tenotomy and
myotomy may ultimately shed light upon the true pathology of this
disease  in the organs of speech, and show M'hich  are the proper
parts upon whose retractions, or other organic defects, the  remedial
agents of surgery should be directed.—T.]
                    SECTION  THIRD.

OF  ANAPLASTY OR AUTOPLASTY, (DE VANAPLASTIE OU AV
    TOPLASTIE,) OR RESTORATION OF DESTROYED PARTS.

  The operations M'hose object is to repair mutilations, constitute
one of the most brilliant triumphs of surgery.   These operations,
known under the name of organic restitution, animal engrafting,
(greffe animate) and  transplantation of parts  by autoplasty, have
not yet been described with precision.  If the term  autoplasty had
been sanctioned in science, I should have adopted  it, however in-
correct it might be;  derived, as  it is, from the Mords auro.c, him-
self, and  tfXatfa'siv, to  create, it properly signifies the spontaneous
creation of a part, the creation of a part by the individual himself,
which in no respect expresses the idea m hich should be formed of
the operations  of M'hich I am about to speak.  Anaplasty, being
synonymous with the words remake, (refaire) or reconstruct, (re-
construire) is evidently much more  appropriate, though in itself
not free from every objection.
                        PART FIRST.

             ANAPLASTY  IN GENERAL.

  Anaplasty has now been brought to such a degree of perfection,
that it is indispensable to divide it into many species, in order to
treat of it appropriately.   It comprises, in the first place, two great
branches, easy of separation:  1. The surgeon confines himself to
replacing (replacer) the organ itself, or some similar parts, (quelques
parties semblables) on the seat of the mutilation, either by restitu-
tion or transplantation; 2. At other times, he repairs the point de- 
ANAPLASTY BY RESTITUTION.
589
stroyed, by the transposition or elongation of parts,  taken either
from the neighborhood or from some remote regions.
                        CHAPTER I.

                 ANAPLASTY BY RESTITUTION.

  The restitution differs according as the organ to be reunited (d re-
cotter) is completely separated, or that it still holds on, by some la-
mellae, to the living parts.

     Article I.—Restitution  of Organs Partially Divided.

  Let a portion of finger, ear, nose, or lip, be divided in such man-
ner as still to hold on by a quarter  part, or half its thickness, and
no one will contest the possibility of reattaching (recoller) it.   Let
the same organ, a finger, we will suppose, be cut off so as to hang,
on the contrary, by only one of its surfaces, and to adhere only by
a strip (languette) of  skin, or epidermis, and most surgeons would
consider it as lost. If doubts may exist on this subject for a portion
of the finger, still greater doubts, M'ith stronger reason, M'ould exist
in respect to an entire hand, leg, arm, or forearm.  Nevertheless,
facts seem to demonstrate, at present, that organs of  considerable
size, almost completely separated from the body, have, when prop-
erly brought together and supported, been enabled to  resume their
vitality, and to cicatrize.
  De Horn cites the  case of a hand which held only by the tendon
of the index finger, and M'hich Jung, (Rougemont, Bibliot. du Nord,
t. i., p. 92,) nevertheless, succeeded in reuniting perfectly.  An ob-
servation  of Hoffman (Ibid., p. 98) is scarcely less remarkable: an
arm, which adhered only by the vessels and a portion of the biceps,
and M'here the humerus and  the integuments were completely di-
vided, (coupes) M'as,  nevertheless, preserved and perfectly cured.
Percy (Mem. de VAcad. Roy. de Med., t. ii., p. 14) appears to  have
been witness to a similar fact.  The arm was held only by the ves-
sels and a flap of integuments.  M. Stevenson relates (Gaz. Med..
1837, p. 390) something much stranger still.  An individual had
the vessels, biceps, and humerus, completely severed by the cut of
a sabre ; the arm was retained only by a flap of skin  at  its  upper
part; the surgeon, nevertheless, effected a reunion !   A  case also
is related,  of a great  portion of the calf, which was held only by a
slight pedicle, and which M. Groenscher succeeded in reanimating,
(revivre) and reuniting to the natural parts.   They have gone much
farther than all that;  for Esculapius (Dujardin, Histoire de la Chir.,
Introduction, p. 15) restored the head to a decapitated woman; and
a soldier, M'ho was decapitated by an enemy, was cured by a peas- 
590           NEW ELEMENTS OF OPERATIVE SURGERY.

ant, (Jour. Gin. de Mid., t. liii., p. 232—S'dillot,) M'ho had the mis-
fortune of putting the head on with the face turned backM'ard, a mis-
take M'hich Pantagruel rectified by saying he did not M'ish to have
a torticollis ! while Rabelais, (Q3uv. de Rabelais, liv. ii.; Pantagruel,
liv. ii., ch. 30, p. 286,) jesting as usual, has preserved to us the his-
tory of Epistemon, who had  had his head cut off, but M'hich Panur-
gus reunited exactly, vein M'ith vein, nerve with nerve, and vertebra
with vertebra, etc.: the aforesaid Epistemon being perfectly cured,
except that his voice remained hoarse, and that he had a dry cough,
M'hich he never M'as relieved of but by the aid of liquor !
  If it is difficult to admit as correct the observation of Jung; if
the facts of M.Percy and  M. Stevenson are equally surrounded by
improbabilities, it is not the same with those of Hoffman and Groen-
scher.  In those last cases, there remained enough of living  parts
to prevent the mortification  of those which were separated.
  Also, it is principally upon the surface of  the skin, and the pro-
jecting parts of the body,  that these divisions  have been observed.
The fingers, the nose, and the ears, have furnished the most exam-
ples of them.

                  § I.—The Fingers and Toes.

  Thomson  (De VInflammation, etc., p. 243) has seen the fifth toe
reunite, though it held  only by  a small cutaneous flap.  The end
of the little finger, which was  prevented from falling only by a
slight pedicle, was also perfectly reunited, in  a patient in  whom
the same author proposed that it should be amputated.
  Two fingers, divided from behind forM'ard, and M'hich M'ere held
only by a flap of a line or two in M'idth, were so exac; ly united togeth-
er by M. Layraud, who showed them to me, that they not only con-
tinued to live, but also reacquired all their functions.  A sausage-
dealer's boy receives the cut of a knife upon his hand; the middle
and ring fingers immediately fall upon their palmar surface, and a
copious hemorrhage  takes  place.  Reaching the young man in
about half an hour after, I find that in the third finger, the wound,
which penetrated  through the middle joint, included the  extensor
tendon, the M'hole thickness  of the bone, the flexor tendons, the ves-
sels, and the nerves.  There M'as no other continuity except by a
small strip of the palmar integuments, which Was from two to three
lines in width.  In the medius, the division Mas forward of the pha-
langeal articulation, and did not comprise as great a width of an-
terior integuments.  The hemorrhage, which had begun to dimin-
ish, did not prevent me from attempting  the immediate reunion of
these two fingers.  A small splint of M'hite-M'ood, strips of adhesive
plaster, and a roller bandage, constituted all my dressing.  It was
in the month of June, 1837 ;  the hand was kept constantly moisten-
ed with water, at the natural temperature ; the immediate reunion
took place ; and this boy, at the present time, uses his fingers the
same as before the injury. 
ANAPLASTY BY RESTITUTION.
591
                         § II.—The Nose.

    It is in the nose that these anaplastic unions have been more es-
  pecially noticed.   Among  other facts of this kind, I will  cite that
  related by Bagieu, (Examen de plus. Quest, de Chir., etc., p. 599,)
  in which we find that the nose, holding only  by a very small fila-
  ment, (filet) completely reunited in the space of eight days, in the
  case of a gendarme named Densi.   The point  of a nose which held
  only by a slender pedicle, was well  restored in 1742, by Dubois.
  Lombard (Thomson,  Oper. Cit., p. 242) succeeded in reattaching a
  nose, almost entirely separated for several hours, though it was
  during  winter.   A similar fact is attributed to Loubet, (Plaies
  d'Armes a feu, p. 31.)  Thomson  (Oper. Cit.,-p. 242) has related
  tM'o similar cases: in one, the nose held only by the skin of one of
  its alae ; the septum (cloison) only retained it in the second.  We owe
  to Boyer (Traite des Mai  Chir., t. vi, p. 59, edit. 1818) a third ob-
  servation, full as conclusive.  The butcher of whom Dionis (Oper.
  de Chir., 7e demonstr., p. 588) speaks, M'as not less fortunate.  Percy
  (Diet, des Sc. Med., t. xii., p. 344) relates, that he has met with many
  cases of noses, which he has successfully reunited when they held
  only by a small flap.   Blasius (Obs. part. 5.  Obs. lre cite par Percy)
^ has given us the history of a nose almost entirely detached, and
  in M'hich, owing  to its tardy reunion, it was necessary to pare (ra-
  viver) the edges of the wound.  M.  Moulinie (Bull. Med. de Bor-
  deaux, 1833, p. 21) also speaks of a bruised nose, in great part torn
  off, and which he succeeded in reuniting, by means of a suture.  I
  myself have seen many similar cases: in a young  man, in M'hom
  the point of the  nose held only by a small pedicle of the  septum, I
  was enabled to  reunite the parts, by means of simple  adhesive
  plasters.
    Without admitting, with many ancient authors, that the eye, in
  certain M'ounds, after hanging down upon the face, has been re-
  placed in the orbit, and been enabled to resume its functions; we
  cannot now deny that portions of the ears, or lips, have been fully
  as well united as the nose.  F. d'Arce says, that a nose even, which
  with a large part of the upper jaw had been torn down (renversi)
  upon the chin, was raised  up and  perfectly reunited.
    From these facts, and from a great number of  others which I
  might have quoted, from Glandorp, Painchchriston,  Ledran, Rava-
  ton, etc., we have these  results at least: that  parts of the  body,
  partially  detached, may in certain cases be  reunited with  those
  from M'hich the wound had temporarily separated them.  Only that
  we should be M'rong in concluding, therefore, that these  attempts
  at agglutination  will be always followed with success. ^ The con-
  ditions which the surgeon  should look to for his prognosis, are the
  following:—All  other things being equal, the chances of success
  are greater in wounds from a cutting instrument, than in cases of
  contused wounds.  In the first cases, the adhesion will almost al-
  ways take place, if the flap M'hich is preserved, includes a certain 
592           NEW ELEMENTS OF OrERATH'E SURGERY.

number of vessels, or presents a thickness of several lines.  It will
also be  practicable and  proper to attempt  it. in cases M'here the
pedicle holds on to the rest of the body only in the  extent of a line
or two, provided it is a  part of the tegumentary tissue,  and that
there  are neither bones, muscles, nerves, nor vessels, of a large size
in the parts separated, as is seen in the ear, at the point of the nose,
and in some regions of the face.  If it M'as an arm, or forearm, as
in the observations of Horn, Percy, and Stevenson, or M'hat is Morse,
the leg, and that the section comprised the whole thickness of the
limb,  M'ith the exception of a flap of integument, M'e ought not, as
I conceive, to count on the  success  of the reunion: every thing
shoM's, that it would be better then to resign ourselves to the sacri-
fice of the part.  In the second case, that is, in cases of contused
wounds, the restitution is hardly possible, except the pedicle has at
least  the fourth or fifth of the  thickness of the injured organ.  If
under these dimensions, it would be more prudent net to attempt
the anaplasty, but to complete  the section of the flap.
   [There can be no harm, as M*e conceive, in at  least making the
attempt, however small the pedicle or flap may be;  for, if the union
does not take place, the decomposition in the  separated parts will
soon be made manifest, without occasioning but very little  delay
in the subsequent treatment, and certainly without producing any
mischief to the sound parts.—T]
   Another circumstance M'hich must be kept in vieM', is that M'hich
relates to the nature of the divided tissues.   Thus the organs whose
integuments are nourished by numerous vessels, or which are uni-
ted in an intimate manner M'ith the subjacent tissues, such as the
fingers, the sole of the foot, the cranium, face, nose, and ear, in a
word, homogeneous parts, offer, in  this  respect, the best  possible
conditions.  If the division comprises, also, tendons or bones, as is
seen  in the fingers, or simple cartilages, as in the nose  and ear,
there  is still no reason to object to anaplasty.  The most unfavora-
ble conditions are those of the division of the muscles, bones, nerves.
and vessels of  a large size.  For the  rest, the chances of success
are in direct relation with the homogeneousness of the parts, and
the absence of large circulating trunks (circulation a grand courant)
in the parts; that is to say, that the organs which  appear to exist
under the  influence of the capillar}' circulation or imbibition, are
more  favorable to the success  of the  operation, than those which
are naturally traversed by vessels or nerves of large size.
   Whenever the surgeon shall  find the parts  in the favorable con-
ditions of which I have spoken, he will attempt the reunion.  It is
important, then, not to leave any foreign body, or any clot, betM'een
the lips of the wound, and to place the tM'o ends of the divided or-
gan in perfect contact.   For that purpose, M'e should wait until the
blood ceases to flow, if the divided vessels are not of sufficient size
to require  the ligature.  A quarter of an hour, a half an  hour, or
even  an hour of delay, under  such circumstances,  should  not dis-
quiet us, but would be rather useful than injurious in a considera-
ble number of cases. 
ANAPLASTY BY RESTITUTION.
593
  If the blood should not stop of itself, and we can suspend its cur-
rent between the wound and heart without too much inconvenience,
we should call in  the aid of compression; if it M'ere actually ne-
cessary to act. upon the wounded vessels, torsion would be the best
means to use.  We should not, consequently, have recourse to the
ligature,  unless it became indispensable.   The parts being well
cleaned,  and properly brought together,  are kept in contact by
means of simple bandages, adhesive plasters, or the suture.  Ban-
dages  generally suffice on the cranium, trunk, and limbs.  Strips
of adhesive plaster are much better for M'ounds of the fingers, which
do not involve the bones, and for some similar wounds in the face.
When the bones make a part of the section, it is almost indispensa-
ble to associate with these strips, splints of wood or pasteboard;  it
is then that  the immovable bandage would also become valuable.
But for the nose, ears, and around the mouth, the suture should al-
most always have the preference.
  It is important, in  these essays,  that M'e should make but very
little pressure upon the parts.  If their  exact contact is indispen-
sable, a compression which would  interfere  with  the circulation,
would cause the whole to fail; in the place of having recourse to
topical refrigerant applications, or  to antiphlogistic  means, it  is
better to wet the parts with aromatic and slightly stimulating lo-
tions, such, for example, as spirits of camphor ;  it is well, also, that
the wounded region should remain in a  dependent  position during
some days.   It is  to be understood, also, that the  surgeon should
watch these wounds with the same  care that he would all others ;
and that he  should carefully prevent their lips from being disturb-
ed, until the reunion is complete, or become impossible.
  [Dr. Mott  mentions to me the case of a penis severed by the SM'eep
of a razor, in the hands of an enraged woman, almost entirely off,
close up to the scrotum.  It hung by a mere thread of integuments.
Dr. Mott did not dare to hope for  its restoration,  but it did take
place in the most perfect and natural manner.—T]

    Article  II.—Restitution of Organs  Completely Separated.

  The restitution of organs partially separated, has rarely been re-
garded as impracticable, under the circumstances which I  have just
mentioned;  but those are not the points of controversy in anaplasty,
which are prevailing at the present time.  The point which has
found the greatest number of skeptics, and given rise  to the  most
contention, is that relating to actual transplantations.   It would
appear difficult, in truth, for a part which has been completely iso-
lated from the body, and then put back in its  place, to be capable,
under such circumstances, of reacquiring its vitality.  Reflecting
persons, therefore, have not been disposed to admit the fact, but
upon proofs altogether conclusive.
  These transplantations, however, were credited  by certain per-
sons in former times, since  Lanfranc, Guy de Chauliac, and other
surgeons of the middle ages, exerted themselves to  prove their im-
                           75 
594       '  NEW ELEMENTS  OF  OPERATIVE SURGERY.

possibility.  There are, also, two kinds of transplantation, M'hich it
is proper not to confound: in one, it  is the  detached part itself
which is reapplied, and M'hich we endeavor  to reunite—in M'hich
case we have a simple restitution; M'hile, in the second kind, it is
at the expense of another individual that we reconstruct the mu-
tilated organ, by an actual transplantation.  The idea of restoring to
its place, a part completely separated from the body, prevailed also
at a very remote time.

                        § I.—The Nose.

  One of the most ancient observations of this kind, appertains  to
Fioraventi, (Secrets de la Chir., liv. ii.,) who, to convince the incred-
ulous, replied  to them thus: '• Go visit  Signior Andreas, M'ho lives
at Naples, and where every one knows his history ;  he will tell you
that, happening on the spot where the accident occurred, I took up
his nose, which had fallen in the sand, and washed it and replaced
it in the best manner  I could.  Examine this nose, and listen to the
statements which will be made to you, and M'e shall see if you can
still  call in question a fact  so clearly demonstrated."  The point
of a nose M'hich  had  been cut off, having been received in a hot
loaf, was also  reattached by Molinelli, (Bonet, Corps de Med., t. iv.,
p. 59,) with complete success.   According to Blegny, (Zodiaque
Med., Mars, 1680,) a nose which had  been cut off by the stroke of
a sabre, was replaced M'ith no less success by Winseult.
  An observation M'hich acquired for Garengeot the title of a liar,
related  to a soldier, whose nose,  bitten off by the teeth of an ad-
versary, who threM' it into the mud as he escaped, was  afterwards
cleaned, replaced in its position,  and reunited by the barber Gal-
lien.  Though looked upon as fabulous  by De la Motte, Dionis, and
Lafaye, the transplantations of the nose are, nevertheless, reassert-
ed in a thousand ways with circumstances  fully as marvellous.
There  is one which is not less extraordinary than that of Garen-
geot :  A man  named  Loudun had his  nose entirely bitten  off by
the teeth of a  smuggler.  The patient had wrapped it in his hand-
kerchief, where the surgeon M'ho was sent for found it, cold and
black.   " I put the piece in camphorated spirit of wine," says Reg-
nault, (Gaz. Salutaire, 1714, No. 26, p. 4,) "and washed it thoroughly;
I  then replaced it in the best manner I  could, and kept the  M'hole
in place by a containing bandage.  Three times a day, I sprinkled
the upper part of the nose with  the same camphorated  spirit of
wine.   At  the end of eight  days I took off the dressing, and saw
that the part  had become attached, (reprena.it.)  As there  M'ere
large lacerations, a suppuration  came  on  which lasted a month;
there finally resulted from  it only tM'o small cicatrices, slightly
sunk in on  the  lower part  of the organ."   Leyser was  not less
fortunate than Fioraventi, in the case of a young man of respecta-
ble family;  and Loubet (Plaie d'Armes d  feu, etc., ou  Rev. Med.,
1830, t. iv., 119) had the same success at the battle of Rocroy.
   Utteily incomprehensible as they would a.ppear to be, these his 
ANAPLASTY BY RESTITUTION.
595
tories seem, nevertheless, to have been confirmed by recent facts.
A student, in fighting a duel, had the point of his nose cut off by
the stroke of a sabre;  having sent to look for the end of the nose,
which was found under a chest, M. Chelius warmed  it, then  re-
placed it, and succeeded  perfectly, though an hour had intervened
between the  accident and the operation !   M. Bridenback says, in
the same  letter, that a dog having got possession of a nose that
had been cut off, finally surrendered  it to  the surgeon, M'ho took it
from his mouth to restore it to its place, and that the operation was
entirely successful.  Germany, also, offers frequent examples of
similar anaplasty.   M. Hoffacker (Annal Cliniq.  de  Heidelberg,
vol. 4.,  cahier 2;  Bullet, de  Ferussac, t.  xvii,,  p. 75 ?  Gaz. Med.,
1830, p. 403) alone, has published sixteen cases of them.  Here is
one of the examples M'hich he gives:—M. Sch*#, aged twenty, of
medium height and strength, was wounded in a duel, January 1,
1825.  The stroke of a sabre carried off,  1. The end of his nose to
the extent of half an inch in all its dimensions;  2. A piece of the
upper lip;  3. A piece  of the lower lip and chin.   All  these parts
fell upon the  ground; the last M'as first found, and fixed in its place
by fifteen points of suture ;  the point of the nose was not found un-
til ten to fifteen minutes after the wound; as to the piece of the
upper lip, it was searched for in vain.  The end of the nose reuni-
ted to two-thirds of its extent, and the wounds of the lips cicatrized
in six weeks.
  When consulted by M. Champion  on  the authenticity of these
facts, M. Chelius replied, that they had taken place under his eyes,
that they could  be received with perfect confidence, and that he
possessed others in every respect similar to them.  To explain their
frequency at  the University of' Heidelberg, it suffices to know that
sabre duels are there  extremely frequent among the young men,
and that M. Hoffacker has  been appointed surgeon of duels, by the
senate. It is next to impossible, therefore, to reject absolutely,
and  without  qualification, all  the histories of this kind that  are
related by authors.  The case of a nose which was  entirely  de-
tached, and which was reunited with success, is  also related by
M. Barthelemy (Journal Hebdomad, et  Univers., t. v., p. 15) on the
faith of Regnault, of the Gros-Caillou.  The nose removed by the
bite of the teeth, could not be replaced until at the end of five hours,
yet it reunited.

                      § II.—The Fingers.

  Similar observations, also, have been made on a great number
of other parts.  I have  had a  case, says Regnault, (Gaz. Salut.,
1774, No. 26, p. 4,) where I replaced, without any unpleasant  re-
sult following, the whole external ear, that had  been removed by
the bite of a horse; and if my observations required proofs, I could
furnish them.
  In a long note by M. Magnen, (Bullet, de la Facult., t. vi., p. 497
et 507,) we find also the case of a portion  of the concha (the exter- 
596
NEW ELEMENTS OF OPERATIVE SURGERY.
nal ear) entirely separated, and then reunited.  M. Manni (Filiatre
Scbczio, Mai, 1834;  et Arch. Gen. de Med., 2C serie, t. v.. p. 300) has
more recently related the  history of an ear cut  off by the stroke
of a sabre, and which he reunited M'ith success, by means of a su-
ture.
  The fingers, also, for half a century past, have been the occasion
of numerous operations of anaplasty, by transplantation or restitu-
tion.  Heister (Institut. Chirur.. p. 468)  cites an  example of it  in
the M'ife of a butcher.   Bossu d'Aras (Thomson,  Trait. Chir. de
VInfl., p.  241) says he succeeded in  a similar  case ; and Flurant
mentions, according to M. H. Berard, (Rev. Med. 1830, t. iv., p. 416,)
the case  of a laborer m ho had the extremity of  his left forefinger
removed, and in whom anaplasty succeeded perfectly M'ell, though
the division had comprised  the articulations of the two last pha-
langes.
  These  facts, nevertheless, were passed by unnoticed, when Bal-
four, in 1814, made known two others, with all the details that could
be desired.  Since that time, there have been published a great
number of them in the  periodical journals.  Thomson,  says that
different  persons, M'hose veracity he has no reason to suspect, have
related to him a great number of examples, in which the phalanges
of the fingers or toes had been totally separated, yet neverthehss
reunited, (Thomson,  p. 242.)  A surgeon of d'Armentiere, M. Les-
pagnol, (Bull, de la Facult.,  t. v., p. 313,) published, in 1818, through
the medium of M. Percy, an observation similar to that of BalfouF.
A similar fact Mas communicated, soon  after, by Agouge, (Ibid., t.
vi., p. 50;) but. information obtained from the spot, authorizes us
to call in question the existence of any such physician, as M'ell as
the authenticity of his facts.
  More  recently, M. Houston (Arch. Gen.,  t. xi., p. 447) has pub-
lished  the  case  of a thumb completely reunited  in this manner.
We find  in the Bulletin of  Ferussac, (1830, p.  229,) an analogous
observation taken from the English journals.  M. H. Berard, (Rev.
Med., 1830, t. iv., p.  417,) on the authority of Wigorn, mentions the
case of a young girl who had the muscular mass  of the left thumb
removed, and M'ho recovered exceedingly well by anaplasty.  One
of the most ancient histories of this kind was published bv Regnault,
(Gaz. Salut., 1714, no. 26.)
  " A youth of fifteen or sixteen years of age, finding himself crowd-
ed  by a  chariot at the corner of a street, placed his  belly against
the MTall  and his left hand upon the angle of the same wall, in order
to hold himself more steadily;  the end of the axle-tree grazing a lit-
tle too near this angle, tore  off the little finger at the  articulation
of  the second with the third phalanx.  The finger had fallen, and
the young man took it up;  I was called immediately, and readjust-
ed the detached finger, M'hich I took  care to keep in its place by
a containing bandage.   I made him hold  his hand down, and the
little finger  in a glass of  brandy during two  hours.   The finger
united exceedingly well in  a few days, and so perfectly, that to-day 
ANAPLASTY BY RESTITUTION.
597
he has as much strength in this part, says Regnault, as if it had
never been detached."
  It has nevertheless been  necessary, in order to draw attention
definitively to these facts, that many surgeons of known reputation
should furnish others of a similar character.   Somme (Traite' sui
VInflam., p. 42) has communicated a case of reunion of the end of
a finger which had been completely separated.  M. Piedagnel has
related a similar case, (Revue Med., 1830, t. iv., p. 405.)  M. Bar
thelemy (Journal Hebdom. Univers., t. v., p.  15) speaks of a portion
of skin removed from  the inner side of the sole of  the foot, and
which reunited  perfectly;  afterwards  of  two similar  reunions,
where fingers had been severed.  M. Beau  (Arch. Gen. de Med., 2€
serie,  t. iv., p. 472) practised anaplasty with success, in a woman
who had lost her thumb at  the Salpetriere.  M. Despres, who at
the Hotel-Dieu endeavored to reunite a finger by the same method,
says that just as Dupuytren, (lb., p. 480.) M'ho-did not believe in
the reunion of the  parts, was going  to pull upon them underneath,
to detach them, it Mas seen that the union, by intercommunication
(abouchement) of the vessels, had in reality begun.
  We ought, nevertheless,  to add,  that many of these  cases not
having been attended, in all their stages, by the same person, and
being found almost always deficient in details, have  continued to
create a certain distrust.  I myself hesitated to admit of their ac-
curacy, until  an observation absolutely conclusive, succeeded, in
1837,  in removing  all my doubts.  A member of the Royal Acade-
my of Medicine, M. Gorsse, cut off  the  pulp of the left  forefinger
by the stroke of a razor; the piece fell upon the ground;  the pa-
tient hastened to pick it up, cleaned it and reapplied it, and held it
in its place by means of a handkerchief.  Having reached my study
in less than half an hour, he again let the end of his finger fall
while unwrapping his hand.  Having picked  up this fragment of
tissue, I M'ashed  it in pure water, replaced it accurately upon the
wound, which still bled, and fastened it there by means of  small
compresses, and then  a roller bandage methodically applied.  It
was agreed that the dressing should be saturated with spirits of
camphor, three or four times a day.   Pains, somewhat'acute, were
experienced for the space of a week.   I renewed the bandage on
the fifth day, and again on the tenth, and finally removed it upon
the tM'entieth.  No suppuration had taken place ; the cuticle  alone
had assumed a dark hue, and came  off in the form of an eschar on
the twenty-fifth day.  The portion of skin and fatty cellular tissue '
had reunited  completely;  and  M.  Gorsse, showing his finger a
month afterwards, perfectly cicatrized, brought conviction to the
minds of his associates, in presence of the whole Academy.  \ sim-
ilar accident happened to another surgeon of Paris, with this dif-
ference, that the flap of integuments still held on by  a filament of
cuticle, and that the size of the flap was only a fourth part that of
M. Gorsse. 
598           NEW  ELEMENTS OF OPERATIVE SURGERV.
      [Reunion of a Completely Separated Portion of Finger.

  The case of M. Velpeau, in the text, is fully confirmed by one of
Mr. Alex. Graham, at Edinburgh, (Edinb. Monthly Journ. of Med.
Science, April, 1841,) in which a joiner, of middle age and healthy
constitution, entirely severed the left forefinger by an axe, between
the first and second phalanges.  He lifted the separated part from
among the shavings, and walked a feM' yards to where the surgeon
happened to be.  Being asked for the separated portion, he took it
out of his M'aistcoat pocket and laid it on the table.  Mr.  Graham
fixed it on by two sutures and an adhesive strap, and on the fourth
or fifth day the patient found that the  part had recovered its sensa-
tion, as he could distinctly feel when  it M'as  touched  by the point
of the scissors.  Complete union was effected, and a perfect restora-
tion of the powers and functions of the finger.
  Another more recent confirmation of  the above cases, is related
by Signor Delia Fanteria.  A girl, aged fourteen, had two of her
fingers severed below the first phalanx by a knife.   The two pieces
were soon after found in some meal, but each piece was separated
into two portions.  He replaced them  together, and kept them upon
the parts from which they had been separated, by sutures and strips
of plaster. In a few days the adhesion M'as complete.   Marvellous
as this case  appears to be, its authenticity is confirmed by Profes-
sors Centofanti and Vacca.—(Vide British and Foreign Med.  Rev..
July, 1842.)—T]
  1 do not, therefore, see how we can possibly call in doubt, at the
present time„the practicability of uniting, by anaplasty, tissues that
have been completely separated from  the body.  In admitting that
most of the facts related until now, are  doubtful, or that they  have
been  imperfectly detailed, it is certain  that  some of  them have a
real existence.   It would be of no avail, for the purpose of refuting
them, that we should adduce facts of a contrary character, or the
M'ant of success in cases of a similar kind.
  In place of rejecting  this class of observations, surgeons conse-
quently will, in future, examine into them, and reserve a place for
them in practice.
  We must  not on that account suppose that all parts of the body
may be thus agglutinated.   The favorable  or unfavorable condi-
tions, also, are the same  for this order of reunions as for  cases of
incomplete division.   It is, therefore, in  the fingers and toes, and in
the palm of the hands and? sole of the feet, in the nose, ears, and face,
and even in the bones of the cranium, as we had already seen by
some observations of Ambrose Pare, M. Maunoir, and M. Walther,
that we may have reason to hope for  success.
   M. Chelius, M'ho  has  frequently seen cases of this kind, thinks
that if success is an object, so far from being in a hurry, we should
await the cessation of the bleeding;  that we ought not to  allow
ourselves to be misled by the unpromising appearance of  the part
which has been separated; that even if it assumes the aspect of gan- 
         ANAPLASTY BY  HETEROGENEOUS TRANSPLANTATION.      599

grene, there ordinarily results from it desquamations only of the
cuticular lamella?, (lames epidermiques;)  and  that the important
point is, to put the wounded surfaces into perfect contact.
  The choice to be made between adhesive plasters, the suture, or
simple bandages, will depend upon the same circumstances as those I
have previously pointed out. Though,  at the end of five or six days,
we notice the tissues to be of a blackish hue and flabby, as if mor-
tified, still we must guard ourselves against abandoning every hope.
Though there should even be an elevation of the cuticle in the form
of phlyctaenae, with a reddish (roussatre) liquid, we should be wrong,
provided the flap  has contracted adhesions, not to continue to use
means of reunion.  The greater part of the facts that are given
with details, prove that  after  the desquamation of some external
layers,  the rest of the flap remains not the less  adherent to, and en-
grafted upon, the primitive  wound.
                        CHAPTER II.

      ANAPLASTY BY HETEROGENEOUS TRANSPLANTATION.

  In all the cases that we have been speaking of, it is the part itself
that we agglutinate ;  but in another series of facts, we see that the
mutilation has only been repaired  by borrowing from other parts,
or other individuals.  It is in this respect  that anaplasty may be
compared, in every particular, to the engrafting of plants.   How-
ever surprising and inconceivable this species of organic reunion
may at first sight appear, it is nevertheless founded, at present, up-
on a certain number of experiments of very great importance.  It
comprises two varieties.  Sometimes, in fact, in order to remedy a
deformity, we borrow a part similar to that which has been de-
stroyed ;  sometimes, on the  contrary, we repair the mutilation at
the expense of parts altogether different.
  The nose and teeth have served as a point of departure for these
two kinds of operations.

       Article I.—Transplantation of Analogous  Parts.

  Ambrose Pare  had already spoken of a sound tooth, which, ex-
tracted by mistake, and immediately reinserted, had continued to
live.  A fact  exactly similar, is related  by Pomarest, (Bonet, t. iv.,
p. 404.)   FVom thence arose the  practice of borrowing teeth, to re-
place those that  had  been  lost.   Hunter says that  he had ascer-
tained an actual vascular reunion between the new tooth and the
socket.  M. A. Cooper possesses  a specimen (piice) similar to that
which served as the foundation for Hunter's assertions.  Fauchard,
afterM'ards corroborated by Bourdet, maintains even that a tooth, 
600
NEW  ELEMENTS OF OPERATIVE  SURGERY.
dead in all respects, M'hen introduced into a living socket may be
retained and  remain  there  for  years, without  the intervention
of any mechanical  means, (Thomson,  p.  230 a 241.)  The proof,
says Fauchard, that these transplanted  teeth actually live, is, that
we can neither plug them nor sound them, when they are carious,
without occasioning the most acute pain.
  [That a human tooth that has been for years out of the body, and
thus, in common parlance, dead, nevertheless possesses the princi-
ple of vitality to a certain extent, and in a dormant state,  like those
seeds  of M'heat that have been for thousands of years hermetically
sealed, as it were, and debarred from the vivification of  their ger-
minating properties, in Egyptian sarcophagi, is a fact that is fa-
miliar to every dentist; since such teeth, set  in  the mouth even
upon  plates of metal, and especially of  seahorse bone,  are well
known to reacquire  their vital energies by this mere contact with
the heat and breath of a living person, so as actually to become
carious, and decay like a living tooth in its socket, though of course
without any pain.   We doubt, however, if such teeth inserted as
stated above in a living socket, could ever possibly become repos-
sessed of that  degree of vitality which would assimilate their func-
tions to those of the living parts in which  they were located.   The
mechanical experiments of charlatans in these matters, and which are
too well known, have produced the most  disastrous  consequences,
in their attempts to  force the agglutination of fresh healthy teeth
of another person,  transplanted into sound gums where decayed
ones had been removed to give place for them.   Destruction of the
alveoli, gums, and parts of the jaw, and extensive ulcerations and
abscesses in the roof of the mouth, vault of the palate,  etc., have
been some  of  the fruits of this empiricism.  And the thing is not
singular, when the immense disparity, and proverbially known ca-
priciousness of form, seen in the roots of teeth, are considered;  for
how is it possible that there ever can be a coaptation of the tooth
of one person to the alveolus of another? though we doubt not, if
by quickly shaping the former to a  mould, taken as quickly, of the
cavity of the latter, by any mechanical means, the  parts containing
and contained could be brought into as close contact as in the case
of the finger  related by  the author of this work, that a reunion,
more  or less perfect, would take place.  There is no knowing, in
fact, whether, in the unexampled progress of scientific discovery in
our days, a mode may not be  discovered, resuscitated even from
the destructive experiments  hitherto made by dental charlatans,
which shall establish a new and most profitable order of anaplastic
operations, by the insertion of fresh living teeth into the toothless
gums of those whose alveolar processes have not yet been absorbed
by age.  A series of well-conducted, careful experiments, might
even  lead  to the formation of an artificial socket  in a sound cica-
trized gum and alveolar border, and the immediate insertion there
of a fresh  living tooth, whose exact form and dimensions had serv-
ed as the  model for the cavity to be excised.  Some curious facts
of deep abrasions of parts in anaplastic operations, and that have 
         ANAPLASTY  BY HETEROGENEOUS TRANSPLANTATION.      601

nevertheless, healed perfectly, might trace the way for such experi-
ments'.—T]

[Transplantationof a Sheep's Tooth into the Alveolar Socket of a Child.

  M. Twiss, of Kerry, (Ireland,) states that he extracted the remain-
der of a. broken front tooth from a young lady aged  fourteen, and
transplanted  into its socket (April 24, 1841)  the front tooth of a
yearling sheep, reeking from the jaw of a living animal, previously
shortening its root about a quarter of an inch.  It sat rather loose,
but after the first week it became firm and  soon enlarged, but less
than it would have done in the animal to which it belonged.  M.
Twiss recommends the teeth of the sheep frdm  the  cleanliness  of
this animal, and from the beauty and aptitude of their form.  He
would prefer the teeth of sheep of two or three years old, as at that
age they are about the size of adult human  teeth, and are more
likely to grow when  transplanted.  The root  may be shortened  or
pared to fit in its new situation, and  kept in  place by waxed silk
ligatures.—(Vide London and Edinburgh Monthly Journal of Medi-
cal Science, Oct., 1842.)—T]
  The history of noses restored in this  manner are  numerous and
ancient.  Van Helmont relates, (De Magnetica Vulner. Curat., p.
459,) that a man thus repaired saw, at the end of thirteen months,
his borrowed nose putrefy and fall, at the moment when the porter
who had furnished it died.  Dionis  was told, (Demonst. des  Oper.,
p. 589,  7e demonst.,) that  a robber, whose  nose had been cut off,
ran to a surgeon, who  asked him  for the piece,  in order to replace
it.  Having lost  it,  his comrades immediately ran out, cut off the
nose of the first person they met with,  and brought it fresh  to the
surgeon, M'ho reunited  it in the most  perfect manner.
  But, besides that none of these facts of anaplasty are authentic,
or even probable, we cannot  see how it would be possible to find
venders of  the article, even though it M'ere allowable to appropri-
ate in this manner the nose of another person.

    Article II.—Transplantation of Parts that are Different.

  A method which consisted  in reconstituting a nose, or any other
organ, by means of integuments borrowed  from the breech of an-
other person, is one which it appears has been very anciently prac-
tised in India.  M. Dutrochet affirms that, upon the evidence of his
brother, a general-in-chief to an Indian prince,  a subaltern officer,
who had had his nose cut off, went to consult some of the natives,
who willingly undertook the cure.   At the end of a  certain time,
these Indians selected a place  upon the breech,  which they excited
into a swelling by repeatedly striking upon it with their slippers.
Having cut out from this part a piece of tissue  of the proper form,
they applied it, and successfully kept it  in  its place  upon the de-
stroyed  nose.  If there were  only this fact  in favor of the animal
engrafting of which  I  am  now speaking, it would be unnecessary
                              76 
602
NEW  ELEMENTS OF OPERATIVE SURGERY.
to occupy ourselves  any farther M'ith  it; but the experiments of
Duhamel. (Acad. ll>y. des Sc, 1746,) from whence it results that
the spur (Vergot) may be engrafted upon the comb of a cock ; those
of Hunter, m hich confirm the same fact;  the case of the testicle
of the same fowl, which, after being introduced into the belly of a
hen, continued  to live;  the  experiments of Baronio, M'hich, if we
are to credit him. would prove that the Ming of  a canary bird, or
the tail  of a cat, can also be engrafted  upon  the comb of a  cock ;
other facts, also, from which, according to Bartholin, it M'ould re-
sult  that the flesh of a sheep, placed  upon the wound of a sailor,
adhered to it, and soon effected a cure; and the fact related  by 0-
laus, of a portion of a fowl  Mhich had been advantageously em-
ployed in the cure of hare-lip ;  all  tend to prove  that actual ani-
mal engrafting is, perhaps, not absolutely impossible.
  Supposing, however, that  this was of easy execution, it would be
difficult, as may be seen,  to derive any advantage from it, seeing
that no person probably Mould be  willing to submit themselves to
such operations.  There has, nevertheless, been  presented in my
division of the hospital of La Charite, a case,  in which, strictly
speaking, it M'ould have been allowable for me to have undertaken
this  species of transplantation, and I really  regret that  I did not
profit of the opportunity. A patient had two deformed toes removed
from him, M'hich M'ere otherwise perfectly sound.  Another patient,
whose fingers had all been  destroyed by being fro:-.en, would have
liked nothing better than to have had a small hook on each of their
stumps.  It might have been, in this manner, easy for me to have
engrafted the toe of the well man upon the metacarpus of the
maimed one.
  In conclusion, the question of animal graftings, by transplanta-
tion from one  individual to another, does not, as yet. offer any facts
which operative surgery can profitably occupy itself M'ith.  With
the few remarks above, therefore, I will conclude what I had to say
on this  subject.
                        CHAPTER III.

                ANAPLASTY BY TRANSPOSITION.

  In place of bringing back to the mutilated part the portion which
has been completely separated from it, as in anaplasty by trans-
plantation, we confine ourselves  in  anaplasty  by transposition to
cutting and  dissecting off the  tissues, Mdthout M'holly detaching
them,  in order  to draw them  suddenly* or by degrees, to the de-
stroyed parts.  Almost the only kind now in use, this species com-
prises  two varieties that are very distinct; the one consists in seek-
ing  at a distance the tissues suitable to repair the mutilation, the 
ANAPLASTY BY TRANSPOSITION.
603
 other, on the contrary, borrows them  from neighboring regions.
 Destroying  but incompletely  the  continuity of the flap, anaplasty
 by transposition has nothing in it repugnant to the laws of the or-
 ganization,  nor contrary to  sound surgery.   The whole consists in
 knoM'ing  how  to cut in a  proper manner  the parts of which we
 stand in need, and  to preserve for them a pedicle, or proper points
 of adhesion.

  Article I.—Anaplasty by  Remote Flaps, or the Italian Method.

   One of the most ancient modes of anaplasty consists dn cutting
 the patches, which M'e have need of, from a region more or less re-
 mote, and completely distinct from  that which it is our object to
 restore.   T3ds  method  seems to have  had its birth  in Italy, or in
 India.  1  shall, however, designate it under the title of the Italian
 method.
   Every thing  shoM's that it Mas first put into use by practitioners,
 of M'hom history has not  preserved the name.  The  family of the
 Brancas do not seem to have  originated it.   If Bojano, or Voiano,
 have been enabled to discover its source in Calabria, without point-
 ing out its author, it is evident, that it was an ancient method, and
 one whose origin M'as already lost. Tagliacozzi, M'ho seems to ap-
 propriate to himself the  title of its inventor, has, in strict justice,
 the merit only  of having  regularized and perfected it, and of ulti-
 mately introducing it into practice.   In this species  of anaplasty,
 the progress of science  has  established many processes.

                    § I.—The Italian Process.

   Tagliacozzi  was in the habit of taking  his flap from the outer
 and  front part of  the  arm.  This flap, of  a triangular form, and
 whose  base remained  adherent, M'as immediately fixed upon the
 destroyed region, which had been previously pared, (avivee)  When
' it was sufficiently agglutinated in its new position, the surgeon cut
 through its root, in order to set the arm at liberty.   Nothing more
 then  remained to be done,  but  to mould the borrowed piece upon
 the organ to be restored, and to shape it to its new uses.
   Frequently performed in  Calabria in the fifteenth and sixteenth
 centuries, the Italian method has been the  object of some new tri-
 als in more recent times.   M. Roux  made use of it in my presence
 upon a young girl,  in whom he wished to  close up  a hole in the
 face ; M. Signoroni likewise  employed it  for a mutilation in the
 face.   It  is, nevertheless, almost  entirely  abandoned.  If we still
 wished, however, to make trial of it, we should not forget that the
 restorative flap suits so much the better, in proportion as the integ-
 uments of which it is formed are thicker, more homogeneous, and
 more vascular.
   As it is almost impossible to keep the parts in a state of perfect
 rest by means of adhesive bandages, stitches of suture^ sufficiently
 approximated, should, I think, merit the preference over containing 
604           NEW ELEMENTS OF OPERATIVE  SURGERY.

dressings, properly so called. It would, furthermore, be superfluous
to dwell upon the necessity of not comprising in the incision any
more than the teguments and  the  sub-cutaneous tissue.  If Vesa-
lius. Pare, and others, in citing the Italian method, have spoken of
the biceps muscle, it has been by inadvertence.  The  plainest re
flection is sufficient to shoM', that the  flap M'hich the Brancas and
Tagliacozzi made use of was never cut at the expense of the mus-
cles.  The  M'ound  M'hich results from it  ought, moreover,  to be
dressed like  any other simple wound.  Before detaching the base
or pedicle of  the flap, we must assure ourselves  that it is perfectly
agglutinated, and  that it has acquired vitality at its edges.  This
separation being made, M'e trim its angles with the scissors, so as
to adjust it accurately upon the region upon which it is to remain.
From fifteen  to thirty days are in this manner generally required to
complete the operation.  Sooner than this period the new circulation
might  not be established ; at a later period it would have nothing
to gain. The adhesion of the borrowed flap is M'ell advanced at the
end of the second week, or it will not  have taken place at all.

                    § II.—Process of Graefe.

  Perceiving that  the patch of skin, separated in this manner, has
a great tendency to become  gangrenous, that it  agglutinates with
difficulty, and also contracts to a considerable degree, some modern
surgeons have adopted the plan of not applying it immediately
upon the new region, and of giving it  time  to contract and to cica-
trize upon  its edges while yet  in its  place.  In operating  upon a
young man, who had already submitted, without  success, to another
kind of anaplasty, M. Graefe, after having cut  the flap  upon the
fore-arm, left it to cicatrize separately, and did not make the at-
tempt  to unite  it to the nose until  after the expiration of  some
months ;  he took thus more than a year to  complete the operation,
which, moreover, succeeded perfectly.  It is, in  fact, true, that in
the  limbs the cutaneous flaps' are too thin, and  are provided with
too large a proportion of adipose cells, to agglutinate with facility
to the teguments of other regions, or to be exempt from readily be-
coming gangrenous. In this respect, there are, in reality, some ad-
vantages in leaving the flap free, after it has been cut.  It is then
seen to retract (revenir) upon itself,  in the direction of its  two
largest diameters,  to become thicker  and firmer, (se durcir)  and
more and more vascular, and to assume, in fact, some of the char-
acters of the  integuments of the cranium, or of the face.  When it
has become so, we may. without fear,  pare (aviver) its edges, and
fasten them, either by suture or bandages, on the part which is to
become their  new residence.  We afterwards proceed for the wound
which results from this flap, and for the  section of its root, when
the flap has become adherent in its place, as we do in the process
of Tagliacozzi himself.
  I should, nevertheless, add, that  these precautions would be un-
necessary for a flap cut from the palm of the hand, the sole of the 
ANAPLASTY BY TRANSPOSITION.
605
foot, or from the cranium or face.  The arteries that  course upon
the internal surface of the skin in those regions, keep up too active
a vitality there, to permit us to have any apprehension of mortifi-
cation.  Even on  the body of the limbs,  the  plan of M. Graefe
would not be necessary, unless the flap should be of great length,
and had more breadth in its free portion than at its base or root.


Article II.—Anaplasty by  Flaps from Neighboring Parts, or  the
                        Indian  Method.

  The method M'hich consists in taking from the neighborhood, tis-
sues to repair the loss of substance in a mutilated organ, comprises,
in truth, a  great  number of modifications; all  of them, however,
may be  reduced to two  principal kinds :—Sometimes, in fact, we
cut a true flap in the neighborhood, but beyond the circumference
of the deformity,  and in such manner as to be  enabled  to reverse
it, turn it around, (le contourner) and adjust it, (le ramener) like  a
patch upon the part that it  is to cover: it is this fundamental char-
acter of a pediculated flap, which constitutes, in  my  mind,  the
Indian method.  At other times, we confine  ourselves to separating
the parts all around the ancient  solution of continuity, in order to
be enabled to elongate, approximate, trim, (decouper) and adjust
them in contact by their free  border, without either reversing or
twisting them.  This is what I shall call the French method.
  The  anaplasty which consists in cutting flaps  completely inde-
pendent of the mutilated organ, but at such distance  as allows of
our immediately covering them  with  it, is  evidently derived from
the Italian method, of which, in reality, it is nothing more than an
improvement.  It comprises, moreover, three or four processes.

                             §1.

  The  Indians of the tribe of Koomas, formed a flap sufficiently
large to fill up, in a suitable manner, the voids in the organ destroy-
ed.  Being turned over from above below, and twisted upon its
pedicle, they afterwards fastened this  flap to the previously pared
(avivees) lips of the part to be reconstructed.   In acting  in this man-
ner, there is generally preserved  only a very narrow pedicle to the
flap, and as this pedicle has to be twisted upon itself, there are but
a very few regions M'here the method of the Koomas presents posi-
tive  chances of success.  Moreover, they employed it only to  the
nose, where the vascularity of the skin, and the homogeneousness
and thickness of the subjacent tissues, render gangrene difficult in
the parts that are separated.  It  results from this, that  in the chest,
arm, and thigh, where I have attempted to employ it, it offers no
longer the  same  chances of success.   It is on that account, that
early attempts were made to modify it. 
606
NEW ELEMENTS OF OPERATIVE  SURGERY
  In cutting the flaps  thicker, (plus largcmcnt) it has been found
practicable, 1. To turn  them back from bdow upM-ard, thus folding
them upon themselves, Mdthout  tM'isting them, as I have  done for
fistulas;  or, 2. To tM'ist them, as  Delpech did  in  cheiloplasty;
or, 3. To detach them (les dedonbler) from within  outwardly, to
bring doM'n their free  border in another direction, as  M. Roux
has done in a case of genoplasty.   In  certain cases, the flap once
cut has admitted, 4. Of  being rolled up like a cork, (route en bou-
chon) and held by a large root,  as I have frequently done ; but all
these modifications, and also some others of the Indian method, will
be more easily understood  in their special applications, than under
the general head of anaplasty.

     Article III.—Anaplasty by Separation of the Tissues.

  We find some expressions in Celsus,  which would lead  us to be-
lieve that at the time of this writer, the mutilation of the ears, nose,
and  lips especially, M'as sometimes repaired by a species of ana-
plasty.  Celsus says, in fact, (Lib. 7, cap. 9,  ou trad,  de  Nine in., t.
ii., p. 275 :)  We begin  by seizing hold of the borders of the mutila-
ted part; after which  we  make incisions at  the inner angles of
the v/ound, in order to separate  its flesh and skin below from those
above:  we  then take  the  portion which has  been thus detached,
and  bring it upon the part we wish to repair.  If the  edges do
not approximate sufficiently, says Cel-us, (Ninnin., t. ii., p. 275,) we
must make, in a crescent form,  two other incisions, whose  points
should be turned towards  the wound,  and M'hich should not pene-
trate deeper (plus avant) than the skin : " Alias duas lunatas, et ad
plagam conversas immittere quibus summa tantum cutis deducatur."
This text, however, is sufficiently obscure to have allowed of dis-
covering therein the internal separation (decollement) of Roonhuysen,
Van Horn, and Pauli, and  the external gashes (balafres) of Guille-
meau and Thevenin.   Valentin, (Recherches Critiques sur la Chir.
Moderne, p. 249,) who  severely reproaches Louis with having mis-
understood these authors, and of imputing to them a practice M'hich
they were not chargeable with,  would have been  in the M-rong, if
Louis had not confounded the precept of Van Horn M'ith that of
Thevenin, since  the semilunar divisions of some, and the internal
dissections of others, seem both  alike indicated in Celsus.  It may
also be urged as an objection, that these different passages, whether
of Celsus, or of  Thevenin and Guillemeau, or of Van Horn, Roon-
huysen, Pauli, etc., relate rather  to  hare-lip, than to  legitimate
anaplasty.

                    § I.—Process of Franco.

   But Franco (Traite  des Hernies, chap. 122, p. 462) explains him- 
ANAPLASTY BY TRANSPOSITION.
G07
self, on  this subject, in a manner altogether unequivocal.   If ana-
plasty by separation  of the tissues  were not found in the Latin
authors, it would, however, be impossible not to recognise  it in an
example related by him with much  detail, and in M'hich we per-
ceive  that  he succeeded, by this  means, in closing a hole M'hich a
man had had for a long time in his face.
  The anaplasty of Franco, or by the  French method, exposes to
fewer deformities than any of  the others.  It is founded upon this
principle, that when  once separated and detached (decolles) from
the subjacent parts, the cutaneous and the cellulo-adipose and mus-
culo-cutaneous tissues, yield, elongate themselves, and allow of be-
ing easily draM'n  to a very considerable distance.  In adopting it,
we succeed perfectly in putting into contact the sides or borders of
very deep notches, (echancrures)  and in filling up (combler) great
losses of substance.   We should,  nevertheless, be wrong  in there-
fore concluding, like some modern surgeons, that by this method it
is always possible to  procure a great elongation of the parts.  In
all regions M'here the teguments are dense, or the tissues are firm
and adherent, it would be necessary  to effect a separation of some
inches to obtain  an elongation of some lines.   Persons with re-
tractile tissues, and firm flesh, are rather unfavorable subjects for
it.  In the face, there is scarcely any other part than the lower
portion of the cheeks, and the  chin, M'hich will advantageously al-
low of it; in the  cranium, we would succeed still less frequently;
on the neck, breast, and abdomen, and  on the body of the limbs, it
is, on  the contrary, a species of anaplasty which gives us great re-
sources.  To sum up, it is the method which is the best safeguard
against  gangrene, and which allows of the speediest cure,  and ex-
poses to the least risk of deformity.  At the same time that it does
not exact the absolute displacement of any flap, it does  not re-
quire M'ounds upon the skin  of sound regions ; but it has the disad-
vantage of not filling up, except by means of tractions, (tiraillements)
and often in an imperfect manner, those voids in which there have
been extensive losses  of substance.   Compelling us to destroy the
natural  adhesions of parts  to a considerable extent, it singularly
favors erysipelatous inflammations,  angioleucitis, and even phle-
bitis and the formation of dangerous  purulent collections.
  It should not, therefore, have the  preference, except, 1.  In indi-
viduals or in regions  where the  integuments have an easy play,
(un glissement facile;) 2. Where our object  is to remedy losses of
substance that are  of greater breadth  than depth ; 3. Where, by
adopting the Indian method, M'e  should be compelled to  cut the
flaps in those places where it was important to avoid all cicatrices
and deformities.   It will be seen, however, that the method of sepa-
ration of the tissues, is one of those anaplasties that we shall have
the most frequent occasion to apply; it  results from this, therefore,
that it embraces many varieties. 
608
NEM" ELEMENTS OF OPERATIVE SURGERY
§ II.—Anaplasty by Internal Incisions, [or scorings,—T.] (decoupures
                internes) or the Process of Celsus.

  Though the text of Celsus leaves much to desire, it seems how-
ever that some surgeons of his  time, M'ith a view to elongate the
lips, the nose, and the ears, separated those parts from the surface of
the bones, and afterwards scored them in different directions, upon
their  internal face.   This process, M'hich  has the advantage of
leaving no cicatrix upon the skin, and of placing all the Mounds in
the interior, is not certainly to be despised, but it procures, in fact.
but a very moderate elongation, and does not ansM'er but in a very
small number of cases.

§ III.—Anaplasty by External Incisions, [or scorings,—T.] (decoupures
              externes) or the Process of Thevenin.

  A modification of  French anaplasty, might  be derived from  the
language of Thevenin, (QZuvres,  in-fob, edit. 1658, p. 28,) and of
Guillemeau, (QZuvrcs,  in-fol., edit. 1649, p. 682.)  In place of cut-
ting the separated  parts perpendicularly, upon their internal sur-
face, it is upon the skin (i. e. externally) that they afterMards score
them, according to the process  of those  authors.  Thus, to  relax
the tissues, they  make on each side, at some distance  from  the
wound,  long straight or semilunar incisions, M'hich go through (com-
prennent) the  entire thickness of the integuments.  There  is no
doubt that by this method  we may, from having a less extensive
internal separation, favor better the reunion of the separated lips
of the M'ound, than by  the process of Franco or Van Horn ; but, on
the other hand, we create cicatrices upon the surface, and deformi-
ties, from which the  other method exempts us.  The regions M'here
the sub-cutaneous tissues are more extensible than the skin, or
where a uniformity of the surface of the body is a matter of little
importance, are consequently the  only places which occasionally
alloM' of a preference for this method.
  [Dr. Mott cannot conceive what utility there could have been in
the incisions upon the inside, as  it is not the sub-cutaneous tissues
that resist.  They are ahvays sufficiently extensible.  It is the in-
cisions on the  skin itself, externally, therefore, which are the im-
portant  point to be attended to—as that is the part whose elonga-
tion we  desire.—T.]

\ IV.—Anaplasty  by  Simple Lateral Incisions.   Process of Dieffen-
                              bach.
                                                           i
  These lateral incisions, which are only spoken of by Guillemeau
and Thevenin in  reference to hare-lip, have been adopted, in our
time,  first  by M. Dieffenbach, afterwards by a great number of
other practitioners, who  have more or less modified them.  Thus,
Mdthout separating the parts upon  their internal surface, they are 
ANAPLASTY BY TRANSPOSITION.
 abraded and then reunited by the lips of the division;  but in order
 to relax the  parts, and to prevent all traction of the suture, there
 is made, upon each side, an incision  which comprises the whole
 thickness of  the skin, and which, in place of being shaped into  a
 semicircle, is made parallel to  the  wound created by the  loss of
 substance.  It is an operative method, which has already been put
 in practice about  the mouth, cheeks, and  velum of the palate, and
 upon the sides of most fistulas, and one which I have made trial of,
 also, in certain cases of artificial anus, ulcers in the limbs, and per-
 forations in the vault of the palate.   I feel that I am also justified
 in saying, that  wherever the cicatrices do not disfigure, as about
 the genital organs, and the anus, and  in the interior of the mouth,
 vagina, and rectum, that it is a process which has not yet been suf-
 ficiently introduced into general practice.

     § V.—Anaplasty by Transportation of a Cutaneous Bridge.

   It has appeared to me, that in certain cases it would  be advan-
 tageous further to modify this kind of anaplasty; that is to say, that
 in order the more easily to approximate the twoi)orders of a great
 destruction of substance,  in the  limbs, for example, it M'ould not
 only be useful to incise the integuments on each side of the deform-
 ity, to a great length, but also to separate  them, [the integuments,]
 in order to construct from them a flap in form of a bridge, adherent
 by its two extremities, but capable of being stretched to a very con-
 siderable distance by its inner border.

 § VI.—Anaplasty by Raising an Arcade of the Integuments, (par sou-
               livement (Tune arcade tegumentaire)

   I have  modified, in  still another form,  the  bridle  which I have
 just spoken of.   After having incised ft, and separated it as in the
 preceding case, I have  thought it advisable to raise the flap which
 I had thus dissected from the recto-vaginal partition, up to the in-
 terior of the bladder,  with the  view of  closing a vesico-vaginal
 fistula.

     § VII.—Anaplasty in the Manner of a Drawer, (en  tiroir.)

  In order to obtain a complete  elongation, Chopart had, as it ap-
 pears to me, the idea, not only of separating the tissues to be dis-
 placed, but also of forming a flap with them, by means  of two par-
 allel incisions.   This  process, which I have many times seen err-
 ployed by M. Roux, in 1824 and 1825, which allows of our giving
 to the flap such shape as we wish, and of carrying it up or drawing
 it across to the opposite border of the mutilation, is now definitively
 introduced into practice.  Applicable  especially to the lower  lip,
 the process of Chopart is equally suitable  to the forepart  of the
 chest, and to some regions of the abdomen and limbs.   I have to
say, however, that in  order  to fill up  in this manner a wound of
                             77 
610            NEM' ELEMENTS OF OPERATIVE SURGERY.

three inches extent, after the removal of a breast, I was obliged to
cut from below a square flap of nearly five  inches in length, and
which ultimately terminated in mortification.

               § VIII.—Anaplasty by Invagination

  M. Blandin (Thises de Concours,  1836) admits, as a species of
anaplasty, the operation which consists of invaginating the integu-
ments in certain musculo-fibrous canals, the inguinal, for example,
to make a radical cure of hernia; but I do not think that this in-
vagination can be arranged under  any head in the class of ana-
plasties.
  As to the other different modifications and varieties of the pro-
cesses of anaplasty which I have been describing, it  will not be
possible to point them out and to appreciate them, but when treat-
ing of this class of operations in the regions to which they are most
easily applicable.
*
                       PART  SECOND.                     •

           ANAPLASTY IN  PARTICULAR.

  Reason points out, and practice proves, that anaplasty is applica-
ble to almost all the regions of the body, and that the different
modifications of this operation should be estimated precisely ac-
cording to the nature of each organ that requires it.
                        CHAPTER I.

                ANAPLASTY OF THE CRANIUM

  There can be no doubt that we could transfer to the cranium, all
the different kinds of anaplasty which I  have spoken of above.
As the mutilations of this region do not, but in a very inconsidera-
ble degree, compromise  the beauty of the person, it has  scarcely
been thought of for them.  The lateral slits of Thevenin, and the
method of Franco, are almost the only ones which permit  of appli-
cation, in cases that relate to the destruction of parts in the hairy
scalp.   But anaplasty by transplantation, or animal engrafting, has
more than once been made trial of on the bones themselves.  Some
surgeons, for example, relying  upon the experiments of Duhamel, 
OTOPLASTY.
611
and of Hunter, have thought, that after the operation for trephining,
it would  be possible to replace and  reconsolidate the osseous disc,
in the part from whence it  had been removed, and to reunite the
soft parts over it.
  Job-a-Meckren (Gooch on the Wounds, fyc) had already mentioned
the case of a Russian  nobleman, who, having lost a portion of the
cranium, undertook to replace it with an osseous plate, taken from
the head of a dog, and that the operation was perfectly successful.
Also,  M. Maunoir (Diet, des Sc Med., art. Ent. Animate) formally
advises this method, to protect the brain after the operation of tre-
phining.  Some facts,  more remarkable  still,  have been since re-
lated.  After having laid bare the cranium of a dog,  M. Walther
removed a disc of it by the trephine ; the piece, completely denu-
ded of its soft parts, was replaced a little while after, and the  in-
teguments having  been  brought over,  it  immediately reunited.
The dog was killed a  year  after, and hardly a trace of  the callus
could be found;  but the bony disc was paler  than the rest of the
cranium.  After having performed the operation of trephining upon
a man, M. Walther, finding no disease existing under the bones,
immediately returned  to its place the disc which he  had just  re-
moved.  A suppuration ensued, which continued three months, and
was followed by the separation of a scaly plate of bone ; but this
plate comprised only the external table of the disc, and did not pre-
vent the other part  from consolidating perfectly. M. Merem, there-
fore, thinks himself authorized to conclude,  that it is proper in this
way to reapply the fragment removed by the trephine, as often as
we wish to  attempt the  immediate reunion of the wound.  For
myself, in reflecting upon the case of M. Meckren, the facts of M.
Walther, or  the  experiments  related by MM. Maunoir, Dubreuil,
etc., I deem it incumbent upon me to proscribe this  kind of ana-
plasty, seeing that  it would be a means of  favoring inflammation,
or suppuration, within the cranium, and that the fact of the recon-
solidation, spoken of by authors, is not yet absolutely demonstra-
ted.
  [Dr. Mott remarks, that he would deem such an attempt in the
highest degree reprehensible.—T.]
                        CHAPTER II.

            OTOPLASTY, (ANAPLASTY OF THE EAR.)

  The art of repairing the ear, is as ancient as that of restoring the
nose.  Galen, and Paul of Egina, as well as Celsus, speak of both.
Every thing leads us  to believe that the Brancas, and other sur-
geons of Italy, made many improvements in this process during the 
612
NEM' ELEMENTS OF OPERATIVE SURGERY.
course of the  fifteenth and sixteenth centuries.   In  the example
given by Tagliacozzi,  he says, that after the cure the resemblance
betM'een the two ears was so exact, that they might readily be mis-
taken for each other.  Otoplasty, however, had ceased to be spoken
of M'hen Dieffenbach attempted to reintroduce  it into Germany.
No doubt, if the M'hole body of the ear (pavilion) was entirely car-
ried away, M'e ought to give up  the idea of restoring it, and to de-
cide, as in the time of Pare, to  replace  it by a metallic ear;  but
when it is destroyed only in part, and that at least one half of it is
remaining, we may endeavor to  restore it to its natural dimensions.
The lobe, especially, could be very easily  reproduced.   While the
loss of substance does not comprise  more  than the  anti-helix, or
though it should even  include  almost the whole of  the helix, we
still should not despair of success.  Without  ever acquiring  the
firmness of the destroyed cartilages, the new tissues that are put in
their place, attain sufficient consistence to render the deformity of
the ear much less repulsive.
   [Dr. Mott has seen the whole external ear restored, where it
hung  down and was held only by a small pedicle.—T]
   The Indian and the Italian methods, moreover, are  the only ones
applicable  to  the  ear.   To the cases of otoplasty by  restitution,
which I have already spoken of,  it is necessary to add  the successful
case of this kind which has been related by M. de Renzi, (Filidtre
Sebezio, etc., Gaz.  Med., 1834, p.  634,) remarking, at the same time,
in reference to myself, that I have twice made trial of it without
success.

               The Operation, (Manuel Operatoire.)

   As with the nose, it is the skin of the neighborhood  which is to
furnish the material for reparation, (raccommodage)
   First Stage, (Premier Temps.)—We commence by excising, shap-
ing, (regulariser) and paring (rafraichir) the mutilated border of
the ear.  We afterwards separate  above, below, or  at  the poste-
rior part of the concha,  (conque) the integuments which cover the
temple, mastoid process, or subauricular fossa (echancrurc) in  the
neck, a little nearer  to  the meatus auditorius  than  in a line with
the abraded, (avive) border, but in a direction parallel with this
border.  Another incision, of greater or less length, made at each
extremity of the first, allows of  our giving to the flap the form and
extent that we wish, an extent which ought at least to  be one half
greater than the loss  of substance would seem  to indicate.  In dis-
secting this flap in a circular direction, (direction exccntrique) that
is to say, from the first wound towards its adherent border, it  is im-
portant to turn over with it a sufficiently thick layer of the cellular
tissue which lines its posterior surface, and which furnishes  it nu-
trition and Life.
   Second Stage, (2e Temps.)—The surgeon immediately adapts the
free border of the flap (opercule) to the bleeding wound of the ex-
ternal  ear, and effects its reunion by means of  short fine needles, 
RHINOPLASTY.
613
and a sufficient number of turns (points) of the twisted suture, deli-
cately adjusted.  To finish the operation, we have  nothing  more
than to pass behind the kind of bridge which results from this ar-
rangement, a small band of linen, spread with cerate, the object of
which is to prevent the reunion of the dissected skin.  After hav-
ing enveloped the whole with compresses, wet with tepid water of
marsh-mallows, we replace or leave the patient in his bed.  At the
end of three, four, or five days, if the adhesion is accomplished, M'e
may remove the needles, those at least that correspond to the points
the most solid.  In the contrary case, we  should examine if it is
not advisable  to substitute new ones in the place of some of the
first.  When the cicatrix is solid, that is  to say, from the fifteenth
to the thirtieth day, we separate from the cranium the tegumentary
flap, which being now liberated, requires  additional  attentions.
   Third Stage, (3e Temps.)—In the  first place, it is requisite  to re-
move all the inequalities of this flap, to round  off its angles, in a  v
word, to adjust its external border.  In the fear that it may mor-
tify, we renew the dressings with emollient applications, for some
days; afterwards we treat it, as well as  the wound which  is left
upon the head, like any other solution of continuity.   In retracting,
it thickens and hardens, and takes the form of a  raised border,
(bourrelet) and after being first pale, then becomes red, and remains
for a considerable length of time more highly colored than the parts
surrounding the external ear.  Such, at least, were the  appear-
ances in a case reported by M. Dieffenbach.
   [Otoplasty has been successfully performed by Dr. M'Clellan, of
Philadelphia, (Reese's Ed.  Cooper's Surg. Diet., Loc  Cit)   The ex-
ternal ear was buried in the adhesions of the cicatrix following a
wound of the head, and the deformity was remedied by dissecting
out  the cartilage, and elevating it to its  normal position,  by flaps
taken from the adjacent integument.—T]
                       CHAPTER III.

          RHINOPLASTY,  (ANAPLASTY OF THE NOSE.)

  In Italy, and also in India, it was formerly the practice td cut off
the nose of criminals.  Sextus Quintus  caused it to  be  enforced
upon thieves and rogues ; the king of Goorka inflicted the  same
upon the  inhabitants of Kirtipoor, in order, he said, that he might
recognise  them everywhere, and to  be able to apply to them  the
vile epithet of Nascatapoor.  Persons have been seen who have
themselves cut off their own nose, to escape pursuit, or who have
deprived others of it from motives of vengeance.  Charles II. thought
he could not inflict a more cruel punishment trpon the earl of  Co-
ventry, who had dared to speak lightly of two actresses. Frederick 
614           NEW ELEMENTS OF OPERATIVE  SURGERY.

II. treated in the same manner a certain nobleman who had com-
plained, in disrespectful terms, of having been enrolled  by fraud.
On the approach of the Danes, a great number of uomen and young
girls cut off their noses, it is said, M'ith the view of securing their
chastity.  An abbess, with her forty nuns, did the same,  M'hen the
Saracens presented themselves at Marseilles.  Let us add to these
unnatural mutilations, those which depend  upon  unforeseen acci-
dents, which are caused by small-pox, syphilis, cancer, frost-bite,
scrofula, burns, etc., and  it will be conceded that the occasions for
restoring the nose  must  have frequently presented themselves to
the surgeon.

                      Article I.—History.

  The hideous appearance of persons who have had the misfortune
to lose their nose, must have early created  a desire to remedy,
as far  as possible, so repulsive a deformity.  Thus Celsus (Meth.
Med., lib. 14) and Galen  (lib. 7, cap. 9) already spoke  of the art of
restoring the nose.  Nevertheless, it is only from the fifteenth cen-
tury that rhinoplasty has taken rank  among regular operations.
P. Ilanzano  (Annul Mundi in Sprengel, t.  viii., p. 172) says, that ,
the Brancas, father and  son, surgeons of Sicily, and M'ho lived in
1442, practised it with great skill.  Bojano (Eloy. Diet., etc.) and
Benedetti (Anatom., lib. iv.)  speak of it as a common practice.
  G. Tagliacozzi, who died in 1599, had acquired so great a celeb-
rity in this matter, that they caused a statue to be erected to him
in the  Anatomical Amphitheatre of Bologna.  Mercurialis, Fyens,
Fallopius, Vesalius, Read, (Sprengel, t. viii.,) and  Gourmelin, have
spoken of the art of remaking the nose.   According to Fabricius,
of Hildanus, (Cent. 4, Obs. 31 ; Bonet,p. 399,) Griffon, of Lausanne,
was a skilful nose-maker, (nasifex;) and A. Pare (QZuvres Compl,
in-fol., liv. 23, p. 671 ;  liv. 17, p. 295) says they were astonished, at
the court of Henry III., M'hen they saM' reappear  there the cheva-
lier de Thoan, who had  been to Italy to have a new nose  made.
Nevertheless, in spite of so  much testimony, to which wc  might
have added that of Cortesius, Molinelli, Dubois, Garengeot, Rosen-
stern,  Moinichen, Leyser, and Fioraventi,  and notM'ithstanding,  1
repeat, so many and such numerous proofs, no one scarcely, among
us, would have dared to  admit the possibility of restoring the nose.
when  the Mork of Doctor Carpue,  published  in 1816, placed the
subject beyond all doubt. A Mahratta, who served in the English
army,  M'as made  prisoner by Tippo-Saib.   This prince caused his
nose to be cut off.  Returning among his comrades, Cowajec (which
was the name of the prisoner) excited the pity of a Hindoo, who
made a new nose for him in the presence of T. Cruso and M. Fin-
ley, physicians at Bombay.   Pennant had  made  known  an obser-
vation of the same kind  in  1798, and Sir Maket affirms that this
operation is in general use  in the  East Indies, where, Lucas says,
it had been practised from the time of Hyder-Ali.   These facts,
transmitted to London, excited  the notice of MM. Lynn, Carpue, 
RHINOPLASTY.
615
and Hutchison, who proceeded immediately to investigate the ori-
gin of the Hindoo methods, as well as the advantages that surgery
might obtain from them.   Doctor Carpue (Account of Two Success-
ful Operations, etc., 1816) himself twice performed rhinoplasty with
success.   M. Graefe (Rhinoplast. sive arte Curt., etc., 1818) also oc-
cupied himself with it, and made known, in 1818, the result of his
essays.  Trials of the  same kind were soon made in  France, by
Delpech,  Dupuytren,  Moulaud, MM. Thomassin,  Lisfranc,  and
Blandin.  MM. Travers, Liston, and Green, in England, and MM.
Dieffenbach and Beck, in Germany, have all endeavored to extend
the art of repairing the nose.
   In consulting the writings of Tagliacozzi, (De Curtor. Chirurg.,
etc., Venis., 1597,) and of M. Carpue and Professor Graefe, we are
compelled to admit that, in certain cases at least, the newly-made
nose does not  differ  as much as might be thought from a natural
one.   One of  the patients, also,  operated upon by Dupuytren, and
who was seen at Paris, had no reason to complain particularly of
this patching, (raccommodage) I have seen the patient whose case
M. Lisfranc has published.   In him, the new nose was far from pre-
senting all the regularity desirable.  Those  of M. Blandin were bet-
ter.  On the other hand, we must not forget that at Paris there are
manufactured, out of plates of silver, leather, pasteboard, and even
wax, false noses, which are capable of being  kept on  the face by
means of different springs, or better still, by suspending them to spec-
tacles, so as almost to entirely conceal the deformity.  Boyer speaks
of a  patient in whom, at the first glance, it was difficult to perceive
that  he was wearing a nose of this kind.  The metallic nose, how-
ever, will never, like a patched nose even of the most deformed
shape, allow of blowing, taking snuff, or the free use of the olfactory
functions.

               Article II.—Operative  Processes.

   As it is for the nose that anaplasty was first invented, it is very
natural that the different methods which I have spoken of above,
should have been transferred to rhinoplasty.

               § I.—Rhinoplasty by Transplantation.

   In the country of  the Parias, men who possess power do not, as
it appears, make any scruple of cutting off the nose of any of their
subjects, and putting it in the place of one that has been lost.  To
believe travellers, this mode has succeeded so well, that, in order
to prevent criminals thus mutilated from remedying their  deformi-
ties,  they take the precaution of throwing the nose into the fire, as
soon as it is cut off.
   Rhinoplasty by restitution and transplantation not requiring any
further special consideration, authorizes me to refer, for what re-
lates to this subject, to what I have said when treating generally of
anaplasty by transplantation and restitution. 
616
NEW  ELEMENTS OF OPERATIVE SURGERY.
               § II.—Rhinoplasty by Transposition.

  Anaplasty by transposition is applied to the nose, as to all other
parts of the body, whether we adopt the Italian method, the Indian,
or the French process.

                     A.  The Italian Method.

  There exist two  varieties of the Italian method: the one ancient.
which  preserves the  name of Tagliacozzi;  the other iicm', and of
which M.  Graefe is the inventor.
  I.  Process of Tagliacozzi. —Though in Sicily and Calabria they
appear to  have proceeded in various modes,  there is one, however,
which has taken the  preference of all others, and which is gener-
ally adopted; it  is that which Tagliacozzi,  has made known, and
the only one which was seriously entertained in Europe, until in
these latter times.  The surgeon commences by imitating a nose
with pasteboard or wax; then bringing the anterior surface of the
forearm in front of the nostrils, he immediately puts it back to its
natural position, in order to spread out upon  the spot which is suit-
able  the pasteboard  nose, the point of ft being towards the shoul-
der ;  having marked out the circumference  of this nose with ink,
he by this means circumscribes a triangular  flap of skin, which he
dissects from the point towards the base, which latter is to remain
adherent.   A strip of adhesive plaster is placed under it, to  ap-
proximate the lips  of the wound.  After the  expiration of a certain
time, we pare the  edges of the deformed nose, as well as those of
the tegumentary flap of the  arm.  Nothing now remains but to
place the  bleeding edges  in contact with each other  by means of
the suture, while the arm is fastened in front of the face by means
of an appropriate bandage.   Dossils of lint,  also, are placed in the
anterior openings of the nares.   When the union is effected, we
separate the base of the flap, and trim the lobe of the new nose in
the best manner we  can.   In certain cases, the surgeon confined
himself to making in the forearm an  incision, to which he attached
the abraded borders of the mutilated nose, until they had contract-
ed intimate adhesions M'ith the skin.  He had then  nothing more
to do than to cut and separate a triangular flap in the teguments
of the arm, on each side, and unite them upon the median line, or
dorsum of the nose.
  II. Process of  M. Graefe.—In the method  of M. Graefe, the  pa-
tient commences by putting on a laced waistcoat, surmounted by a
hood, which will hold the head steady.  One of the sleeves of this
waistcoat, and which is open in front, has four leather straps near
the  elbow, and  two  shorter ones near  the  wrist.  The operator
pares the  openings of the destroyed nose ; takes the measure, as in
the  process of Tagliacozzi;  marks out  and cuts the flap in  the
same manner; fixes the arm thus arranged, by means of the straps
just  mentioned; and makes use of needles and the twisted suture, 
RHINOPLASTY.
617
to maintain in contact the sides of the mutilated nose and the edges
of the flap of the arm.  At the end of a period, which varies from
four to thirty days, the union should be complete.  We then remove
the  bandage, and the base of the flap may be detached.   Having
brought it down upon the subseptum, [i. e., the columna, or inferior
border of  the septum nasi.—T.,] we pierce  it with two openings,
which  should resemble  the natural  openings of the nose,  and in
which are to be inserted small pieces of gum elastic catheter, until
the  cicatrization is complete.
  III. Appreciation.—M. Graefe is almost the only one among the
moderns, who, in modifying the Italian  method, has practised it
with success.  Having  employed it successfully in four cases out
of five, he returned to  it  again, with no less  advantage, in 1834,
(Gaz. Med. de Paris, 1835, p. 168.)   M.  Signoroni, (lb., 1834, p. 3,)
who also attempted it in Italy once, failed entirely.  Here is a fact
which M.  Champion has communicated to me, but which, however,
must be placed by the side of those of M. Graefe:—A young man,
in 1823, having lost his nose in consequence of syphilis, consulted
M.  Wazel, who, after having put him upon a course of mercurial
treatment, restored  the nose by a flap from the forearm.  All visit-
ing to this patient was interdicted, from the moment  the operation
was performed, in order to prevent the slightest movement, and to
exempt him from speaking.   The nose, examined some months af-
ter, appeared thin and meager, and in strong contrast M'ith the rest
of the face, which  was well nourished;  in  other respects,  it was
passable.  The young man, who said he had been punished during
the M'hole time of the cure, from the restraint in which he was kept,
did not, however, at all regret having submitted himself to the op-
eration.
  On the supposition that the Italian method should be practised in
some cases, we should  take care, at  least in the beginning, to de-
tach the flap from the arm only by a very limited incision, in order
to preserve to it a base of sufficient extent and vascularity to sus-
tain its vitality perfectly.  The union of the  borders, and of the
point of this flap, M'ith the abraded lips of the mutilated  nose, would
not afford any prospect  of success, unless it was aided by numerous
stitches of suture.  Joining the immoveable bandage  to this first
means of  union, the surgeon would have every possible chance of  < ^
keeping the parts in the most perfect state of immobility.
  It would, moreover, be required not to use any compression, and
to prevent every kind of traction upon the flap, until it should be
evidently  adherent  to the forepart of the nose.  Another essential
precaution would be, to give to it, at the first, dimensions at least
twice the size of those which it is ultimately to have;  dimensions,
moreover, so much  the  greater, in proportion as the integuments
employed in its construction are thinner, more distensible, and more
pliant.
  If gangrene has not taken place in the flap by the fourth or fifth
day, every thing promises that its vitality will be maintained, and
that the union has actually taken place.   We should not, however,
                              78 
618
NEW  ELEMENTS OF OPERATIVE SURGERY.
be in haste to remove the stitches of suture, and to take off the
bandage.   It should not be, moreover, until toM'ards the fifteenth
day, or later, that we ought to allow ourselves to think of comple-
ting its section, in order to mould it definitively upon the nose.  For
this last stage of the operation, we are sometimes under the neces-
sity of reconstructing both the septum and  the  alio of the organ.
We may do this in two  ways:
  1. The base of the flap, folded upon its cellular surface, and fast-
ened above the upper lip, is afterwards pierced on each side in such
manner as to imitate the two openings of the nose.   Two canulas,
of gum elastic or other substance, prevent the  obliteration of these
openings,  and force them to cicatrize in the shape of holes.
  2. We may cut also, upon the base of the  flap, a pedicle destined
to replace the subseptum.  The rest of this base, brought down on
each side  to a sharp point, is afterwards united, by other sutures,
to the root of the alae of the nose.  The canulas, of M'hich I have
just spoken, are here no less indispensable.
  IV. By means of a Cutaneous  Flap from the Breech.—In some
countries, as soon as a person of rank has lost  his nose, he procures
a slave, who is struck upon his breech M'ith a slipper, until  the in-
teguments in that  place  become considerably swollen.   A nose-
maker, (nasifex) at the expense of this part, so singularly prepared
cuts a flap of the form and width  sufficient to replace the lost nose,
applies it and fastens it firmly upon the nostrils, the openings into
which are maintained by means of small cylinders of M'ood. It is
evident that  this strange operation  will never be practised  in  Eu-
rope.
  V. By  Transplantation of  a Nose.—I  have stated above, what
value is to be put upon rhinoplasty by transplantation or restitu-
tion ; on the testimony of Olaus, who says he had  seen the flesl
of a living fowl  successfully employed in the cure of hare-lip; that
of T. Bartholin, who pretends that a sailor M'as promptly cured
of a wound, with loss of substance, on the  hypochondriac region,
by causing  a surgeon to apply over it some  sheep's flesh, M'hich
soon adhered to and nourished it; on the experiments of M. Ba-
ronio of Milan, contradicted, it is true, by those of MM. Huzard and
Gohier, but corroborated  by those of Duhamel  and Hunter, from
which it results  that the skin from the flanks of an animal, trans-
planted from right  to left, or applied upon  the same parts in an-
other animal, becomes engrafted upon them, and continues to live;
on the custom of those  youth in  the north of Germany,  who, as a
pledge of intimate friendship, each one exchange a flap from the
front surface of their forearm;  in fine, on  those cases of fingers
completely separated from the hand, which so many authors men-
tion, and which I have already related.

            B. The Indian Method,  (Methode Indienne.)

  The different  processes of Indian anaplasty have been applied to
the nose, more than anywhere else. 
RHINOPLASTY.
619
  I.  With the skin of the Forehead, or Process of the Koomas.—In
the process which has been especially followed  in England  and
France, we begin, as in the Italian method, by imitating a nose with
pasteboard, or M'ax;  M'e afterwards reverse this pattern, by spread-
ing it upon the forehead in such manner that its point may be turn-
ed downward.  Its circumference is also touched with some color-
ing matter.   The flap is thus traced out.  The operator, who dis-
sects it, taking care to leave at its base a small prolongation, des-
tined to replace the nasal sub-septum, reverses it from above down-
ward to the ossa nasi;  twists the pedicle, that the cutaneous sur-
face may remain outside; pares and smooths the contour of the
nares ; unites, with their bleeding borders, the edges of the frontal
flap ; maintains the whole in contact, by means of a composition of
Japanese  earth, or the suture ; brings down the median pedicle up-
on the front of the upper lip, and fills up the openings  of this new
nose with small compresses, rolled  into the shape of cylinders, or
with quills, or canulas of gum elastic.
  The Llindoos scarcely ever employ the suture.   But  M. Carpue
has thought  it advisable to put it  in practice, and Delpech, who
says he has performed rhinoplasty several times, insists that it should
not  be neglected, and that we should give the preference to the
twisted suture.
  Among the modifications which this process has undergone, there
are three  which I propose to speak  of.
  II. The first trials, as we have said, of Indian rhinoplasty, were
made in England, Germany, and France, in such manner as that a,
bridge of sound parts might remain intact betM'een the pedicle of
the flap and  the part of the nose which Mas to be restored.   Thus
practised, the operation requires that we should divide  this pedicle,
and excise its free portion, as soon as the adhesion of the flap itself
is effected.   It results from this, that the neM' nose, feebly sustain-
ed  above, sinks down  (s'abaisse) more than is desirable,  shrinks
(se resserre) into  the form of a tumor, and assumes a palish tint,
which contrasts (tranche)  with the rest of the  visage.  A patient
thus operated upon by Delpech, and whom I saw at Paris, had a
nose that  M'as wrinkled (ride) and shrivelled (ratatine) like a potato,
and M'hich a lupus, moreover, finally destroyed.
  III. In order to remedy this inconvenience, M. Dieffenbach makes
a slit (fente) at the root of the nose, and fastens into this cleft the
pedicle of his flap, in order that there may remain no  free integu-
ments below.  By excising, at a later  period, the projecting por-
tion of this pedicle, M." Dieffenbach finds the  flap blended with the
dorsum of the nose, supplied with large-sized vessels, and secured
from all downward tendency towards  the  upper lip.  Many pa-
tients, says  M. Dieffenbach, who were thus treated,  obtained so
much advantage from it, that their nose hardly differed from a
natural one.   It is at least certain, that a woman, somewhat over
thirty years of age, who had the  point (lobule) of the nose destroyed
by a lupus, and M'hom I requested M. Dieffenbach to operate upon
in 1833, in my division of La Pitie, was tolerably well satisfied with 
620
NEW  ELEMENTS OF OPERATIVE SURGERY.
the restoration.  I should add, nevertheless, that rhinoplasty, in the
hands  of this  surgeon,  becomes a very complicated operation.
After having engrafted his flap, he cuts from it, sometimes on one
point, sometimes on another, different portions, M'hich he excises or
transposes according as the neM' nose has need of being  raised up,
depressed, inclined, or flattened, in this or that direction, where it
has the appearance of being too thick  or too pinched, (trop grele.)
Each of his patients, therefore, have to undergo as many as five or
six operations, before they are cured.
  IV. In a patient operated upon in 1825, at La Pitie, M. Lisfranc
brought down the incision of  one of the borders of his flap, quite
into the mutilation; then, in  place of tM'isting this flap upon its
axis, in the manner of the Koomas, he turned it over, brought it
around upon  its side, and was enabled to attach it from one end to
the other, to one of the sides of the opening to  be repaired.
  We have, in this manner, a pedicle which forms a kind of pucker,
(godet) open  below, but M'hich is not separated by any bridge from
the wounded surfaces.   It is  true, that  the nose obtained in this
manner remained quite misshapen ; but as the flap had been badly
united, and the surgeon,  in the place of  sutures, had made use of
simple strips of adhesive plaster, the failure,  under such circum-
stances, proves nothing against the process.
  V. M. Blandin, at a later period, adopted  a  mode somewhat dif-
ferent ;  having brought down and attached the parts in the manner
of the Hindoos, (Indiens) he excised the intervening cutaneous por-
tion, in order to place the pedicle of his  flap in immediate contact
with this bleeding surface, where he kept it fixed by means of com-
pression.
  VI.  The Author.—It appears to me that authors, in this way, are
pursuing the shadow of  the difficulties, and that it is a  matter of
little importance, whether we  follow one of  these processes or an-
other.   If the immediate  adhesion of the pedicle, in one respect, has
its advantages, it has also the  inconvenience of rendering the oper-
ation more difficult and  longer, and of requiring tractions, and a
degree of tension, M'hich manifestly interfere with the  integrity of
the circulation in the flap.
  To prevent the sinking down of the  tip of the nose, which MM.
Dieffenbach  and Blandin appear especially desirous to avoid, I
should prefer, after the principal adhesion has  been effected, to cut
off the  pedicle very  high up, to trim it, (le redresser)  and shape it
into a triangle with  the  point upward, to excavate a notch for it,
and  to attach it, by some additional  stitches of suture, to the root
of the  nose,  and  in a cleft in the neighborhood of the  forehead.
It  would be  the  means  of obtaining every  desirable degree of
regularity in  the new organ, without  having to fear the  embar-
rassments and the difficulties which present themselves in the modi-
fications of which I have been speaking.
  If it be important to preserve carefully, in  the pedicle of the flap,
all the arteries of any considerable size that may exist there, it is not
because the absence here of important arterial  trunks exposes us to 
RHINOPLASTY.
621
 all the inconveniences that M. Blandin has specified; but because,
 whatever M. Dieffenbach may say of it, the more active the circu-
 lation in the flap is, the more  are the chances of our seeing its
 vitality sustained, and of our obtaining its adhesion.                   *
   If, on the day after, or on the following days, the new nose should
 appear swollen, or livid, it may be  advisable to use some bird-peck
 punctures to it, or to cover it with leeches.  Lotions, often repeat-
 ed, of spirits of camphor, and infusion of chamomile, appeared to
 me  to favor the success of the operation, in the  patient whom I
 confided to the care of M. Dieffenbach in 1833.
   It has also appeared to me, that the simple suture, with stitches
 very nearly approximated, as employed by this surgeon, are prefer-
 able to the twisted suture, or to the stitches of suture at long inter-
 vals, as adopted by other practitioners.  We also take away this
 suture on the day after, from the  places  where the adhesion  ap-
 pears evident, and afterwards, on the second, third, fourth, and fifth
 day, from the rest of the wound.
   As to the wound in the forehead, I do not agree in opinion with
 the Professor of Berlin, who recommends that we should approxi-
 mate its borders as much as possible by means of suture, and who,
 in order to favor this approximation, has recourse  to \png  verti-
 cal incisions on the sides of the temples.  In proceeding in this
 manner, we  favor the development of erysipelas, diffused phleg-
 mons, or meningitis, and which we cannot afterwards always con-
 trol. . For, out of five or six patients operated upon in the hospitals of
 Paris, at the time I have mentioned, two of them died, and the others
 experienced  very serious  symptoms.   I M'ould, therefore, content
 myself with a very moderate approximation, made by means of strips
 of adhesive plaster of diachylon, then with simple dressing; being
 well  convinced  that the action of cicatrization itself would soon
 gradually close up the  wound, and finally reduce it to a very unim-
 portant affair.
  To sum up all, the  Hindoo rhinoplasty is a serious  operation.
 Of two patients, M. Blandin came near losing one of them ; one of
 those of M. Lisfranc died.  M. Dieffenbach lost two out of five or
 six, at Paris.   If M. Green, (The Lancet, 1829, vol. i., p. 24,) M. Dou-
 bovitsky, (Gaz. Med. de Paris, 1835, p. 748,) and M. Warren, have
 also  performed it with success,  M. Travers (Bullet, de Ferussac, t.
 i., p. 352) has seen the half of the flap mortify, and his patient left
 with a greater deformity after, than before the operation.
  A  peculiarity sufficiently remarkable is,  that the point of the
 nose of some patients, operated upon  by the  Hindoo method, be-
 comes covered with hair; and  that in some of them, when it is
 touched, it conveys the idea of pressing on the forehead.
  VII. Alee and Sub-septum.—If in the place of the tip, (lobule) the
 patient has lost one of the alae of his nose, it is from the neighbor-
 ing cheek, and not from the forehead, that we should borrow the
 flap;  but it is evident that the French method, in such cases, would
answer better than the Hindoo.
  It would be otherwise, if the sub-septum (sous-cloison) alone was 
622
NEW ELEMENTS OF OPERATIVE SURGERY.
wanting.  Then M'e should imitate M. Liston, (Bulletin de Ferussac;
Practical Surgery, fyc, p. 233, London,  1837,) cut out a vertical
flap of tissues from the middle of the upper lip, and raise it up in
order to fix its apex to the point (lobule) of the nose.  Afterwards
reuniting the wound of the lip, as in hare-lip, we should, of course,
take care to keep the  small flap firmly supported against the sep-
tum of the nasal fossae.  We should, nevertheless, succeed better if
it M'ere possible to unite also the upper edge of this flap, M'ith what
remained of the septum itself.
  [If there  is none of the septum remaining, Dr. Mott thinks it use-
less to attempt this operation.—T]

                    C.  The French Method.

  Rhinoplasty, by the  French method, consists much more  in the
repairing of a nose, than in the formation of a new one.   M. Dief-
fenbach, (Bull, de Ferussac, t. xix., p. 273,) who, following after M.
Larrey, (Clinique Chir., t. ii., p.  15,) has revived  this operation
among  us,  cuts, pares, detaches,  (decoupe) and  raises up, (relive,)
the borders of the mutilated nose; then adjusts  betM'een them, in
order to hold them up and to fill the void that separates them, small
flaps or strips, that  he  takes from the neighborhood; then unites
the whole, with fine needles and the simple or twisted suture.  The
passages of Celsus, which seem to have reference to  rhinoplasty,
had, as I think, this manner of proceeding in view.  It is in dissect-
ing (en decoupant) the circumjacent tissues that Franco succeeded,
as Me shall see further on, in restoring the  cheek of  one of his pa-
tients.   We should add, that a rhinoplasty  of this kind, performed
by M. Larrey in 1820,  was completely successful, and that the sol-
dier M'as exhibited cured to  the  faculty of medicine, M'here I had
an opportunity of examining him.   Among these cases, M. Dieffen-
bach insists principally on that of a young girl, in whom the vomer,
the ossa nasi, and the plate of the ethmoid  bone, had been destroy-
ed by scrofula; and in whom the nose, in  place of  being convex,
was  found depressed, and  as if sunken in, (rentre en dedans.)  Sev-
eral incisions, much more  nearly approximated to each other in the
direction of the forehead,  than towards the upper lip, enabled him
to bring out the middle portion  of this apology (simulacre) for a nose,
and  thus to raise up its sides.   Other incisions, which  were trans-
verse or semilunar, gave  him an opportunity of uniting the little
strips circumscribed by the first, and of borrowing from the lip a
small flap to replace the  septum.   Numerous needles were then
applied, in  different directions, and by the aid of several small re-
pairings, (raccommodages) which some accidents rendered  neces-
sary, M. Dieffenbach finally succeeded in giving to the nose of this
patient a tolerable shape,  and a certain degree of regularity.
  The trials which since the last ten years have been made, of this
method of rhinoplasty,  in France, Germany, England, America, and
Italy, enable us, at the present time, to lay down the  steps of the 
RHINOPLASTY.
623
operation  according to certain  rules.  It  includes, moreover, two
distinct processes:
  I. Rhinoplasty by simple Separation (Decollement) of the Tissues.—
After having separated by dissection the teguments around the de-
formity, to the extent of half an  inch or  an inch, it  is generally
easy to stretch (d'allonger) the parts and draw them towards each
other, (d'attirer) so as to be enabled to bring them into'contact (les
affronter)  by their previously pared  edges.  This  process, which
appears simple and natural, has the inconvenience of requiring  a
considerable separation  of the tissues, where there exists a loss
of substance to some extent, and  of  exposing to a retraction, dif-
ficult to manage.   A nose restored in this  manner, and which I
have had  an opportunity of seeing at the hospital of La Pitie, be-
came by this means so flattened, that it finally sunk to a  level with
the rest of the  face.  In the successful cases cited by M.  Signoroni,
(Gaz. Med. de  Paris, 1834, p. 3,) he does not appear  to  have been
more fortunate.  In spite of the good opinion which M.  Serre has
of it, (Compte rendu de la Clin. Chir. de Montpell, 1837,) this incon-
venience will always render French anaplasty painful, and of but
little advantage in its application to the mutilations of the nose.
It would be useless to rely upon it, for example, when a  portion of
the bones, and of the cartilage of the septum, have been  destroyed.
When  the point (lobule) alone has disappeared, it is yet still more
frequently found  to be unavailing.   It is  for losses of substance,
therefore, of little extent only, that it should be reserved.
   II. Rhinoplasty by Combined Dissections of the Tissues, (par De-
collement Compose.)—If, after having dissected the tissues, as in the
preceding case, we incise them, in order that we may displace them
with more ease, we have a method which  puts it in our poM'er to
repair  a great  number of deformities.  In  a young man who had
lost the whole  of the right ala of his nose,  M. Mutter (Case of Au-
toplasty, etc., Philadelphia, 1838) enclosed the hole by a V-shaped
incision reversed,  and  then  removed it.   A horizontal incision,
carried towards the cheek bone, (pommette) enabled him  then to
make an L-shaped incision of the  outer branch of his first wound.
Then dissecting off the flap thus bounded, he was enabled to bring
it inward  and  in front, up to near the median line, where  stitches
of suture fastened  it to the anterior branch of the A.  The opera-
tion was completely successful.
  Upon the supposition that we might find this method too difficult,
it would be necessary to  call to our aid the  lateral incisions of The-
venin,  or,  better still, to  detach completely the outer or  jugal side
of the  flap, which could then  be transported (transporter) at  the
pleasure of the operator.

            D. Relative Value of the Different Methods.

  Of all the methods, those of the Koomas,  evidently the most pain-
ful, have, moreover, the serious objection of only correcting one de-
formity, by producing anothe \  As one of its consequences, the fore- 
624
NEW  ELEMENTS OF OPERATrVE SURGERY.
head becomes necessarily the seat of an ineffaceable cicatrix, (cica-
trice) sometimes of great size.  In persons whose eyebroM's blend
with each other upon the median line, or who have their hair very
low, the base and another part of the flap may, after the cure, be-
come  covered with hair, and without our  having it in our power
in any way to prevent it.  Few persons among us, at the present
day, would consent to sell their nose to the rich patient, that M'ould
like to make use of it to mend  his own.   Though M'hat has  been
said, therefore,  of this species of animal grafting Mere true, we
could not put in practice the method of the Parias. unless in those
cases analogous to that of which Garengeot speaks.   The process
of the Mongolians, the most outre of all, has  the same objections.
As to the French method, we should do wrong, as I conceive, either
to adopt or reject it exclusively.  Applicable to cases of simple de-
formity, (deformation) to those where there is but little destruction
of parts, it would  no longer answer where there  is an almost  total
loss of the organ.  A patient upon whom M. Serre performed  it,
and whom I had an opportunity of seeing at La Pitie, derived but
very little advantage  from it.  M. Marjolin told  me that he saw a
man who was operated upon in  this manner at Rouen, and who
was not more  fortunate.   Every thing, for the  first few M'eeks,
seems to go on very well, but in proportion as the cicatrices become
more  firm, the tissues retract, and the new nose becomes more and
more  flattened down. The method of the Koomas is still the one
which, in our time, has been the most frequently attended with en-
tire success.
  So  long as the bones  have not  disappeared, and that the point
and cartilages  only are destroyed, rhinoplasty may, to a great de-
gree,  remedy the deformity.   In the contrary case, there is much to
fear that the new organ will  be reduced to a sort of fungous sub-
stance, (morille) [i. e. mushroom,] and  always remain  flabby,  to
such degree, indeed,  as to shrivel (s'affaiser) like a piece  of linen
subjected to the action of atmospheric pressure.'  When M'e make
use of teguments from the forehead to construct it, preserving,  in
the meanwhile, as much thickness as  possible to the flap, it is im-
portant to leave to the tM isted pedicle the width only that may  be
necessary to  keep up the circulation.  Before separating it from
the root of the nose, and cutting off as much of it as extends beyond
the line of  the neighboring parts, we ought to wait  until the re-
union of the tissues, recently brought into contact, shall have been
firmly established.  In the place of linen rolled  in the shape of a
cylinder, dossils of lint, and canulas of gum elastic, I should prefer
rather to  keep in the openings of the nares  a piece of lead  bent
into the form of a ring, and M'hich might, at  the same time, serve
as a mould, or pattern, for the borrowed patch M'ith M'hich  the new
organ has been formed.  In short, it appears to me that  Delpech
has perfectly well combined all the different  stages (temps) of the
operation.   The modification of M. Lisfranc, or better still, that of
M. Blandin, whieh  is only an improvement  of it, Mould, though
never absolutely required, also have its advantages.  As to taking 
RHINOPLASTY.
625
the teguments from the arm, I do not  know which would be the
most advantageous, whether to follow the directions of the  sur-
geons of Sicily, or to adopt the process of the professor of Berlin.
  In conclusion, rhinoplasty is as yet an operation too little practised
among physicians, not to allow of our performing it in any manner
M'e please.  The circumstances, also, under which it may be  re-
quired, are so variable in their nature, that  the details of the  ma-
nipulations may be left to the particular views of the operators who
may choose to undertake it.

 [Rhinoplasty—Operation for the  Columna, (Sous-Cloison, or Sub-
                           Septum)

  In adopting the Indian method, Mr. Liston of London, (in his Ele-
ments of Surgery) says  the hairy  scalp has in most cases to be en-
croached upon, to obtain the slip of  tegument for the  columna.
After engrafting it on the lip, also,  there is a risk of its not adhering,
and if  it does, it will, as happened in a case of his, be difficult to
prevent its shortening  and  turning inward  upon itself,  and thus
pulling down the  apex of the nose.  In the case to which he refers,
a columna  was made after the consolidation of the rest of the or-
gan, by borrowing a thick narrow strip, cut out from the middle of
the upper lip.   This modification  has also been since practised by
him with perfect  success.  The flap from the forehead is made to
supply only the alae and apex, the part for  this  last being only a
slight but  broad  projection of a few lines, serving as well for the
apex as for the attachment of the columna.   The latter must not be
cut till the forehead flap has perfectly consolidated.   This plan of
M. Liston, for the columna, has been found by him of eminent ser-
vice, in reparations where the columna only was wanting, and in
which the  deformity is nearly as great as where the  whole nose is
destroyed.  The  inner surface of the apex  is first pared, and the
middle portion of the upper lip, to the extent of about the eighth
of an inch  on each side  of the median line, and of the breadth of a
quarter of  an tnch, is then quickly insulated, by tM'o successive par-
allel incisions with the sharp-pointed bistoury, piercing through the
lip and proceeding from above doM'nward to the free border of the
lip.  The fraenulum  is then divided, and the prolabium of the flap
removed.   The flap is turned up (not twisted) and fixed to the apex
of the nose by a few turns of suture, made with the small spear-
pointed hare-lip needle.  Twisting the  flap would incur a risk, and
is not  necessary,  as the mucous lining of the lip, forming now the
outer  surface of the columna, readily  assumes the color  and ap-
pearance of integument, after exposure for  some time, as  is well
knoM'n.  The  edges of  the fissure in  the  lip must noM' be neatly
brought together by the twisted  suture, for which  purpose two
needles are sufficient, which must perforate  to the depth of two-
thirds of the thickness of the lip—one passing close to the vermilion
border. Should troublesome bleeding take place from the coronary
artery, one of the needles should be made to pass  through the cut
                              79 
626           NEW ELEMENTS OF OPERATIVE SURGERY.

extremities of the vessel.   Each thread is to be finally sccuicd by
a double knot, and Math a view to more exact compression,  the
thread may then pass from one needle  to the other, but the pins
must not be pulled upon, or the parts pucker in healing.  Tue ends
of the needles are to be  snipped off M'ith plies, and no further dress-
ing is necessary, as it might disturb the wound on being removed,
retain the matter, produce fcetor, and retard the cure.  The needles
may be removed, on the second  or third day, by gently rotating
them.  The crust formed by the threads,  and matter, and blood, is
not to be disturbed, as it serves as  a covering and protection, and
comes off in a few days after.  Some care is necessary in raising
and filling up the alae M'ith lint, in  order  to effect, by proper com-
pression, a repression of the cedematous engorgement M'hich is apt
to ensue in the columna.   The lower part of the columna, also, is
to be pushed upward, that it may come into its proper situation,
which is effected by a small roll of linen, supported by a narrow
bandage passed over it,  and secured behind the vertex.   The flap
from the lip is of great  advantage to that part, because, M'hen the
natural columna is destroyed, the lip is apt to sag doM'n and tumefy,
and become elongated in that very middle portion from M'hence the
flap is taken;  and besides, the  cicatrix being in the natural fossa,
is scarcely perceptible after the cure.
  Mr. Liston further remarks, that the alae of the nose, and deficien-
cies in the upper, anterior, or lateral parts of the organ, in the fore-
head, etc., may be supplied from the neighboring integument  on
the same  principle.  In many of these operations, the flap can  be
so contrived and cut out, that  it can be applied without its attach-
ment being twisted—as by making a more or less acute angle in
its pedicle, etc., M'hich angle is effaced when the flap  is applied.
This last  plan of  Mr. Liston's, then, virtually becomes the French
method, or anaplastic par decollement des tissues.—T]
               [RHINOPLASTY IN AMERICA.  '

  The first successful case of the operation of rhinoplasty perform-
ed in America, is stated, on the authority of Dr. Reese, (Loc Cit.,)
to have  been by Dr. John Mason Warren, of Boston, in 1837.  In
1840,  he again performed it four times ; first on a female, by the
Indian method, the flap being taken from the forehead, effecting in
this manner the restoration of the entire nose. In the second case,
he used the Italian or  Tagliacotian method, the flap being trans-
planted from the forearm, being the first successful case of this
method  in America.  In the third  case, he restored the alae of the
nose,  by sliding the flap from the cheek by the French method.  In
the fourth case, he again adopted the Italian method, for the resto-
ration of the tip end and alae of the nose, the flap being taken from
over the biceps  muscle.  In seventy-two  hours, the  adhesion Mas
sufficient  to allow of the  division of the flap;  being the shortest 
BLEPHAROPLASTY.
627
time on record in which that has been done.  The patient was M'ell
in two months.   [For the first three cases, see the Boston Medical
and Surgical Journal]  As remarked by Professor Velpeau in the
text, the sensations of the patient M'ere generally found by Dr. War-
ren, in his constructions of a new nose, to  be referred to the place
from which the  skin was borrowed ; to the  forehead, in those cured
by the Indian method, and to the arm in the  Tagliacotian. The pins
were used in his first case, but afterwards the interrupted  suture
was preferred.   The new nose, in some of Dr. Warren's cases, was
so perfect as not to be distinguished from a natural one.
  Dr. George McClellan, of Philadelphia, has performed rhinoplasty
four times, with complete success.  Dr. Gibson, of the same city,
eight times successfully, since his first attempt in 1827, which, how-
ever, failed.
  Dr. Mutter, of Philadelphia, has performed rhinoplasty five times.
  Dr. Muzzy,   of  Cincinnati,  (Ohio,) twice; once by the  Indian
method, successfully; the other,  by the Italian, did not succeed.
  Dr. March, of Albany, has had complete success (Reese, Loc. Cit.)
in two cases of rhinoplasty, by the Indian method.
  Dr. Pancoast, of Philadelphia, has operated successfully with rhi-
noplasty, in  three cases.—T]
                        CHAPTER IV.

       BLEPHAROPLASTY, (ANAPLASTY  QF THE EYELIDS.)

  The eyelids, more than any other part of the body, perhaps, are
subject to alterations which daily make us sensible of the value of
anaplasty.   Besides ectropion and entropion, M'hich sometimes re-
quire this kind of operation, there also occur losses of substance in
the eyelids, which can be remedied in no other manner.

              Article I.—History and  Indications.

  The adage of Celsus,  Si palpebra tota deest, nulla id curatio resti-
tuere potest, (De re Medica, lib. vii., cap. 3, sect. 2, p. 391, edit. Va-
lart.,) which has been a law in surgical practice, has given place,
in our days, to an axiom totally opposite.  It is now possible to re-
store the eyelids, as we restore the nose.   Moreover, blepharoplas-
ty, or blepharopoesis, which some surgeons of Paris, in 1833, viewed
as a new operation, although I had pointed it out in the first edition
of this book, is a process which was long since known.   M. Graefe
employed it successfully in 1816 or 1817, since he  refers to a case
of it in his treatise upon rhinoplasty, (Rhinoplastik, etc., Berlin, 1818.)
Another  German  surgeon,  Dzondi,  (Journ. de Hufeland,  1818,)
makes mention of it about the same time.  Nevertheless, the facts 
628
NEW ELEM1NTS OF OPERATIVE SURGERY.
set forth by these practitioners were almost entirely forgotten when
M. Fricke  (Journ. des Progres, 2° serie, p.  56-80) made  a decisive
trial of it in  May, 1829.  At the  same time, almost, M. Jungken
(Journ. d'Ammon, t. i., p. 262 ; Arch. Gen.  de Med., t. xxvii., p. 257)
published tM'o cases of similar attempts, but where it had complete-
ly failed.   From that time, blepharoplasty was  omitted  neither by
M. Langenbeck, (Nosologic und Therap., etc., t. iv., p.  188,) M. Rust,
(Handbuch der Chir.,  1830, p. 97,) nor M. Blasius, (Handbuch der
Akiurgic, t. ii., p. 14,) in their treatises.  It has  since been the sub-
ject of interesting dissertations from the pen of M. Dreyer, (Dissert.
Inaug., etc., Vienne, 1831,) M. Staub,  (Dissert.  Inaug., etc., Berlin,
1830,) and M. Peters, (De. Blepharoplastice, etc.,  Leipsick, 1836,) be-
sides  the articles which MM. Dieffenbach and  Ammon, in Germa-
ny, have devoted to it.
   In France, MM. Blandin, (Journ. Heb., t. viii., p. 95; Gaz. Med.
de Paris, 1835,  p. 406,) Jobert, (Gaz.  Med. de Paris, 1835, p. 404,)
and Carron du  Villards, (Guid. Prat,  des Malad. des Yeux, t. i., p.
364,)  also soon directed attention to it.  We must  add to their ob-
servations those which have been published by M. Robert, (Bar-
bier,  Thise, No.  6, Paris, 1837,)  and the cases which belong to my-
self.  It results from these facts, that blepharoplasty has now been
performed a sufficient number of  times to enable us to appreciate
its value.
   The circumstances under which this operation may be required,
are:  1. The destruction of a greater or less portion of the eyelids;
2. Certain cases of shortening (raccourcissement) of the palpebral
integuments; 3.  Many of the deformities ranged  under the head
of ectropion, entropion, and trichiasis.  Nevertheless, the princi-
pal purpose of anaplasty.to the eyelids, as elsewhere, should be to
supply losses of substance in the skin.
   Blepharoplasty comprises many varieties, which, however, all
belong to  anaplasty by transposition.   No one  has advised  to ap-
ply to the eyelids anaplasty by transplantation, nor even the Italian
method.  I will add, that  blepharoplasty, though it had already
been performed in three  different modes, that is to say, by the
method of the Koomas, or  torsion (contorsion)  of the flap, that of
Chopart, by draMdng (entrainement) or sliding down (inclinaison) of
the flap, and by the method of Franco, or stretching (allongement)
of the parts, has nevertheless continued to be  almost exclusively
restricted to the processes of Indian anaplasty.
   Whatever may be the process adopted, blepharoplasty will afford
no positive chances of success, except where the skin and the cel-
lulo-adipose or fibrous tissues only are destroyed.   Nothing, in fact,
can replace  the muscles of the eyelids, if they  are found  involved
in the mutilation.  It is  through  inadvertence that a surgeon of
Paris (Gaz. Med. de Paris,  1835,  p. 405) has said that  he had re-
stored the entire thickness of an eyelid by means of blepharoplasty.
It is nevertheless true, that in the lower eyelid, and in some cases
of the upper eyelid, where its levator  muscle is preserved, we may
construct, with  the skin of the neighborhood, something analogous 
BLEPHAROPLASTY.
629
to the tutamina oculi, and thus partially mask the deformity.   The
destruction of the eyelids, by leaving the eye in perpetual contact
with the  atmosphere, exposes the patient to ophthalmias of every
kind, and to the destruction (fonte) of the cornea, and makes him
sensibly feel how fortunate it would be, if he could count upon the
efficacy of blepharoplasty.

               Article  II.—Operative  Methods.

  The different modes of performing blepharoplasty, have almost
all been borrowed from anaplasty to the nose.  The three principal
processes for this purpose, which science should  preserve, belong,
one to M. Fricke, if not to M. Graefe, the second to M. Dieffenbach,
and the third to  M. Jones.   The figures annexed to the articles
already cited from  MM. Fricke, Peters, and Carron, give a  very
exact representation of them.

         § I.—Process of M. Fricke, or the Indian Method.

  M.  Graefe  and  Dzondi, having scarcely  alluded  to their  mode
of operating, have in some sort left to MM. Fricke and  Jungken,
all the honor  of blepharoplasty by the Indian method of anaplasty.
In this method, which I have twice employed for the upper eyelid,
and which MM. Blandin, Gerdy, Jobert, and Carron du Villards,
have  also made trial of at Paris, we begin by excising the tissue of
the cicatrices  which deform the eyelid, in  order to make in that
Dart a regular wound.   If there is no inodular tissue there, M'e cut
through the skin transversely, in order to be enabled  to elongate
the retracted (raccourci) part, or that  we may create there a void
in order to lengthen  the part by transferring a piece to this space.
This being done, M'e  cut in the neighborhood a flap which, turned
round by one of its borders, (contourni sur Vun de ses bords) is brought
forward and fixed by a sufficient number of stitches of suture, upon
the part of the eyelid where its  substance has been destroyed.  If
it is the upper eyelid, M. Fricke takes the flap from the forepart of
the temple, above  the outer extremity of the eyebrow.   This flap,
which he detaches from above downward, preserving a large pedi-
cle to it, is immediately brought, by its front border, to  the lower
border of the lid, M'hile its posterior border is attached by degrees
to the upper border of  the lid.   For the lower eyelid,  M. Fricke
takes his flap from the outer side of the cheek bone, and conducts
it also, by the same mode, to the vacancy to be supplied.   M. Am-
mon (Peters,  Oper. Citat., fig. 11, 12, 13, 14) has modified this pro-
cess in such manner that the wound of the  flap, and the wound of
the eyelid, are made continuous with each other in the form of
a capital L;  so that the horizontal branch  of the L ultimately be-
comes filled up by means of the flap, while its vertical branch re-
mains void.  M. Ammon, moreover, proceeds  in all the different
steps  after the method of M. Fricke, or that of M. Jungken.
  If MM. Gerdy, Blandin, and Jobert, have pursued a  somewhat 
630
NEW ELEMENTS OF OPERATIVE SURGERY.
different method in the construction and adjustment (placement) of
the flap, it is, doubtless, because they Mere unacquainted with what
had  been done,  in  this respect, in Germany; for their process is
evidently less" favorable to the complete success of the operation,
than those of which I have just spoken.

                             §11.

  In the first patient upon whom I operated, I felt myself obliged
to conform, in every point, to the rules of Indian anaplasty;  the
flap which I had cut upon the forehead Mras reversed, twisted, and
brought down, like  the arch of a bridge, upon the wound of the eye-
lid.  In the  second  case, I borrowed the flap from  the upper part
of the cheek bone,  and I imitated, in some measure, the process of
M. Fricke ;  but  it has appeared to  me that this  process requires
modification.
   The  rules which I would desire to  lay down upon  this subject
are the following:  1. That for the lower eyelid, the flap should be
cut from the temporal region, rather than upon the cheek, in order
that its root and the wound it leaves may tend, by their natural re-
traction, to draw the lid rather upward than downward; 2. That
this flap should,  at  the first, have twice the dimensions that it is to
retain afterwards;  3. That it  should be fastened by numerous
stitches of suture,  rather than  by compression ;  4. That it shall
have a pedicle as large and thick as the condition of the parts will
permit; 5. Finally, that we should approximate its upper side as
much  as possible to the free border of the eyelid.
   In one of the  patients treated at  the hospital of San Louis, the
operation M'as unsuccessful, because the  flap which had  been cut
from the cheek had agglutinated too far from the ciliary border of
the eyelid.  In one of mine, the deformity disappeared only in part,
because the flap, which  M'as a third larger than  the space it was
to supply, contracted (se  retrec'if) finally to more than one half its
size!  In the second case, the flap seemed to mortify in part, because I
had diminished the pedicle too much, or because I had not fastened
it by a sufficient number of stitches in the suture.  It is evident, that
if the root  of the  flap for the upper  eyelid, is situated  upon  the
cheek, it will be a means of preventing all consecutive ectropion;
and that, for the same reason, where we are treating the lower
eyelid, it is important that its root should be  turned towards  the
temple.

     § III.—Blepharoplasty by Sloping  (inclinaison) of the Flap.

   Chopart's method of anaplasty is applicable  to the eyelids, as to
other  parts of the face.   M.  Dieffenbach, also, has applied it in
such manner as to obtain from it a process of blepharoplasty alto-
gether peculiar.  To follow this method, we begin by excising all
the cicatrices, in  order to transform  them into a regular wound.
 We afterwards cut a flap of sufficient width, at the expense of the 
BLEPHAROPLASTY.
631
integuments on one of the sides of the new wound, so that this flap
shall have the shape of a trapezium, the inner  border  of which
corresponds to the outer lip of the wound, whilst its,upper or lower
border, according to the eyelid which it is to be applied upon, (a re-
tourncr) must be detached upon a line M'hich should extend beyond
the outer palpebral commissure.  To form this flap, therefore, we
must make a horizontal incision, which should be prolonged  to a
greater or less distance from the outer extremity  of the eyelids to-
wards the temple ; then an oblique incision, from above downward,
or from below upward, and  from within outward, according  as it
is for  the upper or lower eyelid, an incision which ought to have
nearly twice the length of that of the horizontal incision. By means
of these two incisions, and those which we have made to remove
the inodular tissues, we form a flap of the figure of a trapezoid, or
parallelogram, which is to be dissected from below upward on the
temple or forehead, for the upper eyelid, and from  above downward
on the  cheek, for the lower eyelid.  Nothing is afterwards easier,
than to draw (entrainer) this flap inward, without twisting or turn-
ing (contourner) it, so as to be  enabled to sew its inner border upon
the inner  lip of the previous  excision, and the free  border to the
teguments  adjacent to the ciliary border of the corresponding eye-
lid.  In conclusion, this flap then takes the place of the parts which
it has  been thought advisable to remove, and the situation which
the flap itself did occupy, is that in which the wound in fact is now
located.  By this process blepharoplasty is, in  reality, an operation
easy enough for any one to perform.   Many cases successfully treat-
ed in this manner, have been related by M. Peters, and I have been
convinced, in examining at Paris one of the patients operated upon
by M. Dieffenbach, that it is a process that should be preserved.  Its
principal inconvenience is that of obliging us to make a considera-
ble dissection of the tissues, of requiring so long a flap that M'e have
to apprehend its mortification, and of not being perfectly applicable
but to losses of substance that have greater length than breadth.

                   § IV.—Process of M. Jones.

  An operation more simple than the preceding, and which is, nev-
ertheless, a kind of blepharoplasty, is that which M. W. Jones states
that he has performed, (Encyclographie des Sciences Medicates, 1836,
p. 91.)   In this process M'e begin  by making two incisions, which,
setting out from the extremities of the diseased eyelid, proceed to
unite under a more or less acute angle, in the form of a V, more or
less elongated either towards the cheek or the forehead, according
to the eyelid for which the operation is to be performed.  We then
dissect this triangle from its point towards its base, to nearly one
half of its length; we then draw upon it, as if  to stretch it, by pull-
ing upon the free border of the eyelid itself.  Then immediately re-
closing, by means of the  suture, the wound which it leaves behind
it, M'e succeed in pressing it (a le refouler) towards the eye, by ac-
tually elongating the eyelid  to the extent to which it is deficient. 
 632          NEW ELEMENTS  OF OPERATIVE SURGERY.

 As this flap is neither twisted, reversed, nor inclined, Mre at the same
 operation reunite its borders, by some additional stitches of suture, to
 the tissues from which they  have been momentarily separated.  I
 have many times made trial  of this method upon the dead body.  I
 had become so satisfied with  it, that I M'ould have performed it upon
 a young girl, had I not recollected that M. A. Berard, in making trial
 of  it some months before, had failed  completely.   It nevertheless
 appears to me to be a modification  of blepharoplasty  which de-
' serves to be tested.   Since it  has reference  to a shortening of the
 tissues, a double incision  M'ill  permit of our drawing, in this man-
 ner, one of the eyelids towards the other as much as we may desire.
 In  order to secure the lid, and  to prevent it from shortening again,
 it suffices to reunite immediately the new wound; we have thus a
 simple rapid  operation, giving but little pain, which does  not re-
 quire the extensive dissections of the Indian method, and rarely ex-
 poses to a mortification of the  tissues.

                   Article  III.—Appreciation.

   We must not, however, deceive ourselves with any illusion in
 respect to the resources which blepharoplasty may supply.  What-
 ever mode we adopt, the eyelid which has been repaired  in the best
 manner possible, rarely fails  to become again deformed ;  sometimes
 the borrowed flap contracts  so much that it assumes the form of a
 small tumor, or of a prominence of more or less  irregular shape;
 sometimes it terminates by reproducing the ectropion, by draM'ing
 the repaired eyelid in one direction or another, in  the manner of an
 inodular bridle.  On the  other hand, it  would be folly to suppose
 that a flap, purely tegumentary, could ever replace an eyelid whose
 orbicular muscle, or tarsal cartilage, had been destroyed.  We may
 also readily conceive, that the eyelashes could not  be reproduced
 by this kind of operation.
    It results from this, therefore, that for all cases M'here the deform-
 ity of the lids is caused  solely by a disease of the skin, blepharo-
 plasty methodically performed offers a remedy which is truly valua-
 ble ; that even where the orbicular muscle is gone,  it may be of
 great benefit, if the eyelashes and the cartilage of the tarsus have
 been preserved. If the destruction should be deeper, still blepharo-
 plasty should not be rejected, provided it would allow us to furnish
 to the eye a protecting covering against the action of the atmo-
 sphere, and the inflammation  or destruction (fonte) of the cornea;
 but we should do wrong, in such cases, to  count upon procuring
 perfect eyelids, or to promise the patient that we  would wholly re-
 lieve him of his deformity.
            [BLEPHAROPLASTY IN AMERICA.

  Dr. George McClellan of Philadelphia has, according to the au-
thority of Dr. Reese, in  his last  and valuable American edition 
KERATOPLASTY.
633
(New York, 1842) of Cooper's Surgical Dictionary, [frequently cited
by us,] (see also North Am. Med. and Surg. Jour.) performed this
operation fifteen times, and Math most  satisfactory results.  Drs.
Mutter and Horner, of Philadelphia, Drs. Mott and A. C. Post, of
New York, and Dr. J. M. Warren, of Boston, have also frequently
succeeded in this delicate process.—T]
                        CHAPTER V.

                     KERATOPLASTY.

  It has, doubtless, never entered the mind of any one to graft on
a cornea, (greffer une cornee) in cases of atrophy, or disorganization
of the eye;  but it often happens,  that this tissue (membrane) only is
changed, and that by its opacity  vision  is rendered impossible.  It
is in such cases that certain oculists have suggested to substitute a
sound cornea, in  the place of the  diseased one.  Keratoplasty, con-
sidered in this  point of view, had already passed,  in the last centu-
ry, from theory to practice, if we are to believe Pellier, who  gives
himself out as its inventor.   The character of this oculist,  and the
few details he furnishes, have prevented surgeons from giving at-
tention to his assertions.  Since Pellier, keratoplasty has been sub-
jected to legitimate experiments by many authors of character
M. Moesner attempted it in 1823, M. Reisinger in  1824, M. Drols-
hagen in 1834; MM. Himly and Bigger (The Lancet, Aug. 1837 p. 750)
have also submitted it to various trials  upon animals.  These ex-
periments, resumed by M. Dieffenbach, and by M.  Stilling, (Ency-
clographie Medicate, 1836, p. 73,)  have induced some German prac-
titioners to make trial of it also  upon man.  Two processes,  even,
have been proposed for this  purpose.  In one, which is that which
experimenters have most frequently employed upon animals, the
diseased cornea is cut out, and replaced by a cornea taken from a
calf or sheep.   I should, as it seems to me, abuse  the patience of
the reader, to describe such an operation, and I should censure that
surgeon who would have the hardihood seriously to propose it to a
patient.  In the second process, which M. Dieffenbach has told me
he performed successfully upon a young girl, we pass, by means of
a fine needle, three threads through the cornea on the sides of the
opacity, (leucoma;) afterwards circumscribing the  spot by two in-
cisions, we remove it from the cornea in the shape of an ellipse, the
wound of M'hich is immediately  after closed by tying the  threads
previously passed through its entire thickness.  Since a man high
in rank in our profession, has said that he has been successful in
operating in this manner, we are bound to believe him; but I should
scarcely credit it if I had done it myself, and I doubt very  much if
M. Dieffenbach will find any imitators among discreet surgeons.
                              80 
634           NEW ELEMENTS OF OPERATIVE SURGERY.

Of two things, one must happen; either the transparent cornea is
opaque in its M'hole extent, in M'hich case there could  be no other
than keratoplasty by transplantation that could in reality be em-
ployed ; or there is but  a spot  in the  middle  of this membrane,
when it is clear that keratoplasty is not  as serviceable as the oper-
ation for artificial pupil.
  Pupil.—It might have  seemed that the experiments which I have
been speaking of, relatively to the cornea, would have formed the
last limits to these kinds of essays ; this, however, is far from being
the truth.  In the article above cited, M. Stilling speaks also of ex-
periments having for their object to create  a pupil upon  the scle-
rotica, by transporting to it a flap from  the cornea. MM. Moesner
(De Conformatione Pupillce de Artifi, etc., 1823) and Dieffenbach, and
M. Ammon himself, have however proved, by their reiterated fail-
ures, that the success of keratoplasty by transplantation is utterly
impossible.  Nor have I learned that the experiments which M.
Stilling instituted, during his sojourn  at Paris, have confirmed those
which  he made in Germany.   To express myself with all sincerity,
I must say that such trials, in my opinion, only seem calculated to
consume the time of the experimenters, and to impede the legiti-
mate march of operative surgery.
                        CHAPTER VI.

             ANAPLASTY OF THE LACHRYMAL SAC.

  Some surgeons, particularly M. Dieffenbach, have had recourse
to anaplasty for certain cases of fistula lachrymalis.  We may in-
deed conceive that the integuments of the neighborhood, separated
by one of the processes of blepharoplasty, might possibly be appli-
ed and secured by strips of adhesive plaster, or appropriate band-
ages, upon losses of substance at the  great angle of the eye.  But
I do not believe that anaplasty can be of any great value in these
cases, even though we should substitute for the other processes the
tegumentary cork (bouchon tegumentaire) which in 1833 I  proposed
(Gaz. Med. de Paris, 1833, p. 317)  to apply to them.  The cutane-
ous opening, in such cases, is but a trivial circumstance in the dis-
ease.  I therefore do not see any reason for directing our attention
to this, when we wish to relieve  a fistula lachrymalis.  In order
that anaplasty in the great angle of the eye should  be indicated, it
would be necessary that there should have been gangrene, ulcera-
tion, or some wound that has caused there a loss of substance, in
which the front part of the lachrymal sac has been involved.  Then,
in truth, the borrowed  flap would have the same object to effect as
on any other part of the body.  It  remains to be seen, if such con-
ditions shall present themselves in practice. 
CHEILOPLASTY.
635
                        CHAPTER VII.

                      CHEILOPLASTY.

   The art of repairing  and restoring the lips, when mutilated or
 destroyed, has in our day made the most astonishing progress.  Un-
 til recently, a loss of substance sufficiently extensive to render sim-
 ple cheiloraphy impracticable, seemed to be beyond the resources
 of surgery; now, on the contrary, the most hideous deformities do
 not appal the skilful operator.  Whether a lip be wanting  on one
 side or the other, whether it be deficient in whole or in part, alone
 or M'ith a portion of the cheek, it is almost almost alM'ays in our
 power to reproduce it, by borrowing what M'e stand in need of from
 the surrounding parts.   Therefore the surgeon is rather to plan out,
 (doit deviner) than to learn cheiloplasty.  It is an operation which
 can scarcely be submitted  to detailed rules,  and which we have to
 modify almost as often as Mre practise it.  Every process of ana-
 plasty has been applied  to it.  Tagliacozzi  says he succeeded  by
 the Italian method, that is, by borrowing from the  arm the materials
 for the new lip.  Delpech, M. Lallemand, Dupuytren, M. Dieffen-
 bach, and M. Textor, have used the Indian method.   Finally, the
 French method now counts a great number of trials.   There are
 none of these methods, not excepting that of  Celsus, in which the
 incisions were made either vertical, horizontal, internal, or external,
 outside, the deformity, that have not found their advocates.  Having
 for their object to remedy lesions of  various form and character, it
 was to be presumed that each one of those methods would soon in-
 clude a number of distinct processes.

                Article I.—The French  Method.

  The method of detaching  the tissues, (decollements) is in these
 cases applicable in all its processes.

             § I.—Process  of Horn, or of Roonhuysen.

  If there is only a  notch  in one of the lips, provided its breadth
 transversely is of no great extent,.even if it should be very deep,
 the cheiloplasty differs but  very little from the operation of hare-lip.
 The first thing to be done,  is to transform the abnormal notch into
 a fresh wound, and  to give it  the form of a V, by excising  its bor-
 ders and every thing about it which is diseased,  with a scissors or
 a bistoury.  In the second place, the  surgeon dissects in succession,
down to beyond the  point of the bleeding triangle, and in a space
proportioned to the width of the void to be filled, the tM'o flaps of 
636
NEW ELEMENTS OF OPERATIVE SURGERY.
soft parts, separates them from the maxillary bone, and turns them
outward.  Nothing afterwards is more easy than to elongate them,
and to put them in contact, by drawing them toM'ards each other.
The suture is applied, as in the hare-lip, and M'ith the  same pre-
cautions.  The posterior surface of the new lip unites to the subja-
cent parts at the same time that its two halves become agglutina-
ted together; and its free  border, after the  cure, differs in reality
from what it was before  the disease, only in  having a little less
length.   Nevertheless, this process has the disadvantage of narrow-
ing the mouth to a very considerable degree, and of sometimes giv-
ing to its aperture a very disagreeable deformity.

                  § II.—The Ancient Process.

  Celsus, it is  very  probable, had  something analogous in view,
when he  advised to make a transverse incision, then a semilunar
one, upon the internal surface of each cheek, between the cheek
bone (pommette) and the commissure of the  lips, in order to admit
of the elongation of the two halves of the divided lip.   Every thing,
in short, induces us to believe that this kind of cheiloplasty, of which
Galen and Paul of Egina also say a few words, had been already
reflected upon in those times.

                  § III.—Process of Guillemeau.

   After having freely dissected off the parts, M. Dieffenbach often
finds it useful to relax them, by means of the lateral incisions of
Guillemeau,  or of Thevenin.

                   § IV.—Process of Chopart.

   The preceding operations may suffice very well, when the loss
of substance has  not been very considerable  in breadth; in the
other cases, however, M'e must renounce it and give the preference
to one of the processes which I am about to  describe.  That which
appears  to have originated with Chopart, and which I have seen
succeed completely in many cases, is one of the most valuable.  If
the case is one of cancer, the surgeon commences by making, exter-
nal to and upon each side of the disease, an incision which descends
vertically from the free border of the lip to beneath the lower jaw;
afterwards dissecting the quadrangular flap traced out by these two
incisions, he detaches it from  above downward, preserves  to it all
the thickness possible, and taking care not to graze too  near the
periosteum, prolongs his dissection to a greater or less distance be-
low the  chin, according to the greater or less  quantity  of diseased
parts he thinks he  shall have to remove, (detruire)   This being
done, he cuts out, in a square shape, every thing which  is changed,
trenching a little, at the same time, upon  the sound tissues;  re-
 moving  thus with a single cut the whole of the cancer, he imme-
 diately seizes the flap that  he has just dissected, adjusts it in front 
CHEILOPLASTY.
637
of the chin, and by gentle tractions raises its upper border to a line
with the upper lip, or with what remains of the border of the lower
lip outside; three or four stitches of twisted suture on  each side,
serve afterwards to secure it to the lateral  parts of the face, begin-
ning always with the upper needle;  nothing more remains to be
done, than  to recommend the patient to keep his head inclined for-
ward, in order to  prevent all traction or tearing.  To understand
with what  facility these flaps yield and become elongated, we must
have been  witness to it.  In one of the cases which I had an oppor-
tunity of seeing, the operator being compelled to remove the whole
extent (epaisseur) of the tissues, up to  the  limits of the  orbicularis
muscle, did not terminate the root of his  flap until he had reached
towards the middle of the supra-hyoidean  region. Nothing, how-
ever, was easier than to bring up its border to a level with the line
which the lip formerly occupied. In four days the reunion appeared
to be completed,  and all the needles  could be removed.  No sup-
puration came on, neither  at the lateral borders nor upon the
posterior surface of the flap, while its upper margin soon became
covered with a reddish  pellicle, to a great  degree resembling that
which naturally covers the vermilion border of the lips,  (Vouverture
buccal;) on the fifteenth day, the patient, who was forty-eight years
of age, exhibited scarcely any trace of the operation.  Another case
was not less fortunate, and I  have not learned  that any accident
has  since happened to them.  This new  lip, however, having no
constrictor muscle, ordinarily remains without motion, (immobile)
resting against the teeth, and as if drawn backward; but such tri-
fling inconveniences cannot enter into comparison with those that
are caused by the necessity of wearing a  silver lip, and patients are
fortunate indeed, when they  can be relieved at such  a price as
this.

     § V.—Process of M. Serre, (Rev. Med., 1835, t. ii., p. 134.)

   If the mucous membrane is not degenerated,  M. Serre  dissects
and preserves it, in order to bring it forward (ramener)  and sew it,
as a covering, (bordure.) to  the skin of the free border of the flap,
or neM^ lip, as he terminates the operation.   We thus obtain a more
regular conformation, and one  more in correspondence with the
original condition of the parts, than by a pure and simple excision.
The only difficulty in this modification is, that it is not  practicable
but in a very small number of cases.

  § VI.—Process of M. Viguerie, (Journ. Hebd., 1834, t. i., p. 186.)

   Upon the supposition that the disease has not involved the mouth,
but extended  rather in  the  direction of the chin, we  might, while
cutting and dissecting  the  flap as in the preceding cases,  leave
a bridle above.   After having removed from it the diseased tissues,
the flap should be raised up towards the  mouth, and fastened by
means of the suture by its upper border, to the preserved bridle of 
638           NEW ELEMENTS OF OPERATIVE SURGERY.

the lip.   The patient thus treated by M. Viguerie, recovered per-
fectly.

                  § VII.—Process of J. N. Roux.

  M. J. N. Roux (Revue Med., 1828, t. i.,  p. 30) has several  times
employed cheiloplasty by a process which he considers as his own,
and from which he has obtained remarkable results.  In the  place
of cutting a flap which is to be raised up after the diseased  parts
have been excised from it, this practitioner begins by circumscrib-
ing, by means of incisions made in proper directions, every thing
which it is important to destroy, and thus removes the cancer.  By
a careful dissection, he then detaches the surrounding  soft  parts
from the maxillary bone, and from the anterior region of the neck;
he thus forms, out of the skin and cellular tissue, a kind of apron,
(tablier) which he raises up to a level with the upper lip, and m ith
M'hich he encloses (emboite) the front part of the jaw ; he secures it
there either with strips of adhesive plaster, or, when it has been
necessary previously to prolong the commissures by a transverse
incision, he fastens and suspends it, by some stitches of suture on
each side, to  the upper border of the wound.  The patient,  as-
sistants, and surgeon place themselves as in the operation for  hare-
lip.
  It the disease extends somewhat beyond the  transverse limits of
the lower lip, M. Roux makes, with the  scissors,  a first  incision of
a semilunar shape, an incision which dilates each  commissure in
the same proportion, by prolonging  them toM'ards  the masseters;
he then, with the bistoury,  makes  another  incision on each side,
commencing with them at the outer extremity of the first, and car-
rying them down to below the cancer, so as to unite them in front
of the chin ; in removing all the diseased (degcnerees) parts, he pro-
ceeds sometimes to the extent of laying bare the entire body of the
jaw; he then dissects upon their  inner  surface  what remains of
the cheeks, returns to the chin, descends to the sub-maxillary bor-
der,  and to the supra-hyoidean region, preserves as much thickness
as possible to  the  integuments, draws them upward, attaches their
extremities to the extended wound of the commissures in such man-
ner  as  to leave a sufficient length of flap free, to represent the
border of the  lower  lip; finally, he supports the whole with  some
strips of adhesive plaster, and  a sling  and containing bandage.
When, on the  contrary, one side  of the lip is sound, (intact)  and the
disease extends to a certain  distance upon the cheek of the opposite
side, there are three incisions required to circumscribe the  cancer;
one somewhat short and transverse, above the affected commissure ;
the second, straight or curved, it  is  of no importance which, is equal
in length to the first, is made continuous with it, and descends ob-
liquely  in front towards the chin ; the third, finally, which commen-
ces near the sound commissure, and terminates by uniting with the
second.   After dissecting  the border cut by this last, we bring it
towards the first  incision, and  the suture is applied, to maintain 
CHEILOPLASTY.
639
the M'hole in contact.  By this  transportation, the last wound as-
cends to the position of the free border of the lip destroyed, which
it represents sufficiently well, and the form of the  mouth is pre-
served.
  Operating upon these  principles, or those of Chopart, M. Cam-
brelin, (Arch. Gen. de Med.,  t. xxvi., p. 263,) M. Thomas, (Journ. des
Conn. Med.  Chir., t. iii., p.  269,) and M. Nichet, (Bouchacourt. Rev.
Med., 1838, t. iii., p. 242,) have each had a fortunate result.  I have
myself, in conforming to the precepts of  M. J. N. Roux, succeeded
in repairing, in part, a deformity in an old man, in whom I had to
extirpate the whole contour of the mouth; and also in a young
girl,  who had  lost her lower lip  in infancy, in  consequence of a
gangrenous affection.  It is nevertheless  true, that the simple pro-
cess  of Chopart, when it  is applicable, merits  the preference, and
that  it answers the purpose where the lower lip alone requires to
be repaired.  If we have also to fill up some void near the commis-
sures, or upon the upper lip, the process of dissections, (decollements)
either simple or associated  with the incisions either of Chopart, or
of Dieffenbach, are evidently to be preferred.  I should add, also,
that  in regard  to transverse elongations, we should do  M'rong to
count much upon the method of dissections practised at the lips;
and  that young subjects, well made and of  firm flesh, are the least
favorable to this kind of anaplasty.

                 § VIII.—Process of Ph. Roux.

   In a young girl, who  had nothing remaining but a very small
portion of the lower lip, and M'ho had also lost, from  her infancy,
more than the half of. her upper lip, the maxillary  bones M'ere so
deviated outward  that they projected to  a  considerable extent,
through the loss of substance.  To remedy this horrible deformity,
M. Ph. Roux (Rev. Med., 1830, t. i., p. 5) concluded to make  the
operation in two stages, (en deux temps)  and proceeded in the fol-
lowing manner:—After having transformed the  lower half of the
wound into a triangle, by the excision of its borders, and after hav-
ing detached its two halves to the extent of several inches, he had
recourse to two cuts of the saw, and removed about an inch of the
jaw. Then having approximated the two portions of the bone, he
brought the two flaps of the fresh wound together, kept them united
by the twisted  suture, and  succeeded thus  in restoring  the lower
lip, and in more than half curing  the young patient, without  much
difficulty.  The success of  this  first stage was complete; but M.
Roux, who M'ished to proceed in the same manner with the second,
and  to destroy also a portion of  the upper jaw, found an insur-
mountable obstacle in the opposition of his patient.  It is evident,
however, that the excision of  bone would have  presented  much
more difficulty there than  below, and that to effect it, he would
have been obliged to make much more use of the gouge and mallet,
or of the cutting nippers, (tenailles incisives) than of the saw.
  By the exsection of bone, the surgeon hoped to diminish sufficient- 
640           NEW ELEMENTS OF OPERATIVE SURGERY.
ly the transverse dimensions of the face, to be enabled to bring into
coaptation the opposite sides of the wound.

§ IX.—Modification by M. Morgan, (The Lancet, July  1829, vol. ii.,
                           p. 537.)

  In 1829, M. Morgan had a case of an old man, whose  lower lip
M'as entirely destroyed by a cancer.  A semilunar incision, with its
concavity above, enabled him to detach and excise all the diseased
tissues.  From the middle of this incision he made another, which
he directed perpendicularly towards the os hyoides;  dissected off
successively the two flaps thus traced out, as in the T incision, from
the median line towards the sides, and from above downward ;  and
thus M'as enabled to bring them up in front of the lower jaw, and
make use of them to  replace the lip which he had just  removed.
Some stitches of twisted suture held them in contact, and sufficed,
together with the sling bandage and plumasseaux of lint, to prevent
them from descending to their natural position.  The success ap-
pears to have been complete ;  but another old man, operated upon
in the same manner  at a little later period, October, 1829, by M.
Lisfranc, was less fortunate.  Towards the fifth or sixth day, the
patient suddenly died.  The operation  is  assuredly more easy by
this process than by that of M. J. N. Roux ; but it is doubtful if we
can by this means give as much regularity to the free border of the
new lip, as by the original  process of M. Chopart.  It is, however.
a modification  which may have its value, and may in part be ad-
mitted into the French method, of which, in fact, the process of M.
J. N. Roux itself is nothing more than a slight variety.
   The great point here is the dissection of the tissues which envelop
the bones about the circumference of the wound; all the rest  has
reference to the modifications  required  by the nature  of the lesion
to be remedied.  Guided by this principle, M. Nichet (Gaz. Mid. de
Paris, 1836, p. 454) was enabled, by merely dissecting a flap of in-
teguments rolled up under the chin, and by paring the contour of the
wound, to cure a large fistula in the supra-hyoidean region, produ-
ced by a discharge of fire-arms.   It is for the surgeon to multiply
or diminish the number of incisions, and  to determine their form,
direction, and depth, as often as he is called upon to put in practice
the French method of cheiloplasty.

                  Article  II.—Indian Method.

   Delpech is the  first, I believe, who applied the Indian method of
anaplasty to the lips.  After having cut and dissected  his  flap upon
the supra-hyoidean region, he raised it, twisted  it upon itself,  and
doubled it upon its cellular face, before attaching  it, by numerous
points of suture, to the two sides of the deformity which had been
previously pared.   This folding (doublure) of the flap, suggested by
Delpech, had for  its object to give to the new lip two cutaneous
surfaces, instead of one, and to prevent the adhesions of its free 
CHEILOPLASTY.
641
border to the alveolar arch.   The operation thus performed, was
not successful.  Gangrene ultimately destroyed nearly the whole of
the flap.
  Appreciation.—Delpech was not more fortunate in a second case
of Indian cheiloplasty.   M. Lynn had, in the  year 1817, performed
it, according to M. Brodie, with better results, and M. Textor (Bull.
de Ferussac, t. xv., p. 326; Journ. de Progris, t. xiv., p. 246) takes
to himself  the credit of having  once  performed it in 1827.   M.
Dieffenbach also appears to have cured some cases by it, (Gaz. Med.
de Paris, 1831, No. 2 ;) but these practitioners took very good  care
not to follow the example of Delpech,  by doubling  the flap  which
they had borrowed from the neck.  In  a case where a  large trape-
zoidal flap M'as taken from below, raised up  but not doubled, and
then fixed by means of suture to the contour of the part M'here the
loss of substance was, M. Voisin (lb., 1836, p. 366) of Limoges, was
enabled to  reconstruct for his  patient all the parts of a lower lip
and chin.
  The advantages of the method of dissecting the  tissues, which
M. Roland (Serre, de la Reun. Immed., p. 514) of Toulouse, once put
in practice  with success, which M. Blandin (Thise de Concours., p.
151) has also made trial of, and which  I myself tested in 1830, (Ro-
mand. Thise, p. 24,) at the hospital of St. Antoine, at La Pitie in
1831, after  the removal  of the inferior maxillary bone, and since
then on four or five patients at La Charite, are not less indisputa-
ble.   The two unsuccessful trials of Delpech (Clin. Chir. de Mont-
pellier, t. i.) with the Indian method, prove that it is but of second-
ary importance, and  then only when the loss of substance is too
deep  or too extensive to allow of remedying it by stretching the
tissues over it.  The  processes of Celsus, (lib. vii., cap. 3, sect. 4,)
and  of Franco, (Traite des Hernies, 1561, p. 462, ch.  122,)  are in
reality nothing more than varieties of this method, a variety which
ought only  to be called to our aid in certain particular cases. As to
the Italian  method, it is no more suitable at the present day, to the
restoration  of lips, than it is to rhinoplasty.   The following  article
will enable us still better to appreciate the force of these remarks.

  Article III.—Cheiloplasty by a Hem  (ourlet) of the Mucous
                          Membrane.

  In consequence of cutaneous affections, burns, ulcerations,  etc.,
the anterior orifice of the mouth sometimes becomes so contracted
and indurated as to disfigure  the patient, and interfere with the
functions of the lips.  [These  abnormal contractions of the mouth
are sometimes congenital.—71]

                             § I-
  In  view of such an evil, the first remedy which presents itself to
the mind is, mechanical dilatation.  Unfortunately, this means can
give only temporary relief, and has rarely effected any permanent
cures.
                              81 
642
NEW  ELEMENTS OF OPERATIVE SURGERY.
                              ML

  After dilatation, comes incision of the labial commissures, which
we should take care to prolong a little beyond what would be really
required, since the wound, in cicatrizing, never fails to contract it-
self more than M'e desire.   If M'e could without difficulty cause the
two  borders of the solution  of continuity to cicatrize separately,
this first operation would effect, as well as we could wish, the ob-
ject we have in view; but it is not so.  In spite of compresses spread
with cerate, pieces of sheet-lead, and the small hooks that are made
to draw constantly upon the angles of the wound, it nevertheless
finally becomes reagglutinated,  and  places  matters in  the same
condition in which they were before, if in truth the deformity does
not thereby ultimately become considerably aggravated.

                             §111.

  Some practitioners have thought that they could more effectually
overcome the  difficulty by treating the contraction (coarctation) of
the lips by means of lead wires, (fil de plomb)  A trochar plunged
through the skin near the mouth, at  the place where the commis-
sure on each side should be, drills (fraie) a hole for the wire, one
extremity of which in the mouth, brought through the natural open-
ing, should be united to the other, in order that  the surgeon may
twist them as in fistula in ano, and gradually cut through the in-
cluded tissues.  This  process, though  less alarming to the patient,
is much longer than the preceding, and can scarcely be considered
more certain.   In proportion as the wire cuts the parts, they reunite
outside of it, so that  in reality the ligature  is not more effectual
than the incision.

   § IV.—Process of M. Serre, (Gaz. Med. de Paris, 1835, p. 317.)

   This difficulty now, however, seems no longer to exist.  The in-
cision being made, M. Serre, by means of the suture, puts in  con-
tact the mucous border with the cutaneous border of each  lip, and
thus prevents  all new agglutination.   Operating in this manner on
a young girl, I have obtained the same successful result as the  pro-
fessor of Montpellier.

                   § Y.—The Hem, (Ourlet)

   Reflecting  upon these difficulties,  and  the insufficiency of the
known means, M. Dieffenbach (Journ. des Progris, t. ix.,  p. 268)
supposed that by excising a portion from the tissues of each labial
angle, to the  extent, for example, of an inch, and leaving the  mu-
cous membrane wholly intact, M'e should probably obtain complete
success.  Facts have justified  his theory,  and already it has been
attended with successful results, that leave nothing to desire.  His 
CHEILOPLASTY.
643
process, which is more easy to understand than to perform, is nev-
ertheless available to every one.  The surgeon introduces into the
mouth of  the patient the point of his finger, to support and protect
the organic layer which it  is his intention to preserve.  With the
other hand, he directs the blade of  his scissors upon the border of
the contracted opening, a little  above the commissure, and intro-
duces it with caution from before backward, between  the mucous
membrane and  the other  tissues,  and  horizontally to the point
where he wishes to place the corresponding angle of the lips ; hav-
ing cut with a single stroke, and square through, (carrement) every
thing which is found included between the branches of his instru-
ment, he makes, a little lower down, another incision parallel with,
and in every respect similar to, the  first,  including as much of the
tissues in the lower lip as he had in the upper; then reuniting the
two wounds by a small  semilunar section at the outer extremity,
he isolates the little strip thus circumscribed, and excises it, without
touching the mucous membrane, which he also afterwards lays bare
all  around the wound; after having done the same on the opposite
side, he gently separates the jaws of the patient, as if to stretch the
membrane which forms the bottom of the wound, and divides it
transversely into two equal portions, and to within three lines  of
its  genal  extremity, [i. e., the extremity towards the cheek.—T.,]
draws it out and turns it  over upon the  labial  commissure which
he has just made, first on the lower and  then on the upper border
of the division, in both which places he fastens it, and  also to the
vermilion pellicle of each border of the  lips, by means of a suffi-
cient number of fine short needles, or  by  the tMdsted suture, either
alone or combined with the interrupted suture.  The operator here
makes use of the mucous membrane as a lining, which he unites to
the integuments by a sort of  hemming operation,  (par une sort
d'ourlage) as the shoemaker unites  to the leather of his shoes the
last side of the riband which is  to cover its borders.
  Operating in this manner upon a young  girl, M'hose mouth was
strongly contracted  in consequence  of a  phagedenic eruptive dis-
ease, I made use of a bistoury in lieu of a scissors, and it appeared
to me that by this means the section of the tissues was accomplish-
ed with greater ease.
  Another modification, which  would also have its advantages,
would be the following :—The excision of the tissues is completed ;
the mucous layer (la couche muqueuse) gently thinned down, (modere-
ment amincie.)  and stretched like a piece of linen, alone remains at
the bottom of the wound.   Before slitting (fendre) this membrane,
we  insert all the threads, one after the other, from the mouth into
the wound, after which we carry them  outM'ard  from the  M'ound
through (a tracers) the cutaneous border  of the division, commen-
cing with the lower range and finishing with the superior range of
each commissure.  Then dividing the  membrane between the two
lines of threads,  the surgeon has only  to  take hold of the ends of
these  latter and  tie  them, to  complete the operation.  I  have
found that I have in this manner been  enabled  to give great regu- 
644
NEW ELEMENTS OF OPERATIVE SURGERY.
larity to the suture, while rendering the operation  evidently more
easy.

                             § VI.

  M.  Campbell, (Gaz. Med. de  Paris, 1833, p. 153,) who has  re-
peated the operation of M. Dieffenbach with success, also used the
bistoury instead of the scissors;  but the  scissors were preferred in
the young lady whom M. Mutter (Cases of Autoplasty, $-c,  Phila-
delphia, 1838) recently operated upon in America, with complete
success.
  If the mucous membrane, which should not be too much thinned
down, is well stretched, and well hemmed upon the bleeding bor-
ders of this wound, it agglutinates to it (s'y colle) with the greatest
facility, and in the space of a few days.  The artificial portion of
the lips afterwards acquiring the same state of organization as the
natural portion, their reunion is hardly any more to be apprehended
at the sides than at the middle.
  There  is nothing more  ingenious than this  process, and even
thing  induces to the belief that it will be generally adopted. Ap-
plicable to every modification and degree of the disease, whether
acquired or congenital, and whatever be the age of the patient, the
only objection to  it is, that it requires great delicacy in its execu-
tion.  It is an operation that should be made trial of wherever the
contraction is not surrounded  with too  extensive an alteration of
the mucous membrane of the lips.
  [Dr. Eve, of Georgia, (U. States,) has recently,  says  Dr. Reese,
(Loc  Cit.) successfully removed a cancerous lip by the method of
Velpeau, (see  North  Am. Med. and Surg. Jour.) separating the  lip
by the French method of anaplasty, and terminating with the con-
tinued suture.—71]
                       CHAPTER  VIII.

                      GENOPLASTY.

  The cheeks, also, are of a nature  to admit, to a greater or less
extent, of a perfect restoration.  Their loss of  substance, also, al-
most  always includes at the  same time a portion of the lips, and
renders the face truly hideous.  And there is scarcely any descrip-
tion of means, that within the last twenty years have not been re-
sorted to, to  remedy this difficulty.   Delpech, and M. Lallemand,
(Archiv. Gen. de Med., t. iv., p. 242,) appear  to have been  the first
who have paid particular attention to it among the moderns. 
GENOPLASTY.
645
                Article  I.—The Indian Method.

  A young girl, ten years of age, had at the lower part of the left
cheek, in consequence of  gangrene, a wound of an irregularly cir-
cular shape, two inches in extent in both its diameters, involving
half an inch nearly of the lower lip, but only some lines in extent
of the upper lip.   To fill up this  void, M. Lallemand  commenced
by trimming off (aviver) its whole circumference, giving it the form
of an ellipse rather more curved above than below, and the outer
extremity of the longer diameter of which reached to the space be-
tween the masseter and  triangular muscle of the lips, while the
other rested upon the upper and outer side of the tuft (houpe) of the
chin.  He then proceeded to cut upon the side of the  neck, under
the angle of the  jaw, and in front of the sterno-mastoid muscle, a
flap of the same form, but full one  third larger.  This flap, ob-
lique from above downward, and from behind forward, and no far-
ther attached to the living parts than by a kind of root  of about an
inch width, and  the upper  border of which flap, moreover, made
part of the wound, was brought  gradually and without torsion, by
drawing  the whole of it from below upward,  on to  the  wound,
where the operator fastened it by several stitches of interrupted su-
ture, strips of adhesive plaster, layers (gateaux) of lint, and some
turns of bandage.  The elliptical form was preferred, with the view
of facilitating the reunion of the wound in the neck, and the torsion
avoided, because the surgeon apprehended it might tend to a gan-
grene of the borrowed parts, as had happened in the case of Del-
pech.
  The operation of M. Lallemand did not succeed without being
attended with some accidents.   The wound  was torn apart (se de-
chira) several times, in consequence of the cries and restlessness of
the child, and perhaps still more owing to the presence of a canine
tooth, which projected outwardly, and which it  became necessary
to extract.   Nevertheless, the cure was ultimately effected.
  Since then, Dupuytren (Journ. Hebd., t. v., p. 110) has made an
attempt of the same kind, but in a case much more complicated.
His operation came under the head both of cheiloplasty and geno-
plasty.  The patient was a child nine years of age, who, in conse-
quence of gangrene, had lost the left half of the lower lip, as well
as of the corresponding cheek, under the labial commissure, and to
within three lines of the masseter muscle.   The flap was taken in
front of the sterno-mastoid muscle, twisted upon itself, and fastened
to the abraded (refrdichis) borders of the wound by five stitches of
suture.  The anterior needle at first, andlhen the one next to it be-
low, having cut  through the tissues, were detached.   The lower
border alone mortified and  suppurated.  A notch of an inch long,
having its  base  upon the free  border of the lip, was the result.
Everywhere else, the union took  place.   To  make this new void
disappear, Dupuytren treated it as a simple hare-lip; but the tongue,
which had for a long  time  contracted morbid adhesions upon this 
  64b           JEW ELEMENTS OF OPERATIVE StR'JI.P.Y.

  side, was an obstacle to the ultimate completion of an agglutinativ.«:i
  which at first seemed  to have  promised entire success.  The fact
  nevertheless proves, that torsion, so  much dreaded by M. Lalle-
  mand, does not necessarily involve the mortification of the (lap
  which has  been submitted to it, and that, in a case of necessiiy, we
  may with great propriety take  from the neck the integuments that
  we may require, to fill up wounds of the  face  that are attended
- with loss of substance.

                 Article II.—The French Method.

                    § I.—Process of J. N. Roux.

    In a similar  case to that of M. Lallemand, M. J. N. Roux (Rev.
  Med., 1828, t. i., p. 30) adopted another mode.  The cancer, M'hich
  had destroyed the left  cheek, and trenched  upon the lips, represent-
  ed at this point an ulcer, two inches in width from above downward,
  and an inch and a half transversely.   By  means of two semilunar
  incisions, which commenced at the lips and united  in front of the
  masseter muscle, the surgeon effected the excision of the carcinoma,
  and obtained in its place a fresh elliptical M'ound, a little  longer
  transversely than from above  downward, (un pen plus large que
  haute,*) in  order to be  able to bring its lips together.  He dissected
  the whole  lower lip to near the masseters, and to below the chin.
  The sides of the wound were then easily brought into contact.  The
  twisted  suture, the strips of adhesive plaster, and the containing
  bandage, applied as usual, prevented all displacement, and the cure
  was completed in a very short  time.

                    §  II.—Process of Gensoul

    A woman, aged fifty years, had, when  nine years old, her left
  cheek destroyed by gangrene.   When admitted into the hospital of
  Lyon, in the month of June, 1829, she presented on the left side of
  her mouth an enormous loss of substance, which left bare a great
  portion of the two jaws, the two lateral incisor teeth, the two canine,
  and the  first three molars upon that side, all of them projecting
  very much outwardly.  The circumference of the ulcer, which had
  cicatrized a long time before, was closely adherent to the  bones,
  and had caused an anchylosis of the lower jaw.  After having sepa-
  rated it  from the bones, and  abraded  it,  M. Gensoul  (Journ.  des
  Hopit. de Lyon, t. i., p.  16) then detached from the subjacent tissues,
  from above downMard, and then  backward, both the remainder of
  the cheek, as well as  the corresponding extremity of the lips, as
  far as the  neck in one direction, and to the masseter in the other.
  Compelled to resort to the gouge and mallet to remove the project-
  ing portion of  the prominent jaw, as well as  the teeth that were
  implanted  in it, he was afterwards enabled to approximate the twe
* [To avoid mistake, we have translated this phrase by a circumlocution.—T.J 
GENOPLASTY.
647
borders of the wound, and to apply the  suture.  A small salivary
fistula, scarcely visible, was all that remained in this woman, after
so vast a destruction of parts.

                  § III.—Process of Ph. Roux.

  Here is a case to which I have been witness, and which, while it
blends with the preceding cases, nevertheless, in some respects dif-
fers from them.  A young girl about twenty years of age, endowed
with determined courage, and of remarkable docility, had had, two
years before,  the ala of the nose, and the half of the upper lip and
of the cheek, situated above the horizontal  line of the mouth, de-
stroyed by gangrene.  A portion of the maxillary bone having also
been  necrosed, there resulted  from it a communication from the
wound to the nasal fossa?, as well  as the sinus  maxillaris and the
tongue constantly hung out of the mouth.  Admitted into La Cha-
rite in the summer of 1826, M. Roux yielded to her entreaties, and
undertook the cure.  To effect this object  he performed seven dif-
ferent operations, which extended  through a whole year.  A first
attempt permitted him to dissect the left side of the lower lip, and
to displace  it, by carrying it upward to make use of it for supplying
the destroyed portion of the upper lip.  Every thing, in this trial,
succeeded to  the satisfaction of the operator.  The buccal opening
was then found completely separated from the wound, which latter
was itself reduced to a large ulcer of a rounded shape, and which
M. Roux in vain endeavored to close by abrading its borders, and
by attempting to approximate them by means of a suture.  A flap,
detached from the posterior surface of the lip by dissecting off its
mucous lining, (par dedoublement) and then reversing  and bring-
ing it out, was followed by no better result.  It  was the same M'ith
an attempt by means of integuments from the palm of the hand.
It was then determined  to draw from above and outward, in order
to unite it  to the ala of the nose, and to the corresponding half of
the wound, the flap which the upper lip had at first borrowed from
the loM'er.   A triangular fissure (fente)  at the  left commissure of
the mouth, and of the shape of a hare-lip of considerable  width,
was the consequence  of this new displacement.  The surgeon did
not hesitate to abrade its edges, at a little later period ; then brought
them together with ease, and applied the suture to them, this trial
being the least difficult of all.  There remains in this patient no
other traces of her ancient deformity, than a certain narroM'ness of
the mouth, and on the cheek some  scars, (stygmates) as if produced
by a burn.

                        § IV.—Remarks.

  Almost all the attempts at genoplasty since 1831, have been made
upon the French method of anaplasty, or that of dissection of the
tissues, (decollement;)  a patient thus operated  upon by M. Serre
(Compte rendu de la Clin.de Montpellier, $c, 1837) was completely 
648
NEW ELEMENTS OF OPERATIVE SURGERY.
cured.  M. Dieffenbach, who also often joins the remote  incisions
(incisions a distance) of Thevenin to the dissections (decollcments)
of Franco, likewise mentions many  successful operations  upon the
same method, and I may now add to those which science already
possesses, three new cases taken  from my own practice.
  Since all the modes of performing genoplasty have been devised
for so many specific and dissimilar  cases, it would be superfluous
to compare them in order to point out their differences.   It is for
the skilful  surgeon to determine what  answers best for the  case
immediately before him.  It is nearly the same  with cheiloplasty.
Therefore, I feel  that I ought to leave the decision of this matter to
the sagacity of the reader.   Franco also  had already looked upon
it in the same  light, and his observation demonstrates indisputably
that he understood cheiloplasty, and especially genoplasty, almost
as well as modern operators: " A man named Jacques Janot," says
he, " had a defluxion which descended upon the  cheek, M'hich or
the greatest part of it was destroyed, (tomba) and also portions of
the jaws with several  of the  teeth, whence  there remained an
opening of about the size of  a goose egg.... To effect the cure,
I took  a  small razor and cut the  border or  skin all  around  it.
Afterwards I slit the skin opposite  the  ear, and towards the eye
and  lower jaw  ;  then  I cut within and lengthwise,  and cross-
wise  to elongate the flaps (labis) taking  care  not to cut through
outwardly, for it was  not  necessary to cut through the skin.
I [then] immediately applied  seven sharp needles, three of which
at the end of four or five days fell out, in the place of M'hich it be-
came necessary  to insert others.   In  short,  he was cured M'ithin
fourteen days."*   But we must read in the author  himself the quaint
narrative of this long  case, and  bear in mind that the dissection
of the parts is attended with much more difficulty, and  procures
much less elongation to the cheeks  than to the lower lip.   In con-
clusion, I  do not  think that  the  Italian  method, which has been
attempted in  one case,  as  we have seen, by M. Roux, answers
better for genoplasty than cheiloplasty.  It is to the Indian method
that we must have recourse, if it should in reality be impracticable
to adopt  the French process.   [Genoplasty has  been successfully
performed bv  Dr. M'Clellan  of Philadelphia, (see Reese's Cooper.)
-T]
  [An interesting operation in cheiloplasty I recently saw performed
  * [As this quotation is from one of the most ancient authors in Surgery, and the style
therefore now obsolete, I will give it here in the original, that it may be seen whether in
the judgment of others I have caught the true meaning: " Un Jacques Janot eust unc
defluxion qui lui descendit en la joue, et tomba la dite joue ou la plus grande partie d'i-
celle, et pareillement des mandibules dont il perdit plusieurs dents, et demeura un pertuis
par lequel un oeuf d'oye pu passer.....Pour venir a la cure, je prins un petit rasoir, et
coppay le bord ou cuir tout a l'environ.  Apres je fendoys la peau contre l'oreille et vers
l'oeil, et vers la mandibule infe"rieure ; puis je coppay au-dedans en long et a travers pour
allonger les labis, me gardant toutefois de venir jusques au dehors, car il ne fallait pas
copper le cuir.  J'appliquay incontinent sept aiguilles ennle"es, desquelles,  au bout do
quatres ou cinq jours, en tomberent trois, dont il fallut en remettre d'autres.   Bref, il fut
gu^ry dedans quatorze jours."—T.] 
GENOPLASTY.
649
by Dr. Mott, upon a patient aged about 62, (Judge E., from the state
of Missouri.)   The whole of the lower lip down to the chin was re-
moved, together with the cancer  which  occupied it, by means of
a free semilunar incision, M'hich was prolonged on the right side
to a little beyond the commissure, in consequence of the disease
extending in  that direction.   The soft parts covering the extreme
point of the chin, and on each side of it and below it upon the neck,
were separated to some extent to within an inch from the os hy-
oides.  The sound margin of soft parts was now brought up. from
the chin and neck to meet the upper lip.  To prevent the puckering
which this elevation  of parts must necessarily have occasioned, a
horizontal incision of an inch or more in extent  was made through
the cheek, close  to  each commissure.   A stitch was  introduced
into each angle of the  mouth, and a second one outside  of that,
through the cheek on each side.   These nicely approximated  the
parts, and perfectly sustained the neM'ly-i'brmed under lip.  Adhe-
sive plasters, and a  double-headed roller M'ere used to  assist in
firmly supporting and keeping in  place  the newly-elevated parts
and the lower jaM\   The  stitches were removed on the seventh
day, and adhesion having  taken  place,  the cure was soon after
readily accomplished.  During the first ten days the patient was
supplied by liquid nourishment, passed into his mouth by a quill
inserted  into the mouth of a  teapot.   For some time after  the
stitches had been removed, the chin and  soft parts continued to be
supported by a double-headed roller.  The cure was rapid and
complete, Mdthout the slightest unpleasant sj'mptom.   The mouth
looked exceedingly natural,  and he  conversed with ease.  The
carcinomatous ulceration had existed twenty years, having been
unusually slow in its progress.  The patient, as may be supposed,
went home delighted.  Being  corpulent, and the parts  soft and
pliant, transverse incisions below M'ere rendered unnecessary.
  Making an entire new mouth. Should a case present where there
was necessity of making an  entire new  mouth, Dr. Mott suggests
the measuring out a  flap of the proper oval shape and  size, trans-
versely upon the supra-hyoid and sub-hyoid regions, M'ith a long
broad connecting pedicle.  During the first days, and  until adhe-
sion of the edges of the flap to  the  excised edges of the corre-
sponding opening to receive  it should have perfectly taken place,
breathing might  be kept up by a small aperture of sufficient size,
made in the centre of its longest diameter, and kept pervious by a
curved piece of gum-elastic catheter.   Dr. Mott has performed
this operation on the dead subject, and it appeared to  answer ex-
ceedingly well.—T.]
                              82 
650
NEW  ELEMENTS OF OPERATIVE SURGERY.
                        CHAPTER IX.

 STAPHYLOPLASTY, (ANAPLASTY OF THE UVULA (LUETTE) AND
                   OF THE VELUM PALATI.)

  Since staphyloraphy came into use, surgeons have had it in their
power to demonstrate that anaplasty to the velum of the palate might
also have its advantages.  M. Roux and  M. Dieffenbach, (Bulletin
de Ferussac, t. x., p. 261 ; t. xv., p. 61,) M'ho appear to  have prac-
tised  staphyloraphy  most frequently, have also  had recourse  to
staphyloplasty; one in conforming himself to the rules  of the ana-
plastic method of Chopart, the other in following the principles  of
Celsus or of Thevenin.  After having pared the borders  of the
primitive fissure, and united them by suture, M. Dieffenbach makes
a long incision on each side to relax the tissues.  M. Roux, pro-
ceeding at  first in the  same manner, afterM'ards divides  trans-
versely each half of the velum  of the palate near its  bony vault.
It is then easy to draM' the two sides of this velum together, what-
ever may have been the distance of their separation.
  The two processes we are speaking of deserve to be retained in
practice.  That of M.*Dieffenbach  (Arch.  Gen. de Mid., t. xviii.,
p. 436) suffices when we have merely to guard  against the trac-
tions  of the  suture.  A young man whom I treated  in this manner
recovered perfectly well. If the separation of the  cleft is of con-
siderable extent, the process of M. Roux  should be preferred.
  Indian anaplasty itself has  been proposed to remedy the losses
of substance in the velum of the palate.   In a case of this kind, a
surgeon of Nancy, M. Bonfils, (Transactions Medicates,  t. ii.,  p. 293
a 308.) dissected upon the posterior part of the bottom of the mouth
a flap, which  he detached from before  backwards, and which  he
then proceeded to attach by stitches of  suture in the  cleft  in the
pharynx.   This  operation  succeeded but  very  imperfectly, and
ought not, in my opinion, to be repeated ; not that the hemorrhage
which seems to alarm M. Burdin, (Ibid. p. 294,) or necrosis of which
M. Jacquemin (Ibid, ib.) speaks,  are  really sources of apprehen-
sion,  but because of the gangrene, or almost  unavoidable  retrac-
tion of the flap.  I shall have  occasion to  speak again  of the
utility of staphyloplasty, in treating of staphyloraphy itself.
   [Dr. J. M. Warren of Boston,  (Reese, Loc Cit.) in a  case of con-
genital fissures of the soft and hard parts of the roof of the  mouth
and palate, proceeded in this manner:  The soft palate having been
prepared for staphyloraphy by the usual abrasion of its edges, and
the introduction of the necessary points of suture,  the mucous
membrane covering the roof of the mouth was carefully raised on
each side of the fissure in the hard palate, and when thus detached 
PALATOPLASTY.
651
they were brought across the fissure, and united like the soft palate
by the interrupted suture, the flaps formed  by the mucous mem-
brane of the  mouth being continuous with the denuded edges of
the soft palate.   This difficult and delicate operation was  com-
pletely successful, and is by no means diminished in value from
having been first devised,  and successfully performed, (as M'e shall
see below,) many years before by a German surgeon, M. Krimer.
Failure after failure, however, so often baffles  the most elaborate
processes  hitherto contrived to  remedy this disease, even in the
hands of the most accomplished surgeons, that we can scarcely
hope for success with all the aid of anaplasty, except in some rare
instances and most favorable subjects.—T]
                        CHAPTER  X.

 PALATOPLASTY, (ANAPLASTY OF THE VAULT OF THE PALATE)

  Anaplasty of the palate is an operation frequently indicated ;
three different conditions may require  it.  Surgeons have remarked
that staphyloraphy often leaves at the root  of the velum a hole
which is very difficult to close up.  It is  also known, on the other
hand, that the perforation of  the vault of the palate may be con-
genital ; it  is not rare, in fact, to find holes produced in the palate
by accidents or M'ounds.  Even if it were  true that, by means of
obturators  (obturateurs) properly constructed, like  those  that M.
Toirac has contrived, we may succeed in perfectly closing up these
holes, it is nevertheless also true, that their effectual  obliteration by
the living tissues would still be preferable.  It is very natural, there-
fore, that in such cases the aid of anaplasty should have been called
into requisition.

                       Process of Krimer.

  The first case of palatoplasty that  has been  published, belongs
to  M. Krimer,  (Journal de Graefe et  Walther, t. x., p. 625.)   This
surgeon made  an  incision at the distance of some  lines outside a
cleft (fente) which remained  in the  vault of the palate after a sta-
phyloraphy.  He was thus enabled to dissect from the sides toM'-
ards the middle two  flaps,  which  he reversed  upon themselves,
and then united by some stitches of suture.  The patient recovered
perfectly.   In the  place of these two flaps, M. Bonfils  (Transact.
Med., 1830, t. ii., p. 307)  proposes to  cut one only behind, and to
bring it afterwards into the hole, (trou,) of which the two  anterior
thirds only are to be abraded.
  MM. Nelaton and Blandin (Bulletin de  Therapeutique,  t. xi., p.
379) have, as it appears, modified the palatoplasty of M.  Krimer. 
652
NEW ELEMENTS OF OPERATIVE SURGERY.
by changing the form of the flap proposed by this author; but, as
they have not applied  it on the living subject, it is scarcely possi-
ble at the present time to appreciate the actual utility of their
process.
  If the hole in the vault of the palate is  not merely the remains
of a fissure of the velum, it scarcely ever closes up spontaneously.
We should do wrong to count  on cauterization in such cases ; the
successful  results  obtained by M. Henry of Lisieux, (Bulletin de
VAcad. Roy. de Med., t. i., p. 291,) those that are attributed to Du-
puytren and Delpech, (Bulletin de Therapeut.,  t. xi., p. 379,)  and
those which belong to  myself,  all have reference to perforations in
the velum of the palate, and not to holes in the vault of the palate.
It  is then  to palatoplasty that we must  actually have recourse in
these last cases.

                     Process of the Author.

  One important  circumstance to be observed is, that the fibro-
mucous membrane of the palate, with its firmness and little vascu-
larity, admits but  imperfectly of the  formation of large flaps, and
that, if it is required to give to these flaps more than half an inch
in  length,  they almost inevitably  mortify in  whole or  in part.
Having tried it in  that manner, and observed that the flap became
gangrenous to one half its  extent, though it had a large base, and
had been borrowed from the root of the velum of the palate, I de-
termined upon  the following process.
  Two strips of tissue, from six to ten lines long, and having the
form of a somewhat elongated triangle, are cut, the one in front,
the other behind the  perforation.   Dissected and  brought  down
towards  each other, and united by means of a stitch of suture at
their  apex, these flaps each leave a wound the approximation of
the borders of which  gradually closes up the fistula in  every di-
rection.   We may  also, in order to aid in  the cure, make from time
to time a longitudinal incision upon the two sides of the hole to be
closed. We may make transverse ones, also, upon the root of each
flap when they are sufficiently  revivified, (revivifies)  It was in this
manner I proceeded in the case of a young man who has become
unfortunately celebrated, and M'ho, in consequence of a discharge
from a pistol, had a hole eight  lines long and six  broad in the vault
of the palate.   This subject also will be recurred to again under
the head of staphyloraphy.

[Anaplasty applied to great loss of Substance in removing Cicatrices
                         from Burns.

  If  America owes to Europe  the first-improved processes of ana-
plasty, there is one remarkable and recent case on record in which
one of our  surgeons, Dr. Mutter of Philadelphia, may lay  claim to
have carried the art to a higher perfection than elsewhere known.
In an adult female, who had  been shockingly burned when aged 
AMERICAN ANAPLASTY.
653
5 years, and who, from the chin being drawn down by the cicatrix
on the neck to an inch and a half from the sternum, had not been
able to close her mouth but for a few seconds at a time during the
space of 23 years, who could neither throw her head back or to the
left side, and whose clavicle on the right side was imbedded in the
lower part of an enormous cicatrix which filled up the space between
the chin and the sternum; Dr. Mutter made a transverse incision
across the  middle of the cicatrix about  three quarters of an  inch
above the sternum, commencing on sound skin near one side of the
cicatrix, and terminating the incision in the sound skin on the other
side.   This was to get at the attachments of the sterno-cleido mus-
cles, which muscles were not over three inches in length.  Carefully
dissecting down over this vital part, through the fascia superficialis
colli, he exposed the  sterno-cleido-mastoid muscle on the right side,
and passing a director under it as low down as possible, divided
both  its attachments.  He could thus raise the head an inch or
two, but perceiving  the retraction of the muscle on the other side
unyielding, he divided its  sternal attachment only, and was de-
lighted to find he could replace the head completely in its natural
position. The clavicular attachment offering little or no resistance,
was not divided.   A shocking wound of  six inches in length  by five
and a half  in  width  now presented itself, yet almost without hem-
orrhage, only three or four vessels requiring the ligature.  He next
detached an oval flap of sound skin six inches and  a half in  length
by  six in  width, by continuing  the first incision  downward and
outward over the deltoid  muscle, leaving a pedicle at the  upper
part of the neck.   This dissection was painful but not  bloody, only
one small vessel being opened.  Making a half turn of thenflap on
its  pedicle, it was brought over the  chasm and carefully attached
by  several twisted sutures to the edges of the primary wound, the
whole being  supported by adhesive  straps.   The edges of the
wound on  the shoulder were completely brought together by straps
and sutures, except its upper third only, on which raw surface was
'applied a  pledget of lint wet with  warm water, after which the
patient was put to bed with  the  head maintained  backward by a
bandage.   No unfavorable symptoms  occurred, and  union  took
place  by the first  intention.  Twelve months after no contraction
of the flap had taken place.  Dr. Mutter has succeeded by this
process in several other cases.   Oleaginous frictions  to the  new
parts are useful to give them flexibility and softness.   He recom-
mends this process  in  cicatrices  from burns in the neck,  cheek,
eyelids, nose, lip, &c.  In the three latter he has effected complete
restoration of the organs.   (Vide American Journal of the Medical
Sciences, July, 1842 ; see  also figures of the above extraordinary
case in Dr. No?~ris's  American Edition  of Fergusson's Surgery, and
in the more recent work (Philadelphia, 1844) on Operative Surgery,
by  Professor Pancoast; also, Professor Mutter's own late work on
Cases of Deformities from Burns.)—T.] 
654
NEW  ELEMENTS OF OPERATrVE SURGERY
                        CHAPTER XI

  BRONCHOPLASTY, (ANAPLASTY OF THE LARYNX AND OF THE
                          TRACHEA.)

  Wounds in the anterior region of the neck, always so dangerous
from the large vessels that they may include, are still more so by
their tendency to become fistulous when they involve  the respira-
tory canal.  It is important, nevertheless, to arrange them, in this
respect, under distinct  heads.   Those of the trachea,  unless the
canal is completely divided through, in  general cicatrize with fa-
cility.   Over the cricoid and thyroid cartilages, also, art triumphs
without much difficulty;  but it is no longer so in the thyro-hyoidean
space.   Here position, bandages, and even  the  suture, do not  al-
ways suffice to keep the lips of the wound properly approximated.

                     Article I.—Anatomy.

  The  cause of these differences lies in the anatomical arrange-
ment of the parts.  Under the  laryngeal prominence, in fact, the
skin and the subjacent tissues possess a  thickness, and enjoy a mo-
bility,  almost everyM'here equal.  The  trachea is sufficiently pli-
ant, and endoM'ed with a sufficient degree of vitality, for the pro-
cess of cicatrization, when properly conducted, to close up its open-
ings without difficulty.   Nothing would  prevent  our applying the
suture  to them if we  judged  it  proper,  and the movements of the
head have but little influence upon the  progress of such M'ounds.
In the  thyro-hyoidean groove, (rainure) it is entirely the reverse.
There, the parts lose  their  parallelism as soon as they have  been
divided,  The angle  of  the cartilage draws the lower lip of the
wound forward and downward,  while the os hyoides draws the up-
per one backward and upward.   The  first presents  a complex
structure.  We remark there, at the same time, a solid cartilage, a
very delicate  skin, very irregular cellulo-fibrous tissues, and the
attachment of some muscles.   If, in the second, the tissues are more
homogeneous, the os  hyoides  gives  it such mobility that surgical
remedies have but little hold upon it, when our object  is to main-
tain it  in connection with the other.  The least movement of the
chin, also, immediately deranges the coaptation.  Mastication and
deglutition, whether of solids or liquids, or of simple saliva, do the
same every moment.   If the epiglottis is below the wound, M'hich
is rare, the  matters coming from the mouth almost always become
entangled in the accidental opening.  If, on the contrary, as gen-
erally happens, this part is found detached from the glottis, the air
and mucous  matters repelled by its postero-inferior  surface  are 
BRONCHOPLASTY.
655
still more easily driven into the wound.  Thus, on the one side we
have the tongue, and epiglottis, and fleshy, vascular,  pliant and
moveable tissue* ;  and on the other, the thyroid cartilage solid and
fixed, and but little vascularity in the tissues.  Is there any thing
more wanting, connecting these with the  other  peculiarities just
mentioned, to explain the fistulas produced by transverse M'ounds
in this part of the neck ?
  Anatomy, moreover, explains  why divisions by cutting  instru-
ments more frequently take place in this place  than elsewhere ; as
it is to attempts at  assassination and suicide  that they are most
generally to be attributed.  The projection of the chin, and the top
of the  larynx, thus in some degree strongly invite the  arm of the
murderer to  this spot.  In other respects, the upper border of the
thyroid cartilage on each side terminating behind in a kind of horn
of considerable length, it is rare that the instrument penetrates be-
yond that part.  The carotids are by this  means protected.  The
superior thyroid artery, and some other branches of still less volume,
being alone accessible, the wounded person almost always survives,
and the fistula has, in this manner, full time to establish itself.

                    Article II.—Indications.

  Most authors have pointed out the dangers of M'ounds  of the
throat, and the difficulty of curing their fistulous  openings.  We
may on this subject consult Pare, (Liv. x., ch.  30, p. 292,) Richter,
(Bibliothique du Nord, t. i., p. 167,) Bousquet, (Thises de Paris, 1775,)
the Memoirs of the Academy  of  Surgery, (torn,  iv., p. 429,) J. Bell,
(Traite Des Plaies, Traduction d'Estor, p. 474,) and the fourth vol-
ume of the Clinique of M. Larrey.  Only that, inasmuch  as these
practitioners have, with  the  exception of a very small  number of
their cases, confined themselves merely to  saying that the respira-
tory passage  had been opened,  without designating specifically the
part wounded, their  observations cannot be of any great assistance
in such matters.
  For the same reason that wounds of the thyro-hyoid space are,
from the very first, difficult to cure, the fistulous openings  M'hich
are produced  by them must be still more difficult to close.  Saba-
tier was so convinced of this, that he hardly deigns to devote  a page
to them in his excellent work.   MM.  Roche and Sanson, (Element.
de Pathol, t. v., p. 280,) who  have not thought it necessary to treat
of them at  greater length, admit that  they are almost always incu-
rable.   To such extent, in fact, has this opinion been carried, that
to judge of these wounds  by the silence of writers, they have not,
up to the present time, been  the object of  any attempt at surgical
relief.   Our latest dictionaries,, and treatises, give no more  details
on this subject, than the M-orks  of past ages, and there  is no scien-
tific work which makes particular mention of them.  The cause of
such an  omission  can only be  explained,  as  I conceive, in three
ways.   Finding that it sufficed  to pare (aviver)  the borders of these
thyro-hyoid fistulas, to cause  them to agglutinate by means of su- 
656           NEW ELEMENTS OF OPERATIVE SURGERY.

tures and bandages, has it not been that surgeons have deemed the
treatment too simple and easy to be worthy of being made the ob-
ject of special consideration ?   The assertions of Sabatier, howev-
er, and the faOts that I am about to state, prove that such a version
is not admissible.
  May we not, on the contrary, be permitted to think, that, having
failed in their efforts, practitioners have deemed  it unnecessary to
make the same known to the  public ?   As they do not jeopardize
life, and  may be covered over by the cravat, or completely shut up
by a tent of linen, lint, etc., is it not therefore still more probable,
that  patients making up their minds to take care of their fistulas
themselves to an indefinite period, have thus thought proper to ex-
clude surgery from an opportunity of interfering with them ?   The
future will reveal to us if it is not these two last motives, as I think
it is, to which more especially the blame must be imputed.  What-
ever, however,  may be the  cause, it is sufficient for me, at the  pre-
sent moment, to prove the difficulty of curing some of these fistulas
by the methods now known.
  [The presumption  is, that  in many instances this  apparently
jiost  singular omission may be as satisfactorily explained, by the
facility M'ith which these fistulous openings sometimes rapidly close
up spontaneously, (as in children especially,) as  by the obstinacy
M'ith  which, in other cases,  they resist all  remedial measures.
Thus, remarks Dr. Mott, as  recently happened to him in a successful
case of  tracheotomy which I had  the satisfaction of seeing  per-
formed by him upon  a child of three years of age; the clean in-
cised  wound, notwithstanding the great  number of arteries  and
veins which necessarily had to be tied, (owing to the engorgement
of all the  vessels of the part, through the  violent and strangula-
ting efforts of the patient to relieve itself,) rapidly granulated, M'hile
the fistulous opening gradually contracted itself as the neighboring
parts  neatly cicatrized, and finally spontaneously closed  up, leaving
scarcely  a trace behind, and without the slightest dressing what-
ever having been used.  Dr. Mott, indeed, is of opinion, that  it is
better in such cases to leave open the artificial incision into the
trachea to its own curative action, as the  air passing a  part of the
time through this aperture, saves the portions of the trachea and
larynx above, from  the  fatigue of the respiratory functions,  and
which exemption, partial as it is, they require, from the extent to
which irritation has been produced there previously by  the foreign
body—in this case above, a large  black  straight pin,  two and a
half inches to three inches in extent, with  the head of the size of
a large pea, and  lying downwards.
  In  adults, on the  other  hand, as is  familiarly known, artificial
fistulous openings between the ribs, and penetrating into the cavity
of the thorax, are often exceedingly difficult to close up.  But even
in the greater part of these, also, the cure  is readily effected, and
the silence of authors, therefore, is upon the whole to be imputed
to the fact, that  such wounds in the trachea, at least,  are, by the
facility with which they are healed up, a matter of very little im- 
BRONCHOPLASTY.
657
 portance.  From the rapid and healthy curative process which took
 place in the case above mentioned, and which will be given in de-
 tail m the appropriate part of this  work, ought not much of this
 result to be imputed to the clean incised and fresh wound made by
 the operation ? And does not this therefore suggest that, in all cases
 of fistulous openings into the trachea, whether congenital or from
 ulceration, or lacerated wounds, it would be advisable to excise the
 edges completely, so as to make as straight an aperture as possible?
 And then, if aid were  required to assist nature, as in cases of long
 standing, what more would be necessary than to approximate the
 lips together, either by strips of adhesive  plaster, or the suture ?
   In making this excision, however, the  utmost care is required,
 because  of the extreme danger of suffocation from the introduction
 even of  a single drop of blood  into  the  air  passages.  To do  it
 properly, therefore, we do not know of a better mode than to do it
 in the manner, and with the precautions,  which Professor Velpeau
 very ingeniously proposes below,  in his own process.—T]

                Article III.—Operative  Process.

   If it be true  that all the modes of anaplasty may be applied to
 fistulas of the larynx,  the French or the  Indian method, however,
 have hitherto been the only ones had recourse to for their cure.

                   § L—Process of the Author.

   One of the patients whom I cured of a fistula, had been already
 operated upon unsuccessfully, in a large hospital; another case be-
 longed to M. P. Denis, ancient laureate of the school of Paris, who,
 fearing that he would not be sufficiently well attended to in the es-
 tablishment which he has the management of, in one of the provin-
 ces, sent  him to me, in the month of December, 1832.  These facts
 of themselves showing that their disease was not easy of cure, I
 mention the circumstance to justify myself for having made use of
 a new method of anaplasty.  This method consists, essentially, in
 the construction of a fold, or tent, (bouchon) of sound tissues, which
 is introduced into and kept in the fistula.   Here is the process:
  First Stage, (Premier Temps.)—The patient  being laid upon his
 back, as  in bronchotomy, is held down in a proper manner by as-
 sistants.  The surgeon, placed on the right, cuts on the front part
 of the larynx, below the ulcer, with a straight or convex bistoury,
 a flap of  integuments, an inch in width and two inches in length,
 more or  less, according to the breadth or  depth of the aperture to
 be closed, shapes this  flap into a cushion, or square  form below,
 gives it a little less width above than  at its under part, dissects it,
 and raises it from its free border towards its root, reversing with it
as much cellular tissue as possible, but Mdthout denuding the car-
tilage, and stops then to proceed to the second stage of the opera-
tion.
  Second Stage, (Deuxieme Temps.)—This second stage includes the
                             83 
658
NEW  ELEMENTS OF OPERATIVE SURGERY.
paring of the edges (Vavivement)  of the fistula.   As it fatigues the
patient by the  cough that it excites, and the repeated movements
of deglutition which it causes, it requires some precautions and pa-
tience.  In place of doing this by removing layer after layer hori-
zontally, (en dedolant) which  M'ould  seem to  be the most easy
mode of performing it, I Mould remark, that it would be  better tc
force in at first the point of the bistoury outside of and upon a part
of the circle to be excised, in order afterwards to go round  its M'hole
circumference,  before dividing, in any part of it, the continuity of
the pellicle that we M'ish  to detach.   We  thus excise an annulai
band of tissues, M'hich is  held successively, at its different points,
by the forceps, in proportion as  the  instrument separates  it from
before backward, until the operation is completed.   As its deep
border [i. e., the bottom of the incision—T] is not to be  detached
until the last step, the blood escapes on the side of the M'ound. Not
entering, unless in very minute quantity, into the laryngopharyn-
geal cavity, this fluid cannot, therefore, excite in the patient a vio-
lent desire to cough, or expose  to any  risk of suffocation.  It  is,
moreover, better to excise in such manner  that  the wound may be
made a little wider superficially, than  at  its bottom, [i. e., flare
outward.—T.,]  and that it may present, in some degree, the form
of a cone or funnel.
   Third Stage,  (Troisieme Temps.)—After allowing a minute or two
to the patient to repose, which is required also to suspend the oozing
of blood from the wound, we proceed to the third stage, that is, to
the adjustment  of the flap.  This part  of the  operation presents
two modifications, sufficiently distinct.
  First Process.—If the fistula has more extent crosswise, than
from above below, we begin by folding the flap double, (par mettre
le lambeau en double) taking care, however, in making this fold, not
to carry up its  point quite as high as the root.   We reverse it  in
this state, without twisting it.  Its cellulo-adipose surface only be-
ing free, the  surgeon then adjusts its heel, that is, its middle part,
into the fistula.  There is nothing more  to be done than  to insert,
from left  to  right, a long needle, which  perforates at the same
time  the lips of the wound, and  the  whole  thickness of  the body
which fills it up.   A  few turns of twisted  suture, a perforated
linen spread with cerate,  some  lint, one or  two compresses, and
some turns of bandage, support the whole.   The flap requires here
a certain degree of attention.   Its point  being free, opposite to the
internal or cutaneous  surface of the  pedicle, would  easily escape
by slipping backwards, if the needle,  by being badly  adjusted,
should pass between its two folded halves, in place of actually per-
forating them.
   This accident happened to my second patient, and made me fear,
for a moment, that I should be  obliged to begin again. It may be
avoided with certainty, by previously fastening together,  with one
stitch of suture, the apex and root of the tegumentary fold.   Then
the deep-seated needle and the twisted suture would not  be indis-
pensable.  A strip of diachylon plaster from before backwards, and 
BRONCHOPLASTY.
659
sufficiently long to surround the neck, could be readily substituted
for them.
   Second Process.—When the fistula has its greatest diameter in
the vertical direction, or takes on the circular form, it  is sufficient
to roll up the flap, cut as we have described it, upon its cutaneous
surface, and parallel with its length, in order to form with it a cyl-
inder or tent, (bouchon)   The operator, then reversing it, inserts its
free extremity to a certain depth into the abnormal opening, fastens
it as in the preceding case, and is careful to leave no void betM'een
the pared (refraichies) surfaces.
   If any circumstance, moreover, should require it, this flap could just
as well be taken from the side, or above, as in front of the thyroid
cartilage.  It is for the  practitioner to determine in what direction
the tissues are  best adapted for this purpose.  It is important only,
that he should give to  it one half more  length and  breadth, than
the size of the  opening  to  be closed would at  first sight appear to
require, seeing that its natural contraction necessarily diminishes its
size considerably, as soon as it is in its place.
   As  to the wound which results from its dissection, we might, in
the greatest number of cases, reunite it immediately by two or three
stitches of twisted suture ;  but the difficulty of establishing a  uni-
form compression in the neighborhood, would expose  to the risk of
an erysipelas, or suppuration throughout the entire  neck.  Pru-
dence  therefore suggests, that we should confine ourselves to ap-
proximating its edges gradually, in place of attempting a perfect
contact.
   I have yet had, it is true, but two occasions to put this method in
practice ; but in both the success was complete.
   First Case.—One of the patients, twenty-eight years of age,  and
in other respects in good health, had had his throat cut four months
before, between the  os hyoides and thyroid cartilage, and from
one sterno-mastoid muscle to the other.   Stitches of suture, a band-
age, and the flexed position of the head, had recourse to on the spot
by M. D«nis, physician of the Hospital of Commercy, procured only
an imperfect union of the wound.   When he came under my care,
December 15th, 1832, the borders of the M'ound had cicatrized apart,
to the distance of about six lines.  When his head was  raised up,
it was easy to insert  into the  fistula the  point of  the little finger.
In this state he  could scarcely make himself heard.  In depressing
the chin, on the contrary, he  regained his voice  and speech.   A
curved sound, introduced into the bottom of the wound, and the left
forefinger inserted  deep into  the back part of the mouth, enabled
me to ascertain that the division penetrated directly above the glot-
tis, and under the epiglottis.  The deglutition  of liquids caused
more cough than that of solids.  Mucous matters escaped in abun-
dance by the fistula.  Much caution, also, M'as required, to prevent
the ingesta from also becoming entangled in it.  The least contact
with these bodies, or of  any foreign body whatever, with the inte-
rior of the wound, produced immediately a paroxysm of coughing
so violent as to render it impossible to make any continued approx- 
660
NEW ELEMENTS OF OPERATIVE SURGERY'.
imation of the  borders of the M'ound.   I operated on the twenty-
second of the same month, after the first  process above described.
The flap,  after  being dissected, was doubled, reversed from below
upward, and then introduced, thus folded, into the excised (avivee)
fistula, and finally attached by a single pin.   I did not remove the
dressing until on the fourth day.  The point of the flap being a lit-
tle too short, or badly fastened against its root, had slipped off and
got into the larynx.  The swelling, in fact, of the tissues, made me
think, for  an. instant, that the whole cutaneous fold had succeeded
in getting into  the passage.   A violent spasm of coughing, which
had come on the day before, still more confirmed this opinion;  but
the event showed that there  was no such thing.  In fact, it was by
retracting itself from behind forward, that this  flap succeeded in
stopping up the fistula, and its pedicle was found, so to speak, distinct,
before the cicatrization was completed.   A  hole, which scarcely
admitted  the head of a pin, and which was with difficulty cicatrized
by cauterization with nitrate of mercury, the red-hot iron, and ni-
trate of silver,  did not  become entirely obliterated until after the
beginning of March, 1833.  The strangulation  caused  by a long
strip of adhesive plaster, placed above to depress its upper lip, pre-
vented also  the  wound of the flap from  cicatrizing  till  very late,
and caused an abscess which had  formed on the outer side, to re-
appear several times afterwards, but not in any  manner, however,
to endanger the success of  the first operation, the cure of which
had been completed a long time previous.    *•
   Second Case.—In the other patient, the wound was  in the same
place, and was produced by the same cause  as in the  preceding
case.  Its size  was rather larger, at least in the vertical direction;
its borders, also, were a little thicker, and the epiglottis was not sep-
arated from the back part of the larynx, but  to  the extent of two
thirds of  its breadth.  When the patient obtained admission into
the Hotel-Dieu, in the month of October, 1831, his fistula had ex-
isted six months.  The publications at the time (Lancette Frangaise,
t. v., p. 240, 310-315) state that Dupuytren dissected laterally the
lips of the wound, to a certain  extent, in order  afterwards to ap-
proximate them, and to unite them in this position by some turns
of twisted suture.  Doubting the  success of his essay, the  skilful
professor had,  as it also appears, (Ibid., t. v., p. 315,) formed the
project of making trial of another method, that is, " of borrowing
from the neighboring parts, and of plugging up the fistula M'ith the
detached flap;"  but  the patient left the hospital and  came to La
Pitie,  in  January, 1832.  A  flap, borrowed from the anterior  sur-
face of the  larynx,  dissected, raised up,  and  rolled  upon its axis,
was inserted into the fistula, which had been previously excised,
 (refraichie,) and was fastened in its place by means  of pins.  The
two fissures which were at first left upon the sides, yielded, at a later
 period, to the  application of the actual cautery, and another point
 of suture.
   The patient did not leave the hospital until a long time after the
 completion of  his cure. 
BRONCHOPLASTY.
661
                    § II.—Ancient Processes.

  The method which I propose, is not the only one that may be ap-
plied to fistulas in the  air passages.   I know, like M. Larrey, (Cli-
nique  Chir., t. iv., p. 290,) that to cure a number of these fistulas, it
suffices  to prolong their angles above and below, then to excise
(aviver)  their borders,  and to keep them approximated, either by
means of a bandage or suture.  A cut of the bistoury crosswise on
each lip of the wound, to detach  its lower extremity, would also
favor  its coaptation.  The lateral incisions of Thevenin would have
the same effect.
  When the perforation is larger, the method employed by Dupuy-
tren, or  anaplasty by dissection of the tissues, is  also of a nature
to procure some advantages.  We might  also  imitate the first
processes of rhinoplasty, and confine ourselves to sewing the bor-
ders of the borrowed flap by the Indian method to the excised bor-
ders of the  fistula.   But  even cauterization  and  simple  band-
ages alone, are sometimes quite sufficient.  I even think that these
two last means, which  have since  succeeded with me  in two
different cases, and the simple suture,  will  be  preferred to the
bronchoplasty which I have  made use of, provided their efficacy
should not appear to be questionable.  But the process, nevethe-
less, which I have suggested, appears to me of a more certain effi-
cacy, more easy in its application, and better adapted to the ability
of all surgeons, than  the other methods hitherto employed, and
which, moreover, certain fistulas obstinately resist.
  When it has  been decided upon to  separate, transversely, the
thyroid  angle  from the perforation, in order  more  effectually to
bring  the lips of the  latter into contact, there remains, most fre-
quently, a transverse fistula underneath the vertical division which
has been cured.   The  solidity of the cartilage, and the projection
which it makes in front, explain this fact.  The lateral dissection
of the tissues, presents an inconvenience much more serious still;
the mucous discharges which come from the trachea, even the sa-
liva, gliding between the approximated flaps and the subjacent tis-
sues,  almost inevitably produce  an  erysipelatous  inflammation,
which may speedily involve a great  part of the neck.  Then, in
fact, it  becomes  an ulcer, whose  orifice we close before  having
cleansed its bottom.  The state of the parts, moreover, scarcely ever
admit of giving sufficient thickness or regularity to the flaps, to re-
move  all fear of gangrene or suppuration.
  The skin in the neighborhood is too thin and pliant to enable us
to form a suitable covering by the mode of the Koomas, or of Cho-
part, and to apply it after the rules laid down by MM. Roux, (Arch.
Gen. de Med., t. xv., p. 468,)  Lallemand, (Ibid., t. iv., p. 242,) and
Dupuytren, (Lancette  Frangaise, t. iii., p.  273,)  for cheiloplasty.
The numerous stitches  of suture that it would require, and the ten-
dency of the  laryngopharyngeal fluids  to escape by the  fistula,
would, in most  cases,  prevent its agglutination from succeeding. 
662           NEW ELEMENTS OF OPERATIVE SURGERY.

This last method, in fact, has all the inconveniences of that M'hich
I brought into practice, without affording any of its advantages.
In reality, it merits the preference only in fistulas too large to admit
of being closed by a tent, or simple cutaneous fold.
                       CHAPTER XII.

                 ANAPLASTY OF THE THORAX.

  It is  scarcely other than large wounds in the chest, with great
loss of substance, that can require the assistance of anaplasty; and
among these M'ounds, those which result from  the removal of the
breast, are the only ones to  which  it  has hitherto been  applied.
When the adhesions of the skin, or the  extent of the tumor, require
a M'ound whose edges it is impossible to place in immediate contact,
we may in reality ask ourselves if there would not be an advantage
in filling the void by some one of the processes  of anaplasty.  Va-
rious  reasons may be advanced in support of this  proposition.  If
after the amputation of the breast, the borders of the wound remain
at a great distance from one another, M'e have to M'ait a long time
for the cicatrix, and  it is not effected but  by the intervention of a
new tissue, whose retraction produces a constant  tendency to the
return of the disease.  The suppuration  M'hich such  solutions of
continuity involve, and the tractions which such cicatrices exercise,
fatigue  and torment the  patient, and  render  the  radical  cure of
such wounds a difficult matter.  If, then, the surgeon could at the
commencement fill up the whole of the  wound, the patient operated
upon  would find great advantage and  security  from it.  For these
reasons, various kinds of  anaplasty have  been  made trial of,  after
amputations of the mammae.

                          Article I.

   The anaplasty known as that of Chopart, or that by drawing, (en
tiroir) has been made trial of by myself.  I had been obliged to re-
move the integuments with an encephaloid tumor, M'hich extended
from  the right clavicle to below the breast.  The woman M'as thin,
and her skin very adherent.   It was impossible to leave a  space of
less than three inches between the borders of the wound ;  prolong-
ing the  sides of this wound to the  extent of four inches below, I cir-
cumscribed  in  this manner a quadrilateral  flap, which I dissected
to the same extent, and which I endeavored then to raise  upward,
in order to  sew its  free border to  the upper lip of the primitive
wound.  I here experienced serious difficulties; for, owing to the
density of the dermoid tissue, the flap elongated but very little under
my tractions.   Having, however, united it by a  great many stitches 
ANAPLASTY OF THE THORAX.
663
of suture, to the entire circumference of the wound of the breast,
I succeeded in fastening it in a suitable manner;  but the operation
M'as long and painful, and the borrowed flap finally mortified, after
having given me, during the space of a week, some hopes that it
would agglutinate to the neighboring parts.

                 Article II.—Indian Anaplasty.

  A surgeon of La Creuze, M. Martinet, speaks of several women
operated upon  by him, and who  did  very well  under the Indian
method of anaplasty.  After cutting a large flap, either from with-
out and near the axilla, or from below and near the  flank, M. Mar-
tinet says that he then isolated, twisted, (contourne) and reversed
it, as is done with the flap of the forehead  in Indian  rhinoplasty.
He adds, that patients operated upon in this manner, and in whom
the disease had already reappeared twice, were ultimately cured,
and that it is a means which may protect the patient from a return
of cancer.
  For myself, I fear that anaplasty, whatever may be  the process,
has hardly fewer inconveniences than advantages in the mammary
region.  Whether the wound,  resulting from amputation of  the
breast, be closed immediately, or left to cicatrize by second inten-
tion, the surgeon is not on that account either more or less secure
against the return of the disease.  Even though he should succeed
in closing this wound by anaplasty, either  by the drawing method,
or by a reversed flap, the cure, to  be complete, M'ill require not less
than fifteen days, or a month.   We cannot fill  up a great loss of
substance in this region without producing a wound in the neigh-
borhood still larger.   The teguments thus dissected, also, are very
much disposed to become gangrenous, in consequence  of the  man-
ner in which the vessels penetrate into or  are distributed to them.
The accessory operation, sometimes worse than the principal one,
scarcely therefore merits being preserved  here, under the form in
which I have described it.

             Article III.—Anaplasty  of Franco.

  All that it would be proper to do, if, in order to obtain a complete
union, a slight elongation only M'as necessary, would be to separate
the tissues of the circumference of the wound to a certain extent,
after the manner of Franco, or to incise the integuments upon  the
sides, after the method of Thevenin.   We would thus  cause a re-
laxation, which would effect, without much difficulty, an elongation
of an inch or two in the lips of the wound.   In  fine, anaplasty in
the mammary region, does not appear to me destined  to occupy a
high rank in surgery. 
664
NEW ELEMENTS OF OPERATIVE SURGERY.
                       CHAPTER XIII.

  ANAPLASTY OF STERCORAL FISTULAS, AND ARTIFICIAL ANUS.

  Fistulas of different kinds may be established in the abdomen,
and in the inguinal regions.  When these fistulas are not kept up
except by an exudation (suintement) from the peritoneum, the cure
is generally easy.   Those that are connected with a wound of the
liver, also disappear without difficulty.  When caused by a disease
of the kidneys, or a perforation of the gall bladder, they ordinarily
resist every remedy.  Those of the stomach would yield, probably,
to some of the processes of anaplasty; but they are so rare, that
they have not hitherto  occupied the serious attention  of  prac-
titioners.  Those which are caused by a perforation of the  intes-
tines, alone merit consideration.  Whatever, then, may be  the part
of the belly where  the fistula exists, it takes the name of artificial
anus, (anus contre  nature.)  Nevertheless,  this last  name is ap-
plied more particularly to fistulas that remain divided at  the bot-
tom  by a kind of partition or spur,  (eperon.)  While this eperon
exists, the intestinal fistula requires a treatment  foreign to that
of anaplasty, and which  I shall recur  to in treating of artificial
anus.
  If the two  ends of the intestine, on the contrary, communicate
sufficiently freely with each other, and in such manner that the di-
gestive canal  is in some sort divided only on one of its sides, or on
its convexity, there is an opportunity of calling in the assistance of
anaplasty.  When  reduced to the state of stercoral fistulas,  artifi-
cial  anus, in other respects difficult to close by the other modes
known, has already  been treated by  several  processes  of ana-
plasty.

Article I.—Anaplasty by Dissection of the Tissues, (par Decolle-
                             ment.)

  Having to treat  a case of this kind, M. Collier detached the in-
teguments on the contour of the fistula, then pared (aviva) its bor-
ders, and immediately proceeded to their  reunion.   The patient
recovered.  Dupuytren, (Diet, de Med., et de  Chir. Prat.,  t.  iii., p.
157,) however, who attempted this method, states that it proved
unsuccessful.   It is moreover evident, that it would incur the risk
of an infiltration of stercoral fluids into the tissues of the parietes
of the abdomen, and that it might then be difficult to prevent gan-
grene, or erysipelas of a bad character.   The process of M. Collier,
therefore, has found but a very small number of partisans. 
      anaplasty of stercoral fistulas, and artificial anus.    665


               Article II.—The Indian Process.

  Very recently, in 1838, M. Blandin, (Bull, de VAcad. Royale de
Med., t. ii.,) having cut a tegumentary flap in the inguinal region,
succeeded in twisting (a pu contourner) this flap, and in attaching
it to the  circumference  of a large artificial anus.  The agglutina-
tion of the parts was effected, and the borrowed operculum, though
thin and  flabby, effectually closed all exit to the matters.  It re-
sulted, however, in this, that the intestine, with the constant  ten-
dency to  produce  a  hernia, pushed  it out like a valve, (soupape)
and obliged the patient to wear a bandage.  This case of success,
however, to which I have alluded, will  not be  sufficient to bring
into general use the anaplasty of the Koomas.  This method, at the
most, could only in fact  be adapted to large fistulas, and  to cases
where the parts admit of cutting from  the neighborhood a flap of
sufficient thickness.

             Article III.—Processes of the Author.

                   § I.—The Plug, (Bouchon.)

  Desirous of transferring to stercoral fistulas the method which I
had tried to the larynx, I endeavored, in 1832 and 1833, by means
of a tent  (bouchon) of integuments, to shut up a fistula of this kind
in a boy aged  about fifteen years.   The anus, about an  inch in
width, was entirely free of an eperon.   Many operations  had al-
ready been attempted for it in vain.  It had its seat in the right
iliac region.  I cut on  its  outside a triangular flap, three inches
long, and twelve lines in breadth. This flap, reversed upon its cu-
taneous surface, then rolled in the form of a plug, (bouchon)  was
introduced  by its cellular surface into the fistula, which had been
previously abraded, (avivee)  I fastened it there by means of  sev-
eral stitches of suture, and kept it in its place by the aid of a slight-
ly compressing  bandage.  Violent colics supervened on the  third
day, which were  soon succeeded  by a stercoral exudation at the
circumference of the flap,  which soon mortified and fell out  in a
state of putridity,  (putrilage.)
  The acrid penetrating humors which  pass under the fistula, in-
sinuate themselves so readily between  the parts, and render the
agglutination of the  tissues so difficult afterwards, that to succeed
in such cases M'ould require a concurrence of circumstances which
we could scarcely be permitted to hope for.

                    § II.—French Anaplasty.

  In other cases I have  proceeded differently.   After having pared
(avive) the fistula, in order to transform it into a  sort of a  slit,
(fente) and to unite it by three or four  stitches of simple suture,  I
made, at  the distance of an inch on each side, an incision which
                              84 
666           NEW ELEMENTS OF OPERATIVE  SURGERY.

extended beyond its two extremities, and M'hich M'ent through the
M'hole  thickness of the integuments and penetrated  down to the
aponeurosis.  I in this  manner  obtained a considerable degree of
relaxation, and the patient M'as completely cured, (Jour. Hebdomad.,
1836, t. iii., p. 5, 33, 65, 70.)  But, as I shall return to these differ-
ent methods  in  treating of artificial anus, I have no occasion of
alluding further to this subject at the present moment.
                       CHAPTER XIV.

           ANAPLASTY OF THE SCROTUM AND PENIS.

 Article I.—Prepuce.  Different Causes may produce the Partial
              or Total Destruction of the Prepuce.

  Gangrene, chancres, and certain  operations, as circumcision for
example, all tend to this morbid conformation.  The desire to rem-
edy it has been felt from the  earliest antiquity.  Galen, in quoting
Antylus, had already described the kind of anaplasty which was
formerly used  for it, viz.:  by  dissecting off the surrounding tissues,
(par decollement peripherique)   After having separated from the
corpora cavernosa the integuments  of the penis in their whole cir-
cumference, and to the extent of about an inch, An!ylus, drawing
upon this sheath, brought it forward so as to cover the glans penis
M'ith it.  The  operation in itself presents neither difficulty nor dan-
ger ; but by the effect of their contractility alone, the integuments
gradually retract backM'ard,  and soon reassume their former po-
sition.   In becoming  agglutinated  to  the  circumference  of the
glans,  they produce a more  serious deformity  than  the first.   I,
therefore, am  of opinion that anaplasty of  the  penis, such as we
understand it  up to the present time, is not worthy of being pre-
served. Composed as it is of a mere fold of the integuments, the
prepuce is not an  organ of sufficient  importance in the animal
economy to justify operations of this kind.

           Article II.—The Penis, Properly so Called.

  It happens  sometimes that the surgeon is obliged to deprive the
penis,  either wholly or partially, of its  cutaneous covering.  We
may conceive  that in a case of this kind it would be practicable to
borrow, either from the scrotum if it was sound, or from the fold
of the  groin, or the hypogastrium, flaps capable of subserving the
uses of the penis.   It is  very  doubtful also if Indian anaplasty
would succeed  here, and I do not believe  that it has ever yet
been tried for this purpose.  It might, however, possibly become
necessary after the removal of  certain tumors of the scrotum,
Uumeurs des bourses.) 
URETROPLASTY.
667
                    Article III.—Scrotum.

  The scrotum is very often the seat of tumors, which, notwithstand-
ing their very great volume, include nothing more than the integu-
ments, and leave uninvolved both the body of the penis and the
testicles.  In such cases, surgeons have conceived that it might be
possible to save (menager) these last-mentioned organs, though the
entire diseased tissues were removed.  It is M'hat Delpech (Clin.
Chirurg. de Montpellier, t. i.)—[See  the first account of this case*,
published  soon after its occurrence, in the New York Medical and
Physical Journal for the year 1822, as the same Mas communicated
to me at  the house Of the lamented Delpech at Montpellier that
year, together M'ith his original manuscript in French,  and the
original colored  plates, all  of m hich I treasure as a precious  relic
of that  truly accomplished  surgeon.—T.]—appears to have been
the first to do with success, in a man from whom he  had removed
a scrotal tumor of the weight of sixteen pounds ;  it is what I also
did in 1835, (Lancette Frangaise, 1835, t. ix., p. 177,) in the removal
of a similar tumor, but infinitely less voluminous.   In these  cases
we circumscribe exactly all the parts to be removed, taking care
to avoid the testicles and penis.  After having dissected the integ-
uments  in  the direction of the perineum, thighs, and hypogastrium,
Mre reverse them, and trim (decoupe) them to make the flaps out of
them.   All the flaps are then brought together, a portion of them
below and inward  to reconstruct the scrotum, the others upon the
body of the penis, in order to remake a sheath and prepuce for this
organ.   Numerous stitches of suture, and a bandage making mod-
erate compression, maintain the whole in its place, and promote
the agglutination of the parts.
                       CHAPTER XV.

                     URETROPLASTY.

  The  great  losses of substance in the urethra, ordinarily lead to
the formation of incurable urinary fistulas.   Various practitioners,
however, have, in  these cases and some other obstinate fistulas.
made trial of different modes of anaplasty.

                Article I.—Indian Uretroplasty.

  To cut a flap of integuments on  the upper part of the thigh, and
afterwards to transport  it and fasten it by means of the suture to
a urethral fistula previously pared, (rafraichie) is a method which
M. Earle appears to have been the first to have essayed with sue- 
669
NEW ELEMENTS OF OPERATIVE  SURGERY.
cess, (Archiv. Gen. de Med., t. i., p. 102.)  M. A. Cooper (Surgical
Essays, vol. ii., p. 221 ; Journ. Hebd., t. v., p. 108) has not been less
fortunate in one out of two of his cases : but Delpech, operating in
the same  manner, completely failed at  two different times on the
same patient,  (Lancette  Fran., t. iv., p. 264, 278. 285, 288. 295.)
Attempted afterwards by other practitioners, this kind of anaplasty
has been  equally unsuccessful.   The objections  I  have made  to
Indian anaplasty, in speaking of stercoral fistulas, exist in all their
force in reference to urethral fistulas.   In order  to succeed, two
things are required:—1.  That for four or five days no urinary dis-
charge  should  infiltrate  into the  contours of the fistula; 2. That
the borrowed flap should be thicker  and more vascular, and less
disposed to mortify in fact, than it necessarily is in those regions.

        Article II.—Uretroplasty by Drawing, (en Tiroir.)

  Desirous of avoiding this double inconvenience, M.  Alliot (Gaz.
Med. de Paris, 1834, p. 348) has proposed to pare (aviver) the fistula
freely upon one side of the urethra, in the direction of its tegument-
ary tissues, then to dissect and draw over to that side, by a sort of
slipping motion, (glissement,) the same tissues from the opposite side,
so that the convex border of the flap may be compelled  to cross and
go several lines beyond the opening in the urethra, in order to rejoin
the excised border of the integuments.  The fistula, resting then
upon tissues perfectly sound, is reduced to the state of a simple ulcer
opening into the urethra.  The patient of M. Alliot was completely
restored, and I doubt not that in transporting thus the integuments
from one side of the fistula to the other, we  may succeed in  es-
tablishing a process of uretroplasty of great efficacy.

        Article III.—Uretroplasty by Lateral Incisions.

  Desirous  of  avoiding  all  dissection  or  detachment of the sur-
rounding parts, M. Dieffenbach  conceived that in  order to cure
urethral fistulas, it would suffice  to pare their edges, to unite them
together by suture, and then to  make a deep and long incision on
each side.

Article IV.—Uretroplasty by Dissecting the Tissues, (par Decolle-
                             ment.)

  In the place of seeking for a flap near the  rectum, or upon the
lateral parts of  the penis, as the  English surgeons have done; of
borrowing it from the groin, or the inner surface of the thigh, as is
preferred  by the Professor of Montpellier; it would, probably, be
better to proceed by dissection and approximation.  In this mode,
the  fistula  being arranged as for an  ordinary suture, we  should
successively dissect off the two  sides from within outM-ard, so  as
to form two flaps, which we should preserve as thick as possible.
The border of these  flaps being afterwards pared, either by the 
              VAGINAL ANAPLASTY, OR ELYTROPLASTY.           669

bistoury or a pair of good scissors, allows, in fact, of our effecting
the coaptation M'ith the simple or twisted suture.  A methodical
compression made upon these  lateral  parts, would keep them in
exact contact with the subjacent tissues, and would serve to prevent
the urinary infiltration.  But experience not having yet pronounced
upon this operation, I do not think  it necessary to say any more
upon the subject.
  I would say the same of the process which I have already spoken
of in treating  of bronchoplasty; since, from not having  yet tested
it  in cases of  urinary fistulas, I cannot regard its success as any
thing more than very probable.

                   Article V.—Appreciation.

  We cannot deny that all these varieties of anaplasty may some-
times be useful in these cases, and that each one of them may have
its indications; but we should, nevertheless, do wrong to repose any
great degree of confidence in any of them, or to have recourse to
them before assuring ourselves of the inefficacy of other therapeutic
means.   It is  evident, also, that the details of the  manipulating
process would be superfluous, and that these are operations that
the surgeon ought in some measure to devise for each  particular
case.  The important point is to know that the stitches of suture
cannot  be too numerous; that we ought not, if the  attempt is
practicable, to leave any void, or any separation of tissue, (decolle-
ment) in the neighborhood of the fistula; that the integuments and
the flaps ought not to be detached but to such extent as is abso-
lutely necessary; that it is requisite to leave a gum-elastic cathe-
ter in the urethra, or to use the catheter every time the bladder
has need of being emptied, in  order that  the urine in passing out
cannot  possibly touch the walls of the  canal.  (See  Operations
which are performed on the Urethra.
                      CHAPTER XVI.

           VAGINAL ANAPLASTY, OR ELYTROPLASTY.

  Of the three kinds of fistulas which may be formed in the vagi-
na, vesico-vaginal, recto-vaginal, and entero-vaginal, there are two
at least  in which  anaplasty may be proposed, and which have, in
fact, been submitted to some trials of this operation.

              Article I.—Vesico-Vaginal Fistulas.

  Whether the fistula which opens a communication between the
urinary  passage  and the vagina, commences  at  the urethra or 
G70           NEW  elements of operative  surgery.
 bladder, it is, nevertheless, always very difficult of cure.  Having
 ascertained that neither cauterization,'the suture, hooks, (irignes)
 nor other operative processes, have ever hardly succeeded in these
 cases, surgeons  very  naturally welcomed the  suggestion  of  any
 thing like a new operation.

                              §1-

   Nevertheless,  it is  scarcely any other than Indian  anaplasty
 M'hich has been employed to  remedy fistulas in the vagina.   No
 one had spoken of it previous to my having suggested, in 1832, the
 shutting up of laryngeal fistulas, by means of a plug (bouchon) of
 integuments.  I added at that time : " If analogy does not deceive
 me, this method would answer equally well for other fistulas, and
 for the closing up of a  great number of other openings.   Deep nar-
 row fistulas M'ith loss of substance in the urethra, thoracic and ab-
 dominal fistulas,  artificial anus when the obstruction to the course
 of matters no longer  exists, and  certain salivary and lachrymal
 fistulas, M'ould probably derive more advantage from it  than from
 the different anaplastic methods hitherto used."
   It is, nevertheless, proper to say, that in expressing myself thus,
 I was guided only by analogy, and that my .assertions were not yet
 sustained upon any known fact in practice.  We have seen above
 that my predictions were in part  realized, in respect to  artificial
 anus and fistula lachrymalis.  A surgeon of the hospitals of Paris,
 M. Jobert, (Bullet, de I'Acad. Roy. de Med., t. ii.,) has taken advan-
 tage of this idea, and appears to have made up to the present time
 numerous applications of it to vaginal fistulas, whether of the
 bladder  or urethra.  It appears  also to have been demonstrated
 that one of the patients, operated upon by him for a fistula at the
 bas-fond of the bladder, has now been radically cured of it for more
 than two years past.  It is true that this process proved unsuccess-
 ful in most of the women he tried  it  upon, and that M. Roux on
 his part (Journ. des Conn. Med.  Chirurg., t.  iv., p. 107)  has com-
 pletely failed with it.   It  is even to be feared that by this method
 we must often anticipate a failure.  Nevertheless, as it is an easy
 process, and one which any one may perform, it deserves, as I think,
 to be retained, at least for  cases where the fistula is of  little ex-
 tent, and where  its edges are neither too much thinned nor too in-
 durated.
  The operative process of M. Jobert is copied precisely after that
 which I have described in treating of bronchoplasty.   The fistula
is abraded (avive) by means of caustic, or a cut/ting instrument; a
flap of much greater length than width, and also of greater or  less
length or breadth, according as the fistula itself is of greater or less
 size, or  more or less deeply situated, is then cut upon one of the
sides of the vulva, so that its point shall be turned towards the sub-
ischiatic groove, (rainure) and that its root may be continuous with
the vulvar opening of  the vagina.  Dissected and separated from
its apex  towards its base, this  flap should be  sufficiently long to 
ANAPLASTY, OR ELYTROPLASTY.           671
 nrpfhr*   ™*?ut *^ty through the fistula into the bladder, or
 foldI wlrb ?HVmiS  Hed ? Up.°n itS cutane°™ face, we pierce the
 S,^h ^ double  thread ; this thread, which  is  to serve as its
 Conductor being  attached  to the head of Bellocque's sound,  pre-
 l^ZtYti  t    6d  /nt°  ^  Urethra  throu§h th*  vagina, easily
 draws the tegumentary plug towards  the fistula, and prevents it
 afterwards from falling back  into the vagina.  As the presence of
 the  thread  in the urethra might cause an ulceration, there  would
 be some advantage, perhaps, in passing it through a female cathe-
 ter, which would serve as a support, at the same time that it would
 give egress  to the urine   It is evident, also, that the flap may be
 taken almost indifferently from the tissue of one of the labia maio-
 ra, or from the inner surface of the thigh, or from near the breech.
 Ihe important point is, that it may have a certain degree of thick-
 ness, especially on the side of its pedicle; otherwise, with the length
 we are obliged to  give to it, it would be next to impossible to pre-
 vent its mortification.  Perhaps it would be well, also, after hav-
 ing doubled it, to  keep it thus folded at its point by means of one
 stitch of suture, and to let it  contract itself and  become  vascular-
 ized, before introducing it into the fistula.   It would  also be advan-
 tageous, as I think, to  draw it by its larger  extremity, and  to use
 some force to make it  enter, in order that its largest portion, being
 in the bladder,  might in some measure  be retained  underneath by
 the fistula itself, which would then perform the office of a  constrict-
 ing ring.  What is also necessary is, that the flap should be placed
 in contact with the fistula by its cellular, and not by its cutaneous
 surface, and that the edge of the fistula  should be in  a state of com-
 plete abrasion,  (avivement)
   In this manner no stitches of suture are necessary, and  the parts
 may remain in their  place of themselves.  Moreover, we should not
 think of dividing  the  pedicle of the flap till at the end of some
 weeks, and after having positively ascertained that a solid agglu-
 tination has taken place between the new substance and  the peri-
 phery of the fistulous opening.  This section, also, should be made
 towards the middle of the  length of the flap, in order that  in re-
 tracting by its new extremity, it may ultimately form a sort of but-
 ton with two heads, one  in the vagina, the other in the  bladder.
 As to the external  wound, it should be treated by suture and other
 uniting  means, to  its outer half, and with the view  of preventing
 all constriction of the pedicle of the flap, it would be advantageous
 not to approximate its edges too near to the base of the flap.  In the
 case mentioned  above, the obturator (obturateur) flap consolidated
 so perfectly, that  it  remained covered  with  a  tuft of hair in the
 interior of the vagina.
  I have no occasion  to remark, that  in regard to attention  to
 cleanliness, and  the  precautions which  the excretion of the urine
requires, we must,  when  elytroplasty is  decided upon, proceed ac-
cording to the rules laid down in treating of vesico-vaginal fistulas
in  general.
  M. Roux, having to close a vesico-vaginal fistula, of tM'o to three 
672
NEW  ELEMENTS OF OPERATIVE SURGERY.
lines in breadth, concluded to cut his flap upon  the  wall of the
vagina itself.  Having reversed this flap upon its  mucous face, he
introduced it into the fistula in the manner we have described, but
the apex of  the plug soon mortified, and  the operation proved un-
successful.

     § II.—Elytroplasty by Raising up a Tegumentary Arcade.

  Having met with many women who had been unsuccessfully op-
erated upon by elytroplasty M'ith the process of the plug, (bouchon)
[literally a cork.—T.,] I determined to make trial, in these cases, of
another mode of anaplasty.  Grasping, by means of an erigne with
a double hook, the posterior wall of the vagina opposite the fistula,
and draM'ing towards the vulva this part, which the forefinger in-
troduced into the rectum  pushes forward, and raises up in front, 1
give the erigne  to an assistant, in  order to have my hand free.  I
then use a  straight  bistoury, held  as a pen, to  incise  the vaginal
M'all to the extent of an inch, or an inch and a half, above and then
below the point raised up by the erigne,  taking  care not to pene-
trate to the  interior of the rectum.   The  limits of  the arcade to be
formed being thus defined, I glide the point of the  bistoury flatwise
from the lower to the upper incision, and through  the tissue of the
partition, so as  to detach the middle part of this patch (plaque) of
the vagina from right to left, and  to the extent of about an inch,
without  opening into the rectum, and also without detaching its
two extremities.  The  fistula, previously pared,  is  immediately
treated  by suture.  Each thread, armed with its curved needle, is
first passed  from before  backward, or from below upward, under
the vaginal  bridge, then from the bladder into the  vagina, through
the posterior lip of the fistula, and afterwards brought under the
bridge, and  then outside.  A second stage of the operation consists
in traversing, from behind forM'ard, and from the  bladder into the
vagina, the anterior lip of the hole with the other extremity of each
thread, each of which is alike armed with a needle. Desiring noMr.
as  the last  step, to  tie these threads, we force up the dissected
arcade into the fistula, to be placed in the bladder at the same time
that the lips of the fistula have been brought into contact under-
neath.  The flap thus borrowed from the vagina,  projects into the
bladder, and is in reality placed astride  upon the  suture, (a cheval
sur la suture.)
  This process, which appeared to me to present some chances of
success, nevertheless failed, in the  only case in which I tried it;
but it  is  to be remarked, that the fistula had more than an inch
diameter, and that all the parts of the vagina had been for a long
time changed, by all kinds of attempts at operations. My intention
was, in  the supposition  that  the  agglutination could have been
made, to divide, at the end of ten or fifteen days, first one of the
extremities< of the flap, and  at a little later period, the other ex
tremity, then to let the wound gradually cicatrize. 
               VAGINAL ANAPLASTY, OR ELYTROPLASTY.           673


                   § III.—Direct Agglutination.

   Another method which I have wished to apply in two cases, but
 which the women would not consent to undergo, would consist in
 actively cauterizing the  edges of the fistula, and the corresponding
 wall of the recto-vaginal partition, then to keep this partition raised
 up by means of plugs (tampons) of lint, and dilating bodies introdu-
 ced into the rectum.  An agglutination obtained in  this manner
 would, at a later period, allow of re-establishing the continuity  of
 the vagina, and of leaving, as an operculum on the fistula, the por-
 tion of tissue which would have been thus dissected.  To what ex-
 tent do these  processes deserve to be employed ? It is what I  do
 not venture to say, having myself failed when I have wished to put
 them in practice.

               § IV.—Excisions in the Neighborhood.

   Would we perhaps succeed better by excising, at each extremity
 of the fistula, an elongated  triangle  to  half the thickness of the
 vesico-vaginal wall ?  The cicatrization of these new wounds are
 of a nature, it seems to me, to retract, and perhaps  completely  to
 shut up the old one.

                  § V.—Depressing the Uterus.

   Another process which might be borrowed from anaplasty, when
 the fistula is  very high  up, would consist in actively (fortement)
 cauterizing  its vaginal region, then  in  hooking the neck of the
 uterus with an erigne, or a noose of thread, in order to pull it down
 and cause it to slide as a drawer to  below the vesical opening.
 But I repeat, all these suggestions want a foundation to rest upon;
 none of them can yet adduce any success in their favor.

    Article II.—Recto-Vaginal Anaplasty, or Elytroplasty.

   All that I have said of vesical elytroplasty, is applicable to those
 fistulas by which the rectum communicates with the vagina.  It  is
 true, however, that the attempts in respect to these have been less
 numerous than for the other, either because this kind of fistula yields
 better to ordinary means, or that it is less frequent, or because fe-
 males are less annoyed by it. The suture to the perineum, how-
 ever, is an operation which will.perhaps draw attention to this sub-
 ject, since when that has been performed, it is not unfrequent to
 find a  hole remain above, in  the  lower part of the recto-vaginal
 partition.  A lady who was in this state, in consequence of a su-
 ture in the perineum, which M. Roux had introduced, was operated
 upon by me in 1837, by means of the Indian mode of anaplasty.   I
cut a flap in the tissue of the left labium majus, two inches long,
and eight to ten lines in breadth at its root.  A thread, affixed to
                             85 
674           NEW ELEMENTS OF OPERATIVE SURGERY.

the upper extremity of this flap, enabled me  to draw it from the
vagina into the fistula in the rectum, and to hold it fastened in this
manner near the anus.  It mortified to tM'o-thirds of its extent, and
contracted adhesions only on one of its sides;  so that the fistula, in
fact, was diminished only by one third of its size.   It is neverthe-
less true, that in patients more tractable, and  by taking every pos-
sible precaution not to weaken the vitality of the flap, elytroplasty
by the tegumentary plug will offer some prospect of success in this
kind of fistula.
                       CHAPTER XVII.

                ANAPLASTY OF THE PERINEUM.

  Clefts (fentes) and fistulas of the perineum in women, might, in
fact, allow of many kinds of anaplasty.   From the pliancy of the
tissues, however, and the ability to bring the lips of the division in
contact, the  incisions of Celsus only have been applied to them.
Thus, after having pared and united these fissures, we may, if the
parts seem too tense, make on each side a long incision, and one of
sufficient depth to prevent the elasticity of the tissues exercising any
further resistance to  the action of the  suture.   Only it would be
necessary then, in order not to lose the advantage of these incisions,
to fill them with dilating bodies, for example, with rolls  (bourrelets)
of lint covered with cerate.  I shall have occasion to refer to all
these chapters, in treating of the genital organs and the anus. 
[CONCLUDING  AMERICAN  APPENDIX.
   Many  things of interest, and some of much importance in sur-
 gery, having occurred while this first volume of this American edi-
 tion has been in the press, we take the occasion, in a concluding
 appendix, to subjoin whatever has reached us of particular value
 of this kind to the student or surgeon, and which  directly apper-
 tains to the matters treated of in this volume ; more especially to
 those new, useful, and attractive departments of modern  surgery,
 which constitute happily the leading feature of this first portion
 of M. Velpeau's great  work.  We mean anaplasty and tenotomy;
 in the contributions to which our own American surgeons, as will
 be seen  by the  liberal citations  we have made from Professor
 Pancoast's, Professor Mutter's, and other publications recently is-
 sued  from the press, furnish a very considerable  and creditable
 amount.—7!]

                         Acupuncture.

   The Chinese and Japanese, from whom this practice,  like the
 massage,  (shampooing,)  rhinoplasty, and much other valuable  and
 practical surgery is derived, as the fruit of the reiterated and es-
 tablished experience of centuries, prefer gold and  silver  needles.
 Those of steel, provided they are finely polished, are most in use
 with us, and are probably better,  from  their direct and doubtless
 salutary chemical action on the tissues, as well  as from  the fact
 that the metal, iron, from its being the only one of the metals which
 is ascertained  to be a  constituent and important element of the
 blood, must necessarily be more congenial  in its adaptation to the
 organism.  The  number of needles  varies from one or  two to
 twenty or thirty; and  in order that  they may be well polished, it
 is advisable, before  using them, to pass them through an emery-
 bag, as recommended by Dr. Elliotson, of London.   In the East,
 the usage is to keep them in for one or two minutes only; but M.
 Cloquet and Dr. Elliotson prefer to leave them in for several days,
 while Professor Bache, of Philadelphia, who has used them to great
 extent, and with much benefit in chronic rheumatism, leaves them
 in for a still longer time, regulating the period according to the time
 the disease has existed.  Mr. Lewis, of England,  has employed
acupuncture with some  success in hydrocele and anasarca, and for
oedema of the scrotum, penis, and eyelids. 
676
NEM' ELEMENTS OF OPERATIVE SURGERY.
                 Electro, or Galvano-Puncture.

  The recent  and extraordinary  developments of electro-galvanic
power, (as in our countryman Morse's Telegraph, &c.,) lead to the
belief that this mysterious agent is destined, at some future time,
to play an important role as a therapeutic means in the animal
economy.  We have for years had a department of mechanical op-
erators, in the application of the galvanic or electric fluid for va-
rious  chronic diseases, more  particularly for the forms of chronic
rheumatism ; but the subject has never, as far as we  have learned,
since the time of the empirical (though, as it  now turns out, scien-
tific) contrivance of Perkins' Tractors, (also an American invention,)
been investigated by competent persons in the  profession.  That
time,  perhaps, is soon to come, and  we count on some curious, if
not valuable discoveries.   We  have recently known of a well-at-
tested  instance in this city, (New York,) in  which an inveterate
and long-continued  permanent contraction of the flexors of the fin-
gers, in a gentleman advanced in  life, has been as effectually cured
almost, by the repeated tranfusion through them of the electro-gal-
vanic currents, as  it could have been by  the  tenotome;  or even
more so, considering the now-ascertained danger of the application
of tenotomy to this part.  (See in the body of the work ; Discussion
at the Academy of Medicine of Paris, on the subject of Tenotomy.)
The fingers were almost completely restored  to their natural posi-
tion and uses.

                       Hcemostatic Means.

   The ball, or point of the thumb, or both thumbs, are generally
preferable for the temporary compression of arteries, where there
is bone to press against;  but where the large  trunks are rolling,
and separate from the bones, as in the course of the thigh and  arm,
the four fingers are most  convenient, aided by a point d'appui for
the grasp of the thumb and palm of the hand on the opposite side
of the limb.
   On the subclavian in the supra-clavicular fossa, between the
scaleni, we may use the thumb and  finger  as directed by Camper,
or the hand-pad. This latter should have  a large pad when used
for the aorta, as recommended by Trehan, Baudelocque, and others,
for uterine haemorrhage after parturition.   The whole hand, in thin
subjects, and where the abdominal muscles are placed in as relax-
ed a condition as possible, may also  be used.
   The artery-pad of Charriere, with its buckles and strap, is a very
 convenient instrument  for the temporal  artery in front of the ear
 and above  the zygomatic arch, while the double compress under
 the jaw protects the skin from the pressure of the strap.
   The newly-devised compressors for the subclavian, by Bourgery,
 Malapert, &c, though complicated,  are well adapted to effect the
 object desired, in a secure and perfect manner.  We doubt,  how- 
AMERICAN APPENDIX.
G77
ever, their applicability to the carotids, for the compression of one
alone would, from the free  anastomosis, be of little avail, while the
compression of both would  certainly be extremely hazardous, if not
immediately fatal.
  The axillary artery, in persons not  thin or emaciated, is difficult
of compression, as the pectoral muscles lie in front of it as it  passes
over the second and  third ribs.   To effect it, however, these mus-
cles  should be relaxed  as  much as possible, by bringing the  arm
partly over the chest in front.  The upper part of the middle third
of the arm is preferable for the humeral, or brachial, as the median
nerve is here some distance within it.  Professor Fergusson prefers
the application of the  tourniquet to  the  femoral, in the popliteal
region, rather  than at the usual place in front of the thigh above.
There is then,  he  thinks, less venous hemorrhage.
  Where the artery is large, and in a state of ossification, Professor
Mutter, of  Philadelphia, has obtained a serviceable plug  by de-
taching a portion of  the adjacent muscular tissue, leaving one ex-
tremity of it unseparated, as in  making a flap, or bouchon, in ana-
plastic operations.
  Torsion unquestionably was suggested by the  fact, that  limbs, fyc,
torn  off, scarcely bleed, the  external coat of the artery, in these
cases, having been found to be drawn out and twisted spirally, be-
yond and around  the two ruptured and receded coats within, and
the clots of blood blended  with  them.   This has suggested, also,
the tearing  out certain tumors in vascular and cellular tissues, after
making the first free incisions and separations.
  It  has recently been  proposed, with more ingenuity than good
sense, to arrest the hemorrhage of a  divided artery, by passing its
bleeding extremity through a slit in the tube above.  The hot iron
after all, and that repeated, is one of  the most valuable styptics in
the small arteries.  This is most beautifully illustrated in the  new
and admirable treatment of ncevi by red-hot needles, (vid. supra.)
  Metallic Ligatures have been, according to  Dr. Levert, (Amer.
Journ. Med. Sc, 1829,) in his experiments upon animals, found  to
answer very well; but we should, until more accurate knowledge
on this head, doubt their adaptation to organic  tissues.
  In Phlebotomy, much stress is laid by some on the danger of se-
lecting the median basilic,  from its proximity to the  brachial arte-
ry, the  filaments of nerves that surround it, and the number of ab-
sorbent vessels that pass over it.  It  is even recommended, before
opening it,  to pronate the forearm  strongly, in  order to twist,  as it
were, the tendon  and aponeurosis of the biceps around the radius,
and so remove the artery further off from the vein.  This, however,
would  be apt  to  disturb the parallelism of the apertures  in the
teguments and vessel. 
678
NEW  ELEMENTS OF OPERATIVE SURGERY.
    SUB-CUTANEOUS SECTIONS IN TENOTOMY AND MYOTOMY.

                          Strabismus.

  Professor Joseph Pancoast, of Jefferson Medical College, Phila-
delphia,  (in his recent work on Operative Surgery,  Philadelphia,
1844, p. 221,) says he has performed the operation three hundred
times, a considerable  proportion of which were in public.   He re-
commends unhesitatingly the following  method, which  he  claims
as his own :—The lids are to be kept open by a small instrument
which he calls  the spring-dilator, or speculum, a kind of wide for-
ceps, (made of  silver-gilt steel wire, it is presumed,)  and with one
or two convolutions or circles of wire at its angle of union, so as to
give it the elasticity or spring required.   The prongs  are thus kept
wide asunder, and their extremities respectively applied to the cu-
ticular surface of the lids, thus causing but little pain, but requiring
the substitution of Pellier's elevator where there is  much spasm.
In nearly one-sixth of his cases, he found the separation with the
fingers quite sufficient.  The sound eye he advises to  be  bandaged,
as (in internal  strabismus) this has the  effect  to make  the corre-
sponding  or diseased  eye naturally turn  more or less outwardly,
and  thereby facilitates the  operation.  A double hook (supposing
the case  to be internal strabismus) is then inserted through the con-
junctiva  into the fibrous expansion of the tendon, at the distance of
two  and  a half to  three  lines behind the margin of the  cornea.
This hook should not, he thinks, be made as generally directed, to
force the ball strongly outward, as this would occasion unnecessary
pain, and lay the tendon to be divided too flat upon the.ball to be
easily raised with a blunt hook.  It is sufficient to turn the cornea
a little beyond  the middle of the orbit, steadying it securely in that
position.   A fold of the conjunctiva and subjacent fascia, a little
below the lower edge of the tendon, is then perforated and raised
by the sharp point of a pair of angular scissors, and immediately
divided.   The  cellular tissue, and intermuscular fascia, may next
be snipped with  the scissors, at  the upper and lower edge of the
tendon.   A blunt hook is then passed from below upward, under
the muscle, when the sharp hook is to  be removed.  The blunt-
pointed branch of the scissors is now to  be introduced beneath the
muscle, between it and the hook, and  the muscle  thus divided.
The surgeon should be careful to cut on  the outer side of the plica
semilunaris, to  avoid hemorrhage.  If the eye has not acquired its
position correctly, the fascia may be still further dilated afterwards,
(by another operation,) either above or below,  according  as the
torsion of the ball is upward or downward. So also, (as enjoined
by Velpeau, vid. supra,) it may be necessary to divide a part of the
insertion of the upper or inferior rectus, or some of the deep-seated
bands of cellular tissue at their place of connection with the inner
surface of the ball.  If this, however, is  carried too far,  it may (as
is well known) occasion a strabismus in  an opposite direction, or a
protrusion of the ball. 
AMERICAN APPENDIX.
679
  This process we have thought it just to give, as coming from an
accredited practitioner; but it appears to us to be too complicated
and tedious, compared with  some others given in the text of the
work.  The spring dilator, if really practicable  in its application,
would  seem to be an improvement, not, however, altogether new.
We regret the author has not given an abrege of his three hundred
cases, that  we might derive  advantage from the  results, whether
cures or failures.

Excision of a Portion of an Elongated or Paralyzed Rectus, and its
                     Tendinous Expansion.

  In witnessing a great  number of operations  for strabismus by
various processes, and the failure in the eye to regain its normal
position,  as frequently as  could be desired,  it has occurred to me
that it might  be advisable,  after the present ingenious mode in
talipes from paralysis, of exsecting a portion of  an elongated par-
alyzed tendon, (vid.  our notes  in  the text,  supra,) to excise, after
the simple division of the rectus internus, (in  convergent strabismus,
for example,) in the  same  manner, a sufficiently large segment of
the rectus  externus, when greatly relaxed,  to enable the cut ex-
tremities of the exterrius to unite so far forward on the ball as to
give that muscle its proper antagonist  force, and restore  the ball
to its normal  position.   The elongated and paralyzed  rectus, on
whichever side it may be, might also, in such cases, in order more
perfectly to secure the reunion of the divided extremities, have these
brought into coaptation by suture.   This modification of the oper-
ation, we believe, has never  yet  been suggested or performed for
strabismus.—[P. S. T]

                       The Tendo-Achillis.

  We take occasion to correct an error in the recent quarto volume
of Professor Pancoast, of Philadelphia, on Operative Surgery, (1844,
p. 363,) wherein he  imputes a misconception, on the part of Tul-
pius, Heister, and  others, in the supposition they entertained, that
club-foot might be caused by a paralysis of  the muscles opposite to
those contracted.  It will be seen by our notes in the text, under
the head of Tenotomy, that this was and is  a soun-d pathology, and
that the  consideration of these cases, and the admirable adaptation
of the tenotome to  their relief, by the  exsection of a segment of
the elongated  paralyzed muscle or muscles, in addition  to the sim-
ple division of the contracted muscle or muscles, form a most im-
portant department of sub-cutaneous surgery.   It is not, therefore,
(as Professor P. seems to think,) only in cases of fibrous  degenera-
tion of the muscles (lb., p. 364) that the use of the knife is ordina-
rily needed.  This author is of opinion from dissections, that, al-
though the retracted muscles are  shrivelled and shortened  from
defective nutrition, caused by the vessels being  greatly diminished,
[for want, probably, of the stimulus  of the contractions of the mus- 
680
NEW  ELEMENTS OF OPERATIVE SURGERY.
cle.—T..] the nerves are, in fact,  occasionally hypertrophied,  or
enlarged, when compared M'ith those on the sound side, (Ib.)   This,
if generally true, is, we  think, a new and curious fact; and, upon
the supposition that galvano-electric currents are the motive power
of muscular action, might, perhaps,  from their being constantly but
unavailingly called into requisition  on the contracted side, account
for this morbid organic growth of the nerves.  We differ entirely
with this author (Ib.) in the rather equivocal approbation he seems
to bestow upon  tendon-cutting surgery, as he terms it; but agree
with him, that if orthopedy has  in reality fallen into disuse, it has
been from the anatomical ignorance, or empirical presumption, of
those who have unadvisedly been permitted to plunge the tenotome
(as has been done in plunging the lancet into an aneurism for ab-
scess, or  applying the ligature to the femoral vein for the artery)
into regions where it could be of no use, or should not have been
introduced.
  In reference to the injudicious severe application of mechanical
apparatus,  in  lieu of subsections, Professor Pancoast says he has
seen some melancholy instances, in which this treatment  has, by
the constitutional' irritation thereby induced, awakened some dor-
mant affection of the heart or lungs.  In this, we believe the more
rational,  discreet, and  experienced  portion of the profession, in all
parts of the world, M'ill be found to be of accord.   And no one can
too strongly proscribe and deprecate the practices of those empiri-
cal and ignorant orthopedic machinists, who, with their crude and
violent contrivances, impose too successfully upon the credulity of
parents and  the  community, in their  professed but impotent at-
tempts to cure curvatures, and  even angulations of the spine, &c,
M'hile the harsh machines they employ not only exhaust the mus-
cular energies, and  atrophize the muscles by confinement, irrita-
tion, and  pain, but too  often aggravate the distortions, and acceler-
ate the death of the patient.
  All other things being equal, no apparatus or machines, as a sub-
stitute for myo-tenofomy, (as we have ventured to designate the gen-
eral  branch of division of the  muscles,  tendons, aponeurotic and
fibrous bridles, &c.,) can be of value, unless, as is now universally
conceded, they admit of, or are associated with, well-timed periodi-
cal, steadily-continued, but not immoderate exercise of the locomo-
tive organs implicated.

   Sub-Cutaneous Section of Muscles of the Face, for Contraction.

  Since the division of the masseter by Dr. Schmidt, of New York,
followed by Dr. Mutter, of Philadelphia, Dieffenbach, of Berlin,
and Fergusson, of London, this section has been applied by Dieffen-
bach to most of the muscles of the face, in cases of severe retrac-
tion  and  distortion, more especially of the angle of the mouth.  It
would seem that there has been too much of a wholesale application
of myotomy, by some who have undertaken these sections, and that
a sweeping division has been made of most of the  sub-cutaneous 
AMERICAN APPENDIX.
681
muscles of the face, without reference to those specifically impli-
cated in the  deformity;  the consequence of which is, that the par-
alyzed  bloated  appearance afterwards, of the side of the face op-
erated upon, constitutes a state of things more repulsive in appear-
ance, than the original deformity.  Prof. Pancoast, of Philadelphia,
in June, 1842, (see his Operative Surgery, Phil., 1844, pp. 368-9,)  in
a case of retraction of the right commissure of the mouth, divided
by puncture with the tenotome in the mucous lining of the mouth,
not only the  zygomatic muscles, and the buccinator, (in part,) but
also the orbicularis, and levator and depressor muscles of the  angle
of the mouth; which, not effecting the object desired, the remaining
portion of the buccinator, and  also  the  depressor labii inferioris,
were also  divided.  This, it  is asserted, removed every trace of the
deformity; but the division of these two last-mentioned muscles
might have been quite sufficient at first, instead of indiscreetly (as
we think it  to have been) making such extensive sections as the
operator did  at the very onset, with the hazard of wounding im-
portant parts, and without, it seems,  accomplishing the purpose  he
had in view.
  The  orbicularis occuli has been divided successfully by Dieffen-
bach, for spasmodic contraction, and by Messrs. Cunier and Phillips,
for ectropion.

                     Talipes, or Club-Foot.

  Prof.  Pancoast, of Philadelphia, considers  those cases in which
the fleshy  part of the gastrocnemii is permanently contracted into
an indurated ball or knot, as in cramp, and where their tendons are
thicker and  stronger than natural, as most difficult of cure. He
also remarks, that after the  deformity commences, the insertion  of
the tendo-Achillis may have the natural obliquity of its insertion a
little to the inner side of the os calcis increased by the twist of this
bone, so as  to aggravate the torsion, and produce a pes equinus
varus.  (See his  Oper. Surgery, p. 371.)  In  talipes equinus,  in  its
worst forms,  (lb., pp. 371-2.) Prof. Pancoast says he has found,  on
dissection, the whole of the  upper articular surface of the astraga-
lus turned forward, so that  the tibia and fibula rest  only on the
back part  of the astragalus,  and the  upper surface of  the os calcis.
The posterior part of the articular surface of the astragalus is then
rendered flat by the pressure of the bones of the leg, while the front
portion, no longer subjected to pressure, or lubricated with synovia,
becomes roughened and  covered with bony deposit, so as to offer
an almost  insurmountable obstacle to any thing like a perfect cure
of the deformity.  The whole  structure of the foot is found, as it
were, twisted from before backward, the tarsal bones, as a conse-
quence, being separated on their dorsal face, and compressed  on
their plantar.  The ligaments undergo corresponding changes;
they are lengthened and  thinned above, and shortened and thick-
ened below.
  In talipes varus, (the torsion  inward,) the scaphoid bone, which
                              86 
682
NEW ELEMENTS OF OPERATIVE SURGERY.
in its normal position should be  placed at the  internal margin of
the dorsal surface, is, he says, (lb.) found rotated from within out-
ward on its smaller axis, so as to have its internal border placed
obliquely near the internal malleolus, while its  external tuberosity
is placed transversely on the back of the foot, looking downward.
In consequence of this rotation, the internal border of the foot forms
an acute angle with the internal malleolus, and the outer two-
thirds of the head of the astragalus leave the cavity of the scaphoid
bone.  The os cuboides undergoes a similar rotation, so as to form,
at its place of articulation with the head of the os calcis, an angle,
obtuse outward and acute inward, consequently leaving uncover-
ed, so as to be felt on the outer side  through the skin, a portion of
the  articular face  of  the anterior tuberosity of the latter bone.
The os calcis is also changed,  so  that  its  tuberosity presents more
or less  downward, M'hile its posterior tuberosity is turned to an
equal extent inward and upward; the  calcis being thus semi-luxa-
ted at  its articulation with the astragalus^  The ligaments which
join the calcis to the  cuboides,  are  found generally in a state of
great relaxation.  The anterior  tarsal and the  metatarsal bones,
are  usually deviated in like manner upon those to M'hich they are
articulated, the toes being thrown in a vertical line, with the greater
one  projecting upward, rendering the dorsal  surface of  the  foot
very convex.   From the general twisting of  the  foot, the inner
margin of the heel is also thrown upward, to near the internal mal-
leolus, and turned backward so as to bring the external malleolus
near the surface of the ground, the weight of the body being  sus-
tained on the external  border,  M'hich in time becomes covered with
a hard corn.   The  bones, in middle life, will  generally be found
atrophied, and, in some feM' cases of congenital club-foot, the as-
tragalus has been found twisted  on its  axis, and xlisproportionately
lengthened.  The twist of the foot also tends to rotate the leg in-
ward, causing  more or less  deformity, and difficulty of motion in
the  knee joint.  The  deltoid,  or  internal lateral ligament of the
ankle joint, is  shortened, while the external lateral ligaments are
lengthened.  A new band of fibres, or  accidental ligament, is often
found  tying the internal malleolus to  the os calcis.  The  inferior
calcaneo-scaphoid ligament is shortened, and tends to keep up the
mal-position of the foot, while the superior calcaneo-cuboid, in ac»
cordance M'ith Scarpa's observation, is found materially lengthened.
The leg is thin from the atrophy of the muscles, and their tendons
are  commonly smaller and longer than usual.
   In the talipes valgus,  (outward,) which is very rare, the three pe-
ronei muscles are considered the usual  cause of the deformity, and
their division generally effects a cure,  unless there  is an  equinus
accompanying, requiring the section  also of the tendo-Achillis, (Ib.)
   In talipes talus, that  is, where the  foot is drawn upward, and
which is the rarest of all, the contraction of the tibialis anticus, ex-
tensor digitorum, and  extensor pollicis pedis muscles, are, in the
opinion of Prof. Pancoast, deemed to be the cause of the displace-
ment, (Ib.) 
AMERICAN APPENDIX.
683
  In talipes plantaris, a new or fifth variety, recently described by
M. Guerin, the deformity is produced by a shortening of the mus-
cles on the plantar surface of the foot, which diminishes the length
of the organ, and causes a marked increase of the convexity of the
dorsal surface.  It may be accompanied with an inclination of the
plantar surface  inward or  outward, causing  the complications
which he has denominated planti-varus and planti-valgus.
  Where, (says Prof. Pancoast, lb., p. 373,) from the weakened and
atrophied condition of the  elongated antagonist muscles, in all the
above varieties of talipes, there is, as frequently happens after the
division and cicatrization of the shortened muscles, a constant ten-
dency to secondary retraction, the apparatus should  be continued
for months, or a longer time, until this tendency is overcome, (Ib.)
[See our notes on  Tenotomy of the Tendo-Achillis, in the body of
the text, supra.]
  In the division of the tendo-Achillis, the point selected in an adult
is about an inch, or an inch and a half, above the os calcis, as the
tendon  is there  least in diameter, (Ib.)  He prefers  inserting the
tenotome between the tendon and skin, and dividing from without
inward.  If,  after the tendon is divided, the anterior part of its
sheath is found  so indurated as to impede the replacement of the
foot, we should take care to divide that also, carefully avoiding the
neighboring vessel and nerve, (Ib.)  If the heel cannot be made to
descend at once, after the complete section of the tendon, the cause,
if it lie in the distorted end of the astragalus hitting against the
upper edge of the ankle joint, may often be removed by gentle and
well-directed efforts upon  the foot;  but if it  be found in some re-
sisting and prominent tendon, which has given a varus or valgus
inclination to the foot, it will be best at once to divide it, (lb., p.
374.)
  Prof. Pancoast considers the usual division of the tibialis anticus,
in talipes varus, rarely ever called for, when the point of the foot
can be elevated after the section of the tendo-Achillis, for this move-
ment itself will place the muscle in a state of relaxation.  If neces-
sary, however, to divide it, and  this is done from before backward,
care should be taken not to wound  the ligaments of the joints, or
the anterior  tibial artery.   To  avoid this latter effectually,  Prof.
Pancoast prefers introducing a curved knife between the tendon
and the artery, (Ib.)
  The section of the tibialis posticus is rarely required in club-foot,
unless the scaphoid  bone is so drawn around that  its anterior end
is nearly in contact with  the internal  malleolus.  Prof. Pancoast
recommends the division  to be made from within  outward, at the
posterior and internal  angle of the tibia, just  above the malleolus,
where it will be found tense, though not very prominent, in conse-
quence of its being confined in its groove.   The nail of the left fore-
finger  should be inserted between the tendon and the  posterior
tibial vessels and nerve, so as to separate the tendon from the lat-
ter structures, and at the same time roll it forward and inward, and
fix it against the tibia, the foot being held extended and  abducted 
684           NEW ELEMENTS OF OPERATIVE SURGERY.

by an assistant.   A slightly concave bistoury is to be then passed
from before backward, under the anterior face of the tendon, and
next the bone, till the point is felt under the nail.  The handle of
the knife is then to be depressed, and  the tendon severed.  The
tendon of the flexor of the toes may, if necessary,  be divided at the
same time.  Professor Pancoast prefers this method  to that of M.
Velpeau, of making the section lower down, near the insertion of
the tendon on the scaphoid bone, because the  latter incurs more
risk of .wounding the vessels and nerve, and the new articulation
formed  here by the distorted joint, in cases of strong inversion of
that bone—the only circumstance which Prof. P. thinks can render
the operation at all necessary, (Ib.)
  In regard to the section of the ham-strings, for flexion of the leg,
it is remarked by Prof. Pancoast, that in the middle of the popliteal
space the great nerve of the thigh sometimes forms a resisting cord
below the skin, which might be  mistaken  for a  tendon; but that it
may be identified by its position and course through the notch be-
tween  the  condyles, while  the tendons are recognised by their di-
rection above to their muscular attachments, and below to the lat-
eral faces of the joint, (lb., p. 377.)
  Dieffenbach  has successfully divided the tendon  of the triceps
extensor cubiti, and restored the flexion of the limb in a case  of
permanent extension from anchylosis, consequent  upon a frac-
ture.
                        ANAPLASTY.

  In the formation of a double undetached flap over fistulous open-
ings, by the ingenious bridge-like process of M. Velpeau, (see the
text of this work, supra,—Anaplasty,) an auxiliary means of sus-
taining the proximate sutured edges of the longitudinal flaps in
coaptation, has been  suggested  and successfully practised by Dr.
Mettauer, of Virginia, and Prof. Mutter, of Philadelphia.  It con-
sists in inserting a slender roll of some soft substance like buckskin,
in the new sulcus on each side the flaps, so as to raise a growth of
granulations from their  bottom, and thus contribute [on the princi-
ple  of the action of a quilled suture.—T.] to sustain the flaps and
promote their union.  (Vid. Pancoast's Oper. Surg., Phil., 1844, p.
344.)
  Professor Pancoast, of Philadelphia, has, since the new impulse
given to anaplasty, performed (we should judge by the accounts he
gives in his late work on Operative Surgery) more difficult opera-
tions, and with eminent success, in the restoration of the nose, lips,
&c, than  perhaps any other American surgeon.
  In rhinoplasty, he recommends the pedicle of the flap at the root
of the nose to be left from half an inch to five-eighths of an inch in
width, so as to preserve, for its nourishment, one or both the angu- 
AMERICAN APPENDIX.                   685
lar arteries of the nose. (Ib., 345.)  He approves of Lisfranc's re-
commendation, to bring the incision down between the eyebrows,
a little lower upon the side opposite to that upon which we intend
to make the twist, as it facilitates this manoeuvre.  He disapproves
of the practice of Mr. Liston, and Dieffenbach, of lodging the pedi-
cle  in a groove cut into the integuments upward from the chasm
of the nose;  as the shaving down the bulky prominence which af-
terwards forms by cicatrization, is attended  with difficulties, or
leaves a deformity.  Prof. Pancoast proposes some  ingenious, and,
as it appears to us, valuable modifications, to the usual Indian pro-
cess of the flap from  the forehead.   He has, he states, met  with
entire success by this mode, in six cases of rhinoplasty;  and, in his
work on Operative Surgery, just published, (1844,) and so frequently
cited by us in this appendix, he  enters minutely, and with the aid
of  numerous well-delineated sketches, into the mode  he adopts.
The first case, and which he published first  in the American Jour-
nal of Medical Sciences of Philadelphia, for October, 1842,  is ex-
ceedingly instructive  from  its formidable  character, as involving,
not only the soft parts of the nose, and septum narium and turbina-
ted bones, but also the total destruction  of the upper lip ;  all of
 which losses of substance were  happily restored by the Professor,
 M'ho thus did as much honor to  himself, professionally, as he con-
 ferred happiness and comfort upon  the individual whose afflictions
 had.rendered.him  a spectacle of revolting deformity.
   The.  patient, Jno. Glover, an  Englishman, aged fifty-three, ac-
 cording to his own statement had, some eight years before, receiv-
 ed a violent  contusion in the face, which resulted in the destruction
 of parts mentioned.  His healthy florid look, as described, and the
 rapid recovery, and firm  granulations in one of his age, seem in-
 deed to imply that there could not have been any syphilitic or mer-
 curial taint in his system.   The cavities of the antra laid bare, and
 now shallow by the destruction of bone,  exposed to view also the
 sphenoidal sinuses.   The teeth, and alveolar processes of each jaw,
 were  entirely gone—all that was left of the upper jaw being  a
 thin plate two lines thick.  The free margin of the lower lip, when
 closed, thus  covered  the edge of the upper gum, and  reached tne
 nasal cavern.  The mouth was diminished by the previous disease,
 and ulceration,having been followed by union of the  lower lip for
  about half an inch from each corner, to the flesh of the cheek above.
  So that the mouth, in fact, when opened, formed a rigid circular
 orifice, three quarters of an inch in diameter.
    The operation consisted of two stages :-In the first, the contract-
  ed mouth was widened, by the  beautiful  operation of  Dieff^ach'
  at the commissures,  [see text of this edition of  \ *lF*^J$™
  the upper lip not less adroitly restored, by Professor Pancoast _taking
  two right-angled flaps (their angles pointing upward and outward)
  from either side of the'cheek, near the ala rfflj^  These cu-
  taneous  flaps, each about an  inch and a^u,^™J!?^Ld
  breadth, were, together with their ™bjacent adipwetoB ^ssect^
  ed off from the muscles  of the  cheeks, while these latter were 
686           NEW ELEMENTS OF OPERATIVE SURGERY.

loosened from the malar bones and  gums, and the surface of the
upper gum made raM'.   The flaps M'ere so ingeniously shaped and
disposed by the  Professor, that, when stretched down, their inner
edges came into perfect coaptation, forming a perpendicular line
where the groove of the upper lip formerly existed.  The general
integuments of the cheek, M'hich, as M'e have  said, had been loosen-
ed, were also  advanced forM'ard by this adjustment, so as greatly
to diminish  the  space from whence the flaps M'ere removed—the
whole of the space remaining being now effectually closed by pins.
" The integument by the side of the nasal  cavern, was loosened
with the knife on each side, and fastened with a cross-pin, so as to
give a cuticular covering to the raw  margin of the new upper lip.
The face was covered with lint, kept wet M'ith lead water, and the
two operations, performed in presence of the class at Jefferson Col-
lege, consumed an hour and a half.  In two  months, the  upper lip
being firm and solidly united to the  gum, the  second stage of the
operation, that of making a new nose, was also performed before
his class."
   The value of the Professor's process, or modification, as differing
from others, seems to consist, first: in bevelling the edge of the flap
while dissecting  it from the forehead, which he does  by inclining
the blade of the knife outwardly.   By this means, he found the lips
of the wound in the forehead could be much more approximated
by the four hare-lip sutures used.   The surface of the new lip and
gums were now made raM'.  But, secondly, the  most important part
of Professor Pancoast's process, and the one upon which he appears
to rest (as far as we are acquainted  with what has been done  in
this part of anaplasty)  a just claim to originality, and for sound
pathological reasoning, is that  which we shall now describe in his
own words.   After  abrading the  new lip and gums, he " carried
an incision down to the bone, just at the outer side of the margin
of the nasal chasm.  The  integuments were  then dissected each
way from  this incision, so as to leave a groove between them for
the lodgment of the edges of the new nose.   The inner margin was
raised up so as to form a vertical wall, for the purpose of bringing
the raw surface into contact with the raw side of the flap, and thus
give an increased probability to the adhesion of the graft;  to ren-
der the union still more certain, the triangular piece of skin en-
closed  by the two grooves at  the end of the  ossa nasi, was cut
away, and the cuticle pared off from the edges of the  flap, with
which the new nose was to be formed.  Three waxed silken liga-
tures, with a needle at  each end, were placed at each side, by
passing one needle from without inward through the inner wall of
the groove, and again in the opposite direction, about an eighth of
an inch above the first puncture, so as to leave the two needles of
each ligature resting on the cheek, with a loop through  the inner
wall of the groove."  The flap from the forehead was then rotated
to the right upon its root, and in such way as  not  to make tension
on the  pedicle.  ''The two needles at the end of each ligature
were then passed through the margin of the flap, from within out- 
AMERICAN APPENDIX.                   687
ward, and again through the integuments on the outer side of the
groove, so that when they were drawn tight, they necessarily sunk
the edge of the flap to the bottom of the  groove, and brought four
raw surfaces into contact.  The threads were tied over small  rolls
of adhesive plaster, after the manner of  Graefe and Labat, so as
not to strangulate the parts included in the loop.  The middle of
the three ligatures were placed a little farthest from the free mar-
gin, and knotted over a roll of adhesive plaster three quarters of
an inch long, which rested against the flap, and sunk it in so as to
support the side of the  nose, and give the depression naturally ex-
isting above the oval cartilage.  The left margin of the new  nose
was  secured before the right,  in order to give greater facility in
the nice adjustment of  the ligatures.  A small ligature  was  then
passed through each edge of the integuments of the new column
(of the flap) near its root, and tied  upon one side, so as to  give a
rounded form to the column, by bringing  the two lateral surfaces
together posteriorly, as  well as prevent its adhering to the margins
of the new alae.   The cuticle was removed from the lower end of
the column by a bevelled cut; the column was then pushed in upon
the gum, and secured upon the new upper lip by two pins, one of
which was semicircular.   A piece of lint, dipped in oil, was passed
on each side up the new nostril; another was laid on each  side of
the nose over the ligatures.  Lint spread with cerate was  placed
upon  the sides of the nose, and over the  wound between the eye-
brows—the whole secured with a split adhesive strap brought down
from the forehead."  The operation was performed in the space of
an hour.   Prof. Pancoast says  his process of attaching the graft has
been since successfully employed by Dr.  W. P. Johnson, of Phila-
delphia, and Professor Baxley,  of Baltimore, union taking place in
each of these instances by first intention.
  The loss of blood, in the above described case, was not over six
ounces.   This novel and certainly very ingenious mode of Prof. P.,
of grafting by a species of bevelling and  dove-tailing of the parts,
seems, indeed, well calculated to promote cicatrization and solidity,
the two great points or desiderata chiefly  to be attained, and which
have  so long baffled most nose-makers, giving them, for the fruits
of their dexterous manipulations, most frequently little else  than
pug-shaped, flabby, and moveable  knobs,  that looked  more  like
small shrivelled potatoes, than bona fide  human noses.   Professor
Pancoast says, however, that his process  was no sooner completed
than the patient (who at no time made any complaint) immediately
presented a new nose which had much of the natural appearance,
" and was held  so  firm in its place as to  be incapable of being
mdved by the  respiratory efforts," which  latter inconvenience is a
very serious one in the ordinary modes of fastening, which consists
of only two bevelled edges in contact, viz., that of the flap and nos-
tril.   The flap retained its sensibility and color, and on the fourth
day was found united, throughout its whole insertion in the grooves,
by first intention, and after the second dressing, preserved its posi-
tion so perfectly as to require no stuffing of the cavity.  The wound 
688
NEW ELEMENTS OF OPERATIVE SURGERY.
of the forehead healed up finely, leaving a very small cicatrix only,
notwithstanding the flap had been made so large (near three inches
at its base) to allow  for retraction.  In five  weeks, the pedicle
which  contained the  angular arteries was divided obliquely up-
ward, from the left to  the right side, leaving thus a loose triangular
lamina  attached to the new nose.   The arteries were stopped by
pinching.   " The triangular piece was diminished by paring off
the sides, and shaving away a portion of its inner surface ;  it M'as
then smoothly fitted down over the root of the  ossa nasi, into a
cavity made  by the excision of a portion of the subjacent integu-
ment for the  purpose.   A feM' stitches of  the  interrupted suture,
and  a  compress  and  bandage,  completed the dressing.  On the
third day, the sutures were removed.  Some suppuration had taken
place along the left line of the junction, and there was considera-
ble  tumefaction of both canthi.   By the twelfth day the union was
smooth and perfect."
  The drawings which the Professor gives, (figures 1, 2, 3,4,5,6, 7,
plate 71, page 348,  of his recent work on Operative Surgery, Phil.,
1841, and especially figs. 1, 2, 6, and 7,) seem fully to corroborate
his assertion, that the nose was, as it must have been from these
representations, so good a one and so natural and symmetrical, as
to attract the particular observation of no  one.  There was, it ap-
pears on inspection, " a slight drooping at  the  apex, and a sort of
abruptness at its line of connection with the cheeks," which, how-
ever, was scarcely distinguishable.   These, undoubtedly, were pro-
duced  by bracing doM'n the nose on the sides, and by its new co-
lumna, so firmly; but it was better to make this trifling sacrifice,
when the great paramount object of resistant firmness and solidity
in this projecting organ was, it would seem, so admirably attained.
Fig. 7  represent! the  patient sixteen months after the operation,
with a very decent mouth and upper lip, and a nose (according to
the plate) of really elegant contour, presenting altogether a physi-
ognomy so passable, if not comely, as to  render it inconceivable
how the same face  could have exhibited the hideous aspect it does
in fig. 1, a  few months before.
  The  last of his six rhinoplastic operations, which the  Professor
says took place during  the past winter, (1843-44,) was performed,
and the dressing completed, in little else than half an hour, (Oper.
Surg., Loc Cit., pp. 345-9.)
  Professor Pancoast was equally successful in an ingenious appli-
cation of anaplasty, where the entire middle portion of the nose was
destroyed,  in a young man, by scrofulous ulceration.   This opera-
tion was performed at the Philadelphia Hospital, January 9, 1841.
(see his Oper. Surg., 1844, pp. 349—52 ; also, Amer. Journ. of Med.
Sc., 1842.)  The destruction of parts was as follows:—A great por-
tion of the hard  palate, the sockets of all  the upper  incisor teeth,
all the cartilaginous portion of the septum narium, the inferior tur-
binated bones, the  whole of the superior lateral  cartilages of the
nose, and a considerable part of the inferior oval cartilages, as well
as the integments of the nose ;  leaving an open cavity, three quar- 
AMERICAN APPENDIX.
689
ters of an inch long, between the ends of the ossa nasi and the tip
of the nose, which latter, with the columna nasi and  the anterior
margin of the nostrils, were uninjured.   This cavity, on the cica-
trization and  closure of the ulcer, drew up the tip of the nose half
an inch, and at the same time depressed it to nearly on a level with
the cheek, while the left ala, which had suffered most destruction
by the ulceration, was retracted  most.  The soft palate was unin-
jured, but the hard palate was destroyed  by a fissure which ex-
tended backward an  inch and a quarter from the upper  lip, and
had, in its widest part, three quarters of an  inch in diameter.   The
gums, uniting across, had formed a fleshy band in front of this open-
ing, while the upper lip was flattened and  depressed.  The  tegu-
mentary covering of the cicatrix was first dissected off, and the tip
of the nose separated from the ossa nasi—leaving a triangular
space with an abraded bevelled  margin.  The normal position of
the tip of the  nose M'as still more effectually obtained, by extending
the incision of the cheek outward and downward through the root of
the oval cartilage, and by nicking the inner margin of the same with
a probe-pointed bistoury, introduced through the nostril on each side.
It was also found necessary to divide some adventitious bridles with-
in the nasal passages.   The cheeks being full and fleshy, as thick a
triangular flap as possible, and of proper  dimensions, was then dis-
sected out from below the malar  protuberances, by an  incision
which was made to bevel inward towards the centre, in order to
adjust correctly  with the bevelled raw edges of the cavity of the
nose.   The base of these V-shaped flaps, and which faced outward,
was rounded  so  as  to  give a prominence to  the ridge of the neur
nose.  The pedicle of each flap was  left opposite the attachment of
the oval cartilage  upon the cheeks,  and  the flaps then twisted
around and brought into coaptation, so as to make that which was
the lower margin on  the cheek  become  the upper margin on the
nose, while the bases formed the ridge of the nose.   The effect of
the twisting,  as  had been  anticipated and  desired, was that the
pedicle on each  side respectively hitched up the root of each ala,
and thus  kept the  tip properly depressed.    The  flaps were  now
neatly fastened and adjusted on  the dorsum by palladium pins and
twisted sutures.  No stitches were used.  Before the pins were
adjusted, the fragment of cartilage left upon the ossa nasi having a
disposition to curve, was divided vertically on either side  of it,
which brought it up to a proper level.  The sides of the two wounds
on  the cheeks were united by  hare-lip sutures, the  stress being
made to act upward towards the canthi,  and not on the middle of
the lower eyelids, which might have caused  ectropion.  The oblique
direction of the pins at the same time prevented any distortion of
the upper lip.   Mr. Liston's dressing of wet lint over the  nose,
covered with oiled  silk to prevent evaporation, was the one pre-
ferred.  The  eyes were covered  and kept shut, and the patient di-
rected not to speak.   The whole process  occupied an  hour, and
though painful, was borne well.  The flaps, immediately after the
dressing, were cold, blue, and insensible; but soon regained their
                              87 
590
NEW  ELEMENTS OF OPERATIVE  SURGEHY.
natural temperature, but not their color till four hours subscquenlly.
Complete union by first intention had taken place, and all the loo e
ligatures M'ere removed,  on the tenth  day.  Some  suppuration,
however, had  taken place at  the median line of  the ridge of the
nose, at the junction of the flaps, from a  pin M'hich had been over-
looked having ulcerated through.  The nose M'as someM'hat flabby
for want of cartilage, but the patient breathed through it freely.
Adhesive straps Mere applied  over the  ulcerated  portion, M'hich
soon closed, leaving, however, a depression at  this point, though
the tip preserved  its natural  position.   OM'ing  apparently to the
traction of the cicatrix, the  pedicles projected on the  cheeks, and
the flaps themselves rose  upon the sides of the nose a little above
the general level.   This defect was removed  by the following in-
genious operation :—" I divided  (says the Professor)  the  pedicle
transversely on a level with the  cheek ;  cut out a V-shaped piece
of integument, with the point dowonvard upon the cheek, and closed
the edges  with  hare-lip suture;  cut out a similar piece from the
new flap, with the point  upward upon  the  side of the nose, and
closed  the wound in lilcfe manner.  This double operation was per-
formed on both sides of the nose. Its object  was  to diminish the
bulge of the flap, and render  the junction between the nose and
cheek smooth and  even.  To  restore  the natural sharpness of the
ridge, and  remove  the sudden depression at  the front part of the
new structure, which gave a pug-like rising to the tip, 1 cut out at
the same time, in front of the graft, a small  triangular piece, the
base of which was upward and  included the depressed parts.  I
then made raw the edges of the flaps  on  the ridge of the nose ; dis-
sected up the margin of the grafted pieces on either side, stretched
them forward and fastened the parts together with hare-lip pins.
The pins were removed  on the third day.   Every step of the second
operation succeeded perfectly, except the  attempt to  stretch the
grafts  on the ridge of the nose.  The texture  of these were [was]
so altered  that it  would not bear extension like  a fresh piece of
skin, and a small  portion of the margin on each  side ulcerated.
Simple dressings were first applied.   In  the course of  a week, the
ulcerated edges  of the flaps on the ridge  of the nose, being left too
high for the general level of the nose, were rounded off by being
lightly touched  with caustic.  Stimulant  ointments  were subse-
quently applied to encourage  granulation.  In this way, the de-
formity on the ridge of the nose was entirely removed, and the new
organ was left presenting  an appearance  nearly natural.   There
M'as still  some tendency in the roots of  the new alae to be drawn
out on the cheek.   In order to counteract this, I directed two pieces
of sheet-zinc, moulded to the shape of the cheek and nose, to be
worn, fastened together with strings  over the bridge, and  secured
with a riband around the neck.   This effected the object complete-
ly, but the patient was directed to wear  it for two or three months
at least, during the night, in order  to preserve the shape of the
nose."......"In the fastening of the flaps in their new position,
I followed (says Professor P.) in this case the  plan of Dieffenbach 
AMERICAN APPENDIX.
691
as described  by Zeis—the introduction of a great number of pins
close together, which were surrounded with circular ligatures and
cut short.  In subsequent operations, (however, he  adds,) I have
given a preference  to the interrupted suture, as I have not found
the nice adjustment of parts accomplished by means of the pins, to
compensate for the  greater irritation and liability to ulceration, to
which these give rise."
  The profile appearance of the patient's nose, ten months after
the operation, as given by the Professor in fig. 4, plate 72, (p. 378
of his work on Oper. Surg.) presenting, in fact, a graceful outline
and contour to the new organ, is well calculated to impress  the
reader with the inappreciable advantages of anaplastic operations,
conducted with the tact and skill which appear  to be possessed by
the Professor in this department of operative surgery.
  In partial losses of the nose, as of  one entire ala, and especially
where the upper lateral part of the nose, and a portion of the cheek,
are also destroyed with the ala, Prof. Pancoast prefers to take his
flap from the forehead, as that from the cheek, which has been the
usual method, constantly tends, by its cicatrization, to draw down
and distort the  organ.   He thus obtained  complete success in  a
case (see figs. 5 and 6, of pi. 72,'of  his Op. Surg., p. 348-351,) in
which, from a morbid ganglionic enlargement, and neuralgic affec-
tion of the infra-orbitar nerve in consequence of a lupus, he excised,
also, the diseased portion of this nerve.  When the defect is small,
and the nose sunken, as in a case which resulted from ozaena, (see
his Op. Surg., p. 352 ; also, Amer. Journ. of Med.  Sc. for 1842,) he
has succeeded, to a great extent, in restoring the organ by cutting
out an oval-shaped  piece, and raising (i. e., stretching) and uniting
the margins with the hare-lip  suture.  When the deformity con-
sists merely of the shrinking of the ala on one side, Dieffenbach has
proposed to reduce  the other to the same dimensions, by removing
from that also an oval piece.   Where the  margin of one ala is de-
ficient, Dieffenbach  splits the back and tip of the nose through the
cartilaginous  septum, loosening the  defective side from the nasal
bone so that  it may be  draM'n doM'n, and taking out a piece from
the opposite side, and from the septum, by two transverse incisions.
The two halves are then to be  placed  upon the same level, and
united along the back by hare-lip sutures.
  In angular, or crescent-shaped  losses of substance, at the margin
of one of the alae, which have been found so difficult to repair, Pro-
fessor Pancoast has exhibited his usual tact in anaplastic arrange-
ments, and completely succeeded by the  following sub-cutaneous
process:—" Having p'ared off the edges of the fissure, a delicate
scalpel  was carried just  below the skin upward and backward,
from the angle of the fissure to the nasal process of the upper max-
illary bone, and then turned with its edge inward, so as to cut into the
cavity of the  nose, dividing the cartilage across.   Another incision
was then made, from the junction of the stump of the ala with the
upper lip, so as to divide the skin, and the curved border of the alar
cartilage below it, by a  semilunar incision, concave downward and
* 
692           NEM  ELEMENTS OF OPERATIVE  SURGERY.
 outward.  The cartilaginous  portion included between these two
 incisions Mas next divided from M'ithin outM'ard, so as  to separate
 Mith the cartilage the soft parts for a little distance from the bone,
 but Mdthout cutting through the skin.  The  lower segment of the
 ala was now  left attached by little more than the integument, and
 by advancing the soft structures of the cheek, was readily drawn
 forward to the upper raw margin of the nose, to which it was at-
 tached by suture, restoring the organ at  once to its proper shape,
 and without leaving any obvious wound.   Some attention  Mas re-
 quired in filling the nostril M'ith lint, in  order to keep it sufficiently
 patulous.  By this means the neM' margin of the nose is left car-
 tilaginous,  and retains its  natural thickness and elasticity—a result
 which the author has not been able to attain by any other process "
 —(Op. Surg.,  p. 352.)                                  r     •
   This surgeon doubts the possibility of ever succeeding in Dieffen-
 bach's proposed process for elevating a depressed nose, by slitting the
 sunken nose into a middle  and two lateral  strips, and then bevelling
 off the edges in such manner  as to make  the organ, in cicatrizing,
 assume the proper curvature as  in  the  construction  of an arch.
 Prof. Pancoast apprehends that the new nose would shrink again,
 from the slow contraction of the cicatrices.  The flap from the
 forehead is, he thinks, to be preferred.   The  following process,
 however, again  happily calling into service  the principle  of sub-
 cutaneous sections, was adopted in the  winter of 1842-3, by Prof.
 Pancoast, with the most perfect and gratifying  success.  The pa-
 tient had nearly the entire  septum destroyed, by an ulceration of
 several years in both  nasal cavities, leaving only the columna nasi.
 The two ossa  nasi, up to their junction  with  the os frontis, and all
 the turbinated bones, were also destroyed.  The case  was one of
 hideous deformity, presenting no  appearance of nose except the
 two apertures on  either side  respectively of the twisted and de-
 formed columna, retracted upward  and into the face  beyond the
 level of the anterior margin of the nasal processes of the maxillary
 bones—all  of which  was rendered yet more disgusting,  by the
 prominence of the forehead, cheeks, and  alveolar processes, and the
 protuberance of the upper lip, which was also retracted upward by
 the cicatrization of the ancient ulcer:
  " A narrow  long-bladed tenotomy knife [tenotome] was introdu-
 ced  on either side, by puncture through the skin, over the edge of
 the nasal process of the upper maxillary bone.  The  knife was
 pushed up  under the skin to the top of  the nasal cavity, and then
 brought down, shaving the inside of the bony wall, so as to detach
the adherent and inverted nose upon either side.  The point of the
 nose could  now  be drawn out.  The nose, however, still remained
 adherent to the top of the  nasal  chasm.  The knife was a third
time introduced  under the skin, in a direction  corresponding nearly
with the long diameter of the orbits of the eyes,  and the adhesions
separated from the nasal spine and internal angular processes of
the os frontis.   This  incision  was exquisitely painful.   The nose
 was now attached merely by the  integuments,  and was so com- 
AMERICAN APPENDIX.
693
pletely loosened  that  the patient forced it out at once by a strong
expiration through the  passage, redeveloping, (continues the Pro-
fessor,) to my surprise, an organ of good  size and of the natural
form.   It was incapable, however, of retaining its position, as it
moved with every respiratory effort.   To  increase the dimensions
of the nose—M'hich remained less than had been natural to the pa-
tient—and [to] diminish its tendency to fall a second time, the knife
was again introduced through the lateral punctures, and the soft
parts separated from the whole  length of the outer surface of the
nasal  processes of the maxillary bones for the space of about five
eighths of an inch on each side.  This involved the division of the
branches of the two infra-orbital  nerves and arteries.  The portions
thus loosened on each side were pushed  over towards the nasal
cavity, so as to increase the prominence of the nose.  In this posi-
tion they were held  by a quilled suture, made with two  ligatures,
passed across the cavity of the nose from one cheek to the other.
Though there was considerable  bleeding,  no vessels needed to be
tied.   The  sutures were removed  on the third day, and  the nose
was found firm  and well-shaped.   In  the course of a couple of
weeks the skin at the  root of the nose, having no bones to support
it, became flattened out, so as to impair the form of the  organ.
This I proposed to relieve by cutting out  an elliptical piece from
its middle, and then turning down, in the space thus made, a small
flap of skin from the forehead, with the cuticle shaved off so as to
gain a raw surface  for adhesion on both  sides;  which flap, when
united vertically in  the opening, should serve as a new septum,
and by its tendency to contraction,  keep the loose integument in its
proper bridge-like shape. The patient, however, was so well satis-
lied with the organ as it was, as to be unwilling to submit  to any
thing more than the removal  of the elliptical piece."—(Oper. Surg.
of Pancoast, Phil., 1844, p. 352-3, and plate  72, figs. 7, 8, 9.)
  The chief difficulty in the  above very ingenious application of
sub-cutaneous surgery, undoubtedly is, in  contriving some substi-
tute for the cartilaginous supports of the nose, and we know of
none that could  act  as a better substitute than  that which was
suggested by the operator, and which would have proved more ef-
fectual, doubtless, could some mode be devised of giving greater
condensation, or a semi-cartilaginous texture, to its tissues during
the process of their granulation.  As to  the transplantation of a
cartilage, the inherent  low degree of organic vitality in such tissues,
and their tendency, therefore, to gangrene, would perhaps render
such  an attempt  quite chimerical; though, from  what has taken
place in all these new departments of surgery, (anaplasty and  te-
notomy,)—born and sprung up to a ripe maturity, it may be said,
in the  incredible  short space of four years—it is certainly impossi-
ble to  predict what  human invention may not discover, in  giving
to them still greater perfection, and in disclosing curative processes
that are now not even dreamed of.  The  extensive sub-cutaneous
sections required, and the pain  necessarily  attendant upon them,
would probably deter most persons from submitting to Prof. Pan- 
694           NEW ELEMENTS OF OPERATIVE SURGERY.

coast's process, unless previously well assured that something could
effectually be done to give prominence to the raised teguments.

                         Cheiloplasty.

  In a case of cancer, in which it was found necessary to remove
nearly the whole of the free border of the lower lip, Professor Pan-
coast,  of Philadelphia, adopted the following process, with, how-
ever, only partial success.  It is certainly  Morthy of consideration,
although the semilunar incision downward, excising the cancer, as
adopted by Prof.  Mott, (as in the case of that surgeon already de-
scribed, supra,) and then dissecting  and loosening the teguments
within freely down to the chin or further, and effecting the union
of the incised semilunar border by sutures at the commissures to
the lip above,  and placing the new lip in situ by traction upward,
steadily maintained by adhesive straps and bandages, is, it  seems
to us, much to be preferred, as  the most simple as well as the most
easy and natural method :—
  Professor Pancoast excised the diseased structure also by a semi-
circular section through the lip.  '"A vertical  incision was then run
down over the symphysis of the chin nearly to the top of the os
hyoides.   This was converted into a crucial incision by a sweep of
the knife along the upper edge of the base of the  jaw.  The two
upper flaps were  then dissected loose from the bone, and a trian-
gular piece, with the base dowmvard, removed from  the free  end
of each, with  a sharp pair of scissors.  The  two lower flaps of in
tegument were in like manner  loosened, and  a triangular piece re-
moved from the  end of each, but with the base presenting  in the
opposite direction, so as to form a vacant space of a lozenge shape.
The  two upper flaps were then closed at  their lower border by a
hare-lip suture.  The effect of the traction necessary to bring these
together, carried  the upper  margin at once  nearly to the  proper
level of the lip.  A second pin was then introduced above the first.
The two lower flaps were then raised  and similarly closed, with a
pin which M'as made to rest on  the mental protuberance, the effect
of which  was to give some  additional elevation  to  the new lip,
though to a less extent than was expected, and nearly [to]  efface
the M'hole of  the vacant  space. The parts were  covered with  a
light compress, secured with a  few turns of a roller, and the head
retained, for three days,  lightly flexed on the chest.   The  saliva
escaped for some time through the opening at the chin, rendering
the cure tedious, but in the end  the operation was in a good degree
successful."—(See his Oper. Surg., 1844, p. 355; also, ib., figs. 3 and
4, of plate 73.)
   To this, as to the greater part of the anaplastic suggestions of
this surgeon, already noticed, we cannot deny much ingenuity; but
the excision of the angles of the flap  must have caused a counter-
traction  downward, a ijesult which is, in such cases, especially  to
be overcome  if possible.  We confess we cannot discover what the 
AMERICAN APPENDIX.
695
intention of the author was in  that part of his process, except to
obtain the natural depression above the chin.
  The principle which we have expressed a preference for, as the
one upon which cheiloplastic operations should be guided, to wit,
that of Dieffenbach, of separating and making traction upon the
entire tissues of the face, and which has been adopted successfully
by M. Meyer of Bruges, was also recently followed by Prof. Pan-
coast of Philadelphia, with most gratifying results, in a young lady
of Virginia, (see  his Op.  Surg., p. 355 ; also, Am. Journ. of, Med.
Sc, Jan. 1843.)  This case is so important that we must claim, in
behalf of American surgery, the right of the author to be heard in
his own words.  The M'hole of the  soft parts between the upper
lip and the lower edge of  the chin, and all the lower alveolar pro-
cesses, had in early life been destroyed by gangrene.  " The pa-
tient was seated upright in a chair.   The cicatrized edges, which
extended from the angles  of the upper lip down to the chin, were
pared off so as to present  a large triangle, with the apex upon the
chin.  The corners of the  mouth were next  thrown widely open by
an incision on each side, three fourths of an inch long, in the direc-
tion of the auditory meatus.  This  was made by a sharp-pointed
curved bistoury, passed from the cavity of the mouth through the
cheek, the M'hole  thickness of which was divided  on each  side at
one cut, to the commissure.  From the distal ends of these incisions,
a descending cut  was made on either side, M'ith a single sweep of
the bistoury, obliquely downM'ard and inward to the top of the
lower jaw-bone.   Two flaps were thus detached from the whole
thickness of the cheeks, lined with skin on one surface, and mu-
cous membrane on the other, and attached to the chin by a pedicle
five eighths of an inch broad.   The flow of blood was arrested, in
a measure, on each side as the division was made, by the thumb
and finger of an assistant.  In order to diminish the hemorrhage,
the horizontal and descending incisions were made on one side be-
fore the other was touched, and the divided vessels immediately
secured by torsion and  ligature.   The flaps were  then rapidly
loosened from the gum on the  inside, by a few strokes  with the
knife, and some few small arteries, which gave out blood, pinched
and twisted.  The loosened portions were then rocked over [i. e.,
slided by traction obliquely inward.—T.] upon their pedicles to-
wards each other, till their inner margins met on the middle  line,
where they were secured  with  hare-lip sutures.  The traction of
the flaps caused  the portion of the cheek in connection Math  the
outer margin of the pedicle to advance forward, so as to supply, in
part, the place occupied by the  flaps previous to their change of
position.   An irregular triangular opening was still left at the cor-
ners of the mouth.  This was filled  up by drawing the cheek from
above downward  and forward, and passing on each side two hare-
lip pins, to connect the three sides of the triangle together.  Though
as much stress was put on the ligatures as was thought at all pru-
dent, the opening  could not be completely closed, a small triangu-
lar fistulous orifice remaining.  The  immediate effect in regard to 
696           NEW  ELEMENTS OF OPERATIVE SURGERY.

the improvement of the features Mas magical.   The flaps of the
new lip, which, as they M'ere rocked inM'ard, moved forward in the
direction of the  line of their pedicular attachment, gave all the
natural fulness and prominence to the lower lip.  The  descent of
the protuberant cheeks restored, in a great degree, the natural
roundness of the lower part of  the face; and from a disagreeable,
the patient presented, at once, a comely countenance.   The result
of the treatment of this case,  which Mas necessarily  somewhat
protracted, was the  restoration  of the face to a form nearly per-
fectly natural.  The new lip remained to a considerable degree
moveable, and fulfilled completely its natural offices, of* retaining
the salivary fluid, and giving distinctness to the articulation."

                         Palatoplasty.

  Prof. Pancoast partially succeeded, by an operation  performed
four years since, (see his Op. Surg., p. 357, and  plate 54, fig. 5, p.
258 ;  also, Dr. McPheeter's account of the case in the Philadelphia
Medical Examiner, Jan., 1844 ;  also, Amer. Journ. of Med. Sc, Jan.,
1843,) in filling up, by flaps of mucous membrane from  the roof of
the mouth, an opening in the centre of the bony palate three quarters
of an inch in diameter.  The flaps were secured by stitches over the
aperture, and their loops held up by a piece of bougie placed in the
nasal passage, and crossing the opening.   By this means, aided also
by a curved pin fitting to the roof of the mouth, and passing through
the edges of the flaps, the flaps were brought in close contact to the
pared edges of the fissure.   A violent spasmodic cough prevented
the completion of the granulations.

                         Posthioplasty.

  Prof. Pancoast (Op. Surg., p.  358) gives this name to the restora-
tion of the prepuce, if required, and which at one time  was prac-
tised  by the Jews to avoid  persecution.   He  recommends the pro-
cess of Galen, by drawing the skin of the penis over the glans, and di-
viding the same merely by  an  annular incision posterior to the
corona—the skin thus loosened  being retained in front of the glans
by being secured to a catheter introduced through the urethral pas-
sage, till the raw surface left behind the glans has become cicatrized.

                         Chalinoplasty,

  From xaXivos, frenum, is a name given by Professor Pancoast, of
Philadelphia,  (Oper. Surg.,  p.  358-9,) to an operation which, to
gratify the  morbid sensibility of patients,  he has  twice success-
fully performed with very  satisfactory  results,  for restoring the
frenum of the prepuce when  destroyed by  disease.  "Reversing
the glans, and grasping it laterally between the thumb  and finger,
a couching  needle  is passed in the middle  line under the mucous
membrane, so as to elevate this at the natural place for  the attach- 
AMERICAN APPENDIX.
697
ment of the prepuce.   An assistant then steadies the organ, while
the surgeon, with a delicate scalpel, makes an  incision  on either
side of the needle, in order to mark  out a small triangular space,
with the apex towards the orifice of the urethra.  The membrane
is next to be dissected off from this space.   A longitudinal fold of
the prepuce is then raised on the lower surface of the organ; through
the base of this a sharp-pointed bistoury is passed, cutting out at
its place of anterior attachment, so as to detach a small, thin, tri-
angular flap, with its apex in front.  This flap is then to be drawn
forM'ard, and secured by three  delicate sutures on either side to the
margins of the raw surface on the glans.  Union readily takes place
by first intention."

 PLASTIC OPERATIONS FOR THE REPARATION OF DEFORMITIES
                         FROM BURNS.

  Since the remarkable and successful case of Professor Mutter, of
Philadelphia, and  which has  been briefly described in  our text,
(supra,) that gentleman has repeated his admirable process in sev-
eral similar cases, and  has published a distinct work on the  subject,
(Cases of Deformity from Burns, treated-by  Plastic Operations.  By
Thomas D. Mutter, M. D., Professor of  Surgery in Jefferson Medi-
cal College, Philadelphia, 1843,) of which we gladly avail ourselves
to make some valuable additions in a most important department
of anaplasty, which Prof. Mutter, by his surgical tact and eminent
success, has almost made exclusively  his own—having through
means of  anaplasty substituted, in lieu of  the clumsy and  ancient
operations of excision of cicatrices, a method which in his hands has
effected results  which had been scarcely anticipated by any one.
  The dense laminated substance found in cicatrices from burns, be-
neath the inodular tissue of Delpech, is composed, says Prof.  Mutter,
of original cellular substance, and that it binds the cicatrix down,
and offers in many cases the chief obstacle to the success of our
operations—especially in severe burns, exacting on that account,
if we  operate, most extensive dissections.
  Another, but  only occasional  difficulty, is the vascularity of the
cicatrix.   It is then red, sensitive, soft, and  moveable, and we have
to fear hemorrhage, presenting therein a more unfavorable  progno-
sis than when the parts are pale, firm,  inelastic, and adherent.
  The prognosis of course is also far more favorable when the cica-
trix is only cutaneous and moveable, than when thick and deep, in-
volving also the superficial fascia, qellular tissue, and muscles—
throwing  the inodular tissue into hard and nearly  immoveable
ridges—requiring severe  and extensive operations.  This condition
must not be confounded, he says, with that contraction of the fascia
superficialis sometimes accompanying  cutaneous burns, but often
the result of other causes, many of which are inappreciable.  Thus
Prof. Mutter has seen  this fascia in the palm of the hand, without
any apparent cause, gradually become thick and contract, while
the skin over it remained pliable and soft.
                            88 
698           NEW ELEMENTS OF OPERATIVE SURGERY.

  Deep cicatrices over important organs, will add to the difficulty
and  danger of the  prognosis and operation, though there  is less
hemorrhage than  one Mould imagine, since many of the  smaller
blood-vessels are found to have been obliterated.
  It  is  an important point, in a wide and extensive cicatrix, that
the reparation does not make one of still greater deformity.  Prof.
Mutter  approves of Dupuytren's directions in such cicatrices, as in
adhesions of the arm and thorax, or thigh and pelvis, to proceed by
fractions, and let the wound of one operation heart before  we under-
take another; as one operation M'ould make too large and danger-
ous a wound—which rule is applicable to extensive  callous promi-
nences.
  Prof.  Mutter also accords, in  general, with Dupuytren's  remark
that  the older the cicatrix, the  greater the success  in  operating,
especially M'here the inodular tissue is superficial, and the cure re-
quires only extension and pressure to keep the incisions apart.
  The peculiar deformity of a cicatrix may arise from their extra-
ordinary power to  contract; thus, in a case of Mr. Earle, approxi-
mating  the shoulders  by causing partial absorption of the clavicles,
and in a case of Cruveilhier, and another of Prof. Pancoast, where
the cicatrix was on the back of the hand, luxating the carpus from
the radius.  Prof. Mutter  alludes, also, to his own remarkable case,
(already described in this work, supra,) as a sample of  curvature
of the lower jaw downward.
  It  is always desirable, if possible, not only to remove the deform-
ity, but  to restore the functions of the part.
  In  recent superficial narrow cicatrices, transverse incisions  at
several  points, followed by slow, gradual, and permanent  extension,
continued for some time after the wounds have cicatrized, will gen-
erally effect a cure.
  In prominent cicatrices, m hich are often accompanied M'ith severe
neuralgic pains, and which generally involve only the skin, with-
out any contraction beneath, the diseased parts are, as recommend-
ed by Dupuytren,  to be sliced  off on a level with  the skin, the
wound  kept apart by machinery, and the excrescent growths re-
pressed by nitrate  of silver.
  In  extensive adhesions, complicated with abnormal contraction
or separation of natural  parts, Prof. Mutter is of opinion that the
process of Dupuytren, of dividing the adhesions and dissecting them
freely beyond their origin, will very often fail.   That of Hildanus,
revived  by Earle and Delpech,  and much approved of  by Brodie,
James of Exeter, Hodgson, &c, which consists in excising the cica-
trix completely,  and then bringing the edges of the wound together,
and  using extension and  splints, thus effecting a lateral  instead of
the previous longitudinal contraction, Professor Mutter deems alto-
gether improper where the cicatrix is broad, or irregular, and situ-
ated  on the neck  or different parts of the face.  In a case where
the  arm and forearm were  rendered useless  by a cicatrix, Prof.
Mutter  found, after excising the tissue, that it was  impossible to
bring the edges of the wound over the raw surface until  he had 
AMERICAN APPENDIX.
699
 made lateral incisions as in the process of urethroplasty by Dieffen-
 bach.  He could then cover the raw surface perfectly, and causing
 the two lateral wounds to granulate by dressing them with warm
 water, the operation, he says, succeeded beautifully.  These lateral
 incisions he has found  equally advantageous in the operation for
 ClCIt DclIEltC.
   The process of Drs. J. Rhea Barton and G. W. Norris, of Phila-
 delphia, derived from that of Celsus, viz., dissecting loose  the in-
 teguments and cicatrix, is, he thinks, severe, and not much to be
 relied upon.                             <
   The operation which he prefers above all others, is his own ana-
 plastic method, which we have already detailed at length, supra.
 It  is especially valuable in  cicatrices of the neck, cheek, eyelids,
 nose, and lips.
   In his recent work, from which we  make  the above abregi, he
 lays down the folloM'ing rules, or principles, for this new, ingenious,
 and admirable triumph obtained for plastic surgery by the eminent
 practitioner in question:
   " 1. Dividing the cicatrix so as to produce a raw surface in some
 part of  its  extent, or cutting it out entirely as proposed by Hil-
 danus.
   " 2. In applying to this raw surface a piece of healthy skin, taken
 from the neighboring parts.
   " 3. In attaching this skin by suture to the margins of the wound
 in which it  is inserted.
   " 4. In approximating the  edges of the wound from which  the
 skin has been removed.
   " 5.  In separating, by appropriate agents, the parts  too  closely
 approximated, and keeping them in this condition some time after
 the flap has united.
   " 6.  In applying oleaginous frictions and motion to the new made
 parts, to give them flexibility and softness.   [The almost extraor-
 dinary suppleness and  elongation of tendinous parts  which such
 frictions, as of camphorated  oil, for example, steadily maintained
 effect, is remarkably seen in those contractions of  the  flexor ten-
 dons  of  the  leg particularly, which are caused by confinement
 during fractures.—T]
  " Many shocking deformities from burns (he adds) have been re-
 lieved by the performance of operations conducted on these princi-
 ples ; for example, the eyelid, the cheek, the nose, and the lip, have
 all  been restored:  but I believe  (he modestly continues)  I may
 claim the merit (if merit there be in adapting an old principle to a
 new operation) of having first performed an operation of the kind,
 for the relief of extensive cicatrices of the throat."
  How true and  just it  is, however, that there is unqualified and
 pre-eminent merit in this most ingenious and happy application, by
an American  surgeon, even of  a well-known plastic principle, is
made strikingly manifest by  the paragraph in Professor Mutter's
work, which immediately follows the above :
  " Mr. Liston, whose  surgical  acumen and  boldness  no one will 
700
NEW ELEMENTS OF OPERATIVE SURGERY.
deny, distinctly states, in his last edition of the Elements of Surgery,
p. 263, that 'such defects  are beyond the reach  of surgery,'  and
gives a drawing  illustrative of the appearance of a person so af-
flicted ; M'hich drawing is almost  a fac simile of my case No. I.  I
have also carefully examined  nearly all the  modern works on the
subject, and find no mention of such an operation having ever been
performed.  Velpeau, in his Medecine Operatoire, [vid. this present
work, supra.—T.,]  article  Cicatrices vieicuses,  merely hints at the
possibility of such  an operation, but this is  all.   [In  our opinion,
however, this  is much, considering the  desponding tone of  cotem-
poraneous  surgeons on this subject, up  to  the time  of Professor
Mutter's discovery.—T]
  " In very extensive cicatrices of the neck,  (says Prof. Mutter.) it
may be well to modify the  operation so  as to take a flap from each
side, by which means we shall avoid the risk of a very large single
flap.
  " In cicatrices complicated with  obliteration of cavities, where the
cicatrix produces partial or complete obliteration of a natural open-
ing, as the mouth, &c, incision of the angles, and introduction of
tents larger than the natural opening, will occasionally do good;
but for the most part all such attempts fail,  and it becomes neces-
sary to perform the operation  of Dieffenbach, (vid. text, supra,  and
also this appendix, supra.)
 * " In  cicatrices complicated with  loss of organs, where organs are
entirely destroyed, nothing  short of a plastic operation, the aim of
which  will be the construction of an organ  as much  like the ori-
ginal as possible, offers the slightest prospect of benefit to the pa-
tient."
  Mr. H. James, surgeon to the Devon and Exeter Hospital, (Eng.,)
in a recent  paper on this  subject remarks, that in the limbs, from
there being but one joint concerned, there is no difficulty after the
removal of the cicatrix, in maintaining the parts in proper position.
But in the neck  it is different, from the  peculiar mobility of that
part, arising from the numerous joints in the cervical spine, so that
the chin and sternum gradually reapproximate as the  wound con-
tinues to cicatrize, shortening  the cervical spine and incurvating it
sidewise or backward.  In one case of severe burn, (and most of
the cases are in children and females,) he has seen the orbit on the
contracted side  much depressed, and the lower incisors pushed
horizontally by the pressure of the tongue, from the counter-pressure
of the muscles of the lower lip being wholly wanting.   To effect
steady, firm,  and permanent extension,  Mr. James  proposes, in
burns of the neck, after excising the cicatrix only, or adopting  also
Prof. Mutter's anaplastic process, to apply an apparatus M'hich he
calls the screw collar, and  which he has found, he  says, exceedingly
useful.   It is to be applied as soon as  suppuration of the wound
is established, and  the screw  is to be lengthened as greater exten-
sion of the head upward and  backM'ard is obtained.  In reference
to  Prof. Mutter's operation, he says the degeneration of the neigh-
boring  integuments, in the greater number  of cases,  will prevent 
AMERICAN APPENDIX.
701
the possibility of procuring flaps.  He thinks the screw collar will
be found always requisite, also, after that process.  In small cica-
trices he has sometimes found it useful to destroy them with caustic
potash, as the  ulcer left opposes no obstacle to necessary extension,
and the cicatrix is of a very different character from that of burns,
(Provincial  Medical Journal,  Aug.  19, 1843 ;  also, Braithwaite's
Retrospect of Practical Medicine and Surgery, part viii., p. 120—
New York edition, 1844.)  In respect to the objection of degenera-
tion of  the  skin, that can rarely much  involve, as we think, the
shoulder, whence Prof. Mutter took his flap in his great operation,
and from  whence, or from some other neighboring undegenerated
part, it would  probably be practicable in most cases  to take  the
necessary supply of tegumentary tissues.
  In vesico-vaginoplasty, as we shall  take the liberty of designating
those plastic operations which are proposed for the closure of fistu-
lous openings communicating  between the vagina and bladder, (as
those  betM'een the rectum and vagina, or between the rectum and
bladder, might perhaps with equal propriety be termed, respectively,
recto-vaginoplasty and recto-vesicoplasty) M. Leroy D'Etiolles of
Paris has, as we perceive, recently suggested the following process :
He raises a  flap from the posterior wall of the vagina, penetrating
with the knife only into the cellular space between the vagina and
rectum, and stopping M'here the point of union between these pas:
sages becomes more  intimate at the recto-vaginal septum.  A short
thick flap may thus be obtained, which is to be applied, by its raw
surface, to the edges of the fistula, which should be made raMr and
bleeding.  The flap  is to be  fastened by a double quilled suture,
(vid. Pancoast's Operative Surgery, Philadelphia, 1844, p. 342, plate
*"(0, figs. 7 and 8.)   This is virtually  the same  as M. Velpeau's
process, (see text supra.)
  To  prevent  the inconvenience  arising from the constant flow of
urine, M.  Leroy D'Etiolles tampons  the vagina with caoutchouc, in
leaves or in paste—a substance  which ;.s elastic and unalterable,
and, as he says, freer from the objections which to this day have
rendered all permanent plugging of the  vagina nearly imprac-
ticable, (Ib.)
  Mr. Barnes  of Exeter, (Eng.,) employs an elongated caoutchouc
bottle, which, when placed in  the  vagina,  presents  an opening
corresponding to the fissure.   Prof. Pancoast of Philadelphia, how-
ever, says he  has had better success with a boot-shaped silver oi
silver-gilt trough, devised by M. Feburier of Paris, which, when
accurately fitted to the vulva, is easily held in position, and effect
ually prevents the escape of urine by any other channel, (Op. Surg.
loc. cit., p. 342.)
                     OPTICAL STRABISMUS.

  Though this has been slightly adverted to in the abrege we have
made (supra)  from Professor Velpeau's Treatise on Strabismus, it 
702            NEW ELEMENTS  OF OPERATIVE SURGERY.

is due perhaps to M. Guerin to hear his own  account of this varie
ty of the disease, as noticed by him.
  Optical strabismus is a phrase by M'hich M. Guerin contradistin-
guishes from  mechanical or primitive  muscular strabismus,  that
form of deviation which is consecutive of secondarily muscular de-
viation, and which arises from a disjunction  of the axis of vision
and the axis of the eye ; which, he says, may be produced in three
ways:  1. From an obstacle to the passage of the visual axis along
the course of the ocular axis ;  2. By a change of relation in the re-
fracting media, without alteration of their transparency; 3. By an
insensibility of the retina at the proper point for the reception of
luminous rays.  1. The first is characterized  by the squint existing
only while the patient is looking at an object.  In these cases the two
visual axes, though no longer concurring with the ocular axes, con-
verge towards one point.  A squint,  then, existing only during ac-
tive or  intentional vision, cannot depend on  permanent muscular
contraction.   A young person, aged nineteen, who had a moveable
clot of blood in the posterior chamber, was observed to squint from
the attempt to place a  transparent portion of the medium opposite
to the  object  looked at, and  thereby to avoid the inconvenience
produced by the presence of the clot  in different  parts of the cham-
ber.  As soon  as she ceased  to look at an  object, she ceased to
squint.  2. A  disturbance in the relation of  the refracting media,
M. Guerin thinks, is the only way of accounting for some cases of
strabismus which are produced suddenly after a blow, or a jarring
fall on the seat or on the feet.   The first effect of displacement is
double vision ; and the squint, at first temporary, lasting only during
attentive vision, is gradually made permanent by the repeated en-
deavor to escape from this fatiguing  symptom.   3. The third form,
viz.: from partial paralysis of the retina, is more difficult of actual
demonstration, though its presence  may be  inferred by induction
rigorous enough for practical purposes.   Amaurotic patients, when
endeavoring to distinguish a light, are seen to turn the  eye in dif-
ferent directions, where they know  the light does not exist; they
present the various surfaces as it were feeling for it.  Those in
whom the paralysis is but partial, contract a  habit of subjecting to
the influence of the rays, that  part  which is most  sensible.   The
author believes that in  no case of secondary optical strabismus,
will the texture of a muscle be found fibrous, and that  in no case
of primary mechanical muscular strabismus, will  such a fibrous
state of the muscle be M'anting.  Where myotomy has been  per-
formed  in cases of optical secondary strabismus, he believes  that
one of three things must have happened—either the case has not
been watched long enough to ascertain the result, or a positive
failure has followed, or the primary cause, whatever it may have
been, has really been removed by the operation, (see Gazette Med-
icate of M. Jules Guerin, Paris, 1843 ;  also, London Medical Gazette,
May,  1843, p. 254, and Braithwaite's Retrospect, part viii., p. 156.) 
AMERICAN APPENDIX                    703
                    Treatment of Erysipelas.

  Mr. J. Higginbottom, (Eng.,) in an essay on this disease, states
that he has met with great success in the cure, by freely pencilling
over the inflamed and previously cleansed  and moistened surface,
and to some distance beyond it, with a stick of the nitrate of silver;
to be applied  once in slight cases, two or three times in common
cases, or more frequently if quick vesication is required.   Though
the inflammation may be spread, it will, he  says, be found of a
feeble character.   Where deep-seated, he uses also emollient poul-
tices.   He totally disapproves the mild solutions of a few grains of
the nitrate to an ounce of water, as  recommended by Mr. Erasmus
Wilson and Mr. Nunneley, but says  where he has substituted a
solution, he uses it highly concentrated, viz.: eight scruples of ni-
trate of silver with twelve drops of nitric acid, in one ounce of dis-
tilled water, applied with a dossil of linen tied on the end of a small
stick, in preference to a camel's-hair  pencil.  (See London Medical
Lancet, July 8, 1843.)
  On extensive surfaces, we should apprehend some danger of ab-
sorption of so  potent a drug as the nitrate, as has happened in
some  melancholy cases where  the color of the whole surface  has
been permanently changed to an almost Ethiopian hue, by its reck-
less internal administration for epilepsy, &c.   In circumscribed re-
gions, as upon the scalp and neck, (such common localities of this
disease,) we have known it used recently with much advantage.
In most cases, M'e should prefer making trial of Professor Velpeau's
new remedy of sulphate of iron, an application which in his hands,
as will be seen by the full abrege we have made (vid. supra, in the
body of this work) of the brochure  he was so kind as to transmit
to us for this edition, was  attended  with  the most promising re-
sults.

    Blepharoplasty for Ncevus Maternus.—Dr. Mott's Process.

  In a case of large oval naevus in a child aged six  months, on the
lower lid of the right eye, and extending down upon the cheek, Dr.
Baumgarten recently effected a radical cure by excising the naevus,
(during which he was obliged to  divide the orbicularis and pene-
trate into the orbit,) and  then  bringing down a flap from the tem-
ple.  The  constant application of cold water to  the  sutured lid
abated the  somewhat  formidable tumefaction, on the third day
union by the first intention had taken place, and on the fourth  the
last suture was removed.  The wound on  the temple suppurated
freely, and the edges being drawn together, soon became filled with
healthy granulations.   In another week the loss of substance was
replaced, and  the  cicatrices  of the  eyelid were  scarcely visible,
(Annales de  Chirurgie, Jan., 1843.)   M. Ammon performed a simi-
lar operation on an old man, for  cancer of the lower lid, but:  the
disease returned, (Ib.) 
704           new elements of operative  surgery.

  Iii the above case of naevus, or aneurism  by anastomosis, as more
correctly named, it might not have been impracticable perhaps, to
have had recourse to  the  admirable and  radically effective and
successful process now employed (but not yet generalized in Europe
or in this country) in  its worst forms, even in  infants of but few
months old.   This new process, (the name of the author of which,
whether  English,  French,  German, or American, we have  never
yet been enabled to ascertain, and of which we have seen no pub-
lished account,) which Dr. Mott  is now constantly in the  habit of
employing, to a greater extent, we believe, than any other Ameri-
can surgeon, and with unvarying success, as has been repeatedly
seen at his  public clinique for the poor at the  University of this
city, and in  his private practice for three years past, consists in in-
serting horizontally through the base of the vascular meshwork or
tumor, and  close to the skin, a considerable number (from four to
six or eight, according to the size of the naevus) of strong but very
slender needles, furnished with small wooden handles; the needles
being kept  red hot on a small chafing dish held near the patient.
The needles are inserted rapidly and successively,  and as quickly
removed.  The little  patient appears  to bear  the  operation with
far  less pain than M'ould  be imagined, and the diseased  mesh of
vessels, so effectually cauterized  into an eschar by the needles as
to prevent even the issue of a drop of  blood, (thus  precluding the
hemorrhage  hitherto  deemed so formidable in the  ordinary mode
by excision,) sloughs off clean in a few days without the slightest
trouble, leaving a healthy granulated surface,  any irregularities
upon which may be afterwards  easily removed by the nitrate of
silver.   For ncevi,  in future all other processes, as that by the kali
purum, &.C., directly applied, or by means of threads  saturated with
it, introduced after the manner  of a  seton, as recommended by
Prof. N. R.  Smith, of Baltimore, (Amer. Journ.  of  Med.  Sc, July.
1843, p. 260,) &c, must be discarded.  The process with red-hot
needles for the cure of naevi materni, might probably, as  we con-
ceive, be employed fully as effectively for  the  removal of certain
superficial cutaneous  tumors (lipomatous, for example) where the
subjacent tissues are not implicated or degenerated, and where the
patient might dread the knife or ligature, or the operator apprehend
unpleasant hemorrhage.

         The actual Cautery, or Red-hot Iron in Phlebitis.

  While on this subject it is  proper to mention, that M. Bonnet, of
Lyons, has met  with remarkable success in the cure and preven-
tion of phlebitis, from dissection and otherwise, by the use of potassa
cum cake, the chloride of zinc, and the red-hot iron.  The red-hot
iron, superficially  applied, produces a very superficial eschar; the
potassa cum calce acts much more deeply; the pain with either,
though sharp, soon ceases,  and the inflammation that succeeds is
slight.  The chloride  of zinc produces much deeper eschars than
either of the others, and the pain and inflammation  are severe; but 
AMERICAN APPENDIX.
705
it is followed by the rapid clearing off of the eschars.   The author
gives a case of phlebitis from venesection, and four of severe con-
stitutional disturbance following wounds received in dissection, which
were treated by the red-hot iron with  immediate and complete suc-
cess.  As many v.  'en cauterizing irons were used  at  once in the
case of phlebitis, ue sub-cutaneous tissue being found in a semi-
gangrenous  state.   In  the dissection wounds, the seat of the injury
alone  was deeply seared; the iron was  elsewhere  carried super-
ficially along the course of the red lines.   The author has employ-
ed the same method to the treatment of hemorrhoidal tumors and
prolapsus ani, (vid. Lond. and Edinb. Monthly Journ. of Medical
Science, July, 1843, p. 650.)
  Certainly, if we reason upon the sound pathology of the terrific
disease from dissection wounds, as laid down by Professor Velpeau,
its author, in this present work, (vid. supra,) and reflect how utterly
futile have hitherto been all  curative agents attempted, we ought
to feel it incumbent upon  us to recommend, in as strong language
as possible, the trial of the therapeutic mode with the red-hot iron,
as introduced in this truly formidable and fatal disease, whose as-
semblage of symptoms are as  peculiar and anomalous as they are
painfully distressing.  If any thing-could possibly exterminate the
infectious gangreno-typhoid or erysipelatous  inflammation of the
worst character, which seems in  such cases to run  continuously
along the course of the veins from the purulent point of departure,
most assuredly the red-hot iron would appear to be the remedy ap-
propriately calculated for  this  purpose.   Its almost  specific power,
as we have stated  in aneurism by anastomosis, in obliterating the
congeries of blood-vessels of which these naevi are composed, and
in establishing a new and healthy action in  their sub-cutaneous
trunks, naturally conducts us to the inference that a similar happy
result would, as is fortunately shown  in  M. Bonnet's cases, follow
from the  early employment of the actual  cautery, where inflamma-
tion has  gained possession of the  internal coat of  the veins from
purulent  infection.  We hope M. Bonnet, or others, will put  this
treatment completely to the test, and  it may not seem improper to
suggest, that the veins or absorbents beyond the wounded part, and
whose implication in the  purulent inflammation is made manifest
by the red lines, and also the glands themselves in  the axilla or
elsewhere, where accessible, should also be subjected to the red-hot
needles, or, by a new application of acupuncture, be  actually en-
tered or  perforated by them as in the treatment of naevi.  Those
who have witnessed cases of purulent  inflammation and death from
dissection wounds, know well  the  necessity of some bold curative
means, which shall no longer make this disease one of the opprobria
for which our art has much reason to feel humiliated, and the too
generally fatal  consequences of which, it cannot be denied, have
proved a lamentable obstacle in  retarding those anatomical re-
searches  which are the very keystone and basis, if not the only true
and legitimate foundation, of all sound pathology and therapeutics,
both in the practice of medicine and in operative surgery. 
706           NEW ELEMENTS OF OPERATIVE SURGERY.

  The actual cautery was, in the earliest periods of recorded medi-
cal history, always deemed one of the most favorite and successful
surgical remedies among the most primitive nations, and it is  M'ell
knoM'n that among the Arabs of the African desert, and the  Hin-
doos of Asia, as among the barbarous aboriginal tribes of our  own
country, this  potent instrument is their great and prompt reliance,
not only (M'hich common sense and ages of accumulated tradition-
ary experience had pointed out to them) as an admirable process
of effecting speedy counter-irritation, and establishing a local dis-
ease and an abundant healthy suppurative drain of humors in  con-
stitutional affections; but also for the immediate and  total eradi-
cation of foul and degenerate ulcers, and tumors, and growths of
every description,  by substituting  a pure and healthy action  and
inflammation, for one of a morbid character.
   Veterinary surgeons, also, in this  as in many other  branches of
surgery, by the more or less irresponsible character of their profes-
sion, and the consequent daring expedients to which they may re-
sort  with impunity, (in the same way as living dissections throw
such  vast  light  on physiology, &c.,) have, by their frequent  and
successful use of the actual cautery, continued to uphold the charac-
ter of this invaluable  resource.
   In conclusion on this subject, M'e may remark, that the value of
nitrate of silver as an external application in erysipelas, (see this
appendix, supra,) is founded in reality, as it seems to us, on the
same well-established principles of pathology, as those we have ad-
duced in behalf of the ancient, and now soon, we hope, to be gener-
ally revived  curative  agent, the actual cautery or red-hot iron.—T.
CASES OF GENO-CHEILOPLASTY (ANAPLASTY OF THE CHEEK AND
                      LIPS) BY DR. MOTT.

  It will be seen by the following cases of restoration of the com-
missure of the mouth, and portions of the cheek, performed at New
York by Dr. Mott, the one as early as about the year 1825, (the
precise date of the year being lost,) at the New  York Hospital, the
other in 1831, that the French anaplastic method, so called, the ruling
principle of which is  deplacement, was adopted  in the practice of
that surgeon at a very early date for the history of this department
of surgery.

                   Case I.—By Displacement.

   This was a middle-aged man, (see  plate A,) in whom the left
commissure, and several inches of the cheek on that side in  a hori-
zontal direction, were totally destroyed, together with a correspond-
ing portion of the alveolar processes and teeth of the lower jaw, by
necrosis, and all the result of violent mercurial  action.
   Upon removing the necrosis, and allowing a  few days to elapse
for the jaw to heal, I performed (says Dr. Mott) the following op- 
AMERICAN APPENDIX.
707
(Dr. Mott's case of Genu- Cheiloplasty, about the year 1825.)
              (Plate A.)
eration:—The hardened
edges  of  the  cicatrized
margin of the chasm were
pared off, the  cheek was
then freely detached above
and below, and as far back
as the edge of the masse-
ter muscle. The fresh sur-
faces were now  readily,
by distension of the parts,
brought into  contact  by
several stitches of the  in-
terrupted suture, one stitch
being applied  to the neat
adjustment of the angle of
the  mouth.  The stitches
were  then supported  by
strips of adhesive plaster.
The wound readily united
by the adhesive process.
  The  yielding nature of
the  tissues involved ena-
bled me to effect  so com-
plete and natural a resto-
ration of the parts, that the little deformity that  remained was
truly surprising.   Nothing  but a  mere seam of cicatrix was left.
This result seemed then the more remarkable, as but few or no
operations of geno-cheiloplasty, by the French method at least, had
then been performed anywhere.  This case has never been publish-
ed until in the present M'ork.

             Case II.—By Displacement and Flaps.

  This case of geno-cheiloplasty was involved also M'ith immobility
of the lower jaw, and comprised the double operation of flaps and
deplacement.   We annex Dr. Mott's own published account of this
case, from Dr. Hayes' American Journal of the  Medical Sciences
for November, 1831:
  "On the 7th of April, 1831, I was consulted in the case of Miss
Mary Park, aged seventeen, of Southbridge, Massachusetts.
  " Her attending  physician, Dr. Samuel Hartwell, gave the fol-
lowing relation of the case.  'In the autumn of 1822, she had  an
attack of typhus  fever: the symptoms were mild in the commence-
ment of the disease, and nothing unusual occurred until the middle
of the third week,  when tumefaction and redness were discovered
on the left cheek, accompanied with slight  delirium* and general
aggravation  of fever.
  " 'At the end of the third week, a dark vesicle, about the size  of
a pea, appeared  at the angle of the mouth, announcing the exist-
ence of sphacelus, and in a few days extended to about two inches 
708
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
in diameter upon the side of the face.   A crisis of fever now super-
vened, which was followed by sloughing of the whole gangrenous
portion, leaving the teeth and gums exposed.  Upon its cicatriza-
tion  the jaMS remained  immoveably fixed, being apparently tied
together by a ligamentous band within and about the cicatrix.
Her  food Mas  introduced into the mouth through a space formed
by the removal of a tooth on the right side.   The first set of teeth
and  the alveolar process of the diseased side, were detached by
caries.  Most of the second teeth were developed in a few years
afterward.
  "' No mercury was used in the treatment of the  fever.   Her
general health is now very good.'
  " Her countenance was much  disfigured, and presented the ap-
pearance represented.  [See Plate B. fig. 1.]
  " As the only means of permanently overcoming the closure of
the jaw was the removal of the cicatrix, I determined upon excising
and replacing it by sound integument from the face and neck."
  The operation was performed by Dr. Mott on the 8th of April,
as follows:—
  " It was commenced by carrying an incision from  a little within
the upper angle of the mouth, around the outer margin of the cica-
trix,  to a little within the lower angle of the under lip, and by the
immediate removal  of the newly-formed parts included within it.
The  adhesions between the jaws were next divided, which enabled
me, in consequence of the relaxation thus produced, to insinuate be-
tween the teeth of the opposite side, the point of the lever used in my
former cases, with which I finally succeeded in opening the mouth.
  " This point accomplished, the lips were brought together at the
angle of the mouth  by a suture,  and  I proceeded to detach a por-
tion  of integument sufficiently large and of corresponding shape to
replace the part removed. [See dotted lines, Plate B. fig. 1.] It was
turned into the space it was intended to fill, leaving a tongue three
quarters of an inch in breadth connected  with the adjacent part,
and  sufficient for all the purposes of circulation.  The  cut edges
were adjusted with  extreme accuracy, by means of interrupted su-
tures and adhesive straps:  the  lower wound was  contracted as
much as possible by adhesive plasters, and the whole covered with
lint,  compress, and bandage.
   " Previous to  the operation she took sol. sulp. morphine, double
strength of Majendie's formula, gtt. xiv.  The operation occupied
about an  hour, and was sustained with a firmness peculiar to the
female sex.
   " Evening.—Had been sick at her stomach, and  vomited some
coagulated blood, which had no doubt been swallowed during the
operation.
   " April 9th. Found her sitting up at  the side of the bed.  She
felt,  she  said, very comfortable, and  had passed a good night.
Hardly any perceptible swelling of the face.  As far as the parts
can  be seen, all looks favorable.  Ordered her a dose of sulph. mag-
nesias.  She can depress the lower jaw, by the effort of the will, to 
AMERICAN APPENDIX.
709
the extent of about half the width of the finger.  I advised her to
continue the motion of the jaw, from time to time, as much as the
soreness at the angle of the mouth would permit.
  " 10th and 11th.  Continues to do well.
  " 12th.  Some little tumefaction under the eye, but she makes no
complaint.   Directed  an emollient poultice  to the hard dressings
upon the wounds on the neck.
  " 13th.  Several poultices have been applied to  the neck, which
have softened the lint; upon carefully removing it  and the plasters,
the wound was again  dressed in the same manner.
  " 14th.  Complains of a  little headache from not sleeping well
last night.   Felt great comfort from the  removal of the stiff dress-
ings yesterday.  Bowels are in a good state.   Cannot say to what
the headache is to be attributed; she thinks it owing to the loss of
sleep last night.  The  swelling of the cheek has subsided.  Chang-
ed the lint again to-day.
  " 15th.  Found her in bed this morning, with pains in her limbs
generally, and with some swelling of the  right knee, and tenderness
to the touch; passed a bad night;  her pulse is much more frequent
than natural.  Is not aware  that she ever had rheumatism before.
Directed general and  local treatment for her disease.  She makes
no complaint of her face, which in all respects is very promising.
I removed  three of the stitches from around the angle of the mouth,
and reapplied lint and plasters.
  " 16th.  Still in bed.   Has less pain and swelling in the knee, but
more in the foot and ankle ; generally she feels better.   Removed
another stitch from the lower part of the  patch.  The wound of the
neck looks well; dressed it with ungt. resinae and  plasters.
  "17th.  To-day she is generally better, but feels most pain and
tenderness in the knee and ankle of the other  leg.  Says her  face
feels very comfortable.  I removed three stitches  from the upper
part of the patch, and for the first time all the plasters, and washed
the whole surface.   Adhesion seems to have taken place at every
point of the flap.  Dressed the face as yesterday.
  " 18th.  Every part of the flap appears to have united.  Dressed
the wounds with dry lint.   Advised her  to move the lower jaw a
little downward, every day, several times.  The rheumatic affec-
tion is  seated in the right  wrist and fingers.   Ordered the use of
tinct. colchici.
  " 19th. Passed a better night; but both arms are now nearly use-
less.  Consented to-day to  be bled.  Repeated  the infus. sennae as
a cathartic;  dressed the face, which looks very well.
  " 20^.  Feels generally  better.   Both  arms still much affected.
Drew the edges of  the wound in the neck together  with adhesive
straps.   Directed the tinct. colchici to be increased.
  " 21s*. In  all  respects better; a slight  rheumatism yet continues
in the left  hand and arm.  The colchicum has  produced some ca-
thartic  action on the bowels.  I dressed the face and wound as yes-
terday ; directed her to open the jaw more frequently; and to  con-
tinue the colchicum. 
 710           NEW ELEMENTS  0E  OPERATIVE Sl'R'iEEV.

   " 22d.  Found  her sitting up, and says she is more comfortable.
 The left hand  and Mrist still a little tumefied and painful.  Face
 and wound continue to improve ;  dressed them as yesterday.  Has
 more motion in the lower jaw.
   " 23c?.  Is free from all pain to-day, and feels  quite M'ell again
 Ordered the colchicum to be discontinued.  Dressed  the wound as
■ before.
   " 25th.  Continues free from rheumatism.   The wound improves,
 and was dressed as yesterday. The jaw moves more freely.
   "May 12th. Patch in the cheek entirely healed, [see Plate B. fig. 2.]
 The wound in the neck  is nearly closed.  She can open the jaws
 sufficiently wide to admit solid food.
   " 14^.  She leaves town to-day in good spirits, and delighted with
 the result of the operation.
   ■' Although I have before often operated for immobility of the jaw,
 and with the happiest results, and have once removed a deformity
 occasioned by a hole in the cheek, by the Tagliacotian method, in the
 New York Hospital, with  perfect  success, [see  Case I., above,]  I
 have  never before seen it necessary to combine both operations in
 one individual; and the gratifying termination of this long and ardu-
 ous case, is a convincing proof of the  excellence  of the means em-
 ployed, and of the power of art in repairing the ravages of disease,
 and in relieving its distressing consequences.
   " 25 Park Place, New  York.
   " N. B.  A letter M'as received from  Miss P.  by the lady M'ith
 whom she resided here, in which she stated her health to be excel-
 lent, the jaw to  have acquired increased motion, and her friends
 much pleased with her improved appearance.—July."
(Dr. Mott's case of Geno-Cheiloplasty, New York, 1831.)
             (Plate B.)
 
AMERICAN APPENDIX.
711
  Since the date of the last operation, Dr. Mott has performed va-
rious operations of a similar kind, as well as blepharoplasty, rhino-
plasty  and  uretroplasty,—of which last more  particular mention
will  be made under the head of Injuries and Diseases of the Ure-
thra.
 INTERESTING CASE OF  METOPOPLASTY, BY DR. JNO. WATSON OF
                          NEW YORK.

       [Communicated by Dr. Watson for this work, and never before published.]

               Metopoplasty, or Forehead-Mending.

   An anaplastic operation on the forehead, probably the first of the
 kind, was recently performed, with marked advantage to the patient,
 at the New York Hospital, by Dr. John Watson, one of the surgeons
 of that institution.
   Hugh McCabe, a native of Ireland, a  carpenter, aged forty-two,
 was admitted into the hospital on the 19th of April, 1844, with ne-
 crosis  of the os frontis of six years standing, probably the result of
 syphilis, which he contracted some twenty years ago, but of which
 for many years past he had supposed himself entirely cured.   Ac-
 cording  to his own account, the disease on the forehead M'as the
 result of a local injury.
   At the date  of admission a large ulcer, exposing a considera-
 ble portion of the os frontis, existed  on the forehead.   The greater
 part of the external table of the bone had  already exfoliated, and
 was held in place merely by the overlapping of the soft parts.  A
 fistulous opening  existed at the upper  border of each orbit, and
 another in the left  temple, and through  these there M'as a consid-
 erable flow of purulent matter.  The upper  eyelids  were  some-
 what elevated and deformed by adventitious adhesions around these
 fistulae.
   A few days after admission, the exfoliated portion of bone was
 removed by Dr. J. K. Rodgers, who,  in order to effect this removal,
 was obliged to increase  the size of the opening by a short incision
 on the  scalp, at the upper and left angle  of the ulcer.  The under-
 mined  integuments, now deprived of support, rolled  in upon them-
 selves, turning a portion of the hair  of the scalp inM'ards upon the
 face of the sore, and adhering in this folded form along the left bor-
 der of the ulcer.
   On the first of June, the date at which Dr. Watson  took charge
 of the case, the central portion of the ulcer appeared to be covered
 by a sort of cuticular cicatrix.   The whole aspect of the forehead
 was exceedingly disgusting.  The cavity was about two  inches
 and a half wide in its shortest diameter; its borders were rugged,
 abrupt, and irregular.  A portion of  diseased bone lay still exposed
and adherent near the upper and right angle of the opening, another
under the fold of integuments along the left border.  A deep sulcus,
exposing some points of diseased bone,  existed above the root of 
712
NEW  ELEMENTS OF OPERATIVE SURGERY.
the nose.  The left frontal sinus was exposed to view, and the rim
of bone along its outer and  lower boundary Mas  carious.   From
these several points of diseased bone there M-as a free discharge of
purulent matter.
  The patient's general health was good.   After deliberating for
some time on the case, finding the internal table  unaffected, and
all the carious portions apparently within reach, Dr. W. advised the
patient to submit to an operation, M'ith a view of removing the dis-
eased bone, and of closing the cavity in the forehead.  To this he
readily acceded, and the operation was accordingly undertaken on
the 27th of July of the present year, 1844.
  After shaving the scalp, and removing the cuticle from the centre
of the ulcer by washing it with concentrated aqua ammonias, the
operation was commenced by unfolding  the integuments along the
left border of the ulcer.   This required the free use of the scalpel.
A small fragment of bone, which lay buried in this fold of skin, was
removed during this first step of the operation.
  The next  step was to carry the point of the knife  completely
around the circumference of  the opening, and through the  whole
thickness of soft parts;  and to remove a strip of integument, vary-
ing from an eighth to a quarter of an inch in M'idth, throughout the
whole of this extent, thus making a smooth and fresh border for the
subsequent adjustment of the  flaps.
  The third step consisted in  raising two large quadrilateral flaps,
the one on the left, and the other on the right side of the opening
in the forehead.   This was effected by four incisions running some-
what horizontally backward, nearly parallel with  each other, two
on each side, one from each upper, the other from each lower angle
of the opening; and afterwards detaching the flaps from the  peri-
osteum.
  The fourth step consisted in the removal of the diseased portions
of bone, as far as they could be detected.  This was effected mostly
by the cutting pliers.  The largest of these portions was the pro-
jecting rim of bone at the left frontal sinus, the removal of which
caused a slight depression over the  left orbit.  The hemorrhage,
which hitherto had been rather free, was now checked by the ap-
plication of ligatures to such  vessels as required them.  The  most
obstinate point of issue was from the  minute vessels of the glabella,
where ligatures were out of the question.
  The fifth step was an attempt to approximate the lateral flaps,
so as to cover the opening.  This, however, could only be partially
effected.  They could be made to meet only to the extent  of an
inch from their lower edges, even after considerable stretching.
The parts thus approximated were secured by two sutures. A large
V-like gap still existed on the upper part of the forehead.
  The next step consisted in  an attempt to fill this by a flap from
the top of the scalp.  For this  purpose a free incision was carried
from near the upper and right angle of the ulcer, in a curved direc-
tion, towards the crown of the head.   The flap thus made was dis-
sected up and then partially  rotated, so as to  bring its lower and 
AMERICAN APPENDIX.
713
 he  emf ninrdT d ^ ^e.ccntre of the forehead'  In th^ -ay
 TL"^?n?«tPH ^My °f mtegUment  Was effectually supplied7
 aloL Srwh^P of tfgGr Were "™ br°ught into exact coaptation
 mre   No n  l°/tl   ^f incision b^ numerous points of su-
 ture.   No part of the wound was left gaping.  The sutures were

 fove^wfth ar^8 °f ^f^ PlaSe" and theflTela:^
 covered with a compress and bandage
  The patient suffered comparatively little subsequent to the oper-

 ^SnfST? %lSTteT PaFt °f the first week he was kept on a
 restricted diet  The  dressings on the forehead were  kept wet with
 cold water.   This had  no effect  in detaching the adhesive straps,
 and was  exceedingly grateful to the  patient.  The first dressings
 were removed on the sixth day.   About three fourths of the lines
 of incision had united by the first intention.  A few of the sutures
 were  removed, and the wound  was dressed as before  At the
 second dressing, on the ninth or  tenth day, cicatrization had pro-
 gressed somewhat further.  The  lower angle of the upper flap had
 not adhered, and it had receded  somewhat, so as to leave a small
gap about the size of a shilling in the middle of the forehead.  All
the  remaining sutures  and ligatures were  now removed, and re-
placed by simple adhesive straps.
(Fig. 1.)
(Fig. 3.)
  Subsequent to  this period, although the central gap increased
slightly in size, the integuments around it became attenuated and
cicatrized firmly to the parts beneath, so as to leave very little de-
pression.   The patient left the hospital about five weeks after the
operation ; at which period the wound had entirely cicatrized, with
the exception of a papillary opening which communicated with a
small point of carious bone that had escaped notice during the op.
                             90 
714
NEW ELEMENTS OF OPERATIVE SURGERY.
eration, and that had not yet exfoliated.  This opening was at the
upper and right angle of the original cavity, and was seated on the
hairy scalp, so  that as the hair grows it M'ill become entirely hid-
den, provided it is not soon allowed to cicatrize by the exfoliation
of the point of bone beneath it.
  Figure  first,  in the accompanying plate, is a representation of
the patient's features just before the operation.   Figure  second
illustrates the  lines of suture  subsequent to the  operation; and
Figure third is a representation of the face at the date of the pa-
tient's dismissal.
OPERATIONS IN BLEPHAROPLASTY, RHINOPLASTY, RHINO-CHEILO-
  PLASTY, STAPHYLORAPHY, STRABISMUS, TALIPES, TORTICOLLIS,
  AND ERECTILE TUMORS; BY ALFRED C. POST, M. D., ONE OF THE
  SURGEONS OF THE NEW YORK HOSPITAL.

  [In illustration of what has been done in anaplastic and sub-cu-
taneous operations by our own countrymen, it is a source of much
gratification to be enabled to incorporate with this work the fol-
lowing very highly interesting summary,  for which we are indebt-
ed to Dr. Alfred C. Post of this city.  It will be perceived that Dr.
Post has had eminent success in almost all of his operations for the
reparation  of deformities, and the restoration of destroyed  parts,
especially in the difficult branch of blepharoplasty, in his very in-
genious and new process for rhino-cheiloplastic operations, and in a
still more marked manner in his division of the rectus-internus mus-
cle in convergent strabismus.  His observations, also, and practical
experience in club-foot and  wry-neck, (in which  latter, it will be
seen, he gives a decided preference to M. Guerin's sub-cutaneous
mode,) and  in  staphyloraphy, together with the  improved modes
he suggests in the treatment of talipes, and of erectile tumors, naevi,
&c, are entitled to be received with much consideration.   We note
that the first suggestion of employing red-hot needles for the cure of
ncevi, is ascribed to the late Dr. Bushe.   Whoever may be the origi-
nator of this process, we Relieve no surgeon, in America or Europe,
has adopted it with such entire confidence, or practised  it to so
great an extent and with such gratifying success, as Professor Mott,
(see supra.)  Dr. Post's paper will be perused with great satisfac-
tion.— T.]

                   Blepharoplastic Operations.

  My first  blepharoplastic operation was performed  on the fifth
June, 1841, in the presence of Doctors J. Kearny Rodgers, Blake-
man, Trudeau, and Buel.   The patient was a boy seven years of
age, whose face had been badly burned three years before the op-
eration.  The left lower lid M'as completely everted, and its margin
much  elongated  and drawn down upon  the cheek, where it was 
AMERICAN APPENDIX.
715
fixed by a firm and unyielding cicatrix.  The following account of
the operation is extracted from the New York Medical Gazette for
Jan. 19, 1842:—
  I first made an incision immediately below the everted lid, by
which 1 detached it from the cheek.  I then cut out a V-shaped
piece  from the  lid, and brought the edges of the incision  together
with a suture, by which means the tarsal edge of the lower lid was
shortened and brought into apposition with the corresponding mar-
gin of the upper lid,  leaving, however, a  considerable  chasm be-
tween the lower lid and the cheek.  I then dissected a vertical flap
from  the integument  covering the anterior edge of the masseter
muscle, about two inches in length and five eighths of an inch in
breadth, leaving it attached at its upper extremity by a neck three
eighths of an inch in breadth.  The flap was then brought around
so as  to fill up the chasm between the lower lid and the cheek, and
was secured in its place by ten sutures.  The sides of the wound,
from which the flap was taken, were  broughtogether and secured
by three sutures, fortified by adhesive strap^HjThe only situation
in which the sides of the wound were not hrjfft into contact, was
at the angle  below the twist in the  neck  o^Rie flap.   A  piece of
lint, dipped in iced water, was applied over the wound, and direc*
ed to  be moistened as  often as it became dry or warm.
  The sutures were removed on the  fifth,  sixth, and seventh days.
Union by the first intention took place throughout the whole wound,
except at three points, viz.: the angle below tnj twist  in  the neck
of the flap, the  junction of the extremity of the flap with  the side
of the nose, and the inferior angle of the part of the wound  from
which the flap was taken.
  The following report  was  made on the 20th June, fifteen  days
after the operation:—The  wound  has healed throughout its whole
extent.  The eversion appears to  be entirely cured.   The patient
has the full power of  opening and closing the lids.   The twist at
the neck of the flap is almost entirely effaced ; but the outer  can-
thus is crowded somewhat towards the nose, so as to make the af-
fected eye appear a little smaller than the  sound one.
  My second blepharoplastic operation was performed on  the 25th
May,  1842, in presence of Doctors Hoffmann, Hitchcock, Hobart,
Buck, Hubbard, Blakeman, and Westmacott.  The patient was a
little girl two and a half years of age, whose face had  been sadly
disfigured by a burn, when she was six months of age.  The mid-
dle  portion of the right  lower lid was drawn doM'n, everted, and
fixed to the cheek by  a firm wrinkled cicatrix, which adhered also
to the nose and drew  its tip  to the right side.  The  patient  was
unable to  close the lids; and the  eye, from its exposed situation.
was subject to inflammation from slight exciting causes.  The op-
eration which I performed  was almost precisely the same as in the
former case.  After the operation  the child was fretful and fever-
ish, and cried a great  deal.  Three days after the operation,  sup-
puration took place between the extremity of the flap and the nose.
On the following day,  I dressed the wound and removed all the su- 
716
NEW ELEMENTS OF OPERATIVE SURGERY.
tures.  Adhesion had taken place between the edges of the Mound
from which the flap had been taken, and along the lower edge of
the flap where it was attached to the cheek.  The adhesion  be-
tween the upper edge of the flap and the eye-lid, and betM'een the
edges of the divided lid, M'as very slight.  I brought all the edges
of the wound together as accurately as possible with adhesive plas-
ter.  The  next day the adhesions between the edges of the divided
lid, and between the lid and the flap, had given way, and the inner
extremity  of the flap had separated about three eighths of an inch
from the nose.  On the 5th of July, about forty days after the op-
eration, the process of  cicatrization was completed. There Mas a
notch at the margin of the lid M'here the edges of  the wound had
been brought together, and a slight degree of eversion remained at
the same point;  but the lids could be closed, and the M'hole appear-
ance of the eye was greatly improved.  A slight additional opera-
tion would have removed the  notch at the edge of the lid, and I re-
commended to the^^rents to bring  the child to me again for  the
purpose, but they^^iot return.
   About a year aglKperformed a third blepharoplastic operation
for the restoration o^fhe upper lid in a case of extreme deformity,
resulting from a burn.   The patient's health  was bad, and I could
not obtain perfectly sound integument for the formation of the flap.
The greater part of the flap sloughed, and the wound was left to
heal by granulation.  She left the city before the wound had heal-
ed, and I have no^been able to ascertain the ultimate result.

                    Rhinoplaslic Operations.

   On the  8th November, 1843, I performed, at the New York Hos-
pital, a rhinoplastic  operation according to  the  Indian method, as
modified by Dieffenbach.  The patient was a girl twenty-two years
of age, whose nose had been partially destroyed by ulceration, sup-
posed to be syphilitic, three years before the operation.   The point
of her nose was drawn up by a cicatrix, so that the nostrils were
very conspicuous in a front view of the face.  The dorsum of the
nose above the point was much depressed, a large portion of the
cartilaginous  septum of the nose  having been destroyed.  In the
depressed portion of the dorsum was a hole with cicatrized edges,
sufficiently large to admit the extremity of  the  little finger.   The
deformity was of so disgusting a  character  that  the patient  had
been in the habit of covering the nose with a plaster.  The ulcer-
ation had been healed a little more  than a year before the opera-
tion,  and  during that period she had enjoyed good  health.
   The operation was as follows:—A transverse incision was made
about three fifths of an inch above  the point of the nose, and ex-
tending through the whole thickness of the organ, from cheek to
cheek.  By this means the point of the nose was liberated, so that
it could  be brought down to its proper situation.  The  depressed
 and  perforated portion of the dorsum  and  sides of the  nose  was
 then excised by two  oblique incisions, extending from  the upper 
AMERICAN APPENDIX.
717
part of the dorsum of the nose to the two extremities of the trans-
verse incision.  These incisions, with the restoration of the point of
the nose to its proper position, left a triangular chasm more than
an inch in length in a vertical direction, and about an inch and a
half in a transverse direction.  To fill this chasm, a triangular flap
was dissected from the forehead, encroaching upon  the hairy scalp,
which had been previously shaved.  The base of the flap was situ-
ated superiorly, and the extent of the flap was considerably greater
than that of the chasm which it M'as designed to fill.  The flap was
left attached to the root of the nose by a neck of integument about
three quarters of an inch in breadth, and  the incision on the left
side of this neck was continued down to the corresponding side of
the wound upon the nose.  The bleeding, M'hich was pretty copious,
was arrested by the application of iced water.  When it had ceased,
the flap was brought down, being twisted towards the left  side, and
its edges were secured by twisted sutures  to the sides and base of
the triangular space included between the  incisions on the nose.
Fourteen sutures were employed to keep the lMx> in its place, and
three  to adjust the edges of the wound upoiTSChe forehead, from
which  the neck of the flap was taken.   No attempt was made to
bring together the edges of the broad part of the wound on the fore-
head, which was simply covered  M'ith dry lint.  A piece of lint,
spread with simple cerate, M'as applied over the whole wound.  The
flap maintained a natural appearance from the time of its transpo-
sition.   After  the lapse of forty-eight hours, the  threads were cut
and removed, but the needles were left in place.  Four needles
were removed on the 12th November, six on the 13th, six on the
14th, and  one on the 15th.  Union of  the flap took place by the
first intention, except on the left side, where there was some sup-
puration.  The lower part of the wound on the forehead also united
by the  first intention.
   On the 29th November, the union of the flap on all sides having
become firm, I divided the neck of the flap and untwisted it;  and,
having cut it to a proper shape, I secured  it to the adjacent parts
by five twisted sutures.  On the 2d December, ulceration had taken
place around the needles and I removed them all:  the wound had
united throughout nearly its whole extent.  The broad wound on
the forehead became filled with granulations, by the contraction of
which its edges  were  gradually  approximated,  and cicatrization
was completed  about  the 15th January,  1844.   A merely linear
cicatrix extended from the root of the nose nearly to the upper part
of the forehead, where the broadest part of the cicatrix which en-
croached upon the hairy scalp could almost be covered with a dime.
The lower part of the flap, which now formed part  of the nose, had
become covered with hair of a much finer growth than that which
proceeded from  the portion of the scalp from which the flap had
been taken.  The sensibility of the flap, which at first was nearly
extinct, had gradually increased, but was much less at the centre
than towards the edges.  The point of the nose was drawn a little
upward, and  above it  was  a deep transverse depression in the 
8
NEW  ELEMENTS OF OPERATIVE SURGERY.
transplanted  skin.  The portion of the flap M'hich constituted the
dorsum of the nose was broad and flat, and a ridge existed on each
side at the junction of  the lower extremity of the flap M'ith the re-
mains of the original alae of the nose.
  To remedy these defects, and to improve the form of the nose, on
the 18th January I performed the following operation :—1 excised
an elliptical portion from each ala of the nose, extending from the
dorsum to the cheek, and including the elevated cicatrices.  I then
made a transverse incision dividing the remains of the dorsum be-
tween  the two lateral incisions, by means of whieh the point of the
nose was liberated, so  that it could be brought down again to its
proper position.   But as the point of the nose M'as disposed to rise
again,  1 divided  the columna with the remains of the septum, and
excised a portion about a quarter of an inch in length M'ith strong
and sharp scissors.   I  then excised a longitudinal strip, about one
third of an inch in breadth, from the whole length of the  dorsum of
the nose, and sloped the edges of the wound at the expense of the
inner surface of th Adrin.  After the flow of blood, M'hich was quite
copious, had  been ^wested by the use of iced water, the edges of
the wound in the dorsum of  the nose were brought together with
five twisted sutures.  The lower extremity of the flap was reunited
with the remains of the alae  by  one twisted suture and  one inter-
rupted suture on each  side.   As the edges of these incisions  were
curved, their approximation pushed forM'ard their anterior extremi-
ties, and thus removed, in a great measure, the transverse depres-
sion which had previously existed.  Finally, the edges of the divided
columna were  brought together by two  interrupted  sutures, and
thus, by shortening the columna, the point of the nose was secured
in its proper position.  The operation M'as necessarily tedious and
painful, but it resulted in a very marked improvement  in the ap-
pearance of  the npse,  which had assumed the form of  a very be-
coming feature.  The  wound was dressed  as after  the first opera-
tion.
   Jan. 20th.  Several of the  needles have caused ulceration ; I re-
moved all the threads from the twisted sutures, and extracted three
of the  needles.                                            ».
   21st.  Removed the  remaining four needles and the two sutures
connecting  the  lower  extremity of the flap with the alae of the
nose.
   22d. Removed the remaining two sutures, viz., those connecting
the edges of the divided  columna.  The  union of all the wounds
appears to be nearly perfect.
   The patient left the  hospital about the 20th February.  The nose
had become considerably flattened since the last operation.  The
growth of fine hair still continued  on the  portion which had been
detached from the scalp, requiring the  occasional use of tweezers.
On the whole, however, a great improvement in her appearance
had resulted from the  operation. 
AMERICAN APPENDIX.
719
                 Rhino- Cheiloplastic Operations.

  During the past summer, (1844,) I performed two operations for
the restoration of the upper lip and of the columna of the nose.
The cases were very similar to each other. The subject of the first
operation was  a young man twenty-two years of age, most hideous-
ly deformed  by a double hare-lip complicated with double fissure
of the bony and soft palate.  The intermaxillary bone between the
two fissures  of the upper jaw, projected forward nearly as  far as
the tip of the nose, and terminated in two prominent  teeth, which
were about  an inch in advance of the lower lip.   This projecting
portion of bone M'as covered in front by the portion of integument
which separated the two fissures of the lip, and which was attach-
ed above to the tip of the nose.  The fissures of the  lip extended
nearly to the angles of the mouth.
  The operation  was performed in  the following  manner:—The
portion of integument betM'een the fissures of the lip  was first de-
tached from the intermaxillary bone, but left attached to the tip of
the nose.  The intermaxillary bone was  then excised  with bone
forceps by two incisions—one  horizontal, on a level with the  floor
of the nose, and the other vertical, on a level with the teeth of the
lower jaw.  The edges of the hare-lip fissure were  then excised
with sharp  scissors, and tM'o horizontal  incisions, each nearly an
inch in length, were made through the cheeks, extending backward
from the alae  nasi.  By this means,  I was enabled to obtain  two
flaps from the cheeks, which I drew together in  the  median  line
and united  by three interrupted sutures, which were fortified by
strips  of adhesive plaster.  The portion of integument M'hich hung
down  from the tip of the nose was  then  pared down to a proper
shape and size, and turned backward and upward so as to  be ap-
plied to the  lower part of the septum of  the nose, from which the
intermaxillary bone had been excised.  It was attached to the sep-
tum of the nose by two sutures.
  I saw the patient two months after the operation: the lip  had
united firmly, but the vermilion border was a little higher on one
side than on the other.  The middle flap had also united to the sep-
tum nasi and had formed a very respectable columna, which, how-
ever, was rather too wide, and which I proposed  to reduce by the
excision of a narrow strip ;  but the patient did not return to me for
the purpose.  The result of the operation  was extremely gratifying
to the patient  and his friends.  The deformity had been of a most
hideous character, and it had previously been examined by several
surgeons, who had regarded it as  beyond  the reach of surgery.
Some  of the steps of the operation were  such as have not gener-
ally been made known to the  profession, and, as far as my know-
ledge extends, had not previously been adopted by any surgeons in
this country.  I  allude particularly to  the  horizontal  incisions
through the cheeks, and to the mode of constructing  the  columna
nasi.  For the plan of operating which I adopted, I am chiefly in- 
720
NEW  ELEMENTS OF OPERATIVE SURGERY.
debted to the valuable work of M. Serre of Montpellier, " sur l'Art
de restaurer les Difformites de la Face," &c.
  The subject of my second operation was a boy about ten years
of age.  The deformity bore a striking resemblance to that which
existed in the case described above, and the steps of the operation
were  so nearly the same, that I do not consider it to be necessary
to describe them  in detail.   When I last saw the patient, M'hich
was a fortnight  after the operation, the lip  had  united perfectly,
and its appearance was symmetrical, except  that it was swollen on
one side, in consequence of ulceration caused by a projecting tooth.
The union of the columna was not yet perfect.

                        Staphylo raphy.

  I performed the operation of staphyloraphy on the 21st August,
1843,  at the surgical clinique of the Castleton Medical  College.
The patient was a young man twenty years  of age, affected with a
congenital fissure of the velum palati and uvula.  The tongue was
depressed by an assistant with a bent spatula; I held the edges of
the fissure  with a double hook, and  excised them M'ith a scalpel.
I then introduced three sutures with needles M'hich were fixed to a
handle, drawing out the ends  with forceps ; I found  it difficult to
draw  out the threads, in consequence of the needles being too little
curved, so that their points were necessarily thrown too far back.
The patient fainted during the operation, which was somewhat
protracted from the difficulty of passing the threads.  The quantity
of blood lost was very small, scarcely exceeding an ounce.  In
tightening the ligatures, I found difficulty in keeping the first knot
from slipping until it was secured by a second.  I accomplished it
by having it held  by an assistant between the blades of a forceps.
After the knots were tied, so much  tension existed in the velum
that I feared that  the threads would cut through the edges of the
wound. I succeeded completely in relieving this tension, by making
an  incision on  each  side parallel to the wound, and extending
through half the thickness of the velum, according to the plan sug-
gested by M. Dieffenbach.
  The first day after the operation,  the patient was  allowed to
swallow nothing but a teaspoonful of milk every hour, and to hold
ice in his mouth.   He  was directed afterwards  to take a pint of
beef tea daily for a week, to be swallowed very slowly, and in small
quantities  at a time.  He was also  directed to  confine himself to
liquids for another week, but to take them more freely.
  Three days after the operation I examined the throat, and found
the edges of the wound in perfect apposition, and very little  ap-
pearance of inflammation.   The  patient complained very little of
soreness of the throat.   On the evening of the same day I left Cas-
tleton.  I visited Castleton again during the following spring: the
patient was absent, but I ascertained from several medical gentle-
men who had seen him, that the operation had  been entirely suc-
cessful. 
AMERICAN APPENDIX.
721
   In the performance of the operation just described I experienced
 considerable difficulty, in consequence of not being provided with
 needles of a suitable form to pass the threads readily through  the
 velum.   1 have since procured needles much better adapted to this
 purpose, but I have  not  yet had an opportunity of making use of
 them.   1 have no doubt that  the operation would have failed if  I
 had not relieved the tension of the velum by incisions ; I think, also,
 that the success of the operation was promoted by allowing the pa-
 tient small quantities of liquids, instead of proscribing all food and
 drinks, as some operators have done.   The  effect of entire  absti-
 nence from drinks, is to  occasion an accumulation of  viscid saliva
 and mucus about  the fauces, and thus to give rise  to frequent at-
 tempts at deglutition, which are much more likely to disturb  the
 healing process than swallowing bland liquids.

                          Strabismus.

   My first operation for strabismus was performed on the 28th Oc-
 tober, 1840.  I have divided the rectus internus muscle sixty-one
 times, and  the  rectus externus  six times.  Of the sixty-seven oper-
 ations, two were for converging luscitas, being performed on  the
 right and left rectus internus muscle of the same patient, and they
 were entirely ineffectual.  Of the fifty-nine operations for strabis-
 mus convergens, fifty-two were successful in restoring the affected
 eye nearly or quite to its normal position ; in some of these, how-
 ever, the eye remained a little convergent, or became slightly di-
 vergent, but not to such a degree as materially to  injure  the ap-
 pearance of the patient.  Of  the seven unsuccessful  cases, there
 were four in which the eye became divergent to such a degree as
 to constitute a serious  deformity.  In the  remaining three, the  op-
 eration failed in consequence of the obstinacy or resistance of the
 patient.  One of the patients was a boy, who struggled so violently
 that I could not satisfy myself  that the muscle was completely di-
 vided.   The two other patients were men, in both of whom the two
 eyes were  affected, and  in each case the failure of the  operation
 was the result of the refusal of the patient to submit to the opera-
 tion upon the second eye.
  Of the six operations for the cure of strabismus divergens, by the
 division of  the  rectus externus muscle, four were successful in re-
 storing or  greatly improving the position of the eye.  In both of
 the unsuccessful cases, the divergence was the  result of the pre-
 vious division of the rectus internus muscle.
  It has been supposed by many persons that the successful result of
 the operation for strabismus was not permanent, and that there was
 a great liability to a return of the distortion.  This opinion has not
 been verified by my experience.  As far as I have had an opportu-
nity of observing the subsequent progress of the cases upon which
I have operated, there has been but one instance in  which there
has been a return  of the distortion after  it  has  been apparently
cured.  In this case, the  strabismus was originally brought on  bv
                              91 
722
NEW  ELEMENTS OF OPERATIVE SURGERY.
an attack of ophthalmic inflammation, and after having continued
a number of years, was perfectly cured by the division of the rectus
internus muscle.  About a year after the operation the patient had
a severe attack of ophthalmic inflammation, in consequence of
which the strabismus returned.

                           Club-Foot.

  I have had considerable experience  in the treatment of club-foot.
In a few instances  I  have tried the  effect of simple mechanical
treatment Mdthout the division of tendons, and I am fully persuaded
that many cases may be  cured by  the  persevering use  of  this
method;  nevertheless, I am firmly convinced that the reduction of
the foot to its proper position is greatly facilitated by the division
of such tendons as are contracted, and that the division of the ten-
dons not  only renders the cure more rapid, but saves the patient a
vast amount of suffering.   I have divided a large number of ten-
dons, and I have never known any serious consequences to result
from the  operation.   The instrument which I employ for the reduc-
tion of the foot in children, is Scarpa's shoe, as modified by Little
and Buck, with the addition of a soft  laced boot, which  is imme-
diately applied to the foot,  and the heel of which is fastened to the
heel of the shoe, M'hile the remaining portion of  it  is free.  The
laced boot  is a modification introduced by myself, and it appears to
me to have the decided advantages, that it fixes the  foot more se-
curely to the apparatus, and that it diminishes the danger of exco-
riation.  For the reduction of the foot in  adults,  I prefer Strohmey-
er's foot-board as modified  by Dr. Detmold.

                           Wry-Neck.

   I have treated a confirmed  case of this distortion  very success-
fully by the sub-cutaneous division of the sternal origin of the sterno-
cleido-mastoideus, folio wed by the use of Winslow's bandage, Joerg's
apparatus, and Dieffenbach's cravat.   I  am inclined  to prefer the
sub-cutaneous to the open division of the sterno-cleido-mastoid mus-
cle.

                        Erectile Tumors.

   I introduced cauterizing needles into one of these tumors as early
as the 2d March, 1836.  In this case  considerable arterial hemor-
rhage followed the operation.  I think that it  was  owing to the
needles having been too sharp.  I would suggest the propriety  of
having blunt points to the needles, so that they may burn their way
through the tumor rather than cut it.   [The actual cautery, heated
to a red  rather than a white heat, has  been recently (as will be seen
farther on) recommended in all cases where this invaluable reme-
 dial agent is required in surgical operations of any kind.   Though
 Dr. Post has not mentioned why he  also  gives it a preference ip 
AMERICAN APPENDIX.
723
erectile tumors, it may be well  to  remark that it appears  to be
founded on correct pathological principles; inasmuch as the needle
heated only to a moderate degree of heat, makes, by burning its
way, a much better eschar in its passage, and is therefore more ef-
fectual in arresting  hemorrhage and procuring a healthy slough,
than by the white heat, which must make it act in some measure
as a cutting instrument.—T.]
  If my recollection does not deceive me, I received the first infor-
mation of  this method of treatment from Dr. Theodore L Mason,
who received it from the late Dr. Bushe.  I have treated erectile
tumors successfully by a variety  of different methods, and it does
not appear to me that any one method is properly applicable to all
the cases which occur.  When the tumor is prominent, and its situ-
ation  is such as to admit of the remedy, I think  that the plan of
transfixing the base of the tumor with two needles at right angles,
and then applying a ligature, is calculated to effect the most safe
and speedy cure.   In some  situations, excision is the  preferable
method.  During  the last summer I saw a case  in an infant four
months old, in whom more than half of the vermilion border of the
lower lip M'as involved, and the tumor was growing rapidly.  I ex-
cised it by an operation similar to that which is performed for the
extirpation of cancer of the lip in the adult, and stretched the rem-
nant of the lip across to the angle of the mouth, where I secured it
by two interrupted sutures.  A very moderate amount of hemor-
rhage occurred, and  the lip united with but little deformity.  [Un-
der erectile tumors we presume that Dr. Post means to include, with
transatlantic surgeons, the different forms of ncevi.—T.]
 IMPROVED EYE-SPECULUM, BY GEORGE TIEMANN, SURGICAL IN-
                STRUMENT MAKER, NEW YORK.
           [Designed particularly for operations for Strabismus, &c.]
  This instrument, invented by George Tiemann, of New York, ap-
pears to us to possess a decided preference over the common spring
speculum, as described by Prof. Pancoast in his work on surgery,
as well as over some of the more complicated but not less objec-
tionable specula used  by others.   The instrument of Dr. Pancoast
will not, when applied to the eye-lids, open them at equal distances,
for the outward points of the hooks will stand farther apart than
those of the inner side.
 
724
NEW  ELEMENTS OF OPERATIVE SURGERY.
  The above eye-speculum, by means of the spiral spring M'ithin
the silver cylinder, opens the two hooks in a direction perfectly par-
allel to each other, and  the regulating  screw secures  them at any
distance  the operator chooses to set them.  This will much alle-
viate the pain of  the patient; for the continued  pressure of the
spring speculum upon the muscles of the eye-lids (there being no
check  to the spring of the instrument) is considered by some, and
no doubt often is, far more painful than the operation itself.
  The profession for many years owe much to Mr. Tiemann for the
very perfect workmanship, not only of all the ordinary instruments
employed in surgery, midM'ifery, &c, but also for the very great
improvements he has made in some of them, and for those more re-
markable instruments of  his  own invention (as his tonsil-scissor-
forceps, &c, all of which will be given in their proper place) which
nave justly given to this very scientific and intelligent artist an en-
viable  reputation.—T]
               GENERAL  REVIEW

                            OF THE

PROGRESS OF  SUB-CTTTANEOUS  SECTIONS AND ANAPLASTIC
                         SURGERY,

    SINCE THE LAST EDITION OF M. VELPEAU'S WORK ON OPERATIVE SURGERY IN 183U.
  As it would have been  impossible, from the length of time that
this first volume of the American edition of M. Velpeau's work has
been in the press, to have  incorporated in  systematic order the va-
rious  improvements, and  new applications of sub-cutaneous and
anaplastic surgery which are constantly being made both in Europe
and in America, especially in the former country, we have, in ad-
dition to the annotations which are found in various portions of the
text, and as a sequel to the more distinguished contributions of our
own countrymen, as contained in what immediately precedes this
part of our concluding appendix, thought it advisable to endeavor
to give, in this place, a brief and consecutive historic summary of
what has been done in this respect on the  continent of Europe and
in Great Britain, in those  important branches of new and  modern
surgery, since the year 1839.  In  this will be found supplied all
omissions in the preceding text and  notes ; and this summary, to-
gether with the abrege  we have also subjoined from the more re-
cent European works and  publications  on  surgery which have only
come to hand immediately on the eve of the publication of our vol-
ume, will  form, as we hope, a useful acquisition for the practitioner
as well as student, in furnishing him with a complete account of 
AMERICAN APPENDIX.
725
every thing of any value that has been done up to the present mo-
ment, or that seems worthy of record, both as a guide to what may
now be safely undertaken, and as embracing matter which may act
as a laudable incentive for further experiments and discoveries.
             THE SUB-CUTANEOUS SECTION.

  It is not to be denied (as is made manifest by M. Velpeau and
others in the text of this work—vid. supra, and especially the dis-
cussion in the Academy of Medicine at Paris) that the sub-cutane-
ous section of the integuments had been long since practised by
many surgeons both of England  and on the continent of Europe.
But it is nevertheless true, that its practical application was never
brought to such perfection,  or proved to be a matter of such high
importance and value, as it  has been in all the varied processes of
tenotomy and myotomy proposed and practised by M. Jules Guerin.
His boldness, tact, and success, and the extent and diversity of cases
of deformities on which he has employed it, have justly given him an
undisputed as well as the most  exalted rank in those invaluable de-
partments of new and modern  surgery.   It is due to M. Guerin, in
order the more effectually to authenticate and enregister his claims,
to quote in this place an extract from a paper in his  Gazette Me-
dicale, 1841, which bears the title of " Remarques Historiques et Cri-
tiques pour servir a VHistoire de la Methode Sous-cutanee, par le Dr. J.
Guerin" and which was intended as part of an introduction to the
work he was then about to publish, entitled " Essais sur la Methode
Sous-cutanee" and which has since been published.  In this preface
he generalizes his method by laying down the following principle:
" that all wounds practised  under the skin, whatever may be their
seat and the nature of the divided tissues, partake  of the character
of sub-cutaneous wounds of tendons; that is to say, that they neither
inflame nor suppurate, and that they cicatrize (s'organisent) imme-
diately."  The peculiar character  of the consecutive action (du
travail  consecutif) in  these wounds, is not a diminution of  inflam-
mation, but one of an altogether different nature, to wit, immediate
organization, (organisation immidiate)  The indirect character is
the absence of all febrile reaction, local or general, even when the
sections are carried to the number of ten or twelve, or even to more
than forty on the same individual, as is seen in the remarkable and
unique  case in which M. Guerin operated at Paris, and which we
have mentioned supra in our notes  on tenotomy and myotomy, em-
bodied with the text, and of which a more exact  account will  be
found in the subsequent pages of this appendix. 
726
NEW ELEMENTS OF OPERATIVE SURGERY.
                         STRABISMUS.

  The absolute necessity of more exact experiments and investiga-
tions in relation to the motive agents and functions of the eye, is
strikingly illustrated  by a  remark  of Mr. W. Hey, jun., in the
Transactions of the Provincial Medical and Surgical Association,
Lond., vol. xii., 1844,  p. 170.  In an interesting retrospective ad-
dress on surgery in that work, Mr. Hey says :  " Before we attempt
the cure of these  affections (strabismus, &c.)  by an operation, M'e
ought to decide, in the first place, whether the disease depends on
an abnormal condition of the mus'cles, or on some defect in  the or-
gan of vision ; and, in the next place, M'e ought to ascertain which,
if any, of the muscles are  in fault;  for it appears  that in myopia
one surgeon divides the obliquus superior, another the obliquus infe-
rior, a third, two of the recti, and a fourth, all four of them."
  Mr.  Bransby Cooper,  in some physiological observations on the
eye, (London Medico-Chirurgical Review, January, 1839,)  draws
certain conclusions from experiments he made on  rabbits, which,
however, as has been justly remarked, from the difference of ana-
tomical structure  in  their  eyes from those of the  human species,
must be taken  with certain allowances, (see some  remarks of Dr.
Franz, infra.)  Mr. Cooper is led to believe that the oblique mus-
cles of the eye, when they  act  together, retain the  globe in a cen-
tral position in the cavity of the orbit, and moderate the retraction
of the four straight muscles ; and that when they act one  after the
other, without  their  power being diminished  by the action of the
straight, they turn the eye on its axis, drawing the globe forward,
and at the same time much enlarging [thereby] the field of vision.
This is clearly inferred  from the great loss of mobility in the eye
after  the  section of one of the oblique muscles.  In dividing the
two obliques of one eye, he found, in rabbits, that the globe was per-
manently retracted into the orbit, and depressed  upon the floor of this
cavity, the pupil being also contracted, Mdthout, however, any lateral
deviation.  By the section of one only of these  muscles, the eye was
not left exclusively to the action of the other, which was  necessa-
rily subject to the  influence of the straight muscles.
  In Dr. David Hosack's theory on the action of the muscles of the
eye, broached by this eminent American practitioner so early as
1794,  (see text of  this work, supra,)  and to  the  ingenious and un-
questionably sound principles of which theory we have thought it our
duty to give full credit in our text, though he  declares the general
fact, he does not pretend to point out precisely, in detail, in what
manner the  various  muscles co-operate or combine in producing
a diminution or elongation of the longer axis of the  globe.   M. Vel-
peau, it will be seen in his treatise on strabismus, (embodied in the
text, supra,) advances some plausible explanations of the manner
in which changes are thus produced  in the globe, (consequently in
its adaptation to distances—in other words, to all the modifications
of vision,) by throwing out  the idea that the  recti  and  the oblique 
I
                       AMERICAN APPENDIX.                   727

act, as Dr. Hosack had intimated, in an antagonist manner to each
other, and thus each order having their fulcra in an opposite posi-
tion, their compound actions are so combined by the will as to draw
the ball  backM'ard, or outward and forward;  i. e., to diminish or
elongate its longest diameter.
  Mr. E. W. Duffin, of London, one of the earliest surgeons to in-
troduce the operation of strabimus  into England, and to illustrate
its pathology, speaks of the action of the muscles as follows, with-
out, however, apparently referring to the indispensable connection
of these movements with the adaptation of the eye to correct vision,
(Lond. Lancet,  1839  40,  p. 925:) " Much diversity of opinion cer-
tainly prevails  in regard to  the functions of the oblique muscles of
the eye ; but if we dissect them M'ith very great care to their inser-
tions, we must  admit, whatever else M'e may call in question, that
the direction of their fibres, as M'ell as their ultimate attachments,
warrant the  conclusion that the function of the superior oblique is
to roll the eye inward  and downward, and that of the inferior to
rotate the organ in the opposite direction.   When both muscles con-
tract at the same time, the effect will be to bring the  eye forward and
render it a little more prominent; thence proceeds  one of the com-
mon results, increased fulness of the eye, when the adductor [i. e.,
rectus internus] is divided."  It is proper to say that Sir Charles
Bell,  on the contrary, believed that the superior oblique assisted in
 rotating the globe  upward and inward.  This Mr. Duffin cannot
 comprehend.   This latter surgeon continues : " that the only mus-
 cles requisite to enable the  eye-ball to move diagonally upward and
 inward, i. e. towards the nasal process of the frontal bone, are the
 superior rectus  and the adductor; although it  is possible  that the
 superior oblique, by rolling the globe downward and  inward, may
 contribute slightly, in some individuals, in causing the pupil to ap-
 proximate the inner canthus, but certainly not in  directing it up-
 ward," (Ib.)  Mr. Duffin proved by his operations in several cases,
 and in one more especially remarkable case of excessive squinting
 of the right  eye upward and inward, that the  division of the supe-
 rior and inner  rectus alone  effected a perfect restoration of the ball.
 (Ib. pp. 926, 927.)
   These ideas, we think, seem consistent with the  principles of the
 composition of forces which must result from the position of  the
 recti; i. e., the diagonal line, (equidistant from any two proximate
 recti,) upon which.this  action must be directed.  The prominence of
 the eye, also, when one or more of the recti are cut, appears to show-
 that  their appropriate  (not conjoint with the oblique) action is to
 retract the globe into the orbit, and that of the oblique to protrude
 or elongate it.                                           ,
   In  respect to the causes of permanent strabismus, besides those of
 some congenital or accidental lesion of the nervous centres, Mr. Lis-
 ten and Mr. Ancram, (Lond. Lane, 1839-40, pp. 609,610,) in a sum-
 mary on seventy-six cases already operated upon by Mr. Liston at
 that date, mention the wearing of a shade so that the light has been
 admitted only  at the inner angle—the eye being constantly directed 
728
NEW ELEMENTS OF OPERATIVE SURGERY.
to this point.  This was the cause in ten patients out of seventy-six,
Violent  exertion, as in whooping-cough, occasioned  the  disease in
five ;  the action of the muscles of the  eye in looking suddenly at
some  object, caused it in seven; falls caused four cases.  The rela-
tive proportion of cases of congenital strabismus is small; more cases
are caused by spasmodic contraction of the internal rectus, than by
paralysis of the external straight muscle.  Mr. Liston, it appears,
(loc. cit., supra,) divided the external rectus for divergent strabismus
previous to July 14, 1840.  Most of the causes of the disease have
operated effectually before three years;  after that  their power de-
creases.  Both sexes and  both eyes these surgeons then, at least,
thought were equally liable to the  disease.   Mr. Liston  cured, and
in a perfect manner, one case of contracted internal rectus of sixty
years standing.  The objection to operating very early is that some
temporary internal derangement [as we have said  in a note in the
body  of the text, supra,—T.] may be  the cause, and require only
pathological  means.  At that time, also, [for it is  proper to recur
to these early steps of this part of new surgery to  serve as  guides
to the future,—T.,] Mr. Liston recommended (in convergent stra-
bismus) to dissect perfectly clean the internal part of the ball of the
eye, " for  (says Mr. Ancram, speaking for Mr. Liston) the slightest
fibre  of the  internal  muscle  that  remains undivided will prevent
eventual success."  Though perhaps this advice, from the now too
frequently observed occurrence of the deformity of exophthalmia,
flaring  of the lids, &c, (see text, supra,) after this unsparing dissec-
tion, can no longer be admitted in practice, we must, with the spirit
of impartiality which should guide us, give Mr. Liston the credit of
having, as early as this period, (July, 1840,) been so impressed with
the necessity of an unrestricted liberation of the fibro-cellular con-
nections of these parts, that he frequently, in convergent strabismus,
where the patient after the operation continued to  have the  power
of turning the eye inward and downward, divided also, wholly or in
part,  the inferior rectus, the contraction of the inner  border of which
Mr. Ancram, with reason, considered as the probable cause of this
partial  degree of the disease remaining after the division of the in-
ternal rectus.  In  every case of  this kind thus treated, the  result
was perfect success.  For the dissection of the ball, these surgeons
gave a preference to, the scissors and forceps, as  we thus avoid
wounding the  sclerotica, evacuating the humors  of the eye, and
consequently destroying vision.   Mr. Liston's first operations for
strabismus, says Mr. Ancram, took place in the early part of May,
(1840.)  In seventy-four cases he failed in but one [!] so avers Mr.
Ancram.   This certainly is a far greater proportion of  cures than
strabotomists are favored with at  this  present advanced epoch of
this branch of surgery, (1844,) and no doubt  Mr. Ancram soon af-
terwards  found that his statement of cures must be taken with
many exceptions.
   Our  author, M.  Velpeau, as will be seen in the text of the body
of the work, enters largely into the importance of a partial division 
                      AMERICAN  APPENDIX.                    729

of the inner border of both the upper and lower rectus, in certain
cases of convergent strabismus.
  It  is proper here to say, so far  as Mr. Ancram (Mr. Liston's ad-
junct) is the exponent of Mr. L.'s opinions, that as early as May 6,
1840, Mr. Liston  had noted the difficulty mentioned above, of the
continuance of the eye to converge to a certain degree after the op-
eration, and had at first imputed  it to  a contraction of the two  ob-
lique muscles, (lb., Lond. Lane, pp. 306, 307.)
  It is just also to Mr. Lucas, of London, to mention that he at that
early period (August, 1840) doubted so  much the propriety of inter-
fering with either the superior or inferior rectus, and feared so much
an external strabismus from their division, that  he felicitates  him-
self, at that time, on never having touched the tenotome to either
of those muscles, or any of their fibres, maugre the unvarying suc-
cess  which Mr. Ancram  assures  us Mr. Liston obtained by these
sections.
  Mr. Lucas, however, claims in most unqualified terms, the honor
of having performed the first operation for strabismus in  England,
as reported by him in the London Lancet, (vid.  London Lancet,
1839-40, p. 709.)
  Mr. E. W. Duffin, of London, however, who at this time appears
to have quite surpassed all his cotemporaries in the first year (1840)
that  the operation for strabismus was domiciliated in England from
the continent, had already, on September 1, 1840, (though the first
surgical  operation  for this deformity ever  performed in England
was  only a few months before,) performed the operation, he  avers,
no less than one  hundred and fifteen  times ; in which operations,
however, he frankly confesses he  met  with frequent total failures,
and expresses, therefore, the utmost surprise at the very marvellous
successes alleged by others.  Mr. Duffin, too, at that time possess-
ed probably of as much if not more experience than any other Eng-
lish surgeon,  distinctly foresaw, even then, one  of  the most formi-
dable difficulties to be avoided, " a staring, vacant, projecting  eye,
of apparently disproportionate  size, or a disagreeable leer;"  the
former now well known as that  repulsive deformity of exophthal-
mia,  and flaring of the lids, which too frequently results from  the
unrestricted division of the muscles and aponeuroses.  Mr. Duffin
then also  recognised that one of the  principal causes of partial
continuance of the deformity (as above mentioned) arose from some
remaining undivided " band of  fibrous  adhesion," that had escaped
the scissors—and possibly, also, from  the rude practice which it
appears some then had (and of  which he highly disapproves) of
pushing the inner divided end of the muscle back into the posterior
and lateral part of the socket of the eye with the handle of the scalpel!
  Mr. Duffin, however, does not seem  disposed to impute the par-
tial continuance of the strabismus after the operation, as Mr.  Lis-
ton thinks, to the inner border of the inferior rectus, "but to a few
upper tendinous fibres, or  a  band of adventitious cellular attach-
ment," still remaining unseparated, the division of which he found
to answer every purpose.  "These fibrous bands or digitations, 
730
NEW  ELEMENTS OF OPERATIVE SURGERY.
Mr. Duffin says, " though so indistinct and lax in the dead eye, are
very energetic in life, and are found  sometimes seated very far
back, even  beyond the greatest diameter of the  eye-ball."  He
therefore  never cut, he says, the fibres of the inferior  rectus, and
never thought of dividing the superior oblique.  He doubted [then
at least]  if the division of the oblique muscles had ever yet been
made by any one, or ever would be found necessary, (vid.  London
Lancet, 1839-40, pp. 894, 895, 896.)
  A v*ery useful suggestion, as it appears to us, in  respect to ex-
ophthalmia of the ball from too free dissection, is that which Mr.
Duffin makes, that if one eye only squints, and is less than the other,
this  freedom of dissection may bring  out  the smaller or diseased
globe more upon a level with the healthy one, and thus cause their
inequality of size to pass unobserved.   The opposite course, i. e., a
cautious and circumscribed dissection, should, he properly remarks,
be pursued where the  faulty eye is largest.  Mr.  Duffin,  at that
early epoch of strabismus, (Sept. 10, 1840,) had, as  we  have said,
a correct appreciation  of many of the more disagreeable conse-
quences (as exophthalmia, sinking of the inner canthus, polypus in
the angle, double vision, &c.) which result from defective modes of
operating.  To avoid the sinking of the inner canthus, he  enjoins
upon the  operator to be particularly careful in preserving the semi-
lunar fold of the conjunctiva, (Lond. Lancet, 1839-40, p. 926.)
  Mr. Duffin has known sloughing of the eye-ball, and total loss of
vision, from too extreme  and clean a dissection of the sclerotica,
(lb., p. 927.)
  Dr. Hocken (in the London Lancet, March 27, 1840-41, p.  8) men-
tions permanent strabismus as not unfrequently complicated with
sympathetic  amaurosis.   Where strabismus occurs (if ever) with
hysterical amaurosis, it is, he thinks, spasmodic and temporary.
  Inasmuch as  the diseased  eye, when the sound  one  is covered,
generally has its motions correct, Dr. Jno. Walker,  of Manchester,
(Eng.,) who  has written much on this organ, thinks  it plain that
the independent movements of an eye  in strabismus are  perfect,
that it is the associated action that is defective, and that the organ is
only inactive  when  it ought  to move  conjointly with its fellow,
(Lond. Lancet, 1840-41, p. 673.)  In most  cases  of strabismus he
considers " that it is merely this absence of agreement in the direc-
tion of the two eyes, which constitutes the defect  in question," (Ib.)
  Dr. Walker seems of opinion that the greater frequency of con-
vergent  strabismus is owing  to the preponderating power of both
oblique muscles in their tendency to bring the eye towards the inner
canthus.  In further illustration of his theory, he  mentions  that pe-
culiar semi-rotary movement of the globe from within outward ob-
served by Dr. Jacob in some cases of paralysis of the orbital nerves,
and which Dr. J. imputes to  the action of the trochlearis  muscle,
(see Dublin Medical Press.)  Dr. Walker says he has seen it exist
where the whole of the muscles of the eye-ball apparently were
paralyzed, every movement but this rotary one being  totally sus-
pended, including paralysis of the levator palpebrae, as well as of 
AMERICAN APPENDIX.                   731
the iris;  he explains it on his theory of the independent and associa-
ted muscular actions of the eye. Thus, by the class of associated move-
ments " the two eyes are directed forward,  inward, upward, and
downward; and there is another class in which the movements are
dissociated, and the eyes directed laterally.  As these are distinct and
independent movements, so they are accomplished by tM'o distinct
classes of muscles, and these muscles have distinct and independ-
ent nerves.  Those movements in which the eyes are directed for-
ward, inward, upward, and downward, are, / conceive, effected by
the muscles supplied by the third pair of nerves,  [i. e., the motor
oculi, which supplies the rectus superior, inferior, and internus, the
inferior oblique, and the lenticular ganglion, the source of the ciliary
nerves;] whilst those movements in which  the eyes are directed
laterally, (one  eye being turned outward and the other inward,) are
effected  by the muscles supplied  by the sixth and fourth pairs of
nerves, viz., the external rectus and the trochlearis,"  (Lond. Lancet,
1840-41, pp. 676, 677,678.)   It is curious to note these remarks, in
connection with the Hosackian theory of vision, (vid. sup.)   It is seen
that Dr. Walker alludes to a, forward motion of the  eye (i. e., we pre-
sume, an elongating one of the longest axis of the globe) as among the
effects of the action of three of the recti and of the  inferior oblique ;
more exact study and observations upon the myology and  the myo-
tenotomy of the eye, will doubtless lead to more correct views of the
true physiology of vision, and of the remarkable  functions of this
almost purely  mechanico-mathematical organ of the human body.
   Dr. Franz, of London, persists in his opinion, in  which, however,
but few participate, that the division of one or both the oblique mus-
cles, as well as of the  internal or external rectus, sometimes  be-
comes necessary to complete the cure of strabismus ; especially the
division of the superior oblique, which, he thinks, (being the longest
of all the six muscles of the eye, and therefore subject to greatest
contraction,) with more or less paralysis of the external rectus, may,
after the division of the internal  rectus, help to retain the eye in
its convergent position.  He thinks both oblique muscles assist in
the inversion [i. e., convergence] of the eye.   He  avers that in six
cases of convergent strabismus, he has not been  enabled to com-
plete.the cure but by the division of the superior oblique.
   In proof of  these opinions he made, he says, in conjunction with
Dr. A. Ure and Mr. F. Fowke,  certain experiments  on animals,
from whence he deduces the following inferences  in respect to the
functions of the muscles of the eye :—
   " That in man the ordinary movements of the  eyes inward, up-
ward, outward, and downward, or in a direction between any two
of these, or in circles intersecting these different directions, are per-
formed by the straight muscles only, and independently of the obliques;
but that while the straight  muscles are moving the eyes in one of
these directions, or after they have moved them towards a certain
object, the obliques assist the straight in keeping the axis of vision
steadfastly fixed upon the  object, which either moves while the
person is at rest, or which is at rest while the person is moving, or 
732
NEW ELEMENTS OF OPERATIVE SURGERY.
while both the object and the person are in motion, or M'hile the
person perhaps, at the same time, turns his head towards one side
or the other; secondly, that the obliques act  the principal part in
accomplishing  those minute  alterations in the inclination of the
axis of  vision between their parallelisms and  their greatest  con-
vergence, which are necessary  for their  decussation  in a given
point.   If, while the head is kept in a vertical  position, this point
is situated on a level with the eyes, the convergence of the visual
axis is effected by the four obliques; if situated above, by the two
inferior only; and if beneath, by the two superior only.  And third-
ly, that by means of the obliques the refraction in the eye is made
dependent on the convergence, or the convergence on  the refrac-
tion.'   He does not give so great a rotatory power to the action of
the obliques, each acting alone, (viz.,  forty-five to fifty degrees,) as
do Professor Volkman and Dr. Hueck, (vid. Neue Beitrage zur Phy-
siologic des Gesichtssinnes, Leipzig,  1836; and Mutter's Archiv.,
1840, Nov.  4, p. 475; also, Ueber  die  Achsendrehung  des Auges,
Dorpat, 1838.)
  Dr. Franz adds, (which is  adverse  to the Hosackian theory of
vision,)  " I am not inclined to think that the adjustment of the eye to
distance is accomplished by a mechanical action of the recti, although
it is not impossible that the obliques may exert some  indirect in-
fluence  by effecting  the convergence of the visual axis; this ad-
justment appears to me to exist in a delicate motion of the lens in
the antero-posterior axis of the eye,  and to be dependent on the cil-
iary nerves  and body."  This is  reverting to the ancient German
opinion of that adjustment being effected by a prodigious muscu-
lar power in the lens itself, (see our notice of the Hosackian theory
in the text of this work, supra.   For  the views of Dr. Franz more
in extenso than we have  given, see the Lond. Med. Gazette, 1840-
41, pp. 611 et seq.; also ib. vol. xxvi.  p. 689.)
  Dr. D. Ross-Lietch, of Tynemouth, Eng., (vide London and Edin-
burgh Monthly Journal of Med. Science, March, 1841,) states at the
date of his publication, that out of 276 cases operated  upon, more
than two-thirds were the  result  of  measles, small-pox, or scarlet fe-
ver. The eye  having been distorted during the  cerebral excite-
ment connected with these diseases, or, having been turned towards
the inner canthus to avoid the light during the ophthalmia accom-
panying these eruptive fevers, had  so remained, until the internal
rectus muscle became structurally shortened. The remaining cases
were ascribable to paralysis  of the  opposing muscle, injuries on
the head, irritation, nebulae, worms, the hair of some portion of the
head-dress having been allowed to hang near or over the eyes,
and rarely to an " amaurotic or cataractous condition of the eye."
  Dr. L. is  decided  in his opposition to the  additional division of
the  inner fibres of the superior and inferior rectus in  convergent
strabismus,  as flaring of the ball  and divergence may ensue.   Also
he  is against the section of the superior oblique, for he has seen
the deviation upward and inward, in  which the superior oblique is
supposed to be particularly concerned, cured without dividing that 
AMERICAN APPENDIX.
733
muscle, and by the section  of the inner rectus only.  He  thinks
tne division of  either of the obliques useless in permanent squint.
   He makes some useful remarks on the uncertainty of opinions
as to the true functions of the superior oblique, and the impossibil-
ity of deriving any very sound deductions from the section of the
muscles of the eyes of lower animals, as the  retractor muscle  in
them presents so different an anatomical condition from that of the
human species.   In the monkey also, whose eye is nearest to man,
there are serious impediments.  Dr. L. proposes to obtain some
light on the action of the obliques by dividing both  in an  amau-
rotic eye,  where the  motions of that eye harmonize  with the
sound one.
   He considers that all  the forward  movements of the eye, up-
ward, downward, and inward, are  effected by the inner and the
superior  and inferior recti, which cannot otherwise act than  in
couples and consentaneously.  All these actions are excited  by one
nerve alone, the motor  oculi.   The greater importance of the ab-
ductor  oculi muscle is shown by its having an appropriate nerve.
But  their field of vision being extensive and opposite, it is neces-
sary that two external recti (i. e. abductores) should never act to-
gether ; for if they did confusion of vision and divergent strabismus
would result.
  To effect this  harmony, he believes  that M'hen one eye is thus
turned outward, the other is not brought into correspondence (that
is, inwardly) by the inner rectus, but by the inferior oblique.
  The  primary action of the superior  oblique  he conceives to be
to draw the eye forward, and that that  of the inferior oblique, from
the nature of its insertion, must be a compound action forward and
inward.  The ball, he says, rests on a cushion of fat upon which it
is revolved, not dragged from side to side;  and that the  eye  is held
back by the four recti, [as  in a  sling, he might have added;] and
that  the internal rectus possesses advantages over the abductor  in
point of origin and insertion ; so that  if the eye  were thrust for-
ward so as to  stretch the recti muscles, it would be dragged in-
M'ard by the mere tension of the internal  rectus, which is shorter
and  inserted nearer the cornea than the abductor.   From all the
above anatomical considerations, Dr. Lietch believes the action of
the oblique muscles is  much more concerned in turning the eyes
inward than some imagine.
  He does not, however, think that the superior oblique of either
eye,  when the opposite eye is directed to its greatest extent out-
ward, can have power to roll the eye deep into the inner canthus.
Its position forbids this opinion.   But the inferior oblique  seems
capable of doing this, by its direction backward, and its  broad
expanded insertion, enabling  it to wheel the eye around deep into
the inner  canthus, while the ball is being held suspended  to the
recti muscles. The action of the obliques, according to Dr. Lietch,
has been much mistaken, from  not  recollecting that the eye may
be considered as fixed, to a certain extent, and that it moves as on
a pivot, not as a body dragged from side to side.  We cannot help 
734
NEW  ELEMENTS OF OPERATIVE SURGERY.
remarking how much in accordance  these rational views appear
to be M'ith many of those of Dr. Hosack's theory.
  The manner in which the obliques are supplied with nerves, jus-
tifies the supposition that their action is independent of the mus-
cular action supplied by the third nerve alone.
  The  superior oblique has its independent nerve, the inferior is
supplied from the third  and the  fifth.   This combination  of  the
motor nerve M'ith one so  essential to vision as the fifth, strikingly
distinguishes, as Mr. Lietch thinks, the  inferior oblique from  the
internal  rectus, and seems to show that  the former  muscle has a
higher action than those actions supplied by a mere motor nerve,
and that its functions are linked by a closer sympathy  to those of
vision.
  For these reasons he believes the oblique  muscles are intended
to turn the eye inward, under circumstances in which the action
of the recti under the influence of the third pair is inadmissible.
  We  are disposed under the head of Strabismus to go the more
extensively into a record of the various  opinions entertained con-
cerning the true physiology and pathology of the muscular motions
of the  eye, inasmuch as the  subject has not been much dilated
upon in M. Velpeau's late treatise, (see text, supra,) and still rests
in much obscurity.  What is found in this place may incite to fur-
ther and more accurate dissections and  experiments, so as to affix
definitively to each muscle  its appropriate and specific functions,
as well  as those M'hich  it  may have conjointly M'ith or in antag-
onism to the others; this result, so much to be desired, having, as
is perceived, a most important and direct bearing  upon what mus-
cle or muscles should or  should not be divided.
  Dr. Lietch thinks care  should  be  taken in  double  convergent
strabismus to divide the inner recti, not in their middle or muscular
part, but in their tendinous portion, and near to its insertion in  the
sclerotic coat, and then the retraction Mill not be so great.  In  the
other case divergent strabismus will be produced,  (see Dr. Lietch's
very valuable paper in the periodical above referred to.)
  As early as Nov. 2, 1841, such had  been the  extent to which
strabismotomy had been  generalized in England from the conti-
nent, that among others  We find Mr.  F. B. Dixon, of Norwich,
(Eng.,)  under that date  had already operated  on  one hundred
cases.   Out of forty-one  cases of convergent strabismus operated
upon, thirty-one had both the pupils  central.  In five the pupil of
the eye treated was perfectly  central, but with slight obliquity of
the other eye.  In three the disease  returned.  In two  the inward
squint became a  leer, that is, diverged.  Mr. Dixon preferred di-
viding the muscle on a curved director with a very sharp bistoury,
as he thinks the divided end of the tendon is then  less contused,  and
can thus, he thinks, make  a  better insertion upon its new loca-
tion on  the sclerotica.   This remark deserves consideration even
at this time.   He also thinks the obliques,  or one of  them, may
have some agency  in  preventing the  centralization  of the eye,
(Lond. Med. Gazette, 1841-2, p. 309, 310.) 
AMERICAN APPENDE5.
735
  The greater part of the cases of strabismus, it is familiarly
known, are convergent.  Out of near five hundred cases of strabis-
mus, examined by E. W. Duffin, M. D., (see his Practical Remarks
on Strabismus, Lond., 1840,) he met with only twenty-three exam-
ples of divergent squint.   Mr. Guthrie met with one case in thirty.
Mr. Ch. Phillips ten in one hundred, (vide his work, Du Strabisme,
Paris, 8vo.)  M. Melchior found six in sixty-one, (De  Strabismo
Dissertatio pro Licentia, fyc. by N. G. Melchior,  Thaunia?, 1839.)
In Mr. Liston's one hundred and twenty-five cases, there were only
two.  In some hundreds Mr. Lucas found one only, (Practical Trea-
tise on the Cure of Strabismus, by P. Bennett Lucas, Lond., 1840.)
  The left eye, it appears, is rather more prone to squint  than the
other.
  In many cases the sound, habitually well-directed eye (where the
other alone is affected with convergent strabismus) squints, while
it is covered, and while the previously squinting eye is properly
directed.  This, according to Melchior, was first pointed out by
Fischer, (Theorie des Schielens veranlasst durch  Buff on's Schrift, In-
goldstadt, 1781, p. 70,) and again by Purkinje, (Beobachtungen zur
Physiologie der Sinne, Berlin, 1825-32, B. pp. 166.)
  In double convergent strabismus one eye will always, Mr. Lucas
says, be a little more turned in than the other.
  Dr. Alison, (on single and correct vision, &c, Trans. Roy. Soc.
of Edinb., vol. xiii., Edinburgh, 1836,) in numerous experiments in
relation to double vision, has found, if the vision of both  eyes was
tolerably good, that when the attention was fairly fixed on the sen-
sations of both eyes, single  objects held directly before the face
were seen double.
   A reviewer of the above works in the British and Foreign Medi-
cal Review,  (1841, p. 477,) considers that the sound eye sees best
because the light falls then  on the  most sensitive part of the re-
tina, and  that  therefore the vision in the  squint eye is better in
proportion as the cast is less.
   Whatever difference of opinion may  exist, whether  defective
vision may occasion strabismus, or  is always the result of it, it is
certain, as we  have ourselves  repeatedly observed, that in two
sound eyes, one will become squint in proportion as it loses from
some organic  defect  (slight opacity of the cornea, conjunctival
inflammation, &c.) its healthy vision, and the  sound eye becomes
habituated to the performance of its functions.   The  remark of
Melchior  on blind eyes not squinting is no argument against the
fact we have stated, and  M'hich  fact, on reflection, must be  famil-
iar to most practitioners.   Nevertheless, it is no doubt true that in
idiopathic strabismus,  if we may use the term, the defect of vision
is imputable to that disease, as Mr. Duffin justly  remarks.
   In regard to the cause of strabismus, Rossi (Memone delle Scienze
de  Torino) found in post-mortem  examinations  of strabismics, that
the axis  of the orbit  was in an abnormal position, obliquely in-
clining upward or  downward, outward or inward, and in one case
only did  he  find an abnormal insertion  of the  muscles, (Brit. $ 
736
NEW ELEMENTS OF OPERATIVE SURGERY.
For. Med. Rev., ib. p. 479.)  But Mr. Middlemore says (Treatise on
the Diseases of the Eye, vol. ii., p. 561) that in a child with diver-
gent strabismus, he found, after death, the external rectus certainly
" much larger  than  it ought to  have been, much larger relatively to
the  size of the other muscles of the same eye, and comparatively
with those of the opposite organ."
  Dr. Cavafra (see  Journal Hebdomadaire, tome  i.,  p. 309, Paris,
1836) says, he has found in his  dissections nothing  unnatural in the
muscles of a squinting eye, or in their attachments.
  M. Bouvier, in a verbal communication to the Paris Acad, of
Medicine, said that in the dissection of a  divergent strabismic,
aged 82, affected from  infancy, he  found the external rectus  in a
state of complete  relaxation, but of the same length  as  the other
straight muscles, and unaltered in texture, M'hich fact confirms the
now more rational pathology of strabismus, (and M'hich the return
of the squint  eye  to a sound direction, M'hen the  sound one is
closed, proves,) that it is not oM'ing, like club-foot, to permanent
contraction of the muscles, but to  the physiological  defect of har-
mony in the muscular contractions, M'hich, however,  the operation
may and does  repair.
  Mr. Guthrie contends that, as far as his observations in the ope-
ration go, the  muscle divided does not appear to  be in the least dis-
eased, whereas Mr. Lucas speaks of the hypertrophy, and highly
vascular state  and deeper color of the  internal rectus.
  Dr. Von Ammon, however, says  (Die  Behandlung  des Schielens
durch den Muskelschnitt, fyc, Leipzig, 1840, pp. 15,16) he  has found
the inner part of the conjunctiva contracted  and dry, and of  a pe-
culiar  blanched appearance, owing,  he thinks, to its thickening.
He  has found also, after dividing the conjunctiva, several bands
of membrane  going from the  sclerotica to  the inner wall of the
orbit.  Where the inversion was very great,  he  has found the in-
sertion of the muscle farther  back  than usual, and the same  in
divergent strabismus.  In a majority of the cases, however, the inser-
tion was normal.   The muscle  itself sometimes  seemed thick and
gorged with blood, and  less easy of division  than  a sound  muscle,
and in such cases it was rather round than flat.  Sometimes it ap-
peared as if it Mas very tendinous, and then either very thin  and
shrunk, or tough and pretty thick, having lost its muscularity, and
the division of it giving a creaking sound.   Very often, however,
every thing normal, in its color,  consistence, and length.
  Mr.  C. R. Hall (see Lond. Med. Gaz., 1841) found, in some cases
of double  convergent strabismus, that the internal rectus of the
less inverted eye was much larger and stronger than that of the
more inverted eye.
  In luscitas, however, or permanently fixed  distortion of the  eye,
Mr.  Duffin found great organic changes, the  inverting membranes
of the muscles in two cases being almost  cartilaginous, and  so
contracted and unyielding that the patients w?re wholly unable
to move the pupil out of the  inner canthus previously to opera-
tion. 
AMERICAN APPENDIX.
737
  Wherever the patient has been able to turn the affected eye (in
convergent strabismus) external to the axis of the orbit, and especially
it he had the power of keeping it in this position for a short time,
both eyes being open,  Mr. Lucas has never found any alteration in
the structure of the muscle upon dividing it.  In some such cases,
however, it was more  developed than natural, but in others it ap-
peared of its natural size, and he has occasionally even found it pale
and very thin.   In  the opposite state of things he has invariably
found •' the muscle  altered in its structure, or most unnaturally de-
veloped."  In a case  operated upon  (for convergent strabismus)
Mr. L. found the internal rectus consisting of three times the natu-
ral quantity of muscular and tendinous substance.   The muscle was
not altered in its  structure.  It was observed by Mr. Liston as
early as 1841, or earlier, that M'hen in convergent strabismus a
slight  squint remained after the operation, he could remove it by
dividing  the inner fibres of the superior  and inferior recti.  It was
also at that time thought, that  the  superior oblique M'as occasion-
ally implicated in  this difficulty.   This division,  however, it was
even then thought,  favored  protrusion of the ball.
  In an autopsy of a case of strabismus, M'hich died of pulmonary
disease after the external rectus had been divided, just at the union
of the tendon and  muscle, by Mr.  Babington,  Mr. P. S.  Hewitt,
curator of St. George's Hospital, found (see Lond.  Med. Gaz., Jan.
22, 1841) the muscle itself had retracted three quarters of an  inch
from its natural attachment, but still remained connected with the
globe by a strong band of  cellular tissue, which  band was about
three lines wide and six in length, and inserted  about two lines
behind the original insertion of the muscle.  This is supposed to
have  been the natural cellular tissue connecting the muscle and
globe, and  stretched by the retraction of the muscle.
  Mr.  Lucas attributes the return of the squint  at some period
after the operation, to  new adhesions of the muscle to the tunica
sclerotica, anterior  to the transverse axis of the ball.   This could
be prevented by excising  a portion of the muscle, especially if it
is unusually developed.
  From what our author (Prof. Velpeau, vid. supra) judiciously says
of the  dangerous fallacies  into which we should be  seduced  by
taking for granted,  at the early period of the history of strabismus,
the reported proportions of  cures until time sufficient has elapsed
to test them, we deem  it of  so much the greater importance to re-
cord the  more candid  admissions of those whose statements, even
at that time, had not so much the appearance of exaggeration  as
those of others.  We therefore, in addition to what we have given
above, present a summary of these results in this place up to the
time of the respective publications.
  Dr. Ure,  in one hundred  cases since June, 1840, found  the ob-
liquity removed in seventy-five, diminished in sixteen, not affected
in nine, (see Brit. $ For. Med. Rev., 1841, p. 490.)
  Dr. Baumgarten,  of  Dresden, (vide Amman's Monatsschrift, vol.
iii., p. 485,) in fifty-two cases on one or the other eye, had thirty.
                              93 
738
NEW ELEMENTS OF OPERATIVE SURGERY.
three perfectly cured, seventeen considerably improved, and two
rendered worse, i. e., affected afterwards  with divergent strabis-
mus.  In twelve of the successful cases the  operation had to be once
repeated, and in one case three times repeated.
  Dr. Ammon, taking his own cases with those of Drs. Zeis, Baum-
garten, and Warnatz of Dresden, in all seventy-two, saw forty-five
quite successful, thirteen less so, and fourteen unsuccessful.  The
operation was performed twenty times on the internal rectus of the
right eye, forty-three on that of the left eye, six times on the exter-
nal straight  muscle  of the  right eye, and three on  that of  the
left.
  Franke,  of Leipsic, operated on  twenty-eight cases, of which
twenty-three were convergent strabismus, and five divergent.   In
three there was perfect restoration in both eyes, in about eleven,
partial success, (ib. Brit, fy For. Med.  Rev., 1841, pp. 490,491.)
  The power of the eye to adapt itself to  near and distinct vision,
Sir Everard Home also ascribes to some modification in the figure
of the crystalline lens, but  produced by bundles of muscular fibres,
of T2osoths of an inch in length, which go all round from the capsule
of the vitreous humor, pass forward over the edge of the lens, and
are attached  firmly to its  capsule, and  there terminate,  (see his
Croonian Lecture, Philos. Trans., part i., 1822, p. 77.)  Dr. Von
Ammon inclines also to the opinion of  the lens being the seat of
this function.   So also Mr. Tyrrell, of London, (late deceased.)
  M. Pravaz,  correspondent of the Paris Academy of Medicine,
in some " Remarks on the Action of the Muscles of the Eye, and the
Cure of Myopy, consecutive upon the Action of those Muscles," (Ar-
chives Generates de Med., 3e serie, tome xi., May, 1841, p. 86 et seq.,)
states that  he published in 1825, in the Archives Generates, (t. viii.,
p. 59,) a memoir on  some anomalies of vision, where the question
of the accommodation of the eye to the variations of distance of illu-
minated (eclaires) objects, was treated in an  incidental manner.  The
explanation, continues M.  Pravaz, which I have given of this phe-
nomenon, has received additional confirmation (une autorite nouvelle)
from the experiments lately made for the cure of myopy.  No one,
in fact, doubts to-day that  the changes of the ocular focus are pro-
duced by the action of the muscles;  but  each  one of the surgeons
who have arrived at similar results by different processes, having
endeavored to deduce a particular theory from it on the conditions
of  distinct vision,  I shall proceed to demonstrate the error of those
different interpretations, and  to show how that which I have pro-
posed can alone satisfactorily account for the circumstances appa-
rently contradictory which observation has noted.
   Thus M. Phillips, from finding myopy, which sometimes accom-
panies strabismus, relieved by the division of the obliquus superior,
naturally therefore supposed that this  muscle was the agent of the
elongation of the antero-posterior diameter of the eye—that elon-
gation being necessary for vision at  short distances.  M. Bonnet,
having cured  many cases of myopy by  cutting the obliquus infe-
rior, assigned the  same function to that.  Hence  comes the opinion 
AMERICAN APPENDIX.
739
which Demours formerly entertained, (see article Presbytie in the
Dictionnaire des Sciences Medicates) that the oblique muscles later-
ally compress the ocular globe, while the four straight muscles flatten
it from before backward, so that there are antagonist effects (oppo-
sition d'effets)  between the actions  of those two systems of con-
tractile organs.   M. Pravaz considers this theory of the action of
the oblique muscles  entirely illusory.  He believes  the  superior
(or great) oblique is especially designed (dispose) to carry the ocu-
lar globe forward at the same time  that it impresses upon it a
slight movement of  rotation; the  lower (or  small)  oblique also
causes a  feeble traction of the  eye from behind forward, but its
principal effect is to  cause  the ball (ce spheroide) to move around
(autour) its antero-posterior axis.   In these combinations M. Pravaz
sees nothing to  produce  lateral depression,  (i.  e. compression.)
That the oblique muscles do not alone elongate the ball, is proved.
by the fact (he says)  that myopy is relieved equally  well by the
section of the recti where the obliques are not touched.
   M. Guerin says myopy has been imputed to one or perhaps all
of these three causes:—1. An increased convexity (courbure) of the
cornea;  2. An active or passive depression of the crystalline, in
the direction of its transverse diameter, (suivant son limb  transver-
sal;) and, 3. A greater "distance  (un plus grand eloignement) be-
tween this disc [the crystalline lens]  and the retina.   M. Guerin
considers that the experiments of Young disprove the first cause,
as they also, in his opinion, overthrow the  experiments of Home
and Ramsden.   M. Guerin  also rejects the two other  causes, since
he is of opinion that in vision at short distances the eye is flattened
from behind forward by the action of the straight muscles.  M. Pra-
vaz, hoM'ever, thinks this is  at war  with  all the laws of optics.
M. Pravaz doubts the accuracy of Young's experiments, and seems*
to think he has overlooked the possibility that  the movements of the
crystalline lens, or its change of form, may assist in the variation
of the ocular focus.
   M. Pravaz contends that he was the first to  showthat the united
action (synergie) of the straight and oblique  muscles, combined with
the elasticity of the envelopes of the eye, perfectly explain all the phe-
nomena of the appropriation of the refracting surfaces  of this organ
to the variations  of distance; which,  he  says, reconciles  the  two
methods for the cure  of myopy.
   The simultaneous action of the recti muscles from their oblique
direction to the back of the orbit, exercises, he thinks, two forces,
viz., one lateral compression, and the other to draw the globe from
before backward.   The latter being the most powerful would pre-
ponderate, and would alone  produce its effect, if it was not event-
ually balanced by a contrarv force.   This antagonist force is that
of the oblique muscles, which thus  indirectly serve for the elonga-
tion  of the ocular globe, and consequently for the vision of near
objects—the only function we can assign to them a priori
  The  section then of the two  opposite muscles which  laterally
compress  the  eye, ought" to give to this organ the power of ap- 
740
NEW ELEMENTS OF OPERATIVE SURGERY.
proximating itself to a spherical form by the elasticity alone of its
fibrous envelope ;  for there is no doubt, he says, that this elasticity
is  put into action whenever one of the ocular diameters is elon-
gated.  It is,  in  fact, an  elementary geometric principle of tM'o
isoperimetar  (isoperimetres)  curved  (courbes) surfaces, that  that
M'hich approaches nearest to a sphere includes  the greatest quan-
tity of solid contents ; but the humors of the eye being incompres-
sible, it is absolutely necessary that the sclerotica should dilate
itself to contain them, when its form becomes more or less ellipti-
cal, (ellipsoide)   The elasticity  which  it possesses to aid in this
expansion may be altered in time, like that of  all similar tissues;
and  hence the section of the straight or oblique muscles does not
instantly cure myopy, and hence also, where the elasticity of the
sclerotica is  much diminished, it would not come to the  relief of
the isolated recti, or oblique muscles.
   M. Pravaz  does not think it  by any means demonstrated that
the contraction of the recti sensibly depresses the globe of the eye from
before backward,  to accommodate it  to the vision of distant objects.
If, in fact, this compression was too energetic, it would injure the
optic nerve against  the  bottom of the  orbit and impair its func-
tions.  Another proof that the  recti have not that compressing
power is, he, says, the winking (clignotement) to  which  we are
obliged to have recourse, when we wish to perceive distant objects
more distinctly.   The orbicular muscle  of the eyelids then acts as
antagonist of the oblique muscles, and the ocular  globe, placed be-
tween two contrary powers which second the elasticity of its fibrous
envelope, returns  then to  the  spheroidal form, or,  perhaps, is even
slightly depressed in the direction of its antero-posterior diameter.
The double eyelid, or membrane clignotante, in birds that fly high.
like  the eagle, which  sees  small objects at an immense  distance,
favors this opinion.
   From all which, M. Pravaz concludes that he has, besides other
principles above  enumerated, incontestably established  that the
oblique muscles,  acting separately,  are incapable of modifying the
form of the eye to the sight of near objects; but, in combination
with the recti, they concur in the elongation of the ocular spheroid.
and their action is indispensable in order to effect this change.
   He however admits that the operation of M. Guerin for myopy
would seem more conformable  to  the results of anatomical sym-
metry, if there were an antagonism between the recti and oblique
muscles ;  but the section of both orders is essential to destroy the
constriction exerted laterally on the globe of the eye by the simulta-
neous action of the recti and oblique muscles.
   M. Pravaz-thinks the obliquus superior acts as a sort  of check
(amarre) destined rather  for  retaining  the globe  of the  eye in a
position nearly stationary, than  as  an organ for  extended move-
ment.  The comparative  shortness of its  muscular fibres, its re-
flection at  an acute angle  on  a  pulley, where it cannot glide
without friction, tend to confirm this opinion.
   He therefore gives the decided  preference to M. Bonnet's sec- 
AMERICAN APPENDIX.                    741
 tion of the  obliquus inferior rather than both for the cure  of
 myopy.
   [The remarks of M. Pravaz, though in many respects ingenious,
 are not altogether satisfactory, as they present contradictions that
 seem irreconcilable.  The action of the orbicular muscle, however,
 appears to have been  judiciously brought into this question and
 well explained.   All these  inquiries  wall stimulate the student to
 further investigations in  a  subject so essential to the  advance of
 surgery in ocular myotomy, as is the true explanation of the action
 of the muscles of the globe  and its appendages.—T]
   In  illustration of the  rotation of the eye upon its axis, Professor
 Hueck of Dorpat, to whom  we  have already alluded, (supra) fur-
 nishes, in a paper on this subject, (Die  Achsendrehung des Auges,
 Dorpat, 1838; vid.  also analysis of the same by M. Szokalski, D.
 M. P., in the Archiv.  Gen. de  Med., 3e ser.  Paris, Aout, 1841,
 p. 439 et seq.,) a minute description of the anatomy of the oblique
 muscles.
   The superior oblique,  evidently perfected with great care, begins
 with short and tendinous fibres  at the  optic foramen, within  the
 levator palpebrag, and on  the upper part of the internal wall of the
 orbit; it advances towards  its inner angle, enlarges in the  middle
 of its length, takes  then  a  spindle shape, gives birth  to a round
 tendon, and  forms  a cord which passes through the ring attached
 to the frontal bone  in the inner angle  of the orbit.   This ring is
 constituted of a cartilaginous layer in form of a groove, whose two
 extremities are attached  to the bone by means of ligaments.  It is
. slightly moveable from before  backward, and its  diameter corre-
 sponds exactly to the thickness of the  tendon, without, however,
 interfering with the freedom of its play ; on the contrary, it facili-
 tates it, owing to the particular form  of the cartilage, which  re-
 sembles a portion  of a pully.   After  having passed through the
 ring, the tendon is reverted outward and backward, so that it forms
 with its primitive  direction  an angle  of  fifty-four degrees,  and
 runs horizontally towards the globe of the eye.  In proportion as
 it approaches it, it becomes wider and thinner, passes under the
 tendon of the superior rectus, on the most elevated point of the globe,
 then passes  farther outward and backward, and  attaches itself
 to the sclerotica  about three  millimetres behind its transverse di-
 ameter.   The external fibres descend a  little lower than the inter-
 nal ;  the insertion, therefore, is  in  an oblique direction, and of the
 width of six  millimetres.  The middle of this insertion  corresponds
 to the outer  border  of the superior rectus, and is situated at about
 seven millimetres behind the sclerotic insertion of this muscle.
   In setting out from the  point where the fibres of this oblique
 muscle are changed into tendinous fibres, (which is nearly at about
 seven millimetres behind the ring,) a mucous bursa embraces the
 tendon and  accompanies it through the ring m the course of its
 passage, to  about  six millimetres in its direction towards  the
 eye, and ceases at  ten millimetres from its insertion.  Owing to
 this bursa, the play of the tendon in the ring is very easy, and may 
742           NEW ELEMENTS OF OPERATIVE SURGERY.

be made upon a  space of about twelve millimetres.  The length
of the tendon from the ring to the point of its insertion upon the
sclerotica is  twenty-three millimetres,  five of M'hich cover the
globe.
  From the anterior edge of this cord is detached a, fine aponeurosis,
M'hich  extends to the insertion of the rectus superior.   Another
similar aponeurosis arises on its posterior border, and is inserted
upon the ocular globe behind and within, near the optic nerve, and
is five millimetres in  breadth.   The anterior aponeurosis is tense
(tendue) when the eye is directed outward and downward, and the
posterior aponeurosis when it is directed inward and upward.
  The inferior oblique muscle is the only one of the muscles of the
eye which arises in the anterior part of the orbit.  It is the shortest
of all.  Its insertion is made upon the floor of the orbit, by a very
short tendon between the intra-orbitar canal and  the lachrymal
bone.  This point is situated at nearly twenty millimetres lower
than the  ring of the superior oblique, and  nearly eight millimetres
behind the vertical plane which  passes by the rings on the two
sides.  The inferior oblique passes almost in a  parallel direction
backward and outward with the reverted tendon  of the  superior
oblique, then passes under the inferior rectus muscle, crosses it ex-
actly at the point of the greatest lower convexity of the globe of the
eye, runs then in contact with the globe of the eye, is then trans-
formed into a tendon of eight to ten millimetres in breadth, M'hich
glides under the external rectus, and is inserted obliquely upon the
sclerotic coat, and in such manner  that its anterior fibres terminate
towards  the middle of the posterior fibres above the upper border
of the tendon of the external rectus.  This insertion is situated tM'o
millimetres farther behind than that of the superior oblique, at
nearly five millimetres  from  the greatest transverse diameter  of
the eye,  and at  eleven millimetres  from its place  of crossing the
inferior rectus muscle.  There  also is perceived a delicate aponeu-
rosis, which  adds nearly four  millimetres to the breadth of the
tendon on each  side.   The entire length of the muscle  is thirty-
three millimetres, twenty-two of which lie between the point of its
origin and that of its place of crossing.
  Albinus, Soemmering, and  others, thought that the superior ob-
lique moved  the globe/of the eye at its upper part inward, and at
its lower part outward, and that it  directed the  pupil downward
into the outer angle of the eye ; and that the inferior oblique exe-
cutes the opposite movement, directing the pupil upward towards
the outer part of the eyebrow, while turning the eye from without
inward  and  downward, (de dehors en dedans par en bus)  When
the two  obliques act together, they thought they carried the globe
forward and inward toward the nose.  Rosenmuller, Weber, Cloquet,
&c, consider that the  oblique [the superior] has the faculty of
moving the eye so that the pupil is directed downward and inward,
while the inferior oblique directs it upward and inward.  Muller,
Haller, and Chroeder Van der Kolk think that when these muscles
act together  they draw the eye into the orbit.   Lawth denies both 
AMERICAN APPENDIX.
743
this and the movement of rotation, but believes with Briggs, Tay-
lor, and Lemoine, that M'hen the oblique muscles of the'eye act
simultaneously they compress this  organ, elongating its anteroposte-
rior dimension, and consequently augmenting the shortness of vision,
(la portee  de la vue)  This last opinion has been triumphantly re-
futed, it is thought, by Winslow,  and more lately by M. Hueck.
  The oblique muscles do not appear to be capable of directing
the axis_ of the eye  either to this  or that side, the recti muscles
being quite adequate  for this function.   There appears to be nothing
in common between the  direction of the axis of vision and the action of
the oblique muscles, for  these last place the pupil differently according
to different  circumstances.   If, for example, the superior  oblique
contracts at the moment when the axis of the eye is directed up-
ward, the  pupil M'ill be carried downward and  inward; if the axis
is directed exactly inward, the pupil will  be carried still nearer to
the nose ;  if the eye is directed outM'ard, the pupil will be carried
still farther outward and inward towards the outer  part of the
superciliary ridge.  The same may be said  of the inferior oblique.
  This direction depends only on  the activity of the recti muscles;
whichever way one of them acts, the others fix the globe in that
direction  by  their simultaneous  action; the  straight  muscles,
when acting simultaneously, drawing  the eye  slightly toward the
optic foramen.  The  action of the oblique can in nowise supply,
exclude, or second that of the straight muscles.   The simultaneous
action of the last M'ould be represented by a line which would pass
through the centre  of the eye and that of the optic foramen, while
the line of the former (or oblique) M'ould pass  through the centre
of the eye  and a point  intermediate  between  the ring  of the
superior oblique and the place of insertion of the inferior oblique,
these two different directions making an angle of a hundred and
three degrees.   When, therefore, the straight  and oblique muscles
act simultaneously, the eye is carried, in conformity to the laws of
the parallelogram of forces, towards the inner wall of the orbit.
  The recti muscles, then, fixing the eye in  a  certain direction,
either of the oblique contracting at the same time would, according
to M. Hueck,  execute a  movement of rotation around the antero-
posterior axis of this organ.   M.  Szokalski,  who  furnishes the
analysis of M. Hueck's paper to the Archives  Generates, and who
himself had about the same period read a paper before the Societe
Medicate of Gand, embracing nearly the same views, says, however,
that he differs from M. Hueck in this last opinion, as he thinks he
(Mons. S.) has proved in his dissertation that in the human eye the
axis of rotation differs essentially from the axis of vision.
  The action  of rotation, M. Szokalski says, may be shown on the
dead body by drawing upon  the  straight muscles and  one of the
oblique.   The particular design  of the muscular apparatus for ro-
tation is  not  only  to give greater mobility to the  eye, but more
especially to  fix the  immobility of the image which  the objects
form on the  retina,  thus  preventing  what would  render vision
nugatory, the necessity of the eye folloM-ing all the movements of 
744           NEW ELEMENTS OF OPERATIVE  SURGERY.

the head.   This arrangement, then, affords a motive poM'er antag-
onist to the movement of the body, like that in quadrants, (cadrans,)
which fix them in spite of the motion of the sea.   The infta-ior and
superior rectus  correct the movements  of the head from below
upward, and from  above dowmvard; the lateral recti rectify the
movements  to the right and left;  but this antagonism would be
imperfect without other means to fix the eye in the vacillating move-
ments of the head.  For this purpose  nature supplies the oblique
muscles, and which can turn the eye in a  direction opposite to that
of the head.  Another important function they have is that of de-
termining  (appreciation)  the position  of the object we look at
relatively to the position of our own body.
  We  acquire  in  the  course of time, and experience  from our
earliest  infancy, an exact appreciation  or consciousness of the
habitual tension of  the different muscles  in different positions;
thus, of those employed in keeping the body erect, which we are
fully  aware of though  the  eyes be shut.   This  thus produces a
consentaneous or corresponding and harmonious action in those
of the eye.   The same with the horizontal position.   By the sense
of the vertical position particularly, we acquire a comparative
knowledge of the dimensions of bodies.  The opposed action of the
superior and inferior recti muscles, being upward  or downward,
makes us thus conscious to a degree of the corresponding vertical
dimensions of bodies, the lateral recti being then in a state of re-
pose.  The  lateral dimensions, on the contrary, correspond with
the action  of the  lateral recti, the upper and lower  recti being
then at rest.  But it is by the perfect  harmony (liaison) between
the vertical dimension of the retina and the  axis of the body, that
we  alone ascertain the dimensions of objects.  This harmony is
preserved by means of the repose of the oblique muscles.  Each
dimension from above  doM'nward is rigorously vertical, and each
dimension from one side to the other is horizontal.
  From various experiments in looking at objects in vertical and
horizontal lines, to test the truth of the foregoing conclusions, M.
Hueck calculated that when  a vertical rectus muscle shortens or
contracts 0.03 millimetres, or y^V o °f its  length, the mind may be
conscious of this difference.   The same experiments were made
with the horizontal line.  The lateral recti are more sensitive than
the superior and inferior (i. e. the  vertical) recti to every move-
ment of retraction, to the degree even of 0.005 millimetres, or ?7V»
of the length of the muscle.

Muscular Cicatrix after the  operation  of Strabismotomy, according
                   to M.  Bouvier's dissection.

  As every thing that can throw light on the organic changes in
strabismus and its  cure is highly important, we give the following
of M. Bouvier from the Bulletin de VAcademie de Paris:
  " M. Bouvier's patient died of consumption  about three months
after  the  cure of a divergent strabismus  in the right eye.   The 
AMERICAN APPENDIX.
745
rectus externus, which had been perfectly divided a few lines from
its insertion in the sclerotica, now adhered anew to this membrane
by a fine cellulo-fibrous production, fixed at about a centimetre be-
hind its  normal place of attachment, and quite analogous to the
bands of new formation which reunite the muscles to the eye, ac-
cording to the experiments of Amussat and L. Boyer upon horses.
The attachment of this aponeurosis to the eye describes a curve
with an anterior concavity.  The middle part has become adherent
to the sheath of the inferior oblique near the ocular termination of
this muscle.  Its superior extremity is less prolonged forward than
the inferior, from which last arises a filament apparently tendinous,
which extends nearly as  far as the old attachment of the muscle.
This seemed to be owing, not  to the inferior edge having escaped
the section, but to the preservation of the ocular fascia to a greater
extent below than above, for  a divided  line of separation divides
the fleshy body in its entire height from the new aponeurosis, and
the muscular fibres are all equally retracted, which could not have
taken place if some had remained intact.   The anterior end of the
muscle has become atrophied;  no distinct trace of it remains,
although it was very apparent after the operation.   The division
of the conjunctiva had left no visible cicatrix."   (London  Lancet,
1841-2, p. 476.)

Statistical Table of Results of the Operation for Convergent Strabis-
   mus  in one hundred cases, after the interval of a year.  By Mr.
   C. Radclyffe Hall, of Manchester, Eng.

   In a hundred cases of convergent strabismus, after the lapse of
from ten to fourteen months from the period of the operation, (see
Lond. Med. Gazette, also Lond. Lancet, 1841-42, pp. 575 to 582,
pp. 624 to 629, pp. 735 to 743,) he found the following results :

  In 3 divergent squint.
    28 inversion not completely removed.
     7 the eye operated upon is straight, but the other slightly
         inverted.
    62 both eyes are perfectly straight.
    61 an appearance of fulness of the eye.
    39 no such appearance.
    23 both eyes were operated upon.  In two instances only
         of these  does one eye appear  more prominent than
         the other.
    62 power of vision materially improved.
    38 the vision, which had been much impaired, is but little
         improved.
    79 double vision followed the operation.
    65 this disappeared within a month.
     U           «           three months.
     2            "            six
                 «            fourteen "   nearly.
                                 94 
746           NEW ELEMENTS OF OPERATIVE SURGERY.

  In every instance, the power of inversion (i. e. convergence) is
greatest when the other eye is closed.   In no case is the adducting
power quite to the natural extent, though in a majority it is.
  Among the causes of strabismus, Mr. Hall, besides those from
intestinal  irritation,  and others familiarly known or  already ad-
verted to in this M'ork, enumerates those diseases in M'hich the
extremities of the fifth nerve are rendered morbidly sensitive to the
influence of light, as in strumous  ophthalmia, irritable ulcer on the
cornea, &c.; also he mentions imperfect cataract.
  In strumous ophthalmia, he  says, the retina, as well  as the con-
junctiva, is morbidly sensitive  to light, and  hence  the  upward
and inward  direction of the eye is from the irritation both  of
the fifth nerve, (common sensation,) and of the retina, or special
sensation.  And in hydrocephalus, not only is there muscular palsy,
but blindness, complete or otherwise, at the stage when strabismus
occurs.
  Mr.  Hall, in the course  of this paper, enters very  elaborately
into a philosophical explanation of double  vision, associate move-
ments  of the eye-balls, identical parts of the retina, direction of ob-
jects, &c, from all of which it appears that he differs entirely from
Miiller, and deems vision to consist, in its normal state, in an habi-
tual consentaneous  movement of the balls, and the  effort of the
mind in combining into a whole distinct parts of an image respec-
tively seen by either eye, &c, that the mind [as is  seen  above in
the memoir of M. Hueck] judges  of the situation of an object by
the muscular action necessary to see it most distinctly, &c.
  Mr.  D.  Henry  Walne (see Lond. Med. Gaz., Sept. 18, 1840, and
Lond. Lancet, 1841-42, p. 783, &c.)  states that he has never found
it necessary, in convergent strabismus, to divide other than the  in-
ternal  rectus,  and that  in  one case inward and upward, compli-
cated  with  congenital pterygium, this  latter  production  M'as
divided, and then the  muscle reached  and divided through this
incision into the conjunctiva.
  Mr.  Walne, after  twelve  months full  experience, has never had
a single failure, [!]
  Dr. Hocken, in an article  on the separate and combined actions of
the  orbicularis palpebrarum, (vid. Dublin Journal of Medical Science,
vol. xxi.   1842.   pp.  57  et seq.,) says  the closure of the lid is a
voluntary act, preceded by relaxation of the levator palpebrae, and
attended by  a corresponding contraction of the inferior oblique
muscle of the orbit; hence, as we close the lid, so  in proportion is
the eyeball rotated upward and inward, and finally upward and out-
ward.   In staphyloma, he says, this motion and position can be de-
tected under the lids by the fingers.   That obliquely rotated posi-
tion, too, he says exists in sleep, as  can be seen when the lids are
suddenly  opened on waking.  The  advantage of this position, he
thinks, is to secure during  sleep the complete  exclusion of light,
and thus greatly  to aid that imperfectly translucent curtain, the lid.
This position he  seems to think is  assumed by the ball through the
action of the inferior oblique, every time we close the  lid, however 
AMERICAN APPENDIX.
747
rapidly, (as we often see.)   That action may be performed, as in
some persons, almost  every few  seconds, from  a bad habit.  If
so, it would  appear, by  Dr. Hocken's theory, that these reitera-
ted partial occlusions of the ball upward and  outward, in  other
words, winking, (a habit  very common in seafaring persons, cap-
tains of vessels, &c, from the necessarily intense straining and fixed
attention of the eye, M'hich, by day as*M'ell as  by night, they are
often compelled to resort to,) must thus,  by the abstraction of the
exhausting stimulus of incessant light, give the organ power to
execute its functions of vision with greater energy.
  When the  levator palpebrae is voluntarily  contracted, the  or-
bicularis  undergoes relaxation and the lid  is  raised,  while the
oblique (i. e. the  inferior) is also relaxed, and the eyeball assumes
its straight position.
  The involuntary closure of the orbicularis during sleep, he thinks,
is maintained by the impression on  the trifacial nerve, inducing a
reflex  action  through  the seventh pair.  A continuous sphincter-
like action is produced.
  A few fibres of the  orbicularis palpebrarum  muscle, spread on
the front  of the tarsal  cartilages, which, being  capable  of an  in-
dependent action, that is, a slight Mink on the approach of bodies,
make  this, especially  where the eyelashes are touched, an ex-
cellent and sure  diagnostic mark, he says, to  detect feigned blind-
ness.
  Dr. Hocken considers that the orbicularis is employed conjointly
with the two orbital  oblique,  and with  the  four recti muscles,
" among other changes effected, to adapt ihe organs of vision for
near and distant sight, and for the scrutiny of large and also very
minute objects.   When the  eyes  are adapted for near-sight, being
elongated by the conjoint action of the oblique, besides other changes,
the eyelids are partially closed, and this also is one of the  actions
employed when near-sighted persons endeavor to discern distant objects.
With the  recti conjointly  it  [i.  e.  the orbicularis] is  employed,
when  the globe  is retracted and fattened by their operation, and
otherwise fitted for use on  distant bodies; hence, when the sight
is strained to  discern something ill-defined, the brows are contracted,
and the lids partially closed.  These  actions are combined, more-
over, with another muscle, the corrugator supercilii, by which the
brows  are contracted, being drawn doMnward and inward toM'ards
the middle line."
  The orbicularis and  inferior oblique also perform a joint function
in diffusing moisture upon and wiping the globe of the eye;  also in
weeping, to bring the  edges of the tarsi together, to form that tri-
angular  canal, by which the  tears  are  conveyed to the puncta
lachrymalia, and thence  through the lachrymal sac to  the  nose;
and  in this operation  the orbicularis co-operates with the  tensor
tarsi, which stretches over and compresses the sac.
  Dr. Hocken says  any one may himself be convinced  and con-
scious of the combined action  of  the  orbicularis with the inferior
rectus, and that of the levator palpebrae with  the superior rectus. 
748
NEW ELEMENTS OF OPERATIVE SURGERY.
Thus, " if M'e depress our  eyes by the  contraction of the inferior
recti, or,  if we observe  this action in others, we can, in the first
place, feel, and in the second, see, that in proportion as the eyeball
is rotated downward, so is the lid proportionately lowered by the
contraction of the orbicularis palpebrarum, and that, in like man-
ner,  as the eyeball  is rotated upM'ard by the  contraction of the
rectus superior, so is the lid elevated by the levator palpebrae."
  The orbicularis differs, says Dr. Hocken, from Hunter's definition
of the ordinary character of sphincters, (i. e., muscles M'ith occasional
relaxation,) in this, that relaxation is " the ordinary,  and contrac-
tion  the occasional condition of this muscle ; besides, its closure is
not  involuntary, and when closed, little if any active poM'er of
contraction is exerted  to  maintain the eyelids  in apposition, al-
though the excito-motory function presides over this aperture, as
it does over the other orifices of the body."   He considers that the
two  halves of the orbicularis, as of other sphincters, are natural
antagonists, though acting together in antagonism to other muscles.
Thus the muscular fibres of the rectum antagonize  the sphincter
ani,  so the orbicularis palpebrarum and the levator palpebrae.
  Dr. Hocken considers that his opinions  are confirmed by  the
observations  of Hunter.   Hunter had said  that, although many
circular muscles may not have the mixed contraction  of sphincters,
as the orbicularis, (see Palmer's edition of Hunter's works, vol.
iii., p.  147,)  yet  that that muscle has a disposition to contract
peculiar to itself.  Its relaxation is active, and may be called the
relaxation of watchfulness; and when tired  it  contracts, which
may be  considered  the contraction  of sleep; or it  may be  con-
sidered as the  elongator  muscle  to the levator palpebrae, with a
disposition to remain relaxed while that muscle is contracted, but
contracting when the levator is  tired.   That the natural contrac-
tion  of the orbicularis  muscle is involuntary, and the relaxation,
both natural and occasional, is involuntary; but that it  has like-
wise a voluntary contraction and relaxation, which  can be made
to exceed the involuntary, resembling what is inherent in all the
sphincters.
  Mr. Gabriel  Stokes, previous to Dr.  Hocken, had  advanced the
opinion,  (Dublin Medical Journal, vol. xviii., Sept., 1840, p. 70,) that
the closure of the eyelids is  not a merely passive condition from
relaxation of the  levator palpebrae, as taught by Bichat, but that
muscular agency is employed in its accomplishment.   He illus-
trated this by a case of paralysis of the portio dura, occasioning
lagopthalmas, in  which, as is  not uncommon, the  upper eyelid
assumes the position which its natural gravity M'ould give it unaided
by muscular effort.  Sir Charles Bell had also remarked, in such
cases, that during sleep the eyeball is turned up, while the affected
eye  remains  open; in fact, the lower third of the eyeball is exposed
in these  cases by the dropping of the upper lid over the two upper
thirds, and the " white of the eye" alone shows, from the more or
less complete action of the inferior oblique.
  Dr. P. Evers, in an article on  the physiology of the muscles and 
AMERICAN APPENDIX.
749
nerves of the orbit, (Dublin Journal of Med. Science, vol. xix., May.
1841, pp. 165 et seq.,) gives as an evidence of the natural disposi-
tion to a consensual muscular movement, the voluntary power of con-
tracting the pupil, by rotating the eye inward, as in viewing a near
object, though  the  quantity  of light remains  the same.   In this
combined movement there is  a consensual action between the
same muscles on  both sides, as  well as between the  rotatory
muscles inward, and the iris on the same side.
   He is of opinion that, during health, the orbicularis and levator
exert but little  influence over the motions of the eye ; but in paraly-
sis of the portio dura, the eye is  protruded between the widely
parted lids, by the pressure of the  levator palpebrae from within;
and, in paralysis of the third nerve, the pressure of the closed lids
from without, by the action of the orbicularis palpebrarum, causes
the eye  to recede  within  the  orbit; the principal  office of these
muscles being to part and  close the lids.
   Dr. Evers also thus takes ground against the Hosackian theory,
(though not naming it, or  totally unacquainted with it, as may be
said of most modern writers:) " The four j ecti muscles arise nearly
from a common point  in the bottom of the orbit, and proceed for-
ward in a divergent manner to their respective insertions around
the anterior part of the sclerotic tunic.   When any one  of them
contracts, it directs the pupil towards its own side, and the simul-
taneous action of any two  is equal to the direction of the  pupil in
the diagonal between them,  while the combined actions  of the four
cause the whole globe to retreat within the orbit."
   In reference to the action of the oblique muscles, which has divided
some of the greatest names of anatomy and surgery, viz., Soemmer-
ing, Cloquet, and Harrison, in opposition to Midler, Monro, and Sir
Charles Bell, the three former assert that the superior oblique rolls
the eye in such a manner  as to direct the pupil downward and in-
ward, and that the inferior oblique moves it  in the opposite  direc-
tions.  The three opposing authorities maintain  that the  superior
oblique turns the pupil downward and outward, and that the infe-
rior oblique rotates it upward and inward.
   Dr. Evers believes the first opinions,  viz., those of Soemmering,
&c, erroneous.
   He (Dr. E.)  maintains that both obliques act toward a point in-
ternal and anterior to the globe of the eye; that they pursue a very
oblique course  from their point of action to their insertion—the one
above and the  other below the  ball of the eye ;  and lastly, that the
eye has two axes, an antero-posterior and a transverse.
   " The superior oblique (says this physician)  having  emerged from
the bottom of  the orbit, takes its second  departure from its  point
of action at the  internal canthus, to be inserted into the  back of
the sclerotic, external to the antero-posterior  and behind the trans-
verse axis of the eye.   It  is  obvious, that from its posterior inser-
tion, it must roll the eye  in such a manner as to direct the  pupil
downwards ;  and from the same  insertion being external to the
antero-posterior axis, it will cause the pupil to look outward.  Then 
750
NEW ELEMENTS OF OPERATIVE SURGERY.
the uncombined action of this muscle undoubtedly has  the effect
of turning the pupil downward and outward.
  " The inferior oblique takes its origin from the inferior and inter-
nal margin of the orbit, and runs upward, backM-ard, and outM'ard,
to be inserted into the inferior surface of the sclerotic, behind the
transverse and  external to the antero-posterior axis of the globe.
When it rolls the eye, in consequence of its posterior  attachment,
it  will direct the pupil upward, and by virtue of its  external at-
tachment, it must  cause the pupil to look imvard.  Its  individual
action, then, will direct the pupil upward and inward.   And in con-
sequence of both obliques arising from points anterior  and internal
to the globe of the eye, their combined influence will have the effect
of drawing the  whole organ forward and inward."
  Dr. Evers, in his experiments on the dead subject and on rabbits,
(to M'hich latter the great  objection  of difference of anatomical
structure attaches,)  found the superior oblique capable of rolling
the eye to a much greater extent than the inferior.
  He enforces the importance of a minute knowledge  of the distri-
bution of the nerves of the orbit.   The  third, or motor oculi nerve,
after entering the orbit, divides into two unequal branches, the su-
perior or smaller going to the levator palpebrae and superior rectus;
the inferior or larger division again subdividing into three second-
ary branches, to be distributed to the inferior and internal  recti
and the inferior oblique.  From the long slender branch going to
the last-named  muscle, the ciliary, lenticular, or ophthalmic  gan-
glion derives its short root;  whilst the long root of the ganglion is
supplied by the nasal nerve, with  a feM' exquisitely delicate fila-
ments from the  cavernous plexus of the sympathetic.
  Thus have we a large nerve (says he)  from an undisputed motory
source,  (the crus cerebri) ministering to five of the seven muscles of
the eye, and  through the short root of the lenticular ganglion pre-
siding  over  the movements of the iris also.  We thus learn why
the pupil contracts when rotating the eyes inward to  view a near
object, " since the inversion of both eyes arises from the action of
the muscles supplied  by the third  pair ;  and M'hen one eye is
everted, the other being closed, the pupil of the former dilates, the
intensity of light remaining the same ; because this action is deter-
mined by another nerve, the sixth.   If,  however,  (he continues.)
both eyes move together in a lateral direction, the pupils undergo
no change, because the contraction arising from  the  inversion of
one eye is balanced by the  dilatation produced by the eversion of
the other, just in the same manner as if  the eyes were exposed, the
one to  an intense, and the other to a subdued light;  the  pupil is
alike in both, and of  a  medium size between  those M'hich the tM'o
different impressions of light M'ould produce if separately applied.
These  considerations (he adds) enable us  to  understand why the
eye, which is insensible to light from paralytic amaurosis, Mali have
its  pupil  contracted  by the admission of light  to the  sound re-
tina."
  In direct contradiction, however,  to the opinion of  Dr. Hocken, 
AMERICAN APPEND .
751
(supra,) Dr. Evers says : " During sleep the pupils are contracted,
and are directed upward and inward;" this is the case also in ex-
treme exhaustion, ebriety, &c., imputed by Sir  C. Bell to the rolling
[i. e., rotating] influence of the oblique muscles ;  but this is denied
by Dr. Evers, because (says he) the inferior obliques and the recti,
which  direct the pupils upward and inward, are under the influ-
ence of the  same nerve, while the action of  the superior oblique
is to turn the pupil  downward and outM'ard.  The branches of the
third nerve, distributed to four of the six acting muscles, direct the
pupil in sleep  upward and  inward,  while its contraction is ex-
plained, he thinks, by the  short motor root of  the ophthalmic  gan-
glion.
  He thinks the contraction of the pupil,  from use of opium, is
owing to its action  on the  origin of the third  pair, and the dilata-
tion of the pupil from belladonna  from its action on the origins of
the fourth and sixth nerves.
  The fourth nerve,  which is also called trochlearis patheticus, and
by  Sir Charles  Bell the respiratory nerve of the orbit, arising by
two or three roots  from the valve of Vieussens  behind the testes,
enters the orbit through the sphenoidal fissure, and having received
a twig from the frontal branch of the ophthalmic, and a filament from
the sympathetic, it is  distributed to the upper surface of the  supe-
rior oblique muscle.
  Sir Charles Bell looks upon  this nerve as presiding over the in-
stinctive and insensible rolling motions of the eye.  He allies it to
the respiratory,'and  asserts  that during sneezing and other involun-
tary respiratory efforts, it  directs the front of the eye upward, un-
der cover of the upper lid.   Yet, contradictory as it may seem, he
agrees also with Dr. Evers, in supposing the superior oblique mus-
cle has the effect of directing the cornea downward and outward.
  The sixth or abducens nerve, arising outside of  the  corpus  pyra-
midale, and before  entering  the orbit below  the other nerves, re-
ceives two or three of the  nervi molles from  the superior cervical
ganglion of the  sympathetic.   In the orbit it is distributed in a di-
vergent manner to the external rectus.
  The consentaneous action  belonging to the muscles supplied by
the third nerve, is denied to those which are supplied by the fourth
and sixth nerves, each of those last muscles having a distinct nerve,
and for a wise purpose.  Thus, " when one eye is directed down-
ward and outward by the action of the superior oblique, the other
is not  turned in the same direction  as it would be if the fourth
nerve of both sides had been associated, but it is turned downward
and  inward.  This  (says Dr. Evers)  is  the normal state of both
eyes in viewing a lateral object below the level of both eyes.   If
the superior oblique, instead  of the fourth, had received a branch
from the third nerve,  the action of both obliques  of the same side
would  be the same.   This  (says he) is the  reason of the  superior
oblique receiving a distinct nerve.  It would  not answer to  have
the inferior oblique supplied by the fourth, and the superior oblique
supplied by the third pair ; as they should have  been, in order to 
752
NEW ELEMENTS OF OPERATIVE  SURGERY.
accord M'ith  the  actions assigned to these muscles by Harrison
Cloquet, Soemmering, &c.
  " A similar line of reasoning applies, and with equal force, to the
sixth nerve.  When the axes of both eyes converge, as in behold-
ing a proximal object, the external rectus of each side acts simul-
taneously to the extent of restoring parallelism, but there their con-
sensual action ends.  Both eyes can never be made to diverge syn-
chronously—it would be quite impossible. Had the external rectus
been supplied by  the third, instead of the sixth nerve, then  inde-
pendent action was at an end; and one  eye could not have  been
directed inward and the other outward at the same time.  In this
last movement, it is true, the two internal recti oppose each other,
but it  is only reasonable to suppose that a weak muscle,  supplied
by a small branch of a  nerve, should be overcome by a  stronger
opponent, under the command of an entire nerve."
  Without vouching for the exactitude of the opinions of the vari-
ous authors we have quoted on the anatomy, physiology,  and pa-
thology of the eye, we  see great plausibility and reason  in many
of them, and think that  they deserve to be spread before the prac-
titioner as well as the student, to incite, we hope, to farther inves-
tigations in a domain where, after all  that has been written, so
much remains to  be explored.   We cannot be too indefatigable in
our researches upon this branch of study, when it has so important
and direct a bearing, not only upon the  operation for strabismus,
but on those of blepharoplasty,  and in fact every thing that con-
cerns the improvement or preservation of a faculty so essential to
our happiness as  that of vision.
  M. Lucien A. H. Boyer (in his late valuable memoir to the Paris
Academy on the operation  for strabismus, 1842) particularly urges
the necessity of abandoning the vertical  incision  into the conjunc-
tiva and aponeurosis, as contributing so  essentially to the abnor-
mal protrusion of the ball,  depression at the caruncula lachrymalis.
&c, which are  often worse  deformities than  the primitive one.
He recommends  not to divide  the portion of  conjunctiva M'hich
extends from the  internal commissure of the eyelids to the cornea,
but, by cutting in such a way  as to leave  a band, to keep the carun-
cula lachrymalis in its place.  The directly transverse or horizontal
incision, from the cornea to the caruncle, and parallel to the fibres
of the muscle, he  proscribes—1. Because it is difficult; 2d.  Because
it is followed by an annoying hemorrhage ; 3d. Because by this
incision we cannot divide  upward or downward on  the sub-con-
junctival aponeurosis, should  the simple division of  the  internal
rectus  not be sufficient; 4. Because it  divides the semi-lunar fold
of the conjunctiva, the  cicatrix of which leaves a repulsive  band
and impedes abduction of the ball.
  M. Boyer prefers cutting a little above the muscle.  Sei''    here
a vertical fold of conjunctiva, he divides it horizontally  v    he
blunt scissors from the cornea toward the internal wall of the   bit,
taking care not to  let the internal terminus of the incision approach too
near to the caruncula. Seizing then with a pair of forceps the eel- 
AMERICAN APPENDIX.
753
lulo-fibrous membrane, and snipping out a bit with the scissors, the
sclerotic is thus disclosed, and is very apparent from its dirty white
color contrasting with the surrounding tints.   Dividing the tendon
raised on the double blunt hook then completes the operation.  He
considers the two incisions a great advantage  for seeking, through
either, the cellular bands without the necessity of denuding the eye
of the conjunctiva.   The  cicatrices, also, by this mode are hidden
under the  eyelids, and the flabby granulations and consecutive di-
vergence rendered less rare.   M. Boyer considers that his method
has some of the advantages  of M. Guerin's, but  that it is rather a
modification of Strohmeyer's and Dieffenbach's.

The Organic Changes of Structure consequent upon ihe  Operation
                        for Strabismus.

  In further elucidation of the interesting observations upon  this
subject  in the text of our author, we think it  right to  add here the
post-mortem examination which M. Lucien Boyer made at the Royal
Academy of Paris, December 20, 1842, of a little  girl aged 12, upon
whose right eye he  had operated twenty-three  months before for
convergent strabismus.  The operation was completely successful,
and restored her sight, though it had been so impaired as to make
her almost blind.  She died of tubercular diathesis.  The internal
rectus of the right eye, it was found, had  contracted a new tendi-
nous and solid attachment to the sclerotic. This was situated at
the distance of nine millimetres from the cornea, while the tendon
of the  internal rectus of  the left eye  was only seven millimetres
from it.  Moreover,  in this  latter  the muscular fibres  were lost
gradually in the substance of the tendon, and could still be distin-
guished at three millimetres from its  insertion  into the sclerotic,
while again,  in the former or right eye,  they disappeared abruptly
at eleven millimetres from its point of adhesion.  It is evident, then,
that a new tendinous structure had formed after the operation, and
that it had become  organized and attached to the  sclerotic behind
the old  or former attachment, of which  last no traces were  any
longer visible.  This patient had been quite  able, after the opera-
tion, to  turn  the eye toward the inner angle of the  orbit.  (See,
also, experiments of M. Lucien Boyer on  the same subject in lower
animals, before the Paris  Academy, January, 1841.)

Results  in the first Two Hundred Cases operated  upon by M. Boinet.

   This  instructive table,  alluded to in  M. Velpeau's treatise on
strabismus, (see text, supra,) gives the following classification :—

                             Causes.

  These are important to know, in  order to establish the most cor-
rect principles for the treatment. 
754
NEW ELEMENTS OF OPERATIVE SURGEKY.
  In the 200 cases there Mere—
  102 Cerebral affections and convulsions during infancy.
   49 Alleged false lights, (faux jours) from the improper position
      of the cradle, through neglect of the nurse.   Among these,
      are included  brilliant objects above the head of the infant.
      M. Boinet, however, is not disposed to receive these alleged
      sources, but supposes it more probable that all these cases,
      without the knowledge of their parents or nurses, have had
      convulsions, under which head, therefore, he ranges them.
   16 From birth.
   11 Imitation and vicious habits, (that is, in the"direction of the
      eyes.)  These tM'o last orders of cases he also imputes to and
      ranks  under  convulsions.  He  doubts very much the al-
      leged cause,  from children mocking and  imitating those who
      squint.
   13 Inflammation, the result of ophthalmias.
    1 Apoplexy.
    5 Unknown.  These he also attributes to convulsions, as their
      probable source.
    3 From wounds.

  Of the total  amount, therefore, he  assigns 183 cases to convul-
sions, or cerebral affections, which  he thinks are the sources of
strabismus in nine cases out of ten.
  The result then is—
  183 Strabismus from convulsions.
    1 Apoplexy.
   13 Inflammation of the eyes.
    3 Wounds, contusions, &c.

                            Age.

  The  most aged M'as a woman of 68  years; and the youngest
were between 7 and 8.
Between  7 and  15  years,  52 cases, ] nr. men'
                    J     '           ( 29 women.

Between 15 and  25  years, 107 cases, j J}? men'
                    J     '           ( 68 women.

Between 25 and  40  years,  19 cases, i _7 men'
                    J     '           ( 12 worn

Between 40 and  68  years,  12 cases, ]  {:
  women.
3 men,
  women.
Sex.
  Strabismus is more common in females than in males. We have
in the above 119 females and 81 males.  This difference,  he  sup-
poses, may in part arise from infants of the female sex being of a
more feeble and delicate constitution, and, therefore, more liable to
cerebral affections and convulsions. 
AMERICAN APPENDIX.
755
                             Seat.

  In the 200 cases,  121  had the right eye affected,
                    94  had the left eye.
  In this enumeration are counted 15 who had both eyes affected,
and  both operated  upon, making  215  operations in the  200
cases.
  In these 15 cases, where both eyes were operated upon, the stra-
bismus in each eye was nearly the same.  But there were 157
cases in which it existed in both eyes, but in different degrees. Of
these last, 142 were operated  upon in one eye only.  There were
42 only that squinted in  one eye only.

                          Direction.

  Of the 200 cases—
  190 were of convergent  strabismus—of which  21 deviated in-
      ward  and upward,  174  inward,  5 inward and  down-
      ward.
   21 divergent—4 outward and upward, 16 outward,  1 outward
      and downward.
     4 strabismus upward.

  In the above are counted separately the 15 cases of double stra-
bismus.

                           Vision.

  Of the 200—
  187 saw well with one eye  only, the strabismic eye  being the
      most feeble.
   13 only appeared to  see equally well with both eyes.
  In 158 cases the pupils were  found  unequal;  in 42 they were of
the same size.

                    Results of the Operation.

  In the 200 patients, there were performed 232 operations:—
  183 on one eye only    ....  183  operations.
   15 on two......30
   13 for a return of the disease    -   -  13
    2 three times on the same  eye  -   -   6
  Out of this whole  number of  operations, a complete restoration of
the eye was effected in 203—incomplete in 29 ; in some of which
last, the continuance of the disease was owing to the unwillingness
of the patient to  submit  to a free liberation of the  restraining bri-
dles : and-of these 29 unsuccessful cases, it is to be remarked, that
14 had divergent strabismus. 
756
NEW  ELEMENTS  OF OPERATIVE SURGERY.
  But it is to be noted, that of the 200 patients, 21 did not return
—of which  21,  two had  both eyes operated upon,  and 19 one
only.
  The  179 patients who were regularly attended upon throughout,
furnished 209 operations.  Of these—

  164  were operated upon on one eye     -     - 164 operations.
   13          "             both eyes        -  26
    2          "             three times          6      "
   13          "             a return of disease  13      "
                  Total.....209  operations.

  Of these 209 operations,  134 resulted successfully, and 65 unsuc-
cessfully.
  Of the 134 successful results, 125 were completely cured—of which
125, there were 104 operated upon on one eye, 9 on two, 10 a sec-
ond time for a return, and the two above three times.
  Of the total 179 cases above, 54 were failures, but many of them
were much benefited.
  Of the 54 unsuccessful cases above, there were—

  42 in which the disease returned after several days or weeks.
  11 divergent cases, but much improved, excepting two.
   9 convergent, which became divergent.
   7 convergent, imperfectly relieved.

  In the total result we have—

  In 179 patients operated upon, ]  _ .      ' ,

  In 209 operations,             j ^ s™cessful
          r                     (  75 unsuccessful.

  But in the 75 unsuccessful operations, there was a marked bene-
fit obtained in 41  of those operations.
  In many patients there was diplopy after the operation ;  but this
double vision disappeared in the course of time.
  M. Boinet gives, also, a table of 27 cases operated upon at  An-
gers by Dr. Chedanne, of that town, and himself.  Of these, there
were 21 patients on whom 27 operations were performed, with
complete success.—(See M. Boinet's Treatise, in the Jour, des Con-
naissances Medico-Chirurg., for  January, February, March,  and
May, 1842.)

               Strabismus at Bristol, (Eng.) 1842.

  Mr. J. B. Estlin, surgeon to the Eye Dispensary, Bristol, gives in
the Provincial Medical Journal for July, 1842, the results  of one
hundred cases operated upon by him for strabismus.  He condemns
in unmeasured terms the sharp hooks to the sclerotica, and the 
AMERICAN APPENDIX.
757
specula to the lids.  His method is chiefly that of Mr. Lucas, and
he uses only a pair of small round-pointed forceps for seizing the
fold of conjunctiva, Lucas' blunt hook, and a strong pair of scis-
sors, straight or angular, for the incisions.  For holding open the
lids he finds the fingers of an assistant, and sometimes even the aid
of a female servant, quite sufficient.  He binds up the eye imme-
diately  after the operation, but removes the bandage  in a few
hours, and keeps the patient in bed for that time, applying warm
water freely to the part, and enjoining low living and rest for a
day or two.
  Of the hundred patients above, thirty-nine were males, and six-
ty-one females, (confirming M. Boinet's table above of the greater
frequency of the disease in females,) and the ages varied between
five and a half and sixty-two years. Of these, ninety-two had con
vergent, and only eight divergent strabismus.  In thirty-nine the
left eye was operated upon, in thirty-two the right, and. in twenty-
nine both.   In five the operation M'as required a second time upon
the same eye, and in one patient, a  youth aged fifteen years, it was
required twice in both eyes.
  Results.—Perfect and satisfactory,  sixty-five ; improved some,
twenty to twenty-five; leaving, Mr. Estlin thinks,  not more than
five failures in the hundred.  Yet he prefers the vertical incision, so
much condemned by M. Lucien Boyer.   We  must remark here
also, that the proportion of cures in Mr. Estlin's cases, in order to
be in accordance with the general and established results of the
present  time, will, M'e are constrained to think, have to be very
considerably diminished in amount.
  The sub-conjunctival section has now been proposed by Dr. Ber-
nard, of Paris, in the operation for cataract.  He fixed the eye-ball
by the double hooks used  in the operation for squinting, and in-
serted the couching needle under the conjunctiva, at the  distance
of four millimetres behind the usual place of entrance, then passed
its point forward and penetrated the sclerotica as usual.   Dr. Ber-
nard thinks this  mode has the great advantage of preventing the
admission of air, and therefore much of that  intense pain and in-
flammation which follow by the old method, (see  Gazette Medicate
de Paris, July 30, 1842.)

                Myotomy of the Levator Palpehrce.

  This was  ingeniously proposed and successfully performed by
Mr. Liston, as long ago as  previous to May 6, 1840, (see Mr. An-
cram  in London Lancet, 1839-40, p. 306,)  to  effect a permanent
closure of the lids in a case in which the patient had lost the ball
by inflammation, and  did not wish to wear  a false eye.  It was
effected by a small transverse incision immediately beneath the
supra-orbitar ridge, which with a little dissection soon exposed the
belly of the muscle backward, which  being  seized  and divided
with the scissors, caused the  lid immediately to fall over the ball.
  Prof. Dieffenbach has cured slighter degrees of strabismus by 
758
NEW  ELEMENTS OF OPERATIVE  SURGERY.
snipping off a piece of the conjunctiva with the subjacent cellular
tissue, near the insertion of the rectus muscle  on the side from
which the eye diverges.  The piece  snipped off must be  larger
when the eye is turned outward than when turned inward, because
the latter is occasioned by the greater power of the internal rectus;
but M'hen the eye is turned outward there is generally paralysis, or
at least a weak state of the rectus internus, (Wochenschrift fur die
ges Heilkunde, 1841.)
   [We should very much doubt if even in the slightest cases such
an operation could  be relied upon, especially when we  see M'ith
what obstinacy (as in convergent strabismus) the eye will persist
in maintaining  its  morbid deviation,  even after the division of
the rectus internus, and the most extensive  dissections of its sub-
conjunctival, cellular, and  aponeurotic connections with the scle-
rotica and other muscles.—T]

       Hook to steady the  Eye in the Operation for Strabismus.

   Whoever may have been the surgeon that first suggested the
improved sharp double hook, with  the teeth turned more or less
acutely back on themselves, so as  to  avoid  penetrating too deep
into the  sclerotica,  (to which contrivance  Prof. Velpeau gives a
decided preference,) it is very certain that as early as Aug. 7, 1840,
(see London Lancet, 1839-40, pp. 785-6,)  Mr. Jas. J.  Adams, of
London,  strongly recommends a hook of this description, and com-
municates to the public a figure and description of one, in which,
as he describes it, " the sharp extremity of the stem is bent upon
itself at such an angle as to require its introduction into the scle-
rotica, not by a sudden  thrust at a right angle with its stem, but
by a gentle motion  in a line with the direction of the  handle of
the instrument, so as to enter the sclerotica obliquely, thus render-
ing all pressure on the globe unnecessary, as the motion is to  direct
the eye outward, and not press it backM'ard."  The  form and posi-
tion of the hook prevent its being " thrust through the sclerotica."
Mr. Liston, however, had already contrived before this a modifica-
tion of the sharp hook, to which some gave the preference over
that of Mr. Adams, (ib. p. 786.)
   " A blunt hook with a cutting edge on its concavity," to  raise  and
at the same time divide the muscle  in strabismus, was, it appears,
also first proposed and used  successfully in Great Britain, by  Mr.
Ross  Lietch, (see London Lancet, 1839-40, p. 786.)

    Escape of the Vitreous Humor from a wound in the Sclerotica.

   Mr. Jas. J. Adams, of London,  (see  London Lancet, 1839-40, p.
858,) has seen this  dangerous accident result from an attempt to
divide the internal rectus, in the operation for strabismus, by means
of a knife without the use of the director or hook. 
AMERICAN APPENDIX.
759
                    Speculum in Strabismus.

  As  long since as Aug. 31, 1840, (Lond. Lancet, 1839-40, p. 908,)
we find Mr. Chas. Clay, of Manchester, complaining of the severe
pain of the sharp hook into the conjunctiva and sclerotica, and the
painful pressure thereof to the ball, as well as that to the lids from
wire specula.   He proposed to do away with  all, and to substitute
his silver-spoon  speculum, notched  out at the  point, then  to pinch
up the conjunctiva with a forceps, make  a bold incision half an
inch long, raise the muscle with a probe, and divide  Math a knife.
We should  suppose  the  spoon speculum, as we have called it, too
heavy and cumbrous on the  cornea to obviate the objection com-
plained of.  As to the bold incision  into the conjunctiva, that is
shown to be now an obsolete error, and highly objectionable in the
present advanced  state of strabotomy, (vid. supra.)
  A probe-pointed curved hook, with a concave cutting edge, for di-
viding the rectus in strabismus, and also the addition of the sharp
hook  to the sclerotica, were proposed in England by Mr. Jno. G.
French, of St. James' Infirmary, as early as  July 27, 1840, being
very soon after the operation for  strabismus  was introduced from
the continent into  England, (vid. Lond. Lane,  1839-40, p.  710.)
  We cannot, perhaps, better conclude these supplemental obser-
vations on strabismus, than by stating that the  committee of the
Academy of Sciences of Paris, in their recent annual distribution
of the Monthyoh prize, (this year, 1844,) have awarded the larg-
est  prize (6000 francs) to be divided into equal portions between
MM.  Strohmeyer and Dieffenbach; the one for having originated,
and the other for having first performed the operation of myotomy
for the cure of  squinting.  The  commissioners declare the opera-
tion to be " justly  admitted into the  domain of surgery, as one of
the recognised  achievements of the art."  Signed by MM. Roux,
Breschet, De Blainville, Pariset, Velpeau, Andral, &c.
                         TORTICOLLIS.

            Proposed Division of the Splenius Capitis.

  Sign. Sani, surgeon of Rome, prefers, for greater safety in torti-
collis, to divide the sterno-mastoid by a transverse incision of prop-
er width through the skin, and from before backward, (see Annali
Medico- Chirurgici;  also Gazette des Hbpitaux de Paris, and Lond.
Lancet, 1841-2, pp. 289, 290.)  This is in accordance, as we have
stated, (supra,) with Dr. Mott's recommendation, who, though he
has so frequently seen the section brilliantly made from within,
out, and sub-cutaneously, by M. Jules Guerin, with his proverbial
adroitness, does not himself feel authorized to adopt this process,
and would especially caution young surgeons against undertaking
it   Even the  mode proposed of late, of obtaining greater security 
760
NEW ELEMENTS OF OPERATIVE SURGERY.
by introducing a grooved blunt director  under and  along the pos-
terior surface of the muscle, might, Dr.  Mott thinks, still  compro-
mise the important vessels and nerves in that immediate neighbor-
hood, rupture the internal jugular, &c.   The knife, of course, must
therefore be tenfold more hazardous.  Mr. Nottingham, of Liver-
pool, Eng.,) thinks the state of the  muscles at the posterior aspect
in wry neck  has been neglected, and says he has  seen one case
where the division of the splenius capitis, as well as of the sterno-
mastoid, might, he thinks, have been beneficial, (London Lancet,
id. ib.)
 DORSAL MYOTOMY,  (MYOTOMIE RACHIDIENNE,) FOR LATERAL
                  CURVATURES OF THE SPINE.

  It cannot be other than a matter of justice and impartiality on
our part to M. Guerin, the author of this  new branch of sub-cuta-
neous  surgery, to give the substance of his letter to the Paris
Academy of Sciences, June 24, 1839, on the  results which he de-
clares  he obtained in  the first tM'elve operations of this description.
This letter, entitled Traitement des Deviations Laterales du Rachis,
par la  Section sous-cutanee des Muscles du Dos,  et de la Colonne Verte-
brate, (see Archives Gen. de Med., torn, v., nouv.  ser., Paris, Aout, 1839,
pp. 501 et seq.,) says, that  the muscles which he had  up to that time
divided in the above cases, were the trapezius, the rhomboideus, the
levator anguli  scapulae, the sacro-lumbalis, the  longissimus dorsi,
and the semi-spinalis colli, semi-spinalis dorsi, and multifidus spinas.
  According to M. Guerin,  as he then wrote,  and still asserts, the
greatest number  of articular deformities  are  the  result of convul-
sive muscular retraction,  dependent upon an affection of the brain,
(affection du cerveau) of the spinal  marrow, or of the nerves them-
selves, which are distributed to the muscles.  By this doctrine, es-
tablished in one of the early treatises of the author, on the deform-
ities of the osseous system,  and demonstrated, according to him, in
its  general  application (dans sa generalite)  to deformities of the
neck, hips, hands, feet, and  other articulations of the skeleton, he
was conducted to the following results for the diagnosis  and the
treatment of these deformities, to wit:—1. That the different kinds
of deformity that each one of these  varieties  is  capable of as-
suming, are the  product  of the retraction variously  (diversement)
distributed to such or such muscles.  2. That the active treatment
of each one of them  should consist in the section of the tendons or
muscles, to whose retractions these particular varieties of deform-
ity are ascribable, (sub-ordonnees)
  To realize this double result, it is necessary, on the one  hand, to
determine precisely (rigoureusement) what, in each deformity, and
in each of the  elements  that make it up, are the muscles whose
energetic contraction (racourcissement actif) produces these deform-
ities ;  and, on the other hand, it is necessary  to effect, by  the sec- 
AMERICAN APPENDIX.
761
tion of these same muscles, the removal of the abnormal forms of
the skeleton, and to confirm by this decisive experiment the just-
ness of the theory and the validity of the practice.   Now, says M.
Guerin, this double result I had already obtained in regard to old
cases  of torticollis, (torticolis ancien) and the different varieties of
congenital pes equinus.  I have extended the same doctrine to the
anatomical determination of the different varieties of lateral devia-
tion of the spine, and to their surgical treatment.   The following
were  then the only details (seuls details) (see the abrege account
in the Archiv. Gen., loc. cit.) that the author gave on the applica-
tions he had at that time made of this method of treatment, on sub-
jects  of both sexes  and  of different ages.  " The  youngest was
thirteen years, the oldest twenty-two.  All the deviations were of the
second and third degree, with  torsion of the column and corre-
sponding (proportionnees)  gibbosities.  In some a single section of
the retracted muscles sufficed; in others, I had to perform it  twice
or thrice; in all  I obtained, immediately  after the  operation,  a
marked degree of  straightening (redressement)  of the column ; and
in one young man, aged tMrenty-one years, who had been for eigh-
teen  months under mechanical treatment, I obtained, by the sec-
tion of the longissimus dorsi, and of the corresponding semi-spinalis
colli,  semi-spinalis dorsi, and multifidus spinas, an immediate  remo-
val of the entire distortion, (un redressement immediat de toute la de-
viation)  In the other cases, I have been enabled to put in practice
(j'ai  pu poursuivre) with  constant success, the treatment by me-
chanical apparatus.   In not one of the twelve operations which I
have  performed have I had the slightest accident: no hemorrhage,
but little pain, no fever, ahd, in all the  cases except one, immediate
reunion of the wounds without suppuration.  I will add, that though
the operation is a delicate one, it is performed almost with the
same facility as at the neck or foot, and by processes that  are sim-
ilar."  At a subsequent  sitting of the Academy of Sciences, (viz.
Sep. 23, 1839,) M. Guerin addressed  a memoir to  that body upon
the Etiology of Lateral Deviations of the Spine by Muscular Con
traction, (retraction) from  an extract from which, communicated bj
the author to the editors of the Archives Generates de  Medecine, of
Paris, for Nov.,  1839, torn, v., nouv.  ser., pp. 379-84, we make the
following summary.
   The memoir is devoted to the development of the principle which
he had already laid down in his previous communication, (supra,)
that the greatest proportion of these deformities are  the result of
muscular retraction.  In reply to  a question, he asks if there are
cases of deviations of the spine, accompanied with material altera-
tions  in the nervous centres, and evidently caused by these altera-
tions  ? he answers in the  affirmative.  He points out in his memoir
a series of cases of fcetal monstrosities, and others  in which there
existed alterations of the brain and spinal marrow, or of one of
those two centres only, from their total destruction to partial cir-
cumscribed lesion of one  portion of them, lesions coincident with a
series of articular deformities of the osseous system, corresponding 
762
NEW ELEMENTS OF OPERATIVE SURGERY.
in number and intensity to the extent and intensity of those lesions.
Among these deformities were found the deviation of the vertebral
column, corresponding also in its extent, direction, and degree, to
the  nervous alteration which had been its point of departure, [i. e.
source:]  it  M'as found bent (replied) in different directions, draM'n
(attiree) and bridled on its two sides by the long muscles of the
back, which became the cord of the curvatures it  took.  All these
deformities were also rendered  permanent by an  excessive short-
ening and tension of the intermediate muscles.
  In a series  of analogous observations to the above, M. Guerin
says he has not only verified, during life and after death, the exact
relationship between the nervous affection which existed anterior
to birth and the deformities, but also the same affections producing
the same deformities at every period of childhood up to the age of
fifteen years.
  M. Guerin then asks, Does there  exist, in the absence of altera-
tions of the  nervous centres, any certain and evident means of rec-
ognising, that a deviation of the spine is  the  product of an ener-
getic (active)  muscular retraction, put into action  by a nervous af-
fection ?
  These means, he replies, are of two orders,  constituting two or-
ders of characters of deviations by  active muscular retraction.
The first consist in  the series of effects caused by the  disease in its
various reactions,  (ses reflets multiples) other than the deformity
[itself,]. and existing outside of the seat of this  last;  the second
consist, on the contrary, in an ensemble of direct characters, be-
longing to the deformity, and which impart a peculiar physiognomy
to it, by the aid of  which it may be easily distinguished from the
other kinds of deviations.
  Among the characters of the first category, he adduces the gen-
eral traces of ancient nervous diseases, an appearance of convul-
sion in the face, an  inequality  in  the two halves of the face, the
traction (tiraillement) of the features, (trails) inequality of the eyes
and of their visual faculty, strabismus, the  unequal prominence
(la  saillie differente) of the  bones of the  cranium, some traces of
paralysis  in one half of the body, or in the limbs only;  on the oth-
er  hand, simultaneous retractions  of other muscles,  for example,
of  the muscles of  the neck, arms, hands, legs, and  feet, whence
arise corresponding deformities.
  Among  the characters of the second category, he would men-
tion the identity of the forms peculiar to a deviation, accompanied
with a material alteration of the nervous centres, with those of a
deformity of the same origin, but which is destitute of direct traces
of  the disease.  In the two cases they  have  the same seat, the
same direction, the same number of curvatures, the same  projec-
tions, (reliefs) the same depressions, &c.; but this identity of forms
may be traced (ramenee) to elementary characters, which emanate
from the character itself (de Vessence mime) of the active muscular
retraction, and its immediate relations with the parts of the column
which it displaces.   Such are the  shortening of the muscle, or 
AMERICAN APPENDIX.
763
muscles actively retracted, which are rigorously adapted to the
space comprised between their points of insertion, and are exhibit-
ed under the appearance of bridles or tense cords, projecting under
the skin, extremely hard, and of fibrous consistence.  These effects
of active retraction, cannot be confounded with those of passive re-
traction, because the muscles, passively  shortened, preserve their
primitive  consistence, are soft, little  resistant, and tend  rather to
pass into a fatty condition, (Vital graisseux)   Moreover,  there ex-
ists a perfect accord between the seat and  direction of  the forms
of the deviation, and  the  seat  and  direction of  the action of the
muscles which determine them.  This relation, common to all the
deformities of the osseous system of  the same nature, is rigorously-
maintained in all the varieties of the deviations  of the spine, and
becomes the basis of the anatomical  history of those  varieties.  As
a last order of characters, he mentions the different  modes of dis-
tribution of the active retraction in the muscles of the back„of
M'hich one,  or many,  or all may be retracted,  or one particular
bundle (faisceau) only;  whence arise the  manifestations, the dif-
ferent prominences (reliefs)  of this  retraction, which is so much
the more intelligible, as  the contrasts resulting from its characters,
and those of the normal muscular  state,  are the more striking,
(sensibles)
   He has (he says) endeavored to determine M'hat are the different
modes of  active muscular retraction in relation  to the deviations
of the spine, and in M'hat limits it ought to be circumscribed as a
cause or active element  of those deformities.
   Muscular retractions  are not only produced by the deep-seated
diseases of the  brain, or spinal marrow, or structural (materielles)
alterations of the nerves distributed  to the retracted muscles ; but
they manifest themselves, also, in a great number of diseases that
act intermediately through the  nervous  system, and  M'hich cause,
incidentally or  consecutively, the retraction of certain muscles in
consequence of temporary general convulsions ; or these deformi-
ties are  seen in simple  contractions of muscles  directly attacked
and entirely isolated, [i.  e., separate,] as is frequently observed in
diseases of infancy, to wit, eruptions, those of dentition, fevers of
every kind, and slightest morbid accidents, from M'hich causes one
or more muscles may become and remain contracted.  The origin
may be also  purely local and external;  thus, wounds, falls, blows,
and contusions of the muscles of the spine, induce their retraction, as
is more especially seen in the muscles of  the calf.   In this case the
nervous alteration  cannot be directly established, but it is  legiti-
mately induced from the lesion of the mobility of the muscle.
   M. Guerin then  inquired whether  we have any means of distin-
guishing  the  deviations produced by active muscular retraction,
from those imputable to other causes.
   The latter deviations  he had established  long ago: such are the
passive muscular deviations,  osseous deviations from unequal de-
velopment of the two halves of the  skeleton, and deviations from
scrofula and rickets.   They all exhibit and may be known by gen-
  t 
764
NEW ELEMENTS OF OPERATIVE  SURGERY.
eral and local characters ;  the general characters from the general
action of causes that manifest themselves almost always elsewhere
than in the seat of the deformity.   The local  are the appearances
peculiar to each deviation, produced by the intimate relation of the
cause of the deviation with  the point of the column on M'hich it
acts, and with its particular mode of action on this column, (tige.)
He gives in his memoir the principal characters of each deviation,
and refers to his Treatise addressed to the concours of the Academy,
for the general and particular applications of these principles to a
general laM' he had  then  given, that " the essential causes of the
deformities of the osseous system, possess such a specific action
(spicificite d'action) in regard to the deformities to which they give
birth, that  each one of those causes is interpreted externally by
characters which are appropriate to it, and by the aid of which M'e
may, in general, diagnose the cause by the deformity, and determine
the deformity by the cause."
  Active muscular retraction not only has the greatest share among
the essential causes of deviations, but exercises even a partial ac-
tion in  the production of each one of those  [deviations] M'hich it
does not exclusively produce.  All  the causes of deviations displace
the column in whole or in part from its vertical  [position.]  When
this mechanic effect (the compulsory intermediate one of every mor-
bid cause) exists, an instinctive effort of the  muscles of the trunk
at the same instant, tends  to keep or bring back the column to its
vertical [direction.]  This  effect, having relation to the  verticality
of the spine,  is the point of  departure and the  cause of the com-
bined (multiples) and alternate curvatures which accompany and
characterize every deviation [of the spine,] of whatever nature it
may be. Therefore, the muscles are the agents of these deviations,
(courbures) by their struggle to overcome the  causes which tend to
disturb  the equilibrium of the trunk, and thus form antagonist cur-
vatures, (courbures de balancement,) and retract afterwards to main-
tain those curvatures fixed, and in number, extent, and degree ne-
cessary to the re-establishment and support of the equilibrium.
This retraction, though different in its object, is essentially the same
in its essence and results; in every instance  (de part et d'autre) it
is an active shortening of the muscles and curvatures of the column.
To diagnose this retraction from that purely spasmodic or morbid,
I name it active secondary muscular retraction, (retraction  musculaire
active secondaire.)  It is important as not only taking an active part
in all deviations, of whatever nature they may be, but as presenting
indications (though restricted) for  the application of surgical treat-
ment, (Archives Gen. de Mid., 3e et  nouvelle  serie, tome v., Nov.,
1839, p. 379 to 384; Seances de VAcad. Royale des Sc,  Seance du
23 Septembre,  1839 ; see  also,  Compte-rendus Hebdomadaires des
Seances de VAcad, des Sc,  1839, 2e semestre, page 383.)
   In the beginning of the year 1840, M. Guerin stated to the Royal
Academy of  Paris that he had then, in nearly fifty cases, divided,
more or less completely, most of the muscles of the  back  and spine;
viz., the trapezius, the rhomboideus, levator anguli scapulae, sacro- 
AMERICAN APPENDIX.
765
lumbalis, and longissimus dorsi.   In each the wound of the muscle
was from three  to four inches long, and in the case of the sacro-
lumbahs and longissimus dorsi, one and a half to two and a half in
depth; in the case of the trapezius and rhomboideus, the  bistoury
traversed from four to five inches under the skin.
  In no case, scarcely, was there local inflammation or feverishness,
and by the third day the patients were  enabled to rise  up and walk
about Mdthout support.
  M. Guerin had then also divided the sterno and the cleido-mas-
toid muscles (separately, simultaneously, or consecutively) for wry-
neck,  twenty-five times, in every case  under  the skin, the wound
healing without  trouble.  Occasionally, however, the operation was
attended with some effusion of blood.
  He had then, also, divided  the tendo-Achillis for club-foot over
two hundred times—in all successfully.
  " I have now  (says M. Guerin) performed the sub-cutaneous sec-
tion of different tendons and muscles  in upwards of  five hundred
cases, and in not one instance has any troublesome inflammation
of  the wound supervened.  The great object, therefore,  (he con-
tinues,) of the surgeon should be, to prevent the entrance of the ex-
ternal air into the wound.  From all  these  circumstances, I infer
that sub-cutaneous wounds  do quickly heal  in consequence of the
exclusion of the  external air; and that it is from this fluid (the air)
neither physically obstructing  the circulation, nor chemically modi-
fying the properties of the blood, nor  altering in any degree its vital
constitution, as well as from its not exerting  any hurtful influence
on  the nerves and other parts which  are protected from it, that the
lacerated or divided  tissues coalesce and unite  by  the first  inten-
tion, without any of the usual inflammatory symptoms,"  (London
Medico-Chirurg. Review, July, 1840.)
  At the sitting of the Academy of Sciences of Paris,  Feb. 2, 1840,
M. Bouvier read a memoir in  which he boldly censured those who
cut the muscles as the cause of the deviations of the vertebral col-
umn.  Such persons, he thinks, have mistaken the effect for the
cause.  In most deviations  after birth, he thinks the  disease com-
mences in the osseous, and especially the fibrocartilaginous system.
The column inclines, and the attachments of the muscles being thus
brought in nearer approximation on  the side  of the  concavity, it is
clear these last must become shorter. Cut the muscles and you
don't remedy the incurvation.  Hence, in cutting the muscles of
the back in the dead body, you in  no manner  redress the dorsal
spine, while the straightening is easily effected by  dividing the
fibro-cartilages.  Nevertheless, some deviations in the foetus seem
to originate in a lesion of the  nervous  system; but  they have spe-
cial characters, and cannot be confounded with those caused by the
bones and cartilages.                        .   .      .
  M. Gerdy, one of the Academy, could not admit this  doctrine, and
thought deviations of the bones were most frequently preceded and
accompanied by some lesion of the nervous system, or at least mani-
fest disturbance  in its phenomena; to wit, convulsive movements of 
766           NEW ELEMENTS of operative surgery.

the face and  limbs, attacks of epilepsy, deafness, temporary blind-
ness, cephalic or rachitic pains, &c.   Add to  this, that individuals
whose body or limbs are deviated have, in general, precocious intelli-
gence, and the greatest  development  of  genius, (esprit)   Do not
such facts lead us to the  belief that there  often exists a chronic af-
fection of the nervous system, M'hich excites the muscles to a per-
manent contraction?  [These ideas were  broached by M. Gerdy  in
the first edition of his Treatise on Bandages, so long ago as in 1826.
They appear to us, however,  to be only the reiteration of a M'ell-
knoM'n fact, and which, perhaps, is susceptible of another explana-
tion than that of M. Gerdy.   The remarkable mental precocity  in
such cases, and in no instance is it seen  in more striking contrast
than in some cases of total paralysis of the whole trunk and limbs,
need not, as we think, exact a pre-existing chronic organic lesion
of the brain or spinal marrow.  For this greater intellectual activi-
ty, often brilliant to a degree that is  surprising, may be owing  to
the distribution of nervous power being now, as it were, suspended,
or vastly abridged and diminished to  the  more or less unexercised
muscles, and therefore concentrated, for the same reason, upon the
intellectual functions proper—in  the same way as the activity of
the circulation  and of the cerebral functions, when in a normal con-
dition, are augmented often in intensity  of energy, by rendering
them, as it were, more compact, or abridging the physical or or-
ganic domain in M'hich their functions are performed, and thereby
husbanding  the expenditure of vital force, as is M'ell known in the
greater health  and vigor often enjoyed by those who have under-
gone amputation of a leg, or the removal of a large tumor, &c.—T]
(See Archiv. Gen. de Med., 3e ser., torn, x., Mars, 1841, pp. 357, 358.)
   Prof. Robert Hunter, of Glasgow, (iiom', we believe, of London.)
says, in a communication to the London  Medical Gazette, March
6, 1841, that he had already, at that time, performed the operation
of sub-cutaneous section of the dorsal muscles for lateral curvatures
of the spine in twenty-five cases; and that, " although  in five of the
cases the latissimus dorsi, the serratus posticus inferior, the longis-
simus dorsi, and sacro-lumbalis, were divided, and the sub-cutane-
ous incision extended from the spinous process of one of the lumbar
vertebrae across to the outer margin of the sacro-lumbalis, dividing
the above-mentioned muscles, yet the  pain M'as so trifling that the
majority of  patients hardly murmured.   The Aom' of blood never
exceeded  a few drops.   The skin over the track of this long and
deep incision never changed its natural temperature or color;  in
no case did suppuration  follow; constitutional disturbance of any
kind never once supervened, and in three  or four days after the in-
cision, the puncture had cicatrized, the swelling from the effused
blood had generally disappeared, and  frequently by that time not a
vestige of the operation could be discovered."  He adds, (and what
is a valuable testimony to the alleged marked success in these sec-
tions by M. Jules Guerin, and especially of that  most remarkable
operation already alluded to in this work, and of which Dr. Mott
was also an eye-witness:)  " During the time I sojourned  in  Paris 
AMERICAN APPENDIX.
767
last summer, M. Jules Guerin operated upon a patient affected M'ith
anchylosis  of nearly all the body, arising from contraction of the
muscles.  He cut across forty-four muscles, and spread out the limbs,
and  although the successive incisions occupied more than sixty
minutes, yet the system of the patient received so small a shock
that  the pulse was not sensibly affected, and the patient slept soon
after the operation, and neither irritability nor febrile  excitement
folloM'ed."
  Prof. Hunter believes he was the^rs^ in Great Britain to perform
the sub-cutaneous section of the dorsal muscles for lateral curva-
ture  of the spine, but candidly acknowledges that  in  no instance
has  he found the operation, of itself, produce  a cure;  but that it
manifestly facilitated that result by the application of mechanical
and  physiological means.  All his cases were of long standing, from
seven to twenty years, had been  variously treated, and  were ac-
companied with considerable torsion and gibbosity, as  well as lat-
eral  curvature.  In some instances the operation effected no change
whatever.

                   Professor Hunter's Process.

   He performs  the section of the dorsal  muscles at four different
places upon the back :
   1st. He weakens the deepest seated layer of muscles—that form-
ed by the multifidus  spinas—by dividing  the thickest part of that
muscle, as it lies comparatively superficially  upon the dorsum of
the sacrum, opposite the posterior superior spinous process of the
ilium.
   2dly and 3dly. He removes the tension of  the middle layer of
spinal muscles—that formed by the longissimus dorsi and  sacro-
lumbalis—by cutting these muscles across, sometimes  in the lum-
bar  region and sometimes in the costal region,  according to the cir-
cumstances of the case ; but more frequently in the lumbar region,
near the origin of these muscles.
   4thly. In order to destroy the tension of the flat and more super-
ficial muscles, he divides these muscles, by a longitudinal incision,
close to the spinous processes of the vertebrae, at the  place where
the tension of these muscles appears to be the greatest.   In one in-
stance he cut through, with considerable  effect, the latissimus dorsi
at the side of the chest, and consequently, at  some distance from
the spine.   The muscle crossed the  contracted and concave side of
the  trunk, and appeared to be accessory  in huddling in the ribs of
that side.   When the  patient attempted to elongate that side, a
cord, as thick as the little finger, was seen stretching from the crest
of the ilium to the scapula ; as soon as  this rigid cord of muscle
was cut through, the  ribs became less huddled together, and the
side could be elongated to a much greater degree, and  the spine
materially affected.
   " In cutting the dorsal muscles," continues Professor Hunter, " I
have chiefly, though not exclusively, followed the method of Guerin. 
768           NEW  ELEMENTS OF OPERATIVE SURGERY.

Guerin  employs  always  two  instruments;  I have  frequently
employed only one.  Guerin uniformly cuts the muscles, by com-
mencing at the  cutaneous surface of the muscle, and proceeding
deep-seatedly; I have repeatedly, and with greater safety, cut in
the opposite  direction, that is, by carrying the instrument more
deep-seatedly than the muscle, and cutting towards the skin.  As
Guerin, however, is a great authority upon this subject, his mode
of operating  is M'orthy of being mentioned.   He  makes the sub-
cutaneous incision  with a narrow, sharp-pointed  bistoury, almost
two inches and a half in length.   He then withdraM's that instru-
ment, and introduces into  the track thus made a sickle-shaped in-
strument of the same length and breadth as the former, the cutting
edge of which is on the convex margin.  Having carried this in-
strument across the muscles to be cut, he turns the  convex cutting
edge to the muscles, and their division is effected, not by one cut,
but by  a number of successive touches, the patient at the same
time calling his  dorsal  muscles into action, by throwing his head
forcibly backward, to  impart a greater degree of resistance to the
muscles, and to  enable the incision to be effected partly by the
pressure of the contracting muscles upon the edge  of the knife."
  Prof.  Hunter claims to have been the first person in Glasgow who
performed  also the subcutaneous section of" the muscles for the
cure of club-foot; in allusion to which he says: " I have seen that
operation performed by M. Guerin for valgus, varus, and  equinus,
and with astonishing success."
  The value of the subcutaneous section of muscles and tendons, in the
cure of deviations of the vertebral column, formed the twenty-first
question proposed in the programme of the Scientific Congress of
France, and was responded  to in the  session  of that body ir *ie
year 1842, at  Strasbourg,  by M. Kuhn, [associate of M. Guerin in
the Hopital des Enfans, Paris,] who maintained that the causes of
the deviations of the spine are numerous, and that  muscular retrac-
tion occasions about the half of them, to which last alone  the sub-
cutaneous section is applicable.   The treatment consists, first, in a
preparatory elongation, which overcomes the  muscles secondarily
contracted, after which we proceed to the section of the fibres,
(faisceaux) which  are  the  seat  of the primitive  retraction.  He
cites a table of one  hundred and sixty patients  treated by M. Jules
Guerin, and upon whom this distinguished  surgeon had performed
three hundred and sixty sections.  The greatest part of these cases
obtained a more or less  complete restoration of the spine, either
immediately, or as the result of consecutive mechanical treatment.
A small number experienced no relief.   There were never any
serious accidents, and  in  two cases only was there suppuration,
which arose from introduction of air into the wound.   (Vid. Journ. des
Conn. Medico-Chirurg., Nov., 1842.)
   In  the sitting of the Academy of Medicine of Paris, Feb. 28,
1843, (vid. Journal des Connaissances Medico-Chirurg., Paris, Avril,
1843,) M.  Malgaigne, in  a  letter to  the Academy, remarks that,
from the safety (de Vinnocuiti)  of subcutaneous wounds, we are 
AMERICAN APPENDIX.
769
 too precipitate in inferring danger  from those which are  left ex-
 posed  to  the air.  M. Malgaigne says he has  injected air  into
 wounds  opening  into  the  articulations, and  even  the  thoracic
 cavity, in rabbits, also  into wounds of complicated fractures made
 in these animals, and has found the union, in all these cases, not less
 perfect and immediate.  We know,  he  says, from this M'hat value
 is to be allowed to the theory which explains, by means  of the in-
 tervention of some bubbles of air, the suppuration which takes place
 in operations performed  by very skilful surgeons, " even by M
 Guerin himself."  M.  Malgaigne thinks this theory has the incon-
 venience  of fixing the attention of  the surgeon exclusively on an
 imaginary danger, and concealing from  him the true causes of
 inflammation and suppuration.
   In the  subsequent sitting  of March 7, M. Guerin took occasion
 to reply to this letter,  by remarking that M.  Malgaigne had ex-
 aggerated the  consequences of the theory  of J. Guerin, on cica-
 trization  in subcutaneous M'ounds.   " I  have never  pretended,"
 says M. Guerin, " that air, in momentary contact with a traumatic
 surface, inflames  it, and necessarily  causes it to  suppurate. Sup-
 puration is, on the contrary, an exception, and it  is in these condi-
 tions  that M. Malgaigne  has placed himself in  his experiments.
 But when the wound is in permanent contact with atmospheric air
 the suppuration is the rule, and the cicatrization an exception so rare
 that there exists no example of it."—(Journ.  des Connaiss., loc. cit.)
   It is necessary, in order that this work may be au courant with
 the latest  movements and  investigations which are being made in
 all the departments embraced in operative  surgery, to remark in
 this place, without in any way committing ourselves  to any party
 or theory, that the treatment of curvature  of the spine  by dorsal
 myotomy, as practised  for some years past by M. Jules Guerin,  has
 recently given rise, we are pained to see, to a very angry  and re-
 criminative discussion in  the Paris  Academy of Medicine. This
 discussion, it appears,  was based  on the absolute denial, on  the
 part of M. Malgaigne, that M. Guerin had effected, in these opera-
 tions, the number of cures that he had alleged.   The consequence
 was, that  a committee of  the Academy, as  is  customary in cases
 somewhat similar, was appointed, to examine the results of his
 treatment.  It is  proper, however, to record here the brief sum-
 mary we   have in the Proceedings  of the  Academy, (as we find
 them reported in the London  Lancet,  May, 1844, pp. 221-2,) of the
 initiatory part taken by M. Malgaigne in this matter.
  M. Malgaigne read  a memoir on  dorsal myotomy, as practised
 by M. Guerin  in  twenty-four cases, between the years 1839 and
 1843.   The whole number thus treated, in this period, at the Ho-
pital des Enfans, was, he says, fifty-seven, of whom it is stated, (he
asserts,) by  M. Guerin, that  twenty-four were completely cured,
twenty-eight much improved, four remaining without amelioration,
and one ending fatally.  M. Malgaigne avers that he has been able
to obtain  information  respecting twenty-four of these patients,
either by  personal inquiry and examination  or from authentic 
770
NEMr  ELEMENTS OF OPERATIVE  SURGERY.
data.   He adds that tM'enty of these patients had undergone sec-
tion of the dorsal muscles from one to nine times.  They had re-
mained at the hospital from two  to  eleven months, the treatment,
however, having been  continued at their own residences.   M,
Malgaigne states that he has not  seen one complete cure, and  Ihat
even the instances of amelioration are problematical.  From his
examination of the patients, he even doubts whether the retracted
muscles were really  divided, and  whether the operation is not one
which  addresses  itself hazardously to overcome imaginary evils.
The  greatest difficulty (says M. Malgaigne) in orthopaedia is, not
to raise the vertebral column, but to give  it the solidity M'hich it
wants by reinforcing its weakened ligaments and muscles.  He
condemns all apparatus for extension, and all dorsal myotomy, as
increasing this weakness.  It is  a bad plan, he  says, to divide a
muscle in order to strengthen it.
  Professor Syme, of Edinburgh, has stated that the only cases of
curvature to which  the operation of myotomy is applicable, are
those which accompany wry neck, and are produced by a perma-
nent contraction of the sterno-cleido-mastoideus muscle.  (See Mr.
W. Hey, jun.'s Address in the Transactions of the Provincial Medi-
cal and Surgical Association, London, vol. xii., 1844, p.  169;  also
Lond. and Edinb. Journ. of Med. Science, April, 1843.)
  A case of unusual interest is related by Mr. Cocks, of Dundee,
(Lond. Med. Gaz., March  10, 1843,) in which the affection of the
dorsal muscles was of a decidedly spasmodic character; being con-
tracted to such degree as to produce an  anterior curvature of the
lower half of the spine, and constituting a tense band on each  side
of it.  The section of these bands gave instant relief, and was fol-
lowed by a permanent cure.
   If lateral curvatures of the spine, as in torticollis, &c, have, of late
years, received almost immediate and substantial relief from myo-
tenotomy, there are those who are forgoing back again to improved
modes of mechanical treatment.
   In a recent essay on diseases of the spine, by Mr. R.  A. Stafford,
(London, 1844,) he claims the merit of having done much to save
cases of lateral curvature from the experiments of charlatanry, and
that he has  effected this  object by  what  he considers a new and
improved treatment  of those affections, viz., by gravitation, lateral
exercise, &c.  Mr. Stafford considers that one of the causes the most
efficient and aggravating in the production of these curvatures, and
which has been too much overlooked, is the position of the centre
of gravity being, by the previous loss  of function, and therefore
inaction, of the contracted as well  as elongated muscles, thrown
thereby upon the edges of the vertebrae.  Muscular action, there-
fore, he deems to be only the initial cause of the disease, meaning
thereby that the irregular and unequal action of the antagonist
muscles, whatever may be the source of it, is only the first step to
the  deviations which afterM'ards, by the cessation  of muscular
function, and the shifting of the centre of gravity as above men-
tioned, become permanently established. 
AMERICAN APPENDIX.
771
  In aggravated cases of long standing, he relies but little on any
kind of treatment.   In cases in which there is a prospect of suc-
cess, the general health  must be  first attended to, and then we
must restore, says Mr. Stafford, "the muscles and ligaments of the
spme to their proper functions, which can only be done by bringing
them into use."  (p. 65.)
  In weakness alone of the spine itself, great benefit is derived from
the recumbent  posture, which, however, must be alternated M-ith
as much daily  exercise  as the patient can bear.  The habitual
vicious use of one limb, or set of muscles, must be corrected by
greater use of their antagonists.
  After the lateral distortion of the  spine, however, is confirmed,
then, Mr.  Stafford says, he has derived the greatest benefit from
lateral exercise, i. e., exercise of the muscles on the side of the spine
upon which the  curvature is situated.
  The machine  he proposes is a semi-circular wooden frame, simi-
lar to the rocker of a hobby-horse, upon which, by means of ropes
attached to pulleys in the wall  and to each end of the  rocker, the
patient rocks himself laterally, from side  to side, giving thus vig-
orous exercise both  upon the dorsal and lumbar curve.  But this
will not suffice M'hen the spine  is thrown greatly from its centre of
gravity, and when the contracted  and elongated muscles have
thereby both lost, in a great measure, their power of action.  Then
he uses a machine which he claims to have invented, which has
the effect to elongate the  spine  itself, by raising the body from the
ground by its attachments alone, and by counter-weights appended
to the hips.  This he calls the spine-elongator, (pp. 77-81,) and its
action better prepares the muscles for the later resumption of late-
ral exercise.  Objections might naturally  suggest themselves  to
Mr. Stafford's system of cure, from  the apparent impossibility, by
such means as he proposes, of  restoring a spine  which has under-
gone, by lateral  deviations, considerable organic  alteration in its
osseous structure. But the cures he relates of remarkable distor-
tions, if not over-colored, would seem to give positive certainty to
the superiority of his method, which we have deemed it right brief-
ly to notice, inasmuch as the tenotome certainly should in all cases
be avoided, if mechanical means can replace it.   (Vid. also British
and Foreign Med. Review, 1844, p. 225 et seq.)
  In the midst of the doubts, denials, and insinuations, which have,
within a year or two past, been promulgated at Paris, by M. Mal-
gaigne and others, in relation to the alleged successes of M. Guerin
in subcutaneous sections in general, and especially in dorsal, or, as
M. Guerin names it, rachidian  myotomy, (myotomie rachidienne) in
the cure of lateral  curvatures of the spine, it is M-ell not to lose
sight of the immense and  universally acknowledged successes of
this surgeon, at the earliest periods of torticollis, talipes, strabotomy,
dorsal  myotomy, (his own appropriate discovery,) and  when he
stood so distinguished, and above all others, that all seemed ready to
acknowledge that he had no competitor, and all vied M-ith each other
who should laud him the most.  This must not be forgotten when 
772           NEW ELEMENTS OF OPERATIVE SURGERY.

the tide of opposition, not  to say persecution, seems to set against
him.  Thus, in the year  1837, a commission, as M. Guerin says,
(Gaz. Med.  de Paris, Mai 4, 1844,  tome xii., pp. 294, 295,) com-
posed of seven of the most eminent members of the Paris Royal
Academy of Sciences, after sixty-three sittings of contradictory dis-
cussions and experiments, adjudged to M. Guerin the great prize
of surgery for his researches on deformities.  The following are the
concluding words of that Report: " After so many researches made
successively on the skeleton, the dead and the  living body; after
so great a number of observations, rigorously and severely inter-
preted ; after this crowd of new facts and new views on the differ-
ent parts of the  subject; finally, after such  numerous,  beautiful,
and  fruitful  (feconds)  results introduced  into  science  and art,
nobody will be surprised that the prize has been adjudged to this
remarkable work."  (Rapport sur le Concours pour le  Grand Prix
de Chirurgie, p. 22.)
  In respect to the direct assault of M. Malgaigne, (which we have
already referred to above,) made in a memoir to the Academy of
Sciences, April 15, 1844, and in a letter, at the subsequent sitting,
M. Guerin, in a  few remarks  in reply, made at the sitting of the
Academy, April  29, 1844, charges M. Malgaigne with gross mis-
representation, touching the failures of  M. Guerin  in  rachidian
myotomy.  Instead of twenty-four  cases  of  cures, and which M.
Malgaigne states that he  had examined and found  to be failures.
M. Guerin says that his table  of the cases treated by him, at the
Hopital des Enfans, comprised one hundred and fifty-five patients,
(not fifty-seven, as M. Malgaigne says,) of which tMenty-four were
cured, thirty-eight relieved, four not relieved, one dead, and ninety-
eight on whom the result M'as not ascertained.
  At the  present moment, when the great chief himself of subcu-
taneous surgery, M. Guerin, is the subject of such severe recrimi-
nations and  investigations before  the scientific bodies of Paris,
every thing that emanates from him awakens, in this country, where
he has so many ardent admirers, and where we look upon those bit-
ter controversies with pain, but without any bias  either way, a
peculiar interest.  In his very recent discourse  at the Hopital des
Enfans, of which he is one of the surgeons, and wjjich is entitled,
" Programme des Conferences sur la  Chirurgie Sous-cutanee" opened
at that hospital, May 22, 1844, "par le Docteur Jules Guerin," (vid.
his Gaz. Med. de Paris, Mai 25, 1844, tome  xii., p. 329 et seq.,) he
remarks that, notwithstanding  the  serious accidents of erysipelas,
phlegmonous inflammation, abscesses, &c, which have  been fre-
quently observed to follow subcutaneous wounds, which are never-
theless, in general, so  often unattended with the least danger, and
followed  by immediate  cicatrization, yet he has never, in all his
operations of sections of tendons, had a single case of suppurative in-
flammation resulting from them, though, as he says, he has operated
upon patients of " every age, in every condition of life, at the hospi-
tal, in the city, on the poor, the rich, or subjects that M'ere plethoric,
nervous, lymphatic, and scrofulous."  (Ib., pp. 329-30 )  To explain 
AMERICAN APPENDIX.
773
these anomalies, he repeats, therefore, the idea that he had already
promulgated, that:
  " 1. The immediate  cicatrization  of tenotomie  (tenotomiques)
wounds is effected without the aid of inflammation, and by means
of phenomena of a kind altogether peculiar, which I call immediate
organization.
  " 2. That this immunity of tenotomie wounds, and this immedi-
ate organization of the divided parts under the skin, are due to the
absence of the contact of air."  (Ib. p. 330.)  The same immunity,
he says, is not confined to tendinous tissues, but applies to every
tissue of the  animal  economy, divided under the skin with proper
precautions.   Thus to  the  muscles, aponeuroses, cellular tissue, the
arteries, veins, nerves, and even the bones, which,  as his experiments
prove, all organize  immediately, and without suppurative inflam-
mation ;  M'hile in the reverse circumstances of exposure to the air,
they inflame  and suppurate.   So also extensive  arterial or venous
effusions under the skin  are  absorbed or transformed, and produce
no trouble, nor the slightest reaction.
  M. Guerin  applied the same reasoning to  cavities containing
liquids;  for,  in fact,  (he says,) all the  tissues themselves may be
considered as an agglomeration of small cavities filled with liquids,
especially the  cellular tissue, of which the  others  are  but trans-
formations or amplifications.   This he proved also, by experiments,
in opening subcutaneously articular cavities, the chest and abdomen,
and collections of effused blood or serum.  He has not said, as they
have made him say, that suppurative  inflammation may be pro-
duced from the temporary passage or presence  of some bubbles of
air, (bulks d'air)  but from  the permanent communication of the
wounds with the external air.  Hence the striking and rapid cure,
so well known, of luxations, fractures, and all lesions without lace-
ration of the  teguments, as contrasted with the opposite state of
things.   Hence the innocuity of old collections of liquid, abscesses,
and effusions, until opened.   Subcutaneous surgery, then, thus ac-
quires hourly importance  from  the immense extent to which the
above general principles of M.  Guerin may be (and, as we have
seen, have already been, vid. supra) applied, viz., not only to all
the tissues, but to all the cavities, including, also, among  the last,
the cranium  as well as the  orbit; the last already illustrated, long
since, by M.  Guerin, in his  sub-conjunctival section  in  strabismus.
The modifications of contained liquid in the cavities must  also be
kept in view, i. e., whether arterial and venous, or serosity, lymph,
synovia, or pus, in a word, all the fluids of the  animal economy-
bile, urine, chyle, fceces, &c, normal or abnormal,  (lb. p. 330-31)
The difference of tissues also must be considered.  In the course ol
his inquiries, M. Guerin asks whether the  process of subcutaneous
immediate organization is similar to or the repetition of what passes
during the primitive nutritive organization in the  foetus
   Anart  from  the  chemical changes produced on the tissues and
fluids by the elements of the atmosphere, (oxygen, hydrogen, mtro- 
 774           NEW ELEMENTS OF  OPERATIVE SURGERY.

 gen, carbonic acid, and ammonia,) M. Guerin attaches much impor-
 tance to the temperature and pressure of the air.
   M. Guerin remarks, with great justice, (instancing the brilliant
 operation for strabismus,) that the eagerness of ignorant empirics,
 without any scientific knowledge of the great principles of subcuta-
 neous surgery, to share the honors of this triumph, have, by their
 failures and gross blunders, brought great discredit upon it.
   M. Guerin proceeds now to class subcutaneous operations under
 two great divisions, viz., sections  and punctures, the former bearing
 direct relation to the non-inflammation of tissues, the other to the
 unalterability of liquids.  (Ib., p.  332.)

                 1. Subcutaneous  Sections include :

   a. Skin :  the separation of the skin in adhesions and morbid cica-
 trices.
   b. Tendons ; for deformities, for old luxations, and for recent luxa-
 tions and fractures.
   c. Aponeuroses ; as an orthopedic means, or to liberate engorge-
 ments or effusions from  inflammation.
   d. Muscles ; as an orthopedic means, or to favor recent luxations
 and fractures; also for strangulated  hernia, and the radical cure
 of reducible hernia;  the  section of the  sphincter ani in cases of
 fissure, [for  years  past  practised with much success by Dr. Mott.
 —T.,] and for  the subcutaneous cauterization of muscles to effect arti-
ficial contraction.
   e. Ligaments ; as  an orthopedic  remedy, or to favor the reduc-
 tion of certain recent  luxations and fractures ; the cauterization oi
 stimulation (calefaction)  of ligaments, to shorten and strengthen them.
   f. Arteries ;  the subcutaneous scarification or cauterization of cer-
 tain fungous tumors ;  the obliteration of arteries by section, scari-
 fication, or punctures, and the subcutaneous ligature.
   g. Veins ; the subcutaneous  section  and scarification of veins, in
 varices, and the different varieties of this disease ; the ligature of
 veins.
   h. Lymphatic vessels and ganglions;  sections  of vessels as  an
 abortive treatment in buboes;  sections and scarifications of gang-
 lions that have been a long time  swollen.
   i. Nerves ; subcutaneous section of nervous trunks or branches in
 neuralgia;  the subcutaneous scarification of nervous filaments  in
 acute pains under the skin; [Hindoo acupuncture must have origi-
 nated from this principle—T.;] cauterization or stimulation under
 the  skin, of certain nerves  in  certain affections, as arthralgias, or
 other similar morbid conditions.
   j. Cartilages ; subcutaneous symphyseotomie.
   k. Bones; subcutaneous  removal of small exostoses, subcutaneous
 fractures for a morbid  callus, extraction of osseous sequestra, (es-
 quilles) and the  exsection of sharp fragments which, in recent frac-
 tures, threaten to protrude through the skin, scarifications of the swollen
 gorged extremities and surfaces of bones, cauterization or  stimulation
 of the same surfaces, extirpation of osseous tumors. 
AMERICAN APPENDIX.
775
                   2.  Subcutaneous Punctures.

  a.  In  commencing phlegmonous tumors, to arrest their develop-
ment, thus acting both on solids and liquids.
  b.  Puncture and evacuation of melicerous tumors, (loupes) with
scarification of the cyst.
  c.  Puncture and evacuation of cold abscesses.
  d.  Puncture and evacuation of abscesses by congestion.
  e.  Puncture and  evacuation of bloody tumors and serous collec-
tions [already anticipated by M. Velpeau's  recent operations on
bloody cysts, see  supra]  which are formed in consequence of sub-
cutaneous operations,  or  in consequence of severe  contusions, and
especially the cephalematomous, (les ciphalematomes)
  f.  Puncture and evacuation of hydrarthose tumors, [i. e., dropsi-
cal collections in the joints.]
  g. Extraction of foreign bodies from the articulations.
  h. Radical cure of hydroceles and haematoceles.
  i.  Puncture of the  cranium in hydrocephalus, [already  antici-
pated, years since, Mdthout any recognition probably of the prin-
ciple.—T]
  j.  Puncture and evacuation of hydro-rachidian tumors in newly-
born infants.
  k. The operation of empyema and puncture of the pericardium.
  1  Puncture and evacuation of tumors of the liver, of ovaries, and
other abdominal cysts.
  m. Among numerous other operations which may come  under
the  subcutaneous principle,  M. Guerin mentions the  Ccesarean,
though the remark may, he says, excite  surprise.

   As the Academy of Medicine have, so  to speak, virtually with-
 drawn their commission  of inquiry into M. Malgaigne's charges,
 and as the subject of subcutaneous sections in general, as practised
 by M. Guerin, was, previously to the action of the Academy, and
 is now, undergoing a rigid investigation by a learned committee,
 appointed, at M. Guerin's request, by the board of commissioners of
 hospitals at Paris, it is  ardently desired that the late animosities
 and controversies  on this subject in that  capital will subside, and
 that strict justice will be done to all the parties concerned.

 Flexion of the three last Fingers from wounding the Median Nerve
                 in the Right Arm, in Venesection.

   Dr   Marshall Hall presented a  case  of this  kind before the
 London  Medical Society, Nov. 7, 1842, in a young woman aged
 t£en£five.  He  effected a perfect  cure by " entirely  removing
 Matrix made by  the lancet and a ^^^^^
 The cure remained permanent until a ye" ait«^n ™e^l<£
 having: been again (very injudiciously if  not rashly) performed  in
 the  Tame arm'and In  a" neighboring ^^^^J^^
 Hall's  advice,) the retraction returned,   lhis second cicatrix was 
776
NEW  ELEMENTS OF OPERATIVE SURGERY.
removed M'ith  the  same good effect; but the cure has  not been
permanent, and the contraction of the fingers has again returned,
with a slight contraction also of the biceps.   Dr. Hall exhibited this
case as  a striking illustration of his theory of reflex nervous action.
By referring to Dr. Mott's case, and also to the remarks of M. Aelpeau,
in the text of this M'ork, it will be seen that the excision of the cica-
trix, and, therefore,  of the portion of the nerve imprisoned in it, ef-
fected a perfect cure of  the severe traumatic neuralgia M'hich the
state of the parts had caused.  Dr. Hall proposed, in his case, to cut
off  the nervous  communication with the spine, by dividing the in-
ternal  and external cutaneous nerves at their lower part, and  re-
moving a small portion of each.   The excision of the last cicatrix,
perhaps, was not extensive  enough, and the source of the contrac-
tion, probably, on both occasions of the venesection, was a strangu-
lated portion of a filament of one of the cutaneous nerves.—T]

                     M. Doubovitski's Case.

  As this case is much spoken of in the discussion  on tenotomy  in
the text, it may be  M'ell to state from his own memoir upon the sub-
ject,  (entitled  Section Sous-cutanee des  muscles pronateurs et des
muscles fiechisseurs  de  la main et des doigts.  Par  P. Doubovitski,
Professeur de Pathologie Externe a l'Academie Imperiale de St.
Petersbourg.  Vid.  also, Archiv.  Gen. de Med., 3e  ser., Mai, 1841,
tome xi., p.  100 et  seq.; also,  Annales de la  Chirurgie Frangaise
et Etrangire, No. 2, Fevrier, 1841,) that, for the retraction of seve-
ral muscles of the fore-arm, produced  by a  badly applied dextrine
bandage for fracture  of the inferior extremity of the humerus,
twenty-nine sections of tendons and muscles were performed upon
him by  M. Guerin,  at Paris.  The reunion,  however, took place in
seven only: 1,  the four tendons of the flexor digitorum profundus,
divided on a line with the phalanges;  2, in  the tM'o tendons  of the
flexor digitorum sublimis (fiechisseur  superficiel) of the index and
medius, divided on  a line with the first phalanges; 3, and in the
flexor longus pollicis.  The  action  of these muscles,  or extremi-
ties (chefs)  of  muscles,  is destroyed-   The deformity has almost
entirely disappeared.   In  respect  to the  movements, those  of
extension and  flexion  in the elbow, of pronation, supination, and
extension of the hand, have obtained a decided amelioration.   In
what relates to- the  fingers,  they cannot be  flexed against the
thumb ; for the  action of the sublimis and ^profundus is nearly lost.
  M. Doubovitski  deduced from this sad experience upon himself,
and from other experiments, that the retraction of the flexor muscles
of  the hand, of the  palmaris longus, and that of the flexor carpi
radialis, is easily cured.  We may cut the tendons of these muscles
with impunity  in the fore-arm.  The  retraction of these  muscles
may exist without  the retraction of the flexors of  the fingers and
pronators.   The disease is then  simple, and easily cured, and the
section may even be repeated several times.  The  disease is more
serious if there is,  at  the same  time, retraction of the pronators, 
AMERICAN APPENDIX.
777
and forced pronation.  We may in this case  cut the pronator radii
teres, but should we divide the pronator quadratus ?  In cutting only
one of these muscles the cure would not be complete.  If to these
retractions were joined those of the flexor digitorum sublimis, the
result would be the flexion of the  articulation of the first with the
second phalanges ;  but it is rare, if not impossible, that it can take
place without that of the profundus also.
  The section of the sublimis, whether  at the palm of the hand or
on a line  with the fingers, has not been folloM-ed with success.
M. Doubovitski has seen many examples of it; he had it performed
on himself, and the divided muscles have not reunited; and as to
the profundus, it would appear to him difficult, if not impossible,
to divide the  tendons  of this muscle  without forever destroying
their action.   The contraction of the thumb, in consequence of the
retraction of the flexor longus pollicis manus of this member, might,
it would seem, be cured by the section of this muscle performed at
the forearm; in his own person, however, the section did not have
this result.
  In fine,  M. Doubovitski thinks that in the above deformities in
the upper limb, viz., retraction of the pronator radii teres, of the
flexor  carpi ulnaris, the  palmaris  longus and flexor carpi radialis,
the flexor longus pollicis manus, the sublimis and  profundus, there
may be a prospect of success, in dividing at the elbow the upper at-
tachments of the pronator  radii teres, and the palmaris longus and
flexor carpi*radialis ; also, a part of the attachment of the sublimis,
and of the flexor carpi ulnaris, at the epitrochlea. Moreover, it is ne-
cessary to make at the forearm, at different  heights, the section of
the tendons of the flexor carpi ulnaris, of the sublimis, of the flexor
longus pollicis, and of the  palmaris longus and flexor carpi radia-
lis, (des petit et grand palmaires;) for the section of the attachments
of these two  last muscles, though complete, is not generally suf-
ficient. Finally, it is necessary  to sacrifice the  tendons of the
profundus, on  a line  with the second  phalanges.   All the other
sections would be injurious.
  " In acting thus," however, says M. Doubovitski, " the cure is not
complete :  the action of the profundus  is lost forever; the move-
ments of the wrist will be free, with the exception of  supination ;
the flexion of the fingers will be free, except those of the third pha-
langes."

 Contraction of the  Fingers of both Hands, from Contraction of the
                        Fascia Palmaris.

  Mr. C. Hawkins, surgeon to St. George's Hospital, London, in one
of his recent clinical lectures at that institution, (see London Medi-
cal  Gazette, May 31, 1844, p. 273, et seq.,)  exhibited the case of
a coachman set. thirty-nine, who  was  admitted into the  hospital
April 17 1844, with contraction, in a greater or less degree, of all
the fingers of both hands, but chiefly of the fore, ring, and little fin-
gers of the right hand.  The fascia in the palm of the hands was 
778
NEW  ELEMENTS OF OPERATIVE SURGERY.
very tense  and hard, and also the portions of the fascia leading
down to the metacarpal bones and the sides of the phalanges.
There was no anchylosis of any of the joints, but  a partial disloca-
tion of the second phalangeal joint of the ring finger of the right
hand, M'hich arose from the pressure of the fingers, in their bent po-
sition, against any thing the man tried to grasp.  The cutis  in the
contracted parts was much condensed and furrowed, and apparently
thickened.
  In this case (says Mr. Hawkins) the contraction  is  only  in the
palmar fascia, though, on first examining the hand, you might easily
suppose that the lines of hard substance which start up when you try
to extend the fingers, are the flexor tendons.
  Mr. Hawkins says he has seen this affection in the higher classes,
in whom the cause could not be, as Dupuytren avers it to be, viz.,
the holding or pressure of hard substances in the palm of the hand,
and therefore occurring among laboring people.  If  the opinion of
Dupuytren were  correct, Mr.  Hawkins  asks why the  contraction
should be confined, as it almost invariably is, to the  ring and little
fingers ; and why it should attack both hands, as in this case, which,
however, is not a common circumstance, for the two hands are very
differently  employed in his labors.  This man had some little con-
traction of the fore finger also, but it has nearly gone since he has
been in the hospital, and it is unusual.
  The remedy for this contraction (says Mr. Hawkins) is the divi-
sion of the portions of fascia which are affected;  and ft would ap-
pear to be  an effectual cure—if not, it can be repeated.   In  a case
he performed the operation upon two or three years since, the con-
traction returned, but only in a slight degree, which gave no  incon-
venience.  In the present  case the existence of  a gouty affection
had as yet delayed the operation.  He should, however, do it soon,
but only in one  hand first;  and upon reflection, intends to operate
as he had usually done, by direct incisions through the skin and sub-
jacent contracted portions of fascia, as he would thereby not only ob-
viate the danger  generally to  be apprehended from wounds  of the
plantar and palmar fasciae, viz., that from  confinement of matter,
burrowing along the  tendons of the muscles, but also the danger
arising from making so many cuts as will be necessary in this case,
viz., the division of the bands of fascia in the palm before its sepa-
ration to the two fingers, and also the probable necessity of making
an incision also opposite the joint of each finger with the metacar-
pal bone, and smaller cuts at  the side of each finger, all  of which,
if made upon the sub-cutaneous principle,  would be difficult, and
also incur  the risk of wounding the digital  arteries  and nerves, as
well as expose afterwards to  greater danger of suppuration, from
the necessity of extension on a hand splint.  If, therefore, the cuts
were made under the skin, the confinement  of the matter, should it
have formed, would be much greater, and  might do much harm.
In the open incisions he  proposes,  there will be, it is true, several
suppurating wounds, as a little lint must be put between their edges
to prevent their union ; but then, on the other hand, there will be 
AMERICAN APPENDIX.
779
no confinement of matter, and eonsequently no probability that the
suppuration will extend itself beyond the small cuts themselves,
which extension is much more dangerous than the open wounds
can be.  It does not appear, says  Mr. HaM'kins, that Dupuytren
met M-ith any mischief when he performed the operation in this
way, and he adds, " when I have done it myself, there was no  in-
flammation of any importance produced."   [Vid.  our remarks in
the text, supra, on the subject of contraction in the flexors of the
hand  as connected  M'ith intestinal derangement in children and
adults.   It is clear, from M'hat Mr. Hawkins says, and  what had
also been long known, that these contractions, m hether of the flex-
ors or of the fasciae, may certainly arise from some functional dis-
turbance, or lesion in the ganglionic and spinal centres  by which
they are supplied;  the further proof of M'hich  is seen in the cure
being accomplished as M'e have mentioned  supra, in the text, not
only by electro-galvanic  agents, but by general remedies directed
to the constitution, and Mdthout  the aid of mechanical or surgical
means.   It is doubtful, however, if after all, in cases like the above,
the sub-cutaneous section is not to be preferred;  and, in order to
prevent the dangers spoken of, limiting the  incisions to a few only
in number—in other Mords, making several  operations of the cure,
and aiding it progressively by extension.—T]

              Section of the Flexor Longus  Pollicis.

   Instances of the abnormal contraction of this muscle are seen in
what is called, in England, Scriveners spasm.   The division of the
muscle has effected  a perfect cure,  (see Mr. He)-, jun., in Trans, of
the Provincial Med. and Surg. Association, London, vol. xii., 1844, p
170;  also, Medico-Chirurg. Review, Lond., July, 1842.)
 DIVISION OF MUSCLES, TENDONS, &c, OF THE LOWER EXTREMI-
               TY.—SUB-CUTANEOUS KELOTOMY.

           Apparatus for excluding Air from Wounds.

  In a letter from M. Jules Guerin to the editors of the Paris Journal
des Connaissances Medico-Chirurgicales, (number for January, 1842,)
he justly complains of the attempt on the part of M. Bouchut, in
the number for November, 1841, to appropriate  to himself, in an
essay on sub-cutaneous kelotomy, (as the last-mentioned physician
names it,) the merit of having first devised or proposed sub-cutane-
ous sections for strangulated hernia.  M. Guerin (justly, as we be-
lieve) claims this  honor to himself.  Although, after the proofs that
are adduced in the text, (vid. supra, our abrege of the discussion on
tenotomy in the Paris Academy,) we cannot agree with M. Guerin
that neither the pathological principle nor the surgical operation of
making as small  a wound as  possible to exclude  contact with the
air had any thing to do,  in the mind of Hunter, with the sub-cuta- 
780
NEW ELEMENTS OF OPERATIVE SURGERY.
neous section, or with  any hope or expectation on the part of that
great surgeon, to prevent suppuration.   We doubt not that  to M.
Guerin alone is due the entire honor of having, as we have repeat-
edly expressed, first philosophically, fully, and lucidly explained the
principle of the sub-cutaneous section, and boldly and extensively
carried out and demonstrated, with his tenotome, its vast practical
application and utility.
  M. Guerin, in the letter referred to,  says:  " It is  nearly three-
years (see  his memoir on Plaies Sous-Cutanees  des Articulations,
read to the Academy  of Sciences  of Paris, May 4, 1840) since I
pointed out, in a very explicit manner, the liberation under the skin
of strangulated hernias, (le debridement sous lapeau des hernics elran-
glees) as among the possible applications of my method ; since that
period I have frequently called the attention of the readers of the
Gazette Medicate to this idea, and I finally myself put it in practice,
with complete success, on the 12th of July last," [i. e., July 12, 1841,]
(Journ. des Conn., fyc, loc. cit., pp. 25, 26.)  This case Mas com-
municated to the Academy of Sciences Aug. 7, 1841, and Mas pub-
lished in the Gazette Medicale Aug. 14, ensuing, and also in other
journals.   M. Guerin,  without calling M. Bouchut by name, asserts
that the kelotomy M'hich he (M. B.) proposes to substitute in  the
place of M. Guerin's, is  altogether too imperfect  and too danger-
ous to be attempted on a human subject.
  The idea, also, of M. Bouchut, of placing wounds in an apparatus
deprived of air, (i. e., in vacuo,) is, M. Guerin says, another appro-
priation of property which  legitimately  belongs to him.   So early
as in the year 1839, in the memoir read  by M. Guerin  to the Acad-
emy of Sciences in July of that year, on Plaies Sous- Cutanees, M.
G. thus expressed  himself: " The second  consequence which results
from the comparison of the phenomena of immediate reunion M'ith
those of the immediate  organization (Vorganisation immediate) of
sub-cutaneous wounds, is that the essential condition of this reunion
and of this organization is the same ;  which is to carefully protect
(soustraire exactement)  the surface of wounds from all  contact with
atmospheric air.   I will  not stop to point out the means of fulfilling
this indication; it is sufficient for the moment to establish it as a
principal and certain condition (cornrne condition capitate et certaine)
of a result which has occupied the attention of surgeons for nearly
two centuries."
  The dressing or apparatus which M. Bouchut describes as his
own invention, is, according to M. Guerin, precisely that which he
(M. G.) had employed for  a  long time, and which he has since
greatly improved.  He has, also, fully explained their principles in
his work entitled  " Essais sur la Mithode Sous-Cutane'e," published
in the beginning of the year 1842, and in his Memoire sur les Plaies
Sous-Cutanees, read at the Academy of Sciences, July, 1839.
   The division of the tendo-Achillis, in injuries to the knee or hip-joint,
causing retraction of the heel, was successfully performed in January,
1841, by Mr. J. Nottingham  of Liverpool, on a laborer who  had
fractured the thigh, and  injured, at the same time, the articulation 
AMERICAN APPENDIX.
781
of the knee, ending in a permanent retraction of the heel on that
side.  By the  division of the Achillis, the foot M'as in a very short
time restored  to the ground and to its uses. (Dublin Medical Press,
No. iii., Nov.,  1841.)
  A reversion  of the os calcis backward, following partial amputation
of the foot, was completely cured  by M. Hippolyte Larrey, by a di-
vision  of the  tendo-Achillis, (Seance de VAcad. de Mid., Nov.  9,
1841 ;  vid. Archiv.  Gen. de Med., 3e ser., Dec, 1841, p. 515.)

  Division of  numerous Muscles of the Thigh for Contracted Hip.

  Mr. R. W.  Tamplin, of London, in  a statistical report  (in the
Lond. Lancet,  April 1, 1842, p. 181, &c.) on distortions treated  at
the " Orthopedic Institution" in  that city, briefly adverts to his hav-
ing, in two cases of contracted  hip or flexion of  the thigh upon the
pelvis, with rotation inwardly, (one of which, we are left to  in-
fer, was a case of  morbus  coccarius) divided  the adductor longus
and brevis, pectineus, sartorius, tensor vaginae  femoris, rectus  fe-
moris, and a portion of the adductor magnus, " which allowed (he
says) complete abduction of the  thigh, and enabled  the patient to
flex and extend  it at will, the feet being brought nearer  to the
ground."   The details of these cases require to be minutely given,
especially that of the hip-joint  disease, before we can clearly com-
prehend the condition  of  the  parts, and the degree  of relief  ob-
tained.  Certainly,  the case  of morbus coccarius, if accurate, is
altogether one of  too unprecedented a nature in the present state
of orthopedy,  to  have merited only so laconic a notice from the
operator.

Division of the Tendon of the Triceps Femoris, of the Ligamentum Pa-
   tellce, and of the Triceps Cubiti, in ununited fractures of the Patella
   and Olecranon.

   These  sections have been  performed by Dieffenbach, and  the
fragments of  bone  afterwards occasionally rubbed together from
time to time, until union and restoration of the parts was in one or
two instances effected : but in other cases the operations were un-
availing, (see Casper's Wochenschrift,  Brit. § For. Med. Rev., and
also Lond. Lancet,  1841-42, p.  767.)

           Rupture of the Tendon of the Triceps  Femoris.

   This accident, by no means  a common one, and the history, na-
ture, and treatment of which are so correctly given  by our author
in the  text, recently occurred to a male  patient of M. Blandin,
(Journ. des Connais: Medico-Chirurg., Nov., 1842, pp. 203-204,)
aged sixty-eight, from making  a violent effort to escape a fall.  M.
Blandin, having used the dextrine dressing in the similar cases  of
fractured  patella, applied  it to this, but very prudently and judi-
ciously not until eight days after the accident, and when all the 
782           NEW ELEMENTS OF OPERATIVE SUnOERY.

tumefaction had disappeared.   First applying  the dextrine band-
age to the foot and leg, he forcibly raised the patella by means of
tongued  compresses, (compresses languettes) M'hile an aid pressing
on the thigh brought  the  upper extremity of the ruptured tendon
as nearly in contact as possible.  The  limb M'as held in complete
extension by a long splint  under the leg and thigh, and the M'hole
limb placed on  an inclined plane.  In twenty-five  to  tM'enty-six
days the dressings M'ere  removed.  The sub-patellar cavity Mas
filled up; but, as the new tendon did not seem sufficiently solid, a
new dextrine dressing  was applied for some further time.  In fifty
days the dressings were  removed, and the patient  marched per-
fectly well but for a slight stiffness in the knee.  This case is re-
lated  by M. Demarquay,  (interne,)  M'ho mentions  also  another,
aged about fifty, treated by Dr. Lebaudy.  The patient, rejecting
all kinds  of dressings or restraint  whatever, submitted to  have his
limb placed on  an inclined  plane.   The cure was, nevertheless.
perfect.  We  doubt very much the safety or utility of  bandaging
in these cases, least of all with the dextrine, (see text, supra.)

For Fractures  of the Patella, 6fC, which may be adapted also to Rup-
     ture of the Rectus  Femoris, or  of the Ligamentum Patellae,
M.  Baudens (vid.  Sitting of the Academy of  Medicine of Paris,
April  29, 1844,  in Gaz. Medicate, torn, xii., May 4, 1844, p. 296)
proposes a very ingenious fracture-box, open  above, like that for
fracture of the femur, but open also at its two extremities for the
passage of the limb.   It does not  reach beyond the middle of the
leg and thigh.   The middle portions of two pieces of bandage are
applied one above the other  below the  fragments of the patella,
and their extremities  fastened obliquely in the holes with which
the sides of the box are perforated.  The apparatus thus acts only
on the fragments, without  exercising  any circular compression on
the limb, and leaves perfectly free the popliteal space.  The force
may be graduated at pleasure.

                  Division of the Ham Sti'ings.

  Mr.  Wm. Coulson, Surgeon  of the  Magdalen Hospital, London,
(vid. Lond. Lancet, 1841-42, pp. 273, &c.,) says  the semi-tendinosus
and semi-membranosus appear to have been first divided in Eng-
land, either by Dr. Little or by Mr. Liston, about the year  1838,
(see Lond.  Lancet, June 23, 1838;  also Dr. Little's case  in the Cy-
clopaedia of Surgery, part iii., July, 1838,) but  Mdthout curing ihe
rigidity of the  knee.  The  tendon of the biceps, he says, had not yet
been divided [i.  e., in England] when this account was published.
About the year 1839, in a case of severe flexion of both knees from
rheumatism, in a  female, Mr. Phillips divided  the  biceps and the
semi-tendinosus and semi-membranosus in the right knee, effecting
a perfect restoration of the limb, (vid. Lond. Med. Gazette, July 20,
1839.) 
AMERICAN APPENDIX.
783
  On July 24, 1841, Mr. Coulson divided the above muscles and
some thickened bands on the inner side of the popliteal space, in a
girl of eleven years, who  had an enlarged rigidly-flexed strumous
joint.  This, followed by a modification of M'Intyre's splint, with a
screw-joint behind and a knee-cap in front, making gradual exten-
sion, effected a cure in five  weeks, leaving the limb perfectly straight.
  Mr.  Henry Symes, of Bridgewater, (Eng.,) also successfully  di-
vided the above three muscles in both knee-joints, in a woman aged
tM'enty-four,  in  M'hom these articulations had been for eighteen
months flexed rigidly at an angle of forty-five degrees.   The ope-
rations were performed Dec. 7, 1842, and on the  18th day, a suit-
able apparatus having been used, was removed, leaving the legs
perfectly straight, (Lond. Lane, 1841-42, p. 860, 861.)
  In 1841, April 16, Mr.  Geo. May, surgeon to the Royal Berks.
Hospital, Reading,  (Eng.,) successively divided the three  flexor
muscles (above) of the knees in a woman aged twenty-nine, and
succeeded perfectly in  straightening the limbs.   In another case,
(a groom, aged sixteen,)  for adduction of the right  knee inward,
interfering with the ability to place the sole  of the  foot on  the
ground,  he divided, Nov. 17,1840, the biceps tendon,  and effected a
perfect cure ; and the biceps again successfully, Feb. 2, 1841, in a
child aged two and  a half, (Lond. Lancet, 1841-42, p. 596.)

             Division of the Flexor Muscles of the Leg.

   In a case related in the Paris Journal de Medecine, (see Lond.
 Med. Gaz., 1841-2, pp. 810-811,) of a girl aged nineteen, who had
 the leg contracted at the  knee-joint  for eight years, and the mus-
 cles of the limb from its disuse thereby relaxed and atrophied, with
 swelling of the knee-joint and projection of the internal condyle of
 the  femur, the cure was effected by division of the  tendons of the
 biceps, semi-tendinosus, and  semi-membranosus, and by gradual
 permanent extension  for some months afterwards.  Mention is
 made in this case of there having been  some danger of wounding
 the  popliteal artery, on account of a cushion  of fat which surround-
 ed the tendons.
   [The  ham-strings, within two or three years past, have been re-
 peatedly divided, with entire success, by Dr. Mott, in adults as well
 as children, where  there had  existed for  a  long time  permanent
 flexion of the knee without anchylosis.—T]

                Section of the Tendons of the Ham.

   Mr W. Rhind, as early as 1841, (vid. Edinburgh Med. and Surg.
 Journ. of that year,) in a  case of a woman aged thirty, whose leg, in
 consequence of position and dressings for a contusion and ulcer at
 the  knee, had the flexors  of the leg so contracted as to oblige her to
 walk on the point of her  great toe, divided successively the tendons
 of the biceps, semi-tendinosus, senu-membranosus, and sartorius,
 which followed -by an apparatus for gradual extension, effected a 
784           NEW ELEMENTS OF OPERATIVE SURGERY.

perfect cure, and the normal position and movements of the limb,
on the thirteenth day.
                          CLUB-FOOT.

  Mr. M. H. Stapleton, one of the surgeons of the Jervis-street Hos-
pital, Dublin, claims to have been the first surgeon in Great Britain
M'ho divided the tendo-Achillis, Oct. 16,  1838, by the  method of
Strohmeyer, in the case of a male child aged about tM-o years, affect-
ed with varus equinus and a small bursa on the cuboid bone.  In
a month the child walked perfectly well, (vid. Dublin Medical Jour-
nal, vol. xv., pp. 405, 406.)
  Dieffenbach inclines to the opinion that the sheath of some of the
large tendons, and especially of the tendo-Achillis, is  probably so
relaxed naturally, (as Strempel's experiments on  the dead subject
would  infer,) that the tenotome transfixes without dividing it, M'hich
he considers a providential circumstance, as it must prevent exten-
sive diffusion of blood, aid in the restoration of continuity,  and
therefore favor the cure, (see Ueber die Durschneidung  der Schnen
und Muskeln, von J. F. Dieffenbach, Berlin,  1841, p.  12.)
  The frequency of club-foot is estimated at tenfold greater than
hare-lip, with which it sometimes coexists ; and, according to Dief-
fenbach, it occurs more frequently in boys than in girls, though the
latter  are  mOre severely affected.   But boys have the disease in
both limbs oftener than girls.   In comparing varus with pes equi-
nus, there are ten of the former to one of the latter.
  Dieffenbach and Jorg estimate the proportion of club-foot every-
M'here at about one in a thousand births.

  Division of the Tendo-Achillis in recent Compound Fractures and
                Dislocations of the Leg, Ankle, fyc

  In a case of this kind of fracture of the  leg, with considerable
projection of the bones, which could not be reduced on account of
the contraction of the muscles of the calf of the leg, M. Jobert ef-
fectually removed the difficulty by dividing the tendo-Achillis, being,
as far  as we are acquainted, the first case in which this operation
has been performed for that purpose, (see Bulletin de Therapeutique,
Paris; also, Provincial Med. Journal, (Eng.,) Aug. 6, 1842.)
  Mr.  Wm. Hey, jun., (Trans, of the Provincial  Med.  and Surg.
Assoc, vol. xii., London, 1844, p. 171,) says that he  has also derived
great advantage from a similar proceeding in a recent case of com-
pound dislocation of the ankle.   The dislocation was easily reduced.
but there was a strong tendency to displacement of the foot back-
ward ; I therefore (says  Mr. Hey) divided the tendons of the tibia-
lis  posticus and  flexor longus digitorum, which were  exposed by
the wound, after which there was no difficulty in retaining the limb
in a proper position.  [Here the divided ends of the tendons, though 
AMERICAN APPENDIX.
785
freely exposed to the air, appear, notwithstanding, to have suffered
as little of the greatly dreaded inflammation of those tissues under
such circumstances, as if the operation had been sub-cutaneous.


     Section of the Tendo-Achillis in Fractures of the Malleoli.

  The difficulty in these fractures, whether of the external or in-
ternal  malleolus, or  both, is  not to reduce the ends of the bones
which usually protiyide through the skin, but to keep them reduced;
that is, to maintain the exact coaptation of the fractured surfaces.
The consequence is, that profuse suppurations, tetanus, &c, thereby
induced, often necessitate amputation.  In a report upon this sub-
ject to the Paris Academy of Medicine, (1844,) M. Berard suggests
the propriety of division of the  tendo-Achillis.   He mentions that
in a fracture of  the leg, accompanied by dislocation of  the foot, he
had divided  the  tendo-Achillis and then placed the limb on a gut-
ter-frame of iron  wire, padded with  cotton, which allowed  the
wounds to be dressed with  the  greatest care.   This operation, he
says, has  been  performed by him three times; .and also about the
same time, in 184!?, by M. Laugier and by M. La Vacherie.  In all
the cases in which it had  been  performed, it had much facilitated
the reduction.   Some of the  patients  had  died, but owing to the
very serious nature of the lesions  which complicated the fracture.
In one case he had also divided the lateral peronei muscles.
  M. Velpeau agreed with M. Berard,  that the section of the Achil-
lis was calculated to render the reduction of  the fracture easier,
but thought that in many cases it was desirable that exsection of the
osseous extremities should also be resorted to, as the fracture is often
oblique, and then it was nearly  impossible otherwise to reduce it.
The muscular contractions, he remarked, which so often occur sub-
sequently in this form of fracture, were much less to be feared M'hen
the length of the bones had been shortened.
  M. Roux remarked, that the traumatic opening of articulations
was not as dangerous as was thought, especially when only opened
on one side.   He therefore considered it a very good plan to extract
a portion of the fractured bones, in extensive traumatic lesions of
the articulations.
  M. Gerdy mentioned a case of fracture of the malleoli, with pro-
trusion of the tibia, and dislocation and protrusion of the astraga-
lus, in which he extracted the latter bone and the patient recovered.
He apprehended great disadvantages from the exsection of the
osseous extremities at  the tibio-tarsal  articulation, as the foot re-
quired  so much  support on each side.  The section of the tendo-
Achillis he should advise only when there existed a state of muscu-
lar retraction which impeded reduction.
  He took occasion to remark upon what he deemed  a  prevailing
error, viz., that in fractures of the lower extremity of the fibula, the
foot was turned outward.  He had seldom seen this in the numer-
ous cases he had treated at  St.  Louis; and even when it was, he
                            99 
786
NEW ELEMENTS OF OPERATIVE SURGERY.
did not find  it necessary to carry the foot inward, but had ahvays
readily effected a cure by maintaining the foot in a rectilinear po-
sition, by means of the ordinary eighteen-tailed bandage.
  M. Roux agreed with M. Gerdy, that in the fracture of the fibula,
very slight means of retention were all that M'as necessary, and that
Dupuytren had evidently much exaggerated the importance of his
apparatus, (see London Lancet, April, 1844, pp. 7, 8.)

 Division of ihe Tendo-Achillis in certain  Cases of Luxation of the
                          Ankle-joint.

  The propriety of an operation of this kind has recently been the
subject of discussion at the Paris Academy of Medicine.   In a late
number of the Dublin Press, however, Dr. Halpin, as it appears, is
entitled to the credit  of having been, it would  seem, the first to
make this suggestion, (viz., in  January in the  year 1840,) M'hich
may, without doubt,  prove of considerable value in some cases of
luxation.  Nor can we perceive why the  same principle might not
be applied, as it had been M'ith eminent success  (years before Dr.
Halpin's suggestion)  by Dieffenbach to the shoulder,  (vid. sup.,) to
all other  irreducible, and especially to old luxations of the  knee,
wrist, &c, unless the danger of inflammation, and the severity of
the suffering, should  render it advisable, in some cases also of recent
luxation of the more  complicated articulations, to have recourse im-
mediately to so prompt a means of great relief, easy reduction, and
permanent cure, as this promises to be, and in fact is proved, as we
have said, by Dieffenbach, to have been in certain cases, (see Lond.
Lancet,  June,  1844;  also, Dr. Halpin, in the Dublin Press,  1844;
and the same  Journal, Jan., 1840.)
  Division of the tendo-Achillis for fracture of the fibula, with dislo-
cation of the foot outward, has recently been performed by M. Berard,
at Paris, (Lond. Lane, 1842-3, p. 557.)

   Division of the Tendon  of the Flexor Longus Digitorum Pedis.

  In contraction of the second toe, by M'hich it was recurvated up-
on itself, so that the  nail rested on the ground, Mr. George May, of
Reading,  (Eng.,) effected a perfect cure  by dividing the tendon of
the above-named  flexor, January 14, 1841, (Lond. Lane, 1841-42,
p. 597.)

                 Subcutaneous Incision of Joints.

   In  M.  Guerin's memoir on subcutaneous  wounds, (1840,)  the
author proceeds to show, by experiments on men and animals, that
the subcutaneous incision of joints is as exempt from danger as that
of tendons, muscles,  nerves,  and  small blood-vessels.  This  he
proved  on dogs, in opening the humero-cubital, the radio-carpal, the
femoro-tibial, and the tibio-tarsal joints;  the  wounds, if carefully
excluded  from air, always healing rapidly. 
AMERICAN APPENDIX.
787
  But if the joints were moved about, a synovial swelling usually ap-
peared around the wound, but M'hen they were kept quite  quiet and
extended, even this trifling accident did not supervene.  Admission
of air invariably caused inflammation and suppuration.
  Guarantied by these experiments, and by what is M'ell knoM'n to
happen after some severe dislocations, M. Guerin had then, in several
cases, divided the ligaments and portions of the capsules of the knees
and ankle-joints, and in none have unpleasant symptoms ensued.
  The wound in the integuments should be, he says, as small as pos-
sible, and far distant from that into the joint.  It should also be made
when the limb is extended, and never M'hen bent; and, lastly, the
joint should be kept perfectly motionless for some days afterwards.
  These two last  injunctions are the  more  necessary, says M.
Guerin, since he had discovered recently that, in all the movements
of the joints, their cavities become more or less enlarged, and  there-
fore that, as a vacuum is  thus formed, there is a strong tendency to
the suction of air, if any communication  exists without upon the
outer surface.
  M.  Guerin then gives the useful applications of such sections, in
serous, sanguineous, or purulent collections in the joints, the subcuta-
neous division of articular ligaments and capsules, with the view of
maintaining in a fixed condition certain  congenital and also some
old dislocations after they have been once reduced;  also the ex-
citing of adhesions, and  favoring  the formation of new articular
cavities.  [M. Guerin probably M'ould therefore use the subcutaneous
section, were it possible, in making  an artificial joint, in anchy-
losis at  the hip,  &c.  See Dr. Rodgers' case, supra, in  text.—T]
  M. Guerin says he has in this M'ay effected the cure of a congeni-
tal  luxation of  the clavicle,  which had  resisted every means, by
making numerous sections of the ligaments all around the displaced
joints.   [Herein we manifestly have the germ of the subcutaneous
principle, as  now beautifully applied by  M.  Goyrand and others,
to the destruction of bursal sacs, and  especially the expulsion of
foreign  bodies in the synovial articular cavities.  In conformity to
M.  Guerin's  idea, (well grounded, as M'e think,) that motion in-
creases these synovial cavities, would it not be well to avail our-
selves of this suggestion, to be better  enabled  thereby to protrude
these  synovial bodies into pouches of the capsular  membrane, and
thence into the neighboring subcutaneous tissues ?—T. See supra.]
(See Lond. Medico-Chirurg.  Journ., Oct.,  1840.)
  The subcutaneous principle, for  the  removal of a  ball, was  inge-
niously  and successfully applied, at La Charite, in March, 1841, by
M.  Velpeau,  (the author  of  this work,) in the case of a soldier,
wounded in 1813, and in  whom the ball lodged  about two inches
above the inner side of the articulation of the knee. The ball wns
pushed  upward  and outward, and  retained in that situation by the
fingers of an assistant.  A very small puncture having been  made
by a bistoury a short distance from the ball, the  tenotome was in-
troduced, and carried towards the ball, dividing thus the capsule
of the joint and  the superincumbent layers.  The ball immediately 
788           NEW ELEMENTS OF OPERATIVE SURGERY.

escaped to the external wound, which latter was then sufficiently
enlarged to enable  t to  fall out.   Before the ball was removed,
pressure was applied betM'een it  and the joint, notwithstanding
which half a glass of synovia flowed from the knee.   The patient
recovered perfectly, without the joint becoming  involved.  (Vid.
Gaz. Med. de Paris, Fev.  4, 1842;  and Annales de la  Chir. Frang.
et Etrang.)

          Subcutaneous Section in Congenital Luxations.
  M. Guerin, in a recent highly interesting memoir on the subject,
considers active muscular  spasmodic retraction  the cause of these
luxations, as of all  other articular deformities.   This  is further
illustrated by their frequent coincidence with congenital defects of
the nervous  system ; the  same as  is seen in striking signs of cere
bral or spinal disease in the dissection of monsters.
  If all  the  chief muscles round a  joint  are affected, the luxation
may be  complete; if only some, and late in fcetal life, it may be
only a sub-luxation;  if the direction only  is changed, a pseudo- luxa-
tion.  M. Guerin  has seen thirty different kinds of congenital luxa-
tion in the joints of the  spine, pelvis, clavicle, and extremities.
  Muscular retraction rarely produces more than the sub-luxation.
except in the very young foetus.  The complete displacement is then
effected subsequently by  the arrest of development in the retracted
muscle ; its physiological  contraction and the influence of gravity,
the same as all those influences, modify the character of club-foot.
curved spine, &c.  One of the first  effects of the muscular retrac-
tion is to prevent the proper development of the muscles it affects,
hence, the skeleton in the foetus  growing  faster than they do, the
partial becomes a complete luxation.
  The practical  rule of treatment, says M. Guerin, is, "that the
muscles of the fibrous tissues which are felt beneath the skin hard.
and strongly resisting the  replacement of the parts, must  be divided
by subcutaneous incision so as to remove those obstacles,  which are
otherwise insuperable  against the  application of  the mechanical
means necessary  for the reduction  of the dislocated bone and  its
maintenance in  its  restored position."   But M'e are to consider
that not only are  those  muscles shortened in which the  active re-
traction commenced, but those which by the dislocation  have their
insertions approximated, are  also shortened and passively retracted.
presenting nearly as great an obstacle to reduction as the first  set.
The first set, whose tension is further increased by the  growth of
the  bone  drawing upon  them, become thus  transformed into  a
tough fibrous structure,  which, however, is  rare.  In  the passively
retracted muscles, on the contrary, the common change is that into
&ifatty  tissue.  Those  muscles which, in the  altered position of
the  limb, have to perform forcible voluntary movements, become
simply hypertrophied.  In short, says M.  G., the rule  is this:  the
muscles that are  stretched become fibrous, those that are relaxed
become weak, then fatty, and those that have  to be much exerted,
hypertrophied. 
AMERICAN APPENDIX.
789
   The first are the chief obstacle to reduction, and their subcuta-
 neous division  is indispensable ; the  second and the third M-ill
 generally  yield to  extension without division.  The actively re-
 tracted,  M'hether fibrous or still muscular, must be divided ;  the
 passively retracted  may not require  more than stretching.  The
 arteries about a congenital luxation are always small and tortuous.
 There is, therefore, no fear of their being torn in attempts at re-
 duction.  The veins do not become so tortuous, but are always
 large and numerous.
   The nerves always go in a straight course, and are often so much
 shortened, as to constitute a considerable obstacle to the reduction,
 both by their  resistance and by  the pain caused by their extension.
 The cellular  tissue  is usually  abundant and loaded with fat, the
 skin elastic and exactly fitted to the subjacent parts, and neither
 of these are likely to form any obstacle to the reduction.
   The ligaments and capsules of the joints may be either elongated
 or shortened—shortened  by active  retraction, or passively, by the
 approximation of their  insertions,  when  the luxation has  taken
 place; or, when the  insertions are separated,  they may  yield,
 elongate, become thin and weak, and exactly adapt themselves to
 all the changes, in form and size, of the parts which they unite or
 enclose ; a circumstance in  which the original luxations may be
 always distinguished from those that result from external violence.
 There is  a condition  in  the capsule of the  hip-joint, when thus
 lengthened, which often exists,  and forms  an insuperable obstacle
 to the reduction of the dislocation, namely, that, as the head of the
 femur moves further from the acetabulum, the middle of the tube
 formed by the lengthened capsule is apt to become constricted, so
 as to produce  a  kind of hour-glass contraction.
   In addition to these  changes of  form, the ligaments, like  the
 muscles, suffer also  alterations of structure.
   In the  same  circumstances under  which  the muscles become
 fibrous, that is,  when  they are  kept tense and still, the ligaments
' become osseous; in those  in which the former grow fatty, the latter
 become weak and thin.  The degree  of alteration is  to be con-
 sidered in connection with the time the luxation  has existed.
   The head of the dislocated bone is  commonly much  deformed,
 but the changes are infinite.
   The head of the femur  is generally decreased in size, and so also
 is  the neck, in general; its sphericity is  lost,  and generally its
 cartilage  is almost or completely destroyed, becoming dry and
 grayish, and then  gradually diminishing in thickness.  When the
 head is so placed  as to become continually pressed against  the
 border of the  cotyloid cavity, or against any  firm surface, it com-
 monly soon receives a  corresponding impression; and a similar
 influence  of local pressure often gives rise to changes in the re-
 lations  of  the head and neck  to the shaft of the bone, the latter
 becoming shorter and more horizontal than is natural.
   The articular cavities, such as the cotyloid, for example, in most
 cases undergo  changes exactly proportioned in  degree to those 
790           NEW ELEMENTS OF OPERATIVE SURGERY.

of the heads  of the  bones displaced from them.   They become
smaller and more shallow, and are sometimes almost  obliterated
by the elevation of their bases, and the production of an excessive
quantity of cellular and adipose tissue within them; such are  the
changes where the luxation is complete.
  The equality of the above changes may facilitate  reduction, but
are obstacles  to  its maintenance.   The  exception to this equality
in the  change of structure does not  exist  M'hen the head of  the
bone, escaping from its capsule, has come in contact with another
osseous surface, so as to be constantly rubbed and pressed upon it;
for then a new joint is always found between  the  two  surfaces,
and  the dislocated head  retains or acquires the same size as it
M'ould have had in the healthy joint.   Both in respect to the bones
and  articular  cavities, the muscles, and  other tissues, the earlier
the attempt at reduction is made, the  greater is the  probability of
success, for  the changes are then less, and less  fixed in their rela-
tions.
  The alterations often extend from the luxation over all the neigh-
boring parts of the skeleton.  The treatment for congenital luxa-
tions embraces: 1. The preparative extension of the retracted mus-
cles ;  2. The sub-cutaneous section  of  those which the mechanical
extension  has not sufficiently  elongated; 3. The continued exten-
sion of the retracted  ligaments, and, if this be not  sufficient, then
sub-cutaneous division; 4. The usual  manipulations for reduction
adapted to each case ;  5. A proper consecutive treatment to con-
solidate the reduction, and then,  by passive motion, to complete
the coaptation of the  articular surfaces, and to restore  the normal
movements of the joints, (vid. Recherches  sur les Luxations Congeni-
tales, par le Dr. Jules Guerin, Paris, 1841 ; also, London Lancet, 1841
-42,  pp. 513, 514, 515',  vid. also, Remarks of M. Guerin, supra.)

The Sub-Cutaneous Section for Psoets Abscess, Buboes, Ganglia, and
  for Melicerous, Adipose, Atheromatous, and Steatomous Tumors.

  It  is well known that  the great principle of the  sub-cutaneous
section was long since insisted  upon in psoas and all large abscesses.
Mr.  Watt, of Glasgow, (according to Professor Hunter of that city,
—see Lond. Med.  Gaz., 1840-41, p. 21, et seq.,) has introduced this
practice for buboes, making the first puncture through the skin with
a narrow lancet, then by a grooved needle  introduced into this
puncture, he carries the point of the latter to the abscess, perforates
it, and  thus discharges as much of  the contents, and as frequently
as may be desired, keeping  the external aperture in the  intervals
closed by gold-beater's leaf.   Prof. Hunter says very truly, perhaps,
that unseemly cicatrices and intractable sores are thereby prevent-
ed ;  but there  are certainly, in our opinion, and practice confirms
it, sub-cutaneous  purulent collections  in the groin and elsewhere,
and  which are caused  generally by mercurialization, whether  the
lymphatic  glands are involved or not, which demand  free dilata-
tion that they may granulate  from  the bottom, and which are thus 
AMERICAN APPENDIX.                   791
far  more speedily and healthily cured by the stimulus of the air.
These will be found (as  M'e have  stated above  in  the text) more
especially in old mercurio-syphilitic cases.
  Prof. Hunter also asserts that Dr. Cumin, formerly of  Glasgow,
was among the first  to recommend the sub-cutaneous section in
ganglia and melicerous tumors, by means of a cataract-needle, and
then pressing  the fluid into the surrounding cellular tissue.   Prof.
Hunter advises, in addition, to break down the cyst, as now gener-
ally recommended.
  He also ingeniously proposes (as we have already ourselves sug-
gested above) the sub-cutaneous section for adipose, aetheromatous,
and steatomous tumors, by the cataract-needle, so as to destro}' the
cohesion of the parts and break up the cyst.  Mr. George Macleod,
of Glasgow, some years since stated that he had succeeded, in this
manner, in dissipating tumors of the eye-lids.

     The Sub-Cutaneous Section for Bursal Tumors, Cysts, 8fC

   M. Velpeau, in a late essay, has drawn more particular attention
to this new mode of dispersing these inconvenient and often serious
enlargements.   This  practice, as  I have hinted in the  text, (vid.
supra,) goes to revive the ancient but so often completely success-
ful method of sudden immediate rupture, and often total  dispersion
and destruction of these cysts by sudden percussion.  M. Velpeau's
treatise, however, is more especially limited  to the utility of this
process in sanguineous  tumors, (De la rupture ou de t'encrasement
sous-cutane des tumeurs en general, des tumeurs sanguines en par-
ticulier,—vid. Jour, des Connais. Med.-Chir., Jan., 1844.)
   The value of this principle of rupture is  of course founded on the
long-recognised and well-established  pathological principle of the
innocuousness and safety of M'ounds sheltered  from  contact  with
the air, and its successes corroborate  to the same degree the phi-
losophy and truth of the sub-cutaneous section of tendons, muscles,
bridles, &c.   Bloody tumors (des tumeurs  sanguines) are also in-
stantaneously  cured by  M.  Velpeau, by rupturing or crushing
them, [i. e., without, of course, breaking the skin,—T.,] though they
 may be of the size of an egg, or of the wrist.  No dressing  is re-
 quired.  The steady downward and utmost pressure of  the thumb
 on a prominent point of the tumor, is all generally that is required,
the part affected being placed on a solid plane.   If this pressure
 does not suffice, a plate of wood on the tumor, and a stroke of  a
 mallet, &c. on this, will answer.  If any bumps remain, these are
 to be also crushed.  Bloody  tumors in accidental cavities are  more
 curable than those in natural ones.  The cure requires (M Velpeau
 thinks) that the contents of  the tumor, thus dispersed in the cellu-
 lar tissue, should be easy of assimilation.  The synovial cyst, though
the only one which for ages has been subjected to this  treatment,
  s the least favorably disposed to it of all; for in  these the walls
 of the cavity, unless compression is used subsequently, will not ad-
here and  thus the tumor will be reproduced.   The same remarks 
792           NEW ELEMENTS OF OPERATIVE  SURGERY.
apply to serous tumors.   The melicerous (meliceris) and  the sL ato-
matous are refractory, and if burst, the infiltrated matter may ex-
pose to suppuration and erysipelas.   [We have not generally found
the enlarged bursas, as we have noted in the text, require any other
treatment than sudden  forcible percussion, in some cases to be
slightly repeated, in order to crush  the remaining irregular small
lumps or fragments of the cyst into which the principal one now
seems to  be broken, but which in fact are, most probably, caused
by the infiltration of the synovial fluid into the neighboring sub-cu-
taneous cellular tissue.   Compression by a roller bandage, or spi-
ca, to the joint for example, or merely long strips of adhesive plas-
ter, properly arranged and made to encircle and embrace the part
closely, should there be no irritation existing from the blow, should
be applied to the part for some ten to twenty days.—T]

                  M. Guerin's Great  Operation.

  This master-operation in sub-cutaneous surgery having been fre-
quently alluded to by us, we  shall, for greater accuracy, here trans-
cribe the  operator's own account  (from his  Gazette Medicate of
Paris, Sept.  5. 1840) in a letter, Aug. 31, 1840, to the Paris Acade-
my of Sciences.  M. Guerin makes the number of forty-two tendons,
muscles, or ligaments, requiring twenty-eight openings through the
skin.  The following were the parts divided :—
  Trunk,  .  . . .—Pectoralis major,........1
                f On each side Biceps cubiti,.....2
                     "     "   Pronator teres,  .... 2
  The arms, . .-(     "     "   Extensor carpi radialis,   . 2
                     "     "   Flexor communis sublimis, 2
                l^    "     "   Palmaris brevis, .... 2
                (Tendons of the Extensor carpi ulnaris on
                                  each side,  .... 2
  The forearms,-^     "     "   Palmaris longus and bre-
                                  vis, .......4
                     "     "   Abductor pollicis, ... 2
                rThe Sartorius — on each side, .... 2
                     Biceps cruris      "     .... 2
                     Semi-membranosus "     .... 2
                     Semi-tendinosus    "     .... 2
                     Rectus femoris    "     .... 2
                     Fascia lata        "     .... 1
                ^External lateral ligaments of the knee, . 2
                rThe Tendo-Achillis — on each side, .  . 2
                     Tibialis anticus    "     "     .  . 2
                     Extensor communis      "     .  . 2
                     Extensor proprius pollicis "    .  . 2
                     Peronei antici            "    .    2
The legs,.  . .<(
The feet,
42 
AMERICAN APPENDIX.
793
  M. Guerin, in his Gazette Medicale for May, 1840, states that he
had then already performed upward of a thousand operations for the
section of muscles or tendons in different parts of the body ; which
(see  supra) up to this time (1844) have been swelled to the number
of upwards of four thousand.  The following is his catalogue up
to May, 1840, (including, no doubt, in this number the  sections in
his great operation—vid. supra:)
   1.  In the neck—the  sterno-mastoideus, cleido-mastoideus, trape-
zius, angularis  scapulas, splenius,  complexus  colli, and cervicalis
descendens.
   2.  In the back—the trapezius, (along its entire attachment to the
scapula,) rhomboideus, (along its entire attachment to the scapula,)
dorsalis magnus, sacro-lumbalis, longissimus dorsi, and transversa-
lis dorsi.
   3.  In the upper extremities—the  deltoideus,  biceps, supinator
longus, radialis anticus, ulnaris anticus, flexor sublimis,  and exten-
sor digitorum communis.
   4S In the lower extremities—the psoas and iliacus, (psoas iliaque)
adductor-longus, sartorius, rectus anticus, tensor vaginae, glutei bi-
ceps, semi-tendinosus,  semi-membranosus, rectus internus, tendo-
x\chillis, tibialis anticus, tibialis-posticus, flexor communis longus
et brevis, extensor longus communis, extensor pollicis, peronei an-
ticus et laterales, plantaris, adductor  et abductor digiti minimi.
   5.  Aponeuroses—fascia lata, and plantaris.
   6.  Ligaments—sterno-clavicular, scapulo-humeral, coxo-femoral
lateral of the knee, tibio-astragular, lateral and posterior astragulo-
scaphoid  capsule, and  scaphoido-cuneiform  scapulas.   [Vid.  also,
London Medico-Chirurg. Review, for October,  1840.  See  Dr.  Dar-
ling's table of French and English  names of the muscles of the
human body, in the beginning of this volume.—T]

Proposed  Division of the Hyoglossus  and Styloglossus Muscles for
                   Stammering, by M. Velpeau.

   At the  time the section of the genio-hyoglossus  (now mostly
abandoned) for this infirmity was first attempted in practice, by
MM. Dieffenbach, Amussat, Velpeau, and others, the  last-named
surgeon, at  a  sitting of the  Paris Academy of Medicine,  Feb. 16,
1841, in speaking of a case in which he made the sub-mucous  divi-
sion  of this muscle, says, that inasmuch as the defect of pronuncia-
tion, or stammering, seems to be owing sometimes to one muscle,
and  sometimes to  another, it might be advisable  to divide also the
hyoglossus and the styloglossus, or even to cut off the  apex of the
tongue   M. Gerdy could not, he said,  rely on the section  of the mus-
cles, as the infirmity did not depend on an inability to pronounce
the vowels and consonants when they are isolated, but upon an in-
ability to  unite  them together so  as  to pronounce the words  con-
secutively.  The lips, teeth, and tongue, and the apex, middle, and
base of the last, and the velum palati, exact for each sound nearly,
varied movements, which do not depend on any one muscle taken 
794
NEW ELEMENTS' OF OPERATIVE SURGERY.
separately.  Therefore, the  section of this or  that muscle cannot
cure stammering, (Archiv. Gen. de Med., 3e ser., torn, x., Mars, 1841
p. 359.)

  Contraction of the Limbs in inflammatory softening of the Brain.

  In ten cases examined by Dr. Hughes Bennett, lesions of the cen-
tral part of the brain, on one side, were discovered. The symptoms,
during life, consisted of contraction or paralysis of the extremities
on the side opposite to the disease.  In six cases there Mere lesions
of the central parts on both sides; symptoms  during life, contrac-
tion  or paralysis on both sides  of the body.  In four cases, lesions
of the peripheral parts only existed ; this group was characterized
by the absence of paralysis or contraction of the extremities, and
by either delirium or coma.   This  paralysis seems favorable to the
hypothesis M'hich ascribes motion and sensation to the central parts
of the brain—intelligence to the surface.
  This subject  has, within a few years, attracted much inquiry in
the more exact investigations M-hich have been made of the anato-
my of the brain, spinal marrow, and  nervous system  generally;
some contending  that  more or less rigidity and contraction of the
muscles always exists, others, that it  is merely  incidental, or not
at all  present.   Dr. Bennett, however, is of opinion that, in idio-
pathic inflammatory softening  of the brain, contraction in one or
more limbs is a common symptom.  In simple hemorrhage into the
brain, on  the other hand, without the existence of any inflamma-
tion, contraction seldom if ever occurs. (See Lond. Medico-Chirurg.
Review; also Lond. Lancet, Sept. 7, 1844.)
  It  has been generally remarked, for many years  past, as  I am
informed  by Dr. John L.  Vandervoort, of this  city, that, in the
practice of the New-York Hospital, M'ith M'hich he has been long
conversant, patients in whom there existed a ramollissement of the
brain ending in idiocy, almost  invariably manifest a constant in:
clination  to place themselves upon the breech, and to draw up
their legs  under them, until more or less permanent  fixed contrac-
tion  is finally produced.
  It  is important that the  precise relation of cerebral or spinal
lesions, or both, with  contraction  of  the  limbs,  a subject M'hich
near two centuries since elicited much inquiry, and more recently.
in our own times, has been ably elucidated by Delpech, (see text of
our  author, supra,)  should  be clearly ascertained  by still more
accurate investigation and experiments.  For all this class, at least,
of contractions  of the muscles, seem destined to become a forbidden
domain, whose  limitations present an almost insuperable barrier to
the prospect of success from the use  of the tenotome—a class of
irremediable deformities, therefore, which should be most carefully
discriminated  and diagnosed from those in which  subcutaneous
sections are indicated.—T.] 
AMERICAN APPENDIX.
795
Diseases to  which the  Subcutaneous  Mode  of Operating may be ex-
                            tended.

 t U?dSrthis title' Prof- Hunter> of  Glasgow, (in an article in the
Lond. Med.  Gaz., 1840-41, p. 22,) sanguinely predicted, as long ago
as at that time, that this principle would,  perhaps, be one day ex-
tended :
  1. To inflammations of fibrous membranes  of the body, perios-
titis, &c, wherever situated, in order to relieve the  intensity  of
congestion,  pain, &c, which, in fact, was an ancient practice, with
this difference, that it  involved the skin.   The principle, however,
is more rigidly carried out in the acupuncture of the Orientals, in
rheumatism, &c.
  He would particularly suggest this section in periostitis, parony-
chia, and other diseases implicating the white  fibrous membranes.
  2. In inflammation of the skin itself, phlegmonous, circumscribed
erysipelatous, scarifying the  parts subcutaneously;  also in cutane-
ous eruptions.
  3. In hydrops articuli, and purulent  effusions  into the joints, as
in hydrocele.
  In reference to the dread  of air in the joints,  he  says: " I have
seen M. Jules  Guerin  frequently cut across the lateral ligaments
of  the  ankle and knee, and penetrate these  articulations, in his
subcutaneous treatment of  deformities of these joints, and in  no
instance did the slightest bad  consequence follow.  Guerin, in his
lectures, states that he is in  the daily practice of performing such
operations, and that his  practice is not only free from danger, but
eminently successful."  This practice, however, he  remarks, re-
quires the utmost  caution,  and the smallest  possible apertures ;
and that  the apertures in the skin and  capsule should be as far
apart as possible.
  In ordinary  tapping for dropsy, Prof. Hunter recommends that
the subcutaneous principle be  closely adhered  to.  This, we think,
would be a great improvement on the ordinary mode with the
comparatively clumsy trochar.  He advises a small trochar  to be
carried for some distance under the  skin, before the  cavity is pene-
trated.
  4. In varicose veins, he  thinks this section by a cataract-needle
would be an improvement, as the ligature  is apt to cause phlebitis.
This suggestion is confirmed, he says, by the less danger of the liga-
ture, when applied to these veins subcutaneously ; and we may here
refer to a further recent corroboration, in a remarkable cure of a
goitre, at Paris, by this same principle.  (See account of this  mode,
infra, from the late edition of M. Malgaigne's Manuel  of Operative
Surgery.)
  In support of Prof. Hunter's proposition, M. Ricord, of Paris, is
cited, as having twelve times applied the  ligature  for varicocele,
with perfect success.
  5  Finally, in neuralgia, the  professor also suggests the subcuta-
neous section, especially in the division of  the fifth pair, to prevent 
796           NEW  ELEMENTS OF OPERATIVE SURGERY.

disfiguration as much as possible ; and in the event of the infra-orbi-
tal and  mental branches being concerned, he  recommends intro-
ducing small dividing instruments through the  mucous membrane
of the mouth.—[See M. Guerin, in text, supra.]
               ANAPLASTIC  OPERATIONS.

                      BLEPHAROPLASTY.

  Among those German surgeons who were the earliest after Dief-
fenbach  in the successful treatment of loss  of  substance in the
eyelids, by plastic operations, we have  to  mention MM. Beck,
SchM'cerer, and Burow, of each of M'hom a successful case is given,
in Von Ammon's Monatschrift, Bd.  1, Heft. 1. (See also Archiv.  Gen.
de Med., nouv. ser., tome v., Nov.,  1839, Paris, pp. 368, 369, 370.)
  Case 1. That of Professor Beck.  The  patient, a robust man,
aged thirty years, had a cancerous ulceration in the inner angle of
the eye, with ectropion,  and  ending in  total destruction of the
lower lid.  Prof. Beck, following the method  of Dieffenbach, made
two incisions from the commissures of the lids, one above and out-
wardly, the other  above  and inward, so as to include in the lower
flap all the parts  degenerated towards the temple and nose.   The
upper lid, on a  line with those two incisions, was dissected  to a
small extent.  Two new incisions, setting out from the external
and internal extremities  of the first, and uniting below upon the
cheek, at an  acute angle, so as to  form M'ith the palpebral border
of the lower lid a triangular flap, allowed the opportunity of re-
moving the altered tissues, one portion of M'hich, deeply seated in
the inner angle  of the eye, had to be dissected with care.  A  new
incision was then made horizontally from the outer angle of the
eye towards the temple, and prolonged to an  extent equal to that
of the base of the  bleeding triangle ; the  flap included by this and
another incision,  directed  downward and inward towards  the
cheek, was dissected with caution, and placed upon the triangular
space  formed by  the loss  of substance, which  it  exactly filled.
This flap was first attached at  the inner angle of the eye by means
of a suture, the needle  being directed downward and  outward,
upward  and inward; afterwards it was attached at  the outer
angle and base. A complete union and cicatrization of the wound
of the cheek were effected at the expiration of some weeks.   Per-
ceiving then that  the external palpebral commissure had too much
extent, an incision was  made  at  the outer angle of the eye, and
the conjunctiva drawn  and attached by suture, upon the upper
border of the solution of continuity, making  a continuation  with
the upper lid, while a layer of cellular tissue was applied to the
lower  border.  The separate cicatrization of  those two  borders, 
AMERICAN APPENDIX.
797
and their adhesion to the parts with which they had been placed
in contact, fully carried out the objects of the surgeon and effected
a complete cure.  The lids now had their normal extent and direc-
tion ;  the lower was not inverted by entropion, its free border was
pliable, and  in no way impeded the ball by its contact.  The cica-
trix on the cheek was scarcely visible.
  Case 2.  That of Prof. Schwcerer. A scrofulous tumor on the free
border of the upper lid of the right eye of a child aged  nine years,
produced excessive  pain  and severe inflammation of the conjunc-
tiva.  The tumor attained the size of a nut, and was accompanied
with an ichorous bloody discharge  of a cancerous character.   The
base and inner fourth of the lid were sound, while  outwardly the
degeneration extended to the palpebral commissure.  The  pro-
fessor made an incision  above the free border of the lid, to the
extent of the three outer fourths of its length.  The two extremi-
ties were united by a second incision which was curvilinear, with
its concavity downward, and  comprising all the degenerated por-
tion, which was completely removed.  To supply this  deficiency,
a flap, setting out at the outer angle of the eye, was cut above the
eyebrow, and placed between the  lips  of the wound.   The union
was effected by second intention, and the cure was complete.   The
new eyelid was well formed and moveable.
  Case 3.  That of Dr. Burow, of Koenigsberg.  A venereal affec-
tion of ten  years' standing, in a  man aged  fifty-four years, had
destroyed  many of the bones of the face, and caused obstinate
ulcerations,  M'hich  produced much mischief  to the left eye, and
total destruction of its lower lid, with the exception of a small por-
tion, which  remained undiseased, at the inner angle, but which
was in a state of ectropion, and so much drawn down that the con-
junctiva  was  completely everted, (didoublee)   The upper lid  at
the outer angle was also drawn downward  by cicatrices in the
same  manner.  The globe of the eye was the  seat of a permanent
inflammation.  Dr. Burow, adopting the method of Dieffenbach,
with some modifications, first  excised a great portion  of the  con-
junctiva which was altered, leaving  thus a bleeding  surface ex-
tending from one angle of the  eye  to the other, then cut upon the
cheek a flap, whose pedicle  was  towards the nose, and, having
adjusted it in its place, fastened it by three twisted  sutures.   The
cure was complete on the fourteenth day, and the new  eyelid per-
fectly fulfilled its functions.
  A new and rather ingenious process in blepharoplasty for ectropion
was proposed  by  M.  Berard, jeune, at the sitting of the Paris
Academy  of Medicine, Nov. 2, 1841. (Vid. Archiv. Gen. de Med.,
3e ser., tome xii., Nov., 1841, p. 387.)   In the removal of a cancer
from  the  cheek of  a  female  patient,  two years before, he  M'as
obliged to destroy the canal of Stenon.  Cicatrization, however, took
place  without a salivary fistula.   The retraction of the  cicatrix,
hoM'ever, produced a traction and eversion of the outer  part of the
eyelid on that side.   M. Berard made a vertical incision at a centi-
metre  from  the outer angle V the  lids, and three to four centi- 
798            NEW ELEMENTS OF OPERATIVE STl'.OEP.Y.

metres in length; the inner lid M-as detached from the cheek-bone,
and the lids thus liberated assumed their normal state.   He took
his flap from the temple, and reversed it upon the vertical wound.
The operation Mas successful,and the ectropion disappeared almost
entirely.  The woman having afterwards died of a visceral affec-
tion, the autopsy showed the union of the flap to  the tissues to
have been complete.  The absence of a salivary fistula after the
section of the canal  of Stenon, M-as explained by the transforma-
tion  M'hich  the parotid gland was  found to  have undergone into
adipose tissue.   This may have taken place after  the  section, or
before, in consequence of the cicatrix of the cancer.

                New Suggestions for Rhinoplasty.

  Mr. William Keith, one  of the surgeons of the Royal Infirmary,
Edinburgh, dissatisfied with the shrivelled, unnatural, and bloodless
character of most neM' noses, proposes, as practised by him  in a
recent operation, (See  Cormack's Lond. and Edinb. Month. Journ.
of Med. Science, Feb., 1844.) to make the pedicle of the  flap not
only unusually broad  and thick, (say fully one-third of  an  inch
M'ide,) but also to leave it undivided, and to agglutinate permanently
to the cutaneous tissues beneath it, in order to have a better circu-
lation  and more nourishment to the flap.  This latter result was
effected, as had been previously recommended by others, (vid. text,
supra.) by causing the pedicle to adhere to the root of the nose by
rawing, (i. e., abrading,)  by means of cantharides plaster,  the two
opposing surfaces.  This plan  of bringing the cutaneous  abraded
surfaces of the  pedicle and root of the  nose together does not, to
us, appear as well calculated to effect extensive  vascular inoscula-
tion as that which has been proposed, of cutting out for it a suitable
groove on the root of the nose under the pedicle, and fastening it
or imbedding it there in the bloody tissues. (Vid. our author in the
text, supra.) This nose, however, of Mr. Keith's construction was,
he says, full, plump, and prominent several weeks after the cicatri-
zation and attachment were complete.
  It  came near  being frozen one cold night, as the  operation was
imprudently performed in winter.

                 Cheiloplasty in Cancerous Lips.

   Should the degeneration of parts be so great on the lower lip, for
example, as to involve the muco-buccal membrane, and prevent our
adopting the new method of M. Serre, of Montpellier, (vid. our no-
tice  of his  recent excellent  work, infra,)  viz., dissecting off that
membrane to cover the border of the new lip, we think it might be
advisable in some cases  to follow a mode practised in 1841, (April
5,) by Professor Andrew Buchanan, of the University of Glasgow,
(see Lond. Lancet, 1841-42, p. 79-82.)  The carcinoma being re-
moved from the lower  lip by an elliptical incision convex doM'n-
ward, and extending from commissure  to commissure, the loss of 
AMERICAN APPENDIX.
799
substance was restored by taking two flaps from the chin, each
bounded by a curvilinear incision,  M'hich began at the median
point on the border of the cut lip,  and slightly curved as it pro-
ceeded dowmvard to near the outer side of the indentation on the
chin.  From this last point a longer and straight incision, being the
exact radius to the curvilinear, extended outward  and upward to
near an inch from the angle of the mouth. These flaps, dissected off
and  rotated on their radii, exactly  filled up the  space  left, and
formed an excellent lip, so that " a perfect mucous membrane" says
Prof. B., " lined the upper margin and inner surface of the flaps form-
ing the lip."  The flaps were secured by the  twisted suture, adhe-
sive plaster, and bandage.   Two narrow triangular spaces, pointing
outward, were left on each side the depression of the chin, in place
of the flaps removed.

Early and successful Operation for Geno-Cheiloplasty,  by Mr. Lis-
                            franc.

   In the ingenious and highly important plastic operations under-
taken at an early period for the reparation of the lips, M'e mention
with pleasure  those of M. Lisfranc.  As early as  the  summer of
1840, M'e have a case, aged  fifty-five, of this eminent surgeon,
M'herein the destroyed parts, including  the whole of the lower  lip
and  part of the cheek, (from, as it  appears, a papulous eruption
treated  by arsenical  preparations,) M'ere completely restored by a
flap from the neck.  The  operation was performed June 28, 1840,
by commencing with  a semilunar  and two horizontal  incisions,
which removed the whole of the diseased edges, the vascularity of
the cut  surfaces requiring torsion for ten small arteries.  The next
incision was along the median line of the  neck to the thyroid car-
tilage, and dissected back a flap at either side.  Diseased portions
of the alveolar process Mere removed by the bone  nippers,  and
several  of the teeth also extracted.   The projecting angle of the
symphysis  was removed  by a saw, to prevent its protruding be-
tween the flaps.   The flaps were  perfectly  adjusted by fourteen
pins with twisted sutures. In three  days all the pins  were  re-
moved,  except at the angles of the wound.  A slight erysipelas on
the neck, small abscesses  at the  angles of  the mouth, and one be-
low the chin, especially the latter, from the purulent sub-cutaneous
infiltration it caused in the neck, gave some trouble; counter open-
ings to the outer side of each jugular vein were found useful; after
the removal of some dead cellular tissue from one of these open-
ings, the erysipelas  immediately subsided,  and the purulent exca-
vations became filled  up  with granulations.   The cure was com-
plete, (vid. Gazette des Hbpitaux, Aug. 20,  1840, Paris; also Lond.
Lancet,  1839-40, p. 879.)                                   .
   [The geno-cheiloplastic  operations, however, of  Dr.  Mott given
above, with plates, (performed in 1825  and 1831,) so far as priority
is concerned, were probably among  the first  ever performed any-
where, especially that at  the New York Hospital  by this surgeon, 
800           NEW ELEMENTS OF OPERATIVE SURGERY.

about the year 1825.   Though the flap operations in  all repara-
tions of the face, however great the loss of substance, (as will be
seen farther on,) are now entirely superseded by the French meth-
od of deplacement, it is, nevertheless, proper to chronicle these early
and bold successes of eminent surgeons, in what now already may
be called the rude period of anaplasty.—T]

        Anaplasty  applied to the Operation for Hare-Lip.

  M. Malgaigne, (vid. Journal de  Chirurgie; also Lond. Lancet,
Aug. 31, 1844,) to remedy the disagreeable depression which  gen-
erally remains on  the free border at the  median line, after the
operation of hare-lip,  proposes  that  the paring should  be  com-
menced from above, and carried downward, the  operator stopping
when he has arrived  so low that but a small pedicle  remains.
This is  to be done on both sides.   By this means  we obtain  two
small flaps, which merely adhere to the lip by their pedicle.   Af-
ter uniting with pins the two sides of  the labial  division in its en-
tire length, except at the lower  extremity, the small flaps  are
turned  downward,  and  placed  in juxtaposition.   The  surgeon,
having formed his opinion as to the length which they ought to re-
tain, in order to form a  substitute  for the  natural median promi-
nence, then shapes them as he thinks fit, preserving a greater or
less portion, according to the extent of the deficiency M'hich he has
to supply.  He then completes the  reunion by uniting the two flaps
by means of a suture or two, or a very fine insect pin.  If the pin
or suture is placed very near the free edge of the  lip, the  cicatrix
subsequently appears scarcely visible.  The operation has  been
twice performed—once  by the author, a second  time by M. Guer-
sant.  M. Malgaigne states that in his case the operation was per-
fectly successful, but in M. Guersant's the median tubercle  appears
to have been rather too  large.  M. Huguier proposes to use the
scalpel instead of the scissors.
  [In relation to the above, Dr. Mott remarks:  " That the object
proposed by M. Malgaigne appears to be to remedy a small notch
or deficiency, which often is, but never should be  found  to exist.
when the ordinary mode of operating for this deformity is properly
and judiciously performed;  which  mode is: 1.  To remove,  by a
smooth cut with the scissors, a sufficient amount  of the lip  on each
side, in  order to take away  all  the flare;  2. To make the lowest
stitch pass close to  the vermilion border, and entirely through  the
lip, and always to tie the knot on the  vermilion border, so as to ad-
just with great accuracy the coaptation of the lower edges; in
fact, the making of  the knot there keeps them adjusted. It may be
asked how it is possible to unite the outer edge of the peduncular
flaps, proposed by M. Malgaigne, so as  to fill up the flare of the
lip, inasmuch as it is bringing a natural surface  to a natural  sur-
face ; and if pared, they would render, we fear, the lip much more
irregular than by the usual method."—T.]
  The editor of the Gazette Medicale of  Paris,  (June  8,  1844, 
AMERICAN APPENDIX.
801
torn, xii., p. 372,) m noticing  this operation of M. Malgaigne, (as
?q!T\ a  m the Journal <& Chirurgie of Paris, Jan., Fev. et Mars,
1844,) does not seem to attach much value to it.  The difficulty is,
he thinks, in giving the normal thickness to the  vermilion border,
and the danger of making the lip too long.  He suggests this mod-
ification of the  hare-hp  operation, viz.: to pare  the edges in a
curved manner, so that their concavities may face each other.

                     Anaplasty for Ranula.

  M. Jobert (vid. his first memoir to the Paris Acad, of Sciences;
also his second memoir to the same, Aug. 28,1843, in the Gaz. Med.,
Sept. 2, 1843, tome xi., p. 562) has applied anaplasty, in tM'o cases,
M'ith complete success for the radical cure of ranula, (grenouillette)
He confines this disease exclusively to the tumor formed by a col-
lection (amas) of saliva from  engorgement, caused by obliteration
or obstruction of the canal or duct of Wharton.  Much difficulty has
arisen, and many failures in the treatment been produced, from the
carelessness of surgeons  confounding with this  disease other tu-
mors which may  form in the same place.  Yet these last, he also
thinks, will have  most  chances of cure by his anaplastic method.

    Anaplastic Operation for the Cure of a Cicatrix from  Burn.

  In according to our countryman, Professor Mutter of Philadel-
phia, the honor of having first ingeniously and happily applied the
principles of anaplasty for the cure of cicatrices from  burns, we
have unknowingly, but, as it will appear, innocently done injustice
to Mr. H. D.  Carden,  surgeon to the Worcester Infirmary,  Eng-
land, who, by a paper of his inserted in the Transactions of the Pro-
vincial Medical  fy Surgical Association, vol. xii., London, 1844, p.
585 et seq., but, as far as we can learn, never before published or
announced, appears to  be entitled to all the honors  of priority in
this new treatment, having performed the operation on a case very
similar to those of Prof.  Mutter's, as early as November 1, 1839;
while the^r^ case of Prof. Mutter's was not performed  until Jan.
12, 1841, (see  The American Journal of the Medical Sciences, by Dr.
Hayes, new series, vol. iv., Philad., 1842, p. 66 et seq.)
  The case of Mr. Carden, M'as a girl  by the name of Mary Ann
Barnett, aged fourteen, who was admitted, says Mr. C, into the
Worcester Infirmary, Sept. 9,  1839.   The burn which occasioned
the deformity, occurred on the anterior and upper portion of the
neck about seven years previous.   " The movements of the head
(by the large cicatrix formed) are (says the surgeon) greatly re-
stricted, the mouth  remains permanently open,  the tongue pro-
trudes, the lower  incisors project horizontally, and there is constant
salivation.  On attempting to raise the head, the eyelids are drawn
considerably downward.  The patient,  as well as her friends, be-
ing most anxious to have something done for her relief, a consul-
tation  was  held  upon the case, when it was admitted that the
                              101 
802           NEW ELEMENTS OF OPERATIVE Sl'RCERY.

experience of modern surgical authorities was not in favor of such
attempts ; and that M'here excision of the cicatrix had been prac-
tised, the  deformity had generally been increased rather than oth-
envise.   Under these circumstances, a new mode of proceeding was
suggested, which, on explanation, was sanctioned by my colleagues,
and performed, November 1, 1839, in the presence of and assisted
by Messrs. Sheppard and Pierpoint, surgeons to  the hospital, Mr.
Cole, house-surgeon, and the pupils.   A  contrivance for keeping
the head  erect during  the after treatment  of the  case, had pre-
viously been provided.
  " The patient being  placed on a well-cushioned table, M'ith her
head and shoulders  somewhat elevated,  I commenced  the  opera-
tion  by carefully gathering up the cicatrix from below the left ear
to the top of the  sternum, between the fingers and thumb of the
left hand, which enabled me to transfix  and divide the whole of
that side  at a stroke ;  the same  was repeated on the right side,
and a short  cut over the top of the sternum  connected the two in-
cisions.   In this manner the  whole transverse extent of the cica-
trix was rapidly divided, the wound terminating  in  sound skin on
each side.   The chin Mas then drawn upward by an assistant,and
every tense band of cicatrix successfully divided by repeated strokes
of the scalpel, until the head was released into  nearly  its natural
position.  By  this mode of dissection, although nothing had been
removed, the hiatus  produced was very great, and  extended from
above the chin and edge  of the lower jaw,  to below the upper  border
of the sternum,  exposing  the  greater part  of both  sterno-mas-
toid  muscles, and  external jugular  and  thyroid  veins, the latter
being particularly large  and prominent.  The  quantity of blood
lost M'as very trifling, scarcely requiring  the torsion forceps.  As
soon as all bleeding had ceased, I proceeded  to select a portion of
sound skin on each side, about three  inches  long  and two  and a
half wide ;  these were raised and detached,  except  at their junc-
tion  with the outer edges of the Mound, and brought together
across the centre of the neck, and there united by hare-lip needles.
The side-wounds left by the flaps were then  brought together, and
the  exposed parts covered with  lint.  The flaps Mere carefully
supported by adhesive plaster, leaving apertures for the points of
the needles, and the  v. hole of the M'ound  and surrounding integu-
ments M'ere well supported by long plasters and bandages.
  " She bore the operation, M'hich was severe and necessarily pro-
tracted, with great fortitude, and without fainting, and M'ent  on
favorably.   The needles were withdrawn two days after the oper-
ation ; the dressings were not removed  until the sixth day, M'hen
the flaps were found to  have retained their position; but the uppei
border of each, being composed of old cicatrix, had perished, diminish-
ing the breadth of each to  less than two inches.  The complete heal-
ing  of the wound occupied  nearly twelve months, during  which
time various contrivances, in addition to that first used, were had re-
course to for keeping the head in the erect position ;  but the bodily and 
AMERICAN APPENDIX.
803
mental suffering ivas so great, each time the wound was dressed, from
these repeated stretchings, that I discontinued them altogether.
  "She was made  an out-patient  in May, 1840, and  in November
following she presented the following appearances:—Wound heal-
ed ; position  and movements of the head greatly  improved ; can
close  the  mouth, retain the saliva, and articulate distinctly:  teeth
regaining their natural position.  A narrow cord has  sprung up be-
tween the  fiaps, which threatens  to draw down  the  centre of the
lower lip, and also to  prevent  the  farther expansion of the  flaps,
which has hitherto been steadily going on, and  forming  the most
satisfactory feature of the case.
  " I passed a curved  bistoury under this and divided it, enjoining
pressure and farther extension; but from that time she avoided at-
tendance  at the hospital, and neglected all directions, and I saw no
more of her until October 23d,  1843, when I sent for her and made
the sketch figure  4, [in the work cited.]   She has become stout in
person, has enjoyed good health, and is very grateful for the im-
provement gained.  The teeth are quite upright, and I regret that
one  was extracted before  the  operation, although at that time it
appeared  hopelessly displaced.  The  flaps now  measure  three
inches on the right side, and two inches and three  quarters on the
left, from  above downward; but there is an increased contraction in
the central cord, M'hich is strongly marked in the sketch.  This she
has consented to  have divided and separated from the flaps, which
may then, I trust, be permanently united, and her appearance con
siderably  improved.
   " Four  years having elapsed since the operation, a fair estimate
may now be formed of its merits.  I should, however, have consid-
ered it premature to submit it to the notice of the profession, until
further trials  in my own practice had rendered the  subject more
complete, had not my attention been called to an interesting paper
by Dr. Mutter, of Philadelphia, in the American Journal of Medical
Science, the result of whose operations, undertaken  at a subsequent
period to that  above detailed, appears fully to establish the  value
of the flap method, or, as Dr. Mutter calls it, the ' autoplastic oper-
ation,' in these very distressing deformities."
   We have given the above in detail, because it is related M'ith a
degree of candor becoming the dignity of the profession, and the
courtesy M'hich should never be forgotten in the  emulous  and hon-
orable rivalry for distinction.
   Mr. Carden, in the concluding portion of his paper, fully concedes
to Dr. Mutter the superiority of his method in completely excising
the cicatrix, dividing one or both the  sterno-mastoid tendons, and
making use of a sufficiently large flap in the beginning.
  The very diminutive flaps, not making allowance for  subsequent
contractions, was  the  principal defect of  Mr. Carden's operation,
and  the cause of the  difficulties which ensued; others M'ere  the
leaving a portion of the cicatrix on the borders of his two small
flaps.  Hence the gap, the  new cord, &c.;  all of which he has very
ingenuously admitted. 
804           NEW ELEMENTS OF OPERATIVE SURGERY.

  Remarking on  Dr. Mutter's proposed modification, by taking, if
necessary,  two flaps instead of one, as Mr. Carden did, the  latter
says he finds, by a curious coincidence, that he also, in his notes of
his oM-n case, (Nov., 1840,) had also, Mdthout then knowing of Dr.
Mutter's case, suggested the  large  single flap which  that surgeon
used in his first  case, thus:—" In a future operation, I should en-
deavor to  procure more complete union  between the flaps  in the
centre, or (which, perhaps, would be better) should, if possible, cover
the whole hiatus  with a single flap."  On this  point he prefers the
operation of Dr. Mutter.  " In future, (says Mr. Carden,) I  should
avoid the inconvenience experienced in my case, and which is very
apparent on looking at figure 4, of  a  cord springing up in the cen-
tre, by making the flap, or flaps, if taken from each side, sufficiently
long to reach across the neck."
  Mr. Carden also, from what he has related in this case, properly
condemns,  in unqualified terms, the use of extension apparatus, and
which (as  is seen supra, in  the  text) Mr. James, of Exeter,  much
enlarges upon the advantage of in these  cases, even after the Mut-
ter operation has been performed.
  It appears, therefore, that there can be no difficulty in adjusting
the respective claims of the English and  American surgeon on this
subject.  Inasmuch as the merit of priority in first suggesting and
partially carrying out this now most invaluable  improvement  in
autoplastic surgery, in a large class of distressing deformities that
have for centuries baffled the greatest minds in our profession, be-
longs unquestionably to Mr. Carden. While  the full  and  entire
honor of establishing, by a most skilful and successful process, the
value of this operation, is to be as unhesitatingly accorded to Prof.
Mutter.
  To both surgeons the profession owe much ;  and but for the per-
fection of the process by Dr. Mutter, we should, from the creditable
modesty of the gentleman who first originated the idea of this op-
eration, not have had an opportunity, probably, of chronicling this
present record in behalf of the priority which belongs to his share
in the matter.

                          Uretroplasty

  The new process proposed by M. Segalas, in a letter to M. Dief-
fenbach, 1840, and which was brought before  the  notice  of the
Paris Academy of Sciences July 26, 1841, (vid. Journal des Connais.
Mid.-Chir., Sept.,  1841,) does not, nevertheless, appear to  have
been generally adopted.  M. Segalas had considered, very proper-
ly, that the chief cause of failure, and of non-union in reparations
of loss of  substance in urethral fistulas, &c, was the difficulty of
preventing the infiltration of urine through them.  This he imagined
he could obviate, by " temporarily diverting the urine from its natu-
ral course, by opening  for it a free exit  (une large issue) in  the pe-
rinaeum, and in  conducting off  the urine through this  passage by
means of  a catheter."  In 1841, M. Segalas furnished, for the con- 
AMERICAN APPENDIX.
805
sideration of the Academy, a case in support of his method.   The
patient had all the intermediate portion of the urethra between the
scrotum and glans destroyed by gangrene.  The process of the sur-
geon named was completely successful.   M. le Docteur Ricord had
also succeeded equally well in another case.  In a third case of M.
Segalas, the fistula was in the  anterior part of the urethra, with
great loss of substance; and  it was for the purpose of inspecting
the process of M. S. in this case, that he solicited a commission of
the Academy, which was granted.  Their report on the subject (if
ever made) we have not been enabled to find.

                  Episcoraphy, or Episcoplasty.

  This operation, which consists in dissecting off each labium with
a small portion of its  mucous surface, and then uniting  the  raw
edges of the  tissues by strong sutures, as recommended by Dr.
Fricke, of Hamburg, and which, in fact, virtually sews up the  pas-
sage, excepting for the mouth  of the  urethra,  was performed in
1841 by Mr. Lightfoot, of Newcastle-on-Tyne, (Eng.,) for prolapsus
of the  bladder with the anterior wall of  the vagina, producing a
tumor protruding through the vulva, (Lond. Lancet, 1841-2, pp. 322,
323.)  It is unnecessary to say that  the remedy must, from moral
considerations, and the physical obstacles it creates to the functions
of the parts, be worse  than the  disease—and can only be justified
in such  extreme cases  as that of Mr. Lightfoot, and in which the
success was complete.

 Penoplasty, or Exsection of a portion of Hypertrophied Penis, and
         Transplantation of the Glans Penis on the Stump.

  An American surgeon, Dr. Mettauer, of Virginia, (see American
Journal of the Medical Sciences, July, 1842,) has the credit, we be-
lieve, of being the first who  has ever performed the operation of
patching and repairing a deformed useless penis  by exsection, so
as to make  a new  organ thereof, for all the  functions  required
of it, and which process may be called penoplasty.
  A young man, aged  nineteen, came under Dr. M.'s care in 1841.
His penis was eight inches in length from the  scrotum to the ex-
tremity of the glans,  in a non-erected state ;  the anterior three
fifths dilated laterally, flaccid and non-erectile,  with great expan-
sion of the corresponding portion of the urethra—the latter being
capable of containing two ounces of fluid, the cavity which it form-
ed being bounded anteriorly by the concave glans.  The other two
fifths, or pubic portion, constituted the stump of the organ, and was
well formed and  capable of erection.   The orifice of the urethra
opened upon this, forming a sort of os tinea, looking into the cavity
above described.   There was also a fistulous opening in the  peri-
neum, from which most of the urine escaped, anterior to which the
urethra for eight lines  was nearly impervious.   There was an  arti-
ficial fistulous opening, also, in the central portion of the pouch-like 
806
NEW ELEMENTS OF OPERATIVE SURGERY.
portion of the urethra above described.  The testes were large, and
strong sensual desire existed.
  Dr. Mettauer laid open the pouch by an incision along the raphe.
A belt was then removed from  the  interior of the cavity, seven
lines in width, entirely round the base of the glans, and  quite to
that organ, so as to leave that part of the wall of the pouch to con-
sist only of integument and cellular membrane.  A like belt M-as
removed from the inferior portion of the pouch, quite down to the
circumference of the face of the  erectile stump, which was then
carefully denuded  in every part of it.  The glans  was  placed with
great care upon the face of the stump, taking care that the  denuded
margin  at its base should  exactly correspond with the circumfer-
enqe of the opposed surface of the  stump.  A short bougie was
passed  in the meatus, and carried to near the contracted portion
above mentioned.   This  holding  the glans in position, the latter
was fastened to the stump by eight points of the Glover's sutures.
The loop-like tegumentary intermedium on the dorsum  Mas re-
duced one half, leaving  the other to nourish the  glans.   On the
twelfth  day, the glans had firmly united  to the stump.   The su-
perfluous  tegument was excised a few months after.  The new
penis was full two inches long, and comely in shape ; and the glans,
which after the operation lost its  sensibility, had now recovered it,
so that  the organ could perform its proper functions, being, when
erected, four and  a half inches  long.   The interruptions in the
urethral passage were removed by a long trochar,  and  the passage
then kept open by a bougie, and the fistula healed by suture.  The
success  was complete.
      ARTIFICIAL JOINTS—EXSECTION OF ARTICULATIONS.

                 The Elbow-Joints and the Knee.

  M. Velpeau, in the text, has placed under the general head of
reparations and restitutions, not only the legitimate and extensive
class of anaplastic operations and  sub-cutaneous sections, but also
the rupture or the exsection of an angular callus or anchylosed joint,
the making of an artificial joint in the bony structure of the body of
a limb, after the example of Dr. J. Kearny Rodgers, of New York,
and the  operation of exsecting a wedge-shaped segment from the
bones of the leg, in order to give perpendicularity to the plane of its
axis, after the ingenious and original method of Dr. J. Rhea Barton,
of Philadelphia.  Had this plan  been carried out by M. Velpeau,
he might, perhaps, have treated in that place still more in extenso
of other deformities  of the bones  and joints in which such repa-
rations are required.  He has, however, gone more largely into the
department  of exsections of bones, in his second volume.
   We will, however, as the subject is one of great interest, recur
briefly in this place to the operation of exsection of joints, which, in 
AMERICAN APPENDIX.
807
the  mattei  oi that most  useful and important articulation, the
elbow, more particularly, has been of late years improved upon to
such extent, by Mr. Syme, of Edinburgh, and others, as to give
this operation an  inappreciable value, in the unexpected success
which has attended it in the restoration of the movements and other
functions of the whole arm.
   As early as 1826, Mr. Syme (as he informs us in  a late interest-
ing paper in the Lond. and Edinb. Month. Journ. of Med. Science, for
August,  1844) published his first paper on the excision of the elbow-
joints; and, in 1829, this surgeon recorded  three cases by him of
excision  of the elbow-joint, (See Edinb. Med. and Surg. Journ., 1826
and 1829.) thus recalling the attention of the profession to what had
long since been performed (but in a far less perfect  manner) by
Moreau, Baron  Percy, and others.   Since then, M. Roux and Sir
Philip Crampton, and others, have performed the same operation;
but in 1831 Mr. Syme published a treatise on the subject, M'herein
he recorded fourteen cases of this operation.
   In his last  paper above  referred to, (Lond.  and Edinb.  Month.
Journ. of Med.  Science, Aug., 1844,) he describes two additional
cases, with a greatly improved mode of operating.  In one, a young
man aged eighteen, the operation was performed June 28th, 1844.
The elbow had become inflamed  and  enlarged, from  the mal-
treatment of a bone-setter, and finally ended in a continued sup-
puration from the joint.
   The operation was  performed by his  usual mode.  The articu-
lating  surfaces  of  all the bones, being  divested of cartilage and
carious, were exposed  in  succession, and  removed by  the saw,
which Mr. Syme prefers to the cutting pliers.  The case went on
kindly, and the parts soon healed.  Such was the entire restoration
of the functions of motion, that the patient was enabled to  return
to his occupation of '• skinner."
   The next case was that of a woman aged fifty-three.   The joint
had swelled to a great size, and gave such severe pain  on the least
motion, that she was  obliged to keep it at rest.   A suppurating
drain here also took place from the joint, and gave some relief.
The disease then remained stationary.   The elbow could  not be
extended beyond  a right-angle.  The  operation  was  performed
Nov. 15, 1844, by cutting out the articulating extremities, which
were completely carious.  The soft parts, being unusually sound,
Sealed quickly, almost entirely, by  the  first intention, so that the
patient was dismissed quite well  on December 18th following, and
soon after was enabled  to employ  herself in knitting  stockings.
Mr. Syme claims to himself the merit of having been the first to
improve  the operation  so as to make it of practical utility.  Thus
before his paper, (1826,) " no  distinction had been drawn between
the truly carious portion of bone, which alone requires to be removed,
and thee fusion of new osseous substance, which causes an irregular
thickening of the bone considerably beyond the extent to which it
is diseased.  In consequence  of thus confounding  the sound  and
morbid parts, much more was taken away than required removal, 
808
NEW ELEMENTS OF OPERATIVE SURGERY.
and the cure was  not  only greatly protracted, but rendered much
less complete than  when the operation is properly performed."
  Excision of the  elbow-joint, for  a caries  of the  humero-cubital
articulation, was successfully performed, in 1841, by JM. Robert, of
Paris, on a  woman aged twenty-six.   The operation appears to
have  been performed  upon the principles enforced by Mr. Syme,
in his cases, as the only secure basis of success; but whether Mr.
Syme had already announced his process before  M. Robert oper-
ated, M'e are not enabled to say.  This process (as is seen in Mr.
Syme's cases, related  above) consisted in sawing as close to the
articulations as possible—in this case, immediately above the con-
dyles of the humerus, and below  the coronary process of the ulna
and articular extremity of the radius.   The limb M'as immediately
placed in the apparatus of M. Guizot.   A tedious suppuration con-
tinued for eighteen months, after which (it being found impossible
to approximate the divided bones) a dense  but very flexible tissue,
when the arm hung down, was perceived to have been formed in the
intervening  space, occupying an  extent of three  fingers' breadth,
and allowing the fore-arm  to  move freely in all  directions.   But
when flexed, this space was effaced by the extremities of the bones
mounting up and  finding a fulcrum  on the humerus.   Thus the
patient could easily carry the hand to  the head and opposite shoul-
der, and raise a chair.   Pronation of the hand could be made in a
moderate degree ; but the movements  of the fingers were perfectly
free, and she could, with some degree of force,  grasp with her
fingers and  hold in her hand bodies of small size. She was enabled
to resume her occupation of  a seamstress, sewing with her left
hand, and fixing and   holding her work M-ith  the right, and re-
lieving the right arm of fatigue by wearing two pieces of leather,
the one embracing the upper,  the  other the fore-arm. (Seances de
VAcademie des Sciences, and Lond.  Med. Gaz., 1841-2, p. 654.)

         Exsection of the Elbow-Joint, in the United States.

  The following two cases occurred in the  service of Dr. Gurdon
Buck, at the New  York Hospital.  I  am indebted for them to my
friend John L. Vandervoort, M. D., of New  York.—T]
  Excision of the elbow-joint, in a case of suppuration and caries
of the bones, by Gurdon Buck, M. D., surgeon  to  the New York
Hospital.  The patient, a seaman twenty-five years of age, of r#
bust health, was admitted into  the New York Hospital  on the 10th
of June, 1841, with inflammation of the  right  elbow, which  had
commenced spontaneously  six  months before,  with  pain in  the
joint, followed in  six weeks by slight  stiffness, which did  not pre-
vent the use of the arm until  two months  prior to his admission.
On admission, the  arm was in  an  extended position, the joint stiff
and painful on attempting motion.   Cupping, blistering, and the
actual cautery were  tried, but without  success.  In August, an
opening  formed over  the outer  condyle, and  discharged a large
quantity of yellowish-white matter.  Up  to January, 1842, no im- 
AMERICAN APPENDIX.
809
provement took place.  The  condition of the limb now was as
ioiiovvs:  it was kept at a right angle in a sling, and admitted only
siignt motion at the joint;  there was  considerable swelling about
the elbow, above  and below, and the limb was much wasted;
there was  an opening of the  size of half-a-dollar over the outer
condyle ; the head of the radius was exposed, and could be rotated;
the bone was carious ; along the inner margin of the joint there
were two small openings, and there was abundant discharge with
synovia.
   Operation, Jan. 16th, 1842. A transverse incision was first.made
across the triceps muscle at its insertion, M'ith a straight bistoury,
introduced at  nearly  a finger's breadth  above and on the radial
side of the inner condyle, and  carried down to the bone, the point
of the bistoury emerging at the outer condyle, and the edge kept
close to the olecranon process.  Two  longitudinal incisions were
next made ;  the M'hole together  in form of the letter H.  The
olecranon process, being freed from  its muscles, &c, was sawed
about two-thirds through, an inch and a quarter from its extremity.
This section, from the  extent  of the disease  above the external
condyle, was made to include one inch of the extremity of the hume-
rus on its outer edge, and half an inch on its inner.   Nearly half an
inch of the radius was then saM'ed off.  All the soft parts M'ere in-
filtrated and thickened.  The case, excepting an attack of erysipe-
las, progressed favorably, and the patient left the hospital in March,
much improved.  He now  (October, 1844) is  able to use his fore-
arm in his usual occupation, an hostler, nearly as M'ell as any of his
co-laborers.  The principle of Mr. Syme appears to have been here
as closely adhered to as possible.
   A second case analogous to the former was admitted into the
hospital,  June 6th, 1844, and M'as operated on in the latter part of
July.   An incision Mas made  from the middle  of the olecranon,
three inches upward, and carried the same length  downward along
the fore-arm.   The triceps tendon  and muscle M'ere next raised
towards the outer condyle.   The olecranon process being denuded,
more than  an inch M'as sawed off; an  inch and  a half M'as then
removed from the lower end of the humerus; subsequent  to this,
the end of the radius, as well as the articular surface on the side of
the olecranon, were removed. After the operation the arm M'as laid
on an angular splint, which was suspended from the ceiling.  This
case, like the former,  has  progressed favorably, and the parts are
now nearly restored to a healthy  condition.  The principle of Mr.
Syme here also formed the  basis of Dr. Buck's process.

         Exsection of the entire Knee-joint, for Anchylosis.

   A case of anchylosis of the knee-joint of seven years' standing,
the result of a wound made by an axe over the inner condyle, was
recently admitted into the  New York Hospital, and an operation
performed in the month of October,  1844, by the same surgeon, Dr.
Buck, with the view of straightening the limb, which was bent at
a right-angle.
   6                           102 
810           NEW ELEMENTS OF OPERATIVE SURGERY.

  A T-incision was made in front, the extremities of the bones ex-
posed and sawed  off, including a portion of the patella, the  con-
dyles of the femur, and the head of the tibia, as near the articu-
lating  surfaces  as  possible.   The  sections  formed together a
wedge-shaped segment.   The  details  of this  case, and M'hich M'e
merely allude to  noM', as  being the first of its kind  ever  per-
formed in this country, M'e hope to be able to give in  its more
appropriate place in the second volume, under the head of Exsec-
tion of Bones.   We Mill only remark, that the wedge exsected  Mas
made narrow  and acute,  the  apex pointing posteriorly,  in order
that the  consolidation might bring the leg into slight flexion upon
the thigh, so that  its shortened length Mould be compensated by
the extension of the foot bringing the metatarso-phalangeal articu-
lations to the ground.  [This  case is still  progressing favorably,
Nov. 15, 1844.—T]
  In regard to the elbow-joint, we have the authority of Dr. Hayes,
in his excellent American Journal  of the Medical Sciences, (Oct.,
1842, vol. xxx., p.  517,) that the first operation for  exsection  [not
resection, the M-ord here commonly used, for that means that there
has been a previous section—T] of the  elbow-joint in this country,
was that described  in the  same journal, for Feb., 1837, p. 341 et
seq., as performed by Dr. Thomas  Harris, (surgeon of  the U. S.
Navy,) in June, 1835.
  The above  case of the  total exsection  of the knee-joint,  was
made as  close as possible  to its articulating surfaces, these being
sound, and thus admitting,  to their full extent, Mr. Syme's injunc-
tions on the exsection of the elbow-joint.  Should it terminate suc-
cessfully, as there is every reason to hope from the present favorable
symptoms, M'e believe it will be the first case on record M'hich has
so resulted, and will therefore be a notable triumph for the opera-
tor, and for American surgery.  We are sustained in the opinion
that this exsection has never been successfully performed, from this
remark of Mr. Syme : " Though experience has not yet fully de-
cided whether the limbs that might be preserved by cutting out the
knee and ankle-joints, would be preferable to the artificial substi-
tutes which may be M'orn in  their stead, it seems pretty well as-
certained that they would not."  Similar objections, also, he makes
to  exsection of the  wrist-joint.   (Principles of Surgery, by James
Syme, F. R. S. E., &c, third edition, 1842.   See also, Lond. Medico-
 Chirurg. Rev., Jan., 1843, vol. xxxviii. p. 185.)
 ANAPLASTY, AS APPLIED TO THE DEFORMITIES OF THE FACE.

  Since this work has been going through the  press, we have had
an opportunity of examining the  interesting volume recently pub-
lished  at  Montpellier and  Paris, 1842, by Professor Serre, of the
University of Montpellier.   This invaluable  contribution, being
the first elaborate and regularly-systematized work on the whole
of that extensive and most important class of deformities to which 
AMERICAN APPENDIX.
811
anaplastic surgery is so happily applied, those of the face and fea-
tures, is entitled, " Traite sur Vart de restaurer les difformitis de la
Face, seton la methode par deplacement, ou methode Frangaise. Par M.
Serre, Professeur de clinique chirurgicale a la Faculti de Medecine de
Montpellier," fyc.  It is accompanied by a beautiful quarto atlas, of
thirty lithographed plates, representing a hundred and fifty figures
of anaplastic restorations, effected upon the nose, cheeks, lips,
corners of the mouth, eyelids, eyebrows, &c, for cancerous affec-
tions, contractions and losses of substance from syphilis, burns, &c,
all of which are delineated in an excellent and perspicuous style
of execution.  They present, it may be truly said, perfectly arranged
diagrams and outlines of incisions, combined and adjusted on true
mathematical  principles, as well in relation  to the shapes  and
forms of the voids or chasms of the destroyed parts to be embraced
by the flaps of those incisions, as in relation to the composition of
forces which are afterwards to come in play upon those reparations,
by the tractions in various directions resulting from the processes
of agglutination and cicatrization, so as to produce the most perfect
degree of coaptation of the new tissues, and as near a resemblance
to the previous normal condition  and position of the parts as pos-
sible.
   We look upon this work,  indeed, of M. Serre, as one  which
displays  a  masterly  talent and  tact in this  delicate mechanical
department of  surgical science, more especially by the ingenious
application  which he has made of sound mathematical principles in the
composition of forces to the laws which govern the restitution of parts
in organic life.   This will be  seen  to be beautifully illustrated, by
 inspecting his diagrams of incisions, and noting the truly scientific
 manner, we repeat, in which he arranges their outlines, so that they
 may all combine harmoniously in the process of cicatrization and
 agglutination;  by which exact calculation the different kinds of
 flaps, whether angular, rectilinear, circular, or elliptical, are made
 to come  together, or  to dove-tail, as it were, into nice, accurate,
 and natural coaptation, with the  corresponding spaces left by the
 diseased  parts which  have been excised and freshly pared.
   We deem this part of anaplasty to the face, and indeed to any
 region—we mean  the  proper calculation, arrangement, and de-
 marcations, required  to be made  before-hand,  of the length and
 character of the incisions and excisions to be executed in reference
 to the direction and  force of the tractions which will be brought
  nto play during the process of healing-as a matter of far higher
 importance in the  success of anaplasty than the mere cutting out
 Lnd adjustment of the flaps, which in themselves are operations of
 Snorug^rv  demanding, comparatively speaking  but little skill,

 aTS

 ^^^^^^^^^^  "  -**
 Guarantees of perfect success.  Inasmuch therefore, as the frequent
 Shireso ' thell operations, and the substitution, which they too
 of en  produce, of  *  deformity  worse than the  original,  are the 
812
NEW ELEMENTS OF OPERATIVE SURGERY.
result of inattention to the exact rules laid down by M. Serre, and
the importance of which Mre would earnestly wish to enforce, his
work should, in  our opinion, rank as one of the most valuable, if
not the best, manual  and vade mecum on the subject, for the stu-
dent and practitioner, M'hich has yet been published.
  It was precisely from the absence of any systematized  classical
work on anaplasty, whatever detached and scattered notices had
been  made of it by  MM. Dieffenbach, Labat, Blandin, Zeis, and
others, or that had appeared in  almost  every periodical, that M.
Serre felt  the necessity  of precisely such a work  as that with
which he has favored the profession.  Thus, as may be anticipated
from  what we have  said, M. Serre  does not, for example, think
M'ith  M. Velpeau, (vid. text, supra,) that cheiloplasty (or the art
of restoring the lips) is, any more than  any other branch of this
department of surgery, one  that the surgeon has rather  to devise
than learn, and  which cannot be submitted to  detailed rules, but
must be modified as often as performed, (loc. cit., p. vii.)  Although
we may agree, however, with M. Serre, that certain  general rules
may be established applicable to this or any other branch of ana-
plasty, M'e must  concede to M. Velpeau the  justness of his remark,
that each particular case demands special modifications and a plan
of operation  peculiar to itself, and for success  in M'hich  the sur-
geon, however aided he may be by certain general principles, must
finally rely on his own immediate tact and  resources, to overcome
the obstacles  which  each individual case  presents   as contradis-
tinguished from all others.
  In proof of the success of his method, M. Serre states  that in a
hundred and fifty operations he has lost but one single patient.
  In allusion  to  the  utility, and necessarily, therefore, the  spread
of plastic surgery, M. Serre  states that osclteoplasty,  as first prac-
tised  by Larrey, Delpech, and  others, has been introduced into
Egypt, at Alexandria and Cairo, by M. Clot-Bey.
  M. Serre thinks it quite as probable as otherM'ise, that the Bran-
cas of Sicily were the inventors of what is called the  Italian meth-
od, as that the hints for it M'ere imported from India;  because there
was a period formerly when criminals throughout Italy and Sicily
M'ere  punished with the loss of the nose, lips, and ears. Of which
opinion  is the Italian jurist, Paul Zacchias,  (see Diction, des Sc.
Med., Art. Ente Animate,  par Percy,  torn, xii., p. 346.)  M. Serre,
though he  does  not look upon Tagliacozzi as the inventor of the
Italian method, considers his work, published in 1597, on restora-
tions  of the face, and entitled " De Chirurgid Curtorum  per Insi-
tionem," as the only  one which  had  ever  beeyn M'ritten  with an
enlarged view and with surgical ability.   Ambrose Pare, however,
who appeared soon after, retarded any farther progress in this art,
by the derision which he threw upon the work and method of Tagl-
iacozzi.
  M.  Serre, in an historic resume of anaplasty, (or, as he prefers
to call it, autoplasty,) makes particular mention of the recent la-
bors of those surgeons of Italy and Spain, who, notwithstanding 
AMERICAN APPENDIX.
813
the political oppression which those  countries have suffered under
for so long a time, have made valuable contributions to this useful
department of our art.  Among these, he enumerates Baroni of
Rome, Signoroni  of Padua, Riberi of Turin. Pecchioli of Sienna,
Regnoli of Pisa,  (vid. Bulletino  delle Scienze Mediche di Bologna,
1833, vol. vii., p.  267  ; et Novi Commentarii Acad. Scient. Instituti
Bononiensis—Omodei, Annali Universali di Medicina, Agosto et Set-
tembre, 1833, vol. lxvii.; ib. id., Aprile et Maggio, 1833, vol. lxxiv.;
Osservazioni Chirurgiche  Raccolte nella  Clinica  e Pratica del P.
Regnoli, Pisa, 1836 ;)  also the late work  of M. Hysern y Molleras,
in Spain, on blepharoplasty, (Tratado de  la Blefaroplastia Tempero-
Facial, 6 del Mitodo de Restaurar las Destrucciones de los Pdrpados,
Madrid, 1834.)  Senor Castells, of Barcelona, is also mentioned as
having performed with success many plastic operations on the face
according to the  French method.
   In  Germany, which has been appropriately called " the classic
land of autoplasty," we have, of course,  among  other well-known
and eminent names, the following as the most  distinguished con-
tributors : Ammon, Beck, Benedict, Bunger, Chelius, Dieffenbach,
Dzondi, Frich, Heidenreich, Rimer,  Ruppius, Rust, Textor, Walter
Vernuk, &c.
   We have cited these names  from one of the  most modern and
valuable works on anaplasty, for the  benefit of the  student who
may wish to recur to the works and writings of the authors them-
selves.
   M. Serre M'holly and justly condemns, as we  think, the Italian
process, except where the neighboring parts are too  much degen-
erated to have recourse to the Indian or  French method.
   It is unnecessary to dwell on the inferiority of the Indian method,
or that of torsion, (as M. Serre not inaptly terms it,) to the French
method of diplacement, (or glissement, or en tiroir) as it is obvious
that  it not only  makes a new  wound,  but that the torsion of the
flap must, from  the  obstruction it  creates to  the lymphatic and
sanguineous circulation, necessarily expose to  gangrene.  Never-
theless, it is the only  method  available in rhinoplastic operations,
where there is great  loss of substance  to repair.
   Among those M'ho have particularly distinguished themselves by
the improvements they have made in  plastic  surgery, M. Serre
gives  a pre-eminent  rank to MM. Graefe, Dieffenbach,  Lisfranc,
Labat, and Blandin.
   Among  the more recent improvements of importance, he speci-
fies two in rhinoplasty: 1. That of preserving better the primitive
form of the nose, by  doubling the deep-seated  surface of the flap
upon itself, inasmuch as the flap is found to retract less in propor-
tion as there is  less  suppuration from  it.  2.  That of dispensing
with  substances to keep the nostrils open, by means of shaving off
(en dedolant) the  skin destined to form them, and making use of it
as a mucous membrane to cover their edges.  [Experience having
proved that the cutaneous surface will become a mucous one, and
vice versa, whenever they reciprocally change their  normal posi- 
814
NEW  ELEMENTS OF OPERATIVE SURGERY.
tion.—T]  3. That of dissecting the mucous membrane of the
buccal cavity in cheiloplasty, to hem  the same upon the free bor-
der of the new lip, and M'hich, M. Serre says, he has demonstrated
will be found to be  sufficientl}' healthy, M'hen taken even from the
surface of cancerous tumors.   4. In blepharoplasty, the fact stated
by MM. Dieffenbach, Dzondi, and Wisemann, (De coalitu partium a
reliquo Corpore prorsus disjunct arum, 1824,) of transplanting hairs,
so as  to form eyelashes in a  new eyelid.  5. Those plastic opera-
tions  M'hich  have, in fact, resulted in the recovery  of the sight,
smell, and  taste; b}' which he unquestionably means, (making al-
lowance for the  enthusiasm of the  author on this subject,) not the
creation  of those senses, but such reparation of the tissues or parts
essentially connected with  them, as shall enable them to perform
their  functions.
  M.  Serre  makes  a correct distinction, as we think, as to the
prospect of  success, betM'een  repairing congenital  deformities,
which, in fact, seem to be  only the  result of a limited develop-
ment, while the surrounding parts to take the supply from are fully
formed;  and those deformities which  are the result of severe  trau-
matic lesions, suppurations, &c, and where we are too often  com-
pelled to make further losses of substance before M'e can  effect a
restoration.
  In  allusion to the sound pathological views of Delpech, on the
formation of that inelastic contractile material which he calls the
inodular tissue, and which constitutes the substance of cicatrices
resulting from loss  of  substance and  suppuration, M. Serre justly
remarks, that a  great portion of the deformity resulting therefrom
M'ould be prevented, could losses of substance from cutting instru-
ments or fire-arms be immediately repaired, as soon as they occur
by the coaptation of their  borders.  This was the course pursued
by  Baron Larrey during  the memorable campaigns of Napoleon,
in which he relates the case of an  officer in whom the cheek was
carried away, from the commissure  to the masseter, by a pistol-
ball, but so M'ell repaired  on  the spot, by paring the edges  and  the
application of sutures, that scarcely any deformity remained,  (Lar-
rey—Clinique Chirurgicale, torn, ii.,  p. 4.)  M.  Serre might  have
added, that if Baron Larrey had known of the cheiloplastic opera-
tions  of the present day, his natural surgical adroitness wrould have
been  made still  more effective by loosening the cheek from its nat-
ural attachments to the jaws, according to  the  method of Franco
and Chopart, i. e. the French  method,  or decollement, or deplacement.
   In  cases of constitutional affection, M. Serre doubts the policy
of attempting too rigidly to efface, before  operating, every  trace
of the disease, or of the deformity which it may have caused.   Ho
remarks, with much good sense, that the general  affection some-
times seems  to have departed from the system, except upon a par-
ticular  point, [externally,] where its force would appear to be  cir-
cumscribed  (se  cantonner) and  concentrated, and that the plastic
operation, now coming into play, may happily result  in extinguish-
ing it effectually. 
AMERICAN APPENDIX.
815
  In only one instance, out of the numerous cases of cancers of the
lace and other parts  that the author has removed, has he found it
necessary, contrary to the recommendation of M. Martinet,  (de la
Lreuse,) to take the flap from a distance, and not from the parts in
the immediate neighborhood.
  The analogy which M. Van Mons (Ponomonie Beige, Experimen-
tal et Raisonnee, Louvain, 1833)  supposed  to exist of animal flaps
to vegetable graftings, by imputing to the former a high degree of
vitality, M-hich even influences and predominates (as in the  latter)
over the organization of the part M-hich it is grafted upon, is clear-
ly erroneous.   The remark of M. Burggraeve, (Annales de la So-
ciete de Medecine de Gand, Juillet, 1839 ;  Memoire sur une Restau-
ration de la  Face, par le Professeur  Burggraeve,)  that autoplastic
flaps generally remain alienated (etrangers) to the vital motions of
the surrounding parts, is much more consonant to truth.
   M. Burggraeve cites, in illustration, a case of M. Dieffenbach, in
M'hich, six months after complete restoration of the nose by a flap
from  the  forehead, the patient was attacked with jaundice, and
was suffused M-ith a yellow color in every part but the new nose,
M'hich, moreover, assumed a  white color M-hen the patient M-as ex-
cited, and a blue color when he was  cold.  M. Serre  therefore
considers  the idea chimerical and unpathological, that for such rea-
sons as MM. Van  Mons, Martinet, Dieffenbach, C. Phillips, &c.
have  advanced, autoplasty could eradicate from, and protect the
system  against syphilis, cancer, and  other  constitutional affec-
tions.
   He appears to agree with M. Phillips, that the most  frequent
cause of failure is the engorgement and death of the flap  from the
current of arterial blood, constantly conveyed to it through the ped-
icle, finding  at first no means  of exit, either  through the cut arterial
branches  which have been  closed by the sutures of the borders,
nor any means of passing into the  circulation through the veins,
inasmuch as these latter are no longer  continuous with their cor-
responding arteries.   Such are too  often the results of the  Indian
method, or  torsion;  but the reverse takes  place in the French
method, which constitutes one of its  chief advantages.
  Besides the beautiful operation of Dieffenbach, in enlarging a
contracted mouth, (vid. supra, text,) wherein he practically applied
the well-known fact, that the mucous and  even serous membranes
exposed to  the air  assume the character  of skin, it is to Delpech
(says  M. Serre) that we owe  the  application of the opposite, and
to autoplasty no less valuable principle, that the surface  of the
skin, secluded from the air, acquires the character and properties
of mucous membrane.

                       Facial Autoplasty.

  Erysipelas is the accident most to be dreaded  in these repara-
tions   The  preparatory practice of dry frictions, stimulants, &c,
to the part  whence  the flap is to be taken, as recommended by 
816           NEW  ELEMENTS OF OPERATIVE SURGERY.

some, in order to give greater vitality to the tissues, is censured in
unqualified terms, as calculated to induce erysipelatous  inflamma-
tion and gangrene.  Even the razor and soap in shaving the part,
except it be five or  six hours before the operation, may tend to the
same  results.   So also the  nitrate of silver, which some use to
mark out the flap.   JM. Serre has ahvays found common ink to an-
swer this purpose sufficiently M'ell.
  M.  Serre  has seen  rhinoplasty by the Indian  method practised
twelve times M'ith perfect success, [the greater part, it is presumed,
his  own  operations.—T.,] M-hich, we  presume, is as much, if not
more, than almost any other surgeon (if M'e  except, perhaps, Dief-
fenbach) can say.   Twice only he has seen  it attempted by a flap
from the arm, and in both it was folloM'ed by gangrene.  This dif-
ference is readily explained.  The cutaneous tissue of the scalp is
not homogeneous M-ith that of the arm; the former being not only
more  abundantly supplied M-ith vessels, but nourished by one iden-
tical and special arterial arrangement, viz., the temporal, auricu-
lar, and occipital arteries.  But what so  often secures  success in
the Indian mode  of rhinoplasty is, as Delpech  pointed out, this.
that the arterial branches of the  ophthalmic, which go to the root
of the nose, are included within the pedicle  of the  flap.
  The defect of vascularity in  the arm explains why the Taglia-
cotian method required, as a preliminary, that the flap should re-
main  detached  for some time, in order to acquire a separate vitality
before being applied.
  These facts above explain why M. Serre disapproves entirely of
the recommendation of Dieffenbach, not to leave any large arterial
branches in the pedicle, but to  divide them if they are met with.
Dieffenbach says, if we do leave them, M-e  expose to sanguineous
engorgement and gangrene of the flap, and  are compelled to have
recourse to leeches, &c.  Though  there are cases  where  leeches,
cold applications, &c, are found necessary, M. Serre has seen oth-
ers, where hot  and stimulating applications have been attended
M'ith the best effects.
  The flap  should  not  be  applied at the moment it is  separated,
as the tissues at first undergo a sort of spasmodic  movement, and
the cut vessels  of the  borders of the flap, and of  the part, to which
it is to be accommodated, bleed too much.  The proper time for
the attachment is after the  lapse of ten or fifteen minutes, M'hen
the sanguineous effusion has given place to a serous exudation, the
diminution of activity in the skin, as has been remarked by Dief-
fenbach, (Considerations Generates sur la Transplantation des Par-
ties Animates, par Dieffenbach, Journ. Complementaire des Sciences
Med., torn, xxxviii., p. 278,) evidently favoring the elaboration of
the plastic  processes.  Hence the interval of  time, M'hich  has
usually elapsed between the total  removal of a nose and its re-
placement, has been  fortunate  and favorable to  reunion, rather
than the contrary.
  M.  Serre  has never, in all his cheiloplastic operations, found it
necessary to have recourse to the incisions of Celsus, to give greater 
AMERICAN APPENDIX.
817
distensibility to the flaps.   Extensive dissection of the cheeks from
the maxillary bones, however, in  order  to facilitate the displace-
ment, he deems of the greatest importance in cases of great losses
ot substance.  Another means of great value is, the division [i. e.,
scoring] of the lining membrane of the mouth, (la muqueuse buccale)
by incisions made through this membrane, in a direction perpendic-
ular to that which we wish to give to the flap.  This was suggested
to him from the resistance which he found this membrane made in
the dead body, to the  displacement of the  skin, (see his Reclama-
tion on this subject, against Dr. Payan, of Aix, in the Revue Medi-
cate, 1839, t. ii., p. 461.)  This has the preference over the external
incisions of Celsus, because it does not enfeeble the flap so much,
and leaves no visible cicatrix.
  In many cases  it is only necessary to dissect loose the  parts, to
restore an organ that M'as apparently lost; as, for example, a sunken
nose, in which case, as M. Dieffenbach calls it, the operation is a
simple rhinoraphy, rather than rhinoplasty.
  Often, in actually enlarging the loss of substance by our incisions
for  the flaps, we effect, by means of very acute angles properly ar-
ranged, and  by thus changing the form of the wound, a far better
restoration of the part than by any other means.
  Every arterial vessel should be immediately secured by ligature,
or torsion.   M. Serre  has not found  ligatures so reprehensible, in
point of consecutive inflammation and suppuration, when compared
with torsion, as  Mr. C. Phillips represents them  to be, (Esquisse
Physiologique sur les Transplantations Cutanees, p. 24.)   The subse-
quent hemorrhage M'hich may arise from neglect of this precaution,
is not to be confounded M'ith that  caused by the centrifugal reflux
of the general febrile  reaction M'hich may follow the operation, and
render bleeding by the arm necessary.
  MM. Graefe and Dieffenbach prefer  the  twisted  suture for the
flaps, and pins similar to those used by entomologists for impaling
insects.  M. Serre  inclines  rather  to the practice of M. Blandin,
who does not multiply the pins to the extent that Dieffenbach does,
but generally, in rhinoplasty, for example, uses but five; that is,
one for the columna, and two to each  side of the new nose.  In
blepharoplasty, M. Blandin abstains altogether  from any sutures,
using only a small roll of lint for compression on each side the
wound, and keeping  the  edges together by adhesive straps.  M.
Serre  imputes two  of his failures  in autoplasty to the obstruction
to the  circulation from too many pins.   M. Dieffenbach contends
that gangrene never occurs, except some days after the operation.
and from the parts  having become heated and SM'ollen.  M. Blan-
din  says there are two kinds of gangrene: one during the first days,
and dry from defect of blood; the other, generally after the sixth
day, is humid from too much blood, and the inflammation which
such engorgement produces.  He  has never seen  or met with a
well-attested case of  alleged gangrene from cold, any considerable
period  of time after the operation.
  M Serre considers the pins used  by MM. Dieffenbach and Graefe
                              103 
818
NEW ELEMENTS OF OPERATIVE  SURGERY.
   not strong enough, at least in the  French method.   He even finds
   the hare-lip pins, which he is in the habit of using, not always of
   the proper strength.   Adhesive plasters, he thinks, are particularly
   objectionable from their tendency to favor erysipelas.  So of all
   uniting bandages and dressings which impede the venous and lym-
%  phatic circulation, and mask the parts.
     Absolute silence and  repose, and exclusion from cold, are indis-
   pensably necessary.   Hence,  in cheiloplasty and genoplasty par-
   ticularly, it is not advisable  to operate in those who have catarrh,
   or who  are asthmatic.  The  vertical  position, slightly inclined, is
   the best, as it  gives greater relaxation  to the muscles of the neck
   and face, and retards the upward arterial current of the blood, as
   well as facilitates (he  might have added) the gravitation of the
   general mass of the blood downward.
     Though  some cases render it necessary to defer the completion
   of the "operation  to two or  three stages, M. Serre  recommends it,
   if possible, to be finished at the first sitting.   He, however, lays it
   doM'n very properly as a most important  principle, that the opera-
   tion should not be hurried, as the length of time required has nothing
   to do M'ith  the dangers that may exist.  Out of all the numerous '
   autoplastic operations he has performed at Montpellier, during the
   seven years he has been surgeon-in-chief of the Hotel-Dieu of that
   city, he has lost but one patient, which patient was seventy years
   of age, and died in consequence of inflammation of the throat, re-
   sulting  from the tearing out  of the sutures, in consequence  of fall-
   ing upon his face from  the bed on the third day after the operation.
   All, it is true, hawe not been so fortunate.  Thus, out of eighty-foui
   autoplastic operations performed by M. Blandin, thirty-nine were for
   rhinoplasty, seven for blepharoplasty, fourteen for cheiloplasty, nine
   for genoplasty, one only for otoplasty, three for  bronchoplasty, two
   for cystoplasty, four for uretroplasty, and five for various kinds of
   cutaneous autoplasty.
      The youngest was six years of age, and the oldest sixty-seven.
      Twelve of them had morbid bridles from burns or old ulcerations;
    three had congenital defects of conformation; nine, losses  of sub-
    stance  from gangrene ; fifteen had been recently operated  upon for
    cancer; nine had old fistulas; the remaining thirty-six presented
    mutilations from wounds, and eruptive, scrofulous, or syphilitic dis-
    eases.  Five of these died from consecutive diseases, of which the
    operation had been the accidental cause.
      Forty-two had been affected with various accidents after the op-
    eration ; in nine there  was gangrene of the flap; in three the parts
    did not unite; twenty-three had  inflammation, in almost every in-
    stance erysipelatous ; and six had nervous symptoms, more or less
    severe.
       Sixty-one out of the eighty-four cases were cured in a satisfactory
    manner.
       Cancer returned in two of the fifteen who had been operated up-
    on for  that disease; but  in both these, which  were  cancer of the 
AMERICAN APPENDIX.
819
th?' tahr^°peration was Performed by simple sliding (glissemenf) of

  Thus, by this statement three out of four in autoplasty are cured,
one out of seventeen dies, accidents are developed in one half, and
gangrene occurs in one out of nine, (Blandin—Autoplastic p. 263.)
  Ihe want  of success is often  to  be ascribed, according to M.
Serre, to neglect of preparatory precautions on the part of the sur-
geon, as in operating  upon persons whose skin  is not  freed  from
syphilitic or exanthematous affections.   Besides repeated purgation
and blisters in such cases, he has found an issue to the arm or leg
a serviceable drain from the skin, to diminish its predisposition to
inflammation.
  Robust, sanguineous patients do not do so well, and in such it is
advisable to  use  such means as will  moderate  the inflammatory
and febrile tendencies, especially towards the head.
  Immediately after the operation, he warmly recommends, as in
the  practice of Delpech in most  operations, a suitable  opiate,  as
nervous  accidents are thereby often suppressed  in the very onset,
and a manifest amelioration obtained in the condition of the pa-
tient.
  The surgeon should guard against operating in seasons when an
erysipelatous predisposition is prevailing ;  and should this disease
supervene, active  depleting remedies  must, be  had recourse to,
avoiding those evacuants that provoke vomiting.
  M. Serre, after his extensive experience, is constrained to believe
that there is much less danger of such accidents as phlebitis, angio-
leucitis, and purulent collections, from the French method of auto-
plasty, than is apprehended by M. Velpeau.  [The marked differ-
ence in the dry, mild, and sunny atmosphere, and pure sea breezes
of Montpellier, as compared with the long M'intry damps of Paris,
may (as we can  from a residence in both  assert) in part account
for the far greater prevalence of such results from  autoplastic op-
erations in the latter city, to say nothing of the hospital class of pa-
tients at  Paris being generally of a much  more vitiated and im-
poverished  constitution than the more hardy and rustic poor of
Languedoc and Provence, on the healthy shores of the  Mediterra-
nean.—T]
  In fine, the most minute and careful attention  to the dressing is
fully as important as the operation itself, (pp. 1 to 94, inclusive.)
    OPERATIVE PROCESSES IN RESTORATIONS OF THE FACE.

                          Cheiloplasty.

  The method of Chopart and others, of displacing the dissected
teguments in mass from the neck, having, like the Indian and Italian
methods, the constant objection of introversion, or wrinkling (reco-
quillement) of the lip, and the exuding of the saliva, M. Serre at last 
820
NEW ELEMENTS OF OPERATIVE SURGERY.
devised the means of obtaining, for the prevention of these difficul-
ties, a remedy, which Delpech had long foreseen the M'ant of, but
sought for in vain.   This consists in making use of the lining mem-
brane of the mouth to serve as a suitable covering for the free border
of the new lip.
  M. Serre claims this new method as legitimately his own, and as
one which he has been in the constant practice of for seven years
past.   [This discovery is, however, as is seen  in the text, supra,
usually given to Dieffenbach, but, as it seems, and as M'ill be  seen
farther on, erroneously.—T]
  Its originality and high value  may be  appreciated  (as already
remarked) in those common  cases of cancer of the  lower lip, [of
which  Plate II. of M. Serre's excellent and most  useful work is a
graphic example,]  M'here, strange to  say, the mucous  or  buccal
lining directly beneath is frequently found, according to M. Serre,
totally free of any degeneration.   Thus, a perpendicular incision im-
mediately outside the cancerous ulceration, externally, was carried
down from each angle of the mouth to below the chin.   A rectan-
gular portion, including the lower lip and its cancer, was  then care-
fully dissected off clean from its attached mucous lining on its  buc-
cal surface.  A sufficient portion  below this, of the remainder of
the tissues between  the two  incisions, was then detached from the
jaw, and chin, and supra-hyoid  region, and the  new flap, being
drawn and lifted up to its place, Mas carefully adjusted to the lining
mucous membrane, upon which it exactly fitted, the  upper edge of
this membrane being first brought over and  hemmed to  the upper
border of the new lip, for its new vermilion border, and the sides of
the flap adjusted to the raw surfaces of the perpendicular incisions
on either side, and carefully fastened  there, as  well  as its  middle
portion to  the reserved buccal mucous, by tMdsted  sutures.  The
mucous membrane  thus served  as  a posterior partition-wall, or
floor, to secure the exact and proper coaptation and  position of the
neM' lip.  For, as on either side beyond the excision  of the cancer,
it M'as continuous with  the  general buccal lining of the mouth, it
acted as a broad plane, or distended velum, for the transposed new
tissues from below to rest upon, and adapt themselves to, in  their
new situation, much better  than  any mechanical  or forced means
possibly could enable them to do—such we understand  to  be the
peculiarities of M. Serre's process.
   We certainly consider this pressing into  the service  of cheilo-
plasty, of a large and continuous portion of the entire natural mu-
cous lining  of the buccal cavity intact, and ready for the reception
of the new lip, (however much M. Serre may for its first suggestion,
or its point of departure, be  indebted to the  operation of M. Wer-
neck, or M. Dieffenbach, in  their operation for enlarging the  com-
missures of the lips,) a new, original, and most invaluable improve-
ment in anaplastic surgery.   It seems to  have been all  that was
wanting to give the finishing stroke to this  branch  of restorations
upon the face.   All the functions of the lip, in the case we  have
 alluded to, were completely restored—the normal flow of the sali- 
AMERICAN APPENDIX.
821
 va, the articulation, &c, to  say nothing of the perfectly natural
 orm and expression of the external contour, and especially that of
 the vermilion border.  According to the figures of Plate II., the re-
 storation was most perfect and natural.
   This first case will fully answer as a sample for all of this order,
 and for illustrating the great principle which M. Serre claims to be
 the author  of, and upon the value of which reposes the extraordi-
 nary success (as we  learn from his work) he has met with in these
 operations   There  can be no doubt, that where the buccal mu-
 cous is undegenerated, that the preservation, by M. Serre's method,
 of a normal membrane like this, in normal position and continuity
 with the general mucous lining of the cheeks and mouth, must con-
 stitute a more perfect and sure guide or platform for the exact ad-
 justment of the newly-raised-up  tissues, than the sutures alone to
 each side, directed by the eye only, could possibly effect.  Where
 the cancer  does not extend down below the union of the tissues to
 the chin,  [i. e., the bucco-mental, or genio-buccal  groove, as it may
 be called,] it need not  be  at all invaded by the knife, and success
 is so  much the more  certain.
   Before  proceeding to notice less important  improvements  than
 the above-described fundamental process of M. Serre's plastic op-
 erations for the face, it is  requisite, says  Dr. Mott, to caution the
 operator, in respect to cancerous degeneration of the lips,  that,
 where the  disease  has legitimately assumed  the  carcinomatous
 character, but faint reliance can, in his judgment, be  placed upon
 any expectation of finding the buccal mucous lining unimplicated.
 So that it would be  labor lost, or, what is worse, it would be giv-
 ing extension to the disease, to attach the undiseased flap below to
 the dissected mucous partition, M-hen this latter has  previously be-
 come involved in the cancerous diathesis.  Previous to such change,
 and while a scirrhous condition only of the tissues exists, the process
 of M. Serre might, Dr. Mott thinks, be available, and would  then,
 indeed, be a resource of incalculable  value, and the credit of de-
 vising which reflects much praise upon its author.  In affections of
 the lips, of a truly cancerous character, however, Dr. Mott never has
 seen the lining mucous membrane to such tissues within, otherwise than
 participating fully in the disease, and does not believe that they can
 then be at all depended upon in the process of restoration or repara-
 tion.
   [Within a few weeks past, (October, 1844,) Dr. Mott had an op-
 portunity, for the first time that he has attempted it, of testing M.
 Serre's process of lining the new flap, in a cancerous lower lip, with
 the buccal mucous.   The patient was about forty years of age, and
 the cancerous affection had existed for seven years, during which
 the destruction of parts by the ulceration had left several irregular
 deep grooves, running lengthwise on the vermilion border—while
 the lining of the lip within, though the tissues themselves there were
 also so indurated  and scirrhous as to be in a state almost  cartila-
ginous, was comparatively sound, so far  as  its  glossy natural ap-
pearance indicated.   Dr. Mott made two parallel vertical incisions, 
822          NEW ELEMENTS OF OPERATIVE ST.RGERi.

one from  each commissure down to the supra-hyoid region.  He
then, at right angles to these, made one below the cancer down to
its inner mucous  lining membrane, which he dissected  upward so
as to detach perfectly from the diseased lip.  Thus excising out the
cancer, he shaped and brought the narrow hem of the mucous lining
in front and upon the fresh-incised lower border of the  transverse
incision, and fastened it there carefully by interrupted sutures.  He
now proceeded to detach this new-formed  vermilion border, and
the flap of which it formed the superior edge, from their connec-
tions with the chin, and base of the jaw, down to the extent of the
vertical incisions.  This rectangular flap  was brought up  with
great facility (as the tissues were here thick) to its proper place, on
a line with the commissures, where, and also on the sides of the
vertical incisions, it was carefully attached  by suture.  To all ap-
pearance  the  man's mouth immediately looked perfectly natural,
and one could scarcely imagine that the orbicularis could not play as
usual in the functions of speech, instead of being immoveable when
he spoke in reply to questions put.  The jaw  and parts were kept
in place by a containing bandage.   In a few days, however, though
the parts were left free to the air, and every symptom went on per-
fectly well, Dr. Mott had the chagrin to find that the new vermilion
mucous border lost its vitality, and sloughed off from the  parts to
which it had been attached.—T]
  M. Serre himself is evidently impressed  with doubts of the in-
tegrity of the  buccal lining in such cases, though he would desire
to dispel them by the fact that cancerous tumors are often dissect-
ed out  without at all interfering with or removing their enveloping
cysts, a remark which can scarcely be made to apply to tumors
truly cancerous.
  Mr. Charles Phillips was the first  to  adopt or follow the new
method of M. Serre, and speaks of the facility  with which  the buc-
cal, after dissecting it off from the border of the incision for a quar-
ter of an inch, may be freely separated, even with the handle of the
scalpel  alone. (See his  treatise, Autoplastic  apris VAmputation des
Cancers, 1839, p.  36.)
  One  of the first patients upon  whom M. Serre appears to have
operated by his new method, and M'ho is the first in his  list,  (see
his Case I., Plate II.,) entered the hospital of Saint-Eloi, (Montpel-
lier,) of which M. Serre was then and is now the principal surgeon,
Oct. 18, 1834, and, though  no mention is made of the  date M'hen
the operation M'as performed, we are  left to infer that it took place
very soon  afterwards.  He speaks also of another  similar case,
which  he does not  detail, but which was operated upon by him,
April 3, 1836, with the same happy results as to the perfectly natu-
ral, and even elegant, aspect of the vermilion lip, &c, (see this case,
as related by M. le Docteur Burin, Thises de Montpellier, annee 1836,
No. 49, pp. 18,19.)  A similar, but more formidable case than either
of these last, (see his Case II., Plate III.,) involving also a portion
of the cheek, above the left angle of the mouth, was operated upon,
with complete success, by an equally felicitous arrangement of the 
                       AMERICAN  APPENDIX.                   823

incisions, (viz.. before the preceding case, and as early as June 29,
1835.)   In this last case, as an evidence of the extremely distensi-
ble nature  of these tissues, the sound portion of the lip (less than
one half of it) was stretched so as to serve effectually for an entire
lip and natural mouth,  and for the attachment to it of the upper
border of the flap below, and of the lower extremity of the united
flaps which covered the acute angular space from whence the can-
cerous portion on the cheek had been removed.
   But  if there be  not some  error  of date, there was still another
case (see his Case iv. and Plate v.) in date, but not in the order of
description, anterior to the three  preceding, in which M. Serre
operated, and with, if possible, a more brilliant success, and by a
more ingenious application  of his new method than in the prece-
ding, or in any case subsequent thereto.  This dates as far back
as Sept. 15, 1831, M'hile M. Serre was officiating in the  hospital in
the absence of Delpech.  The lower lip was occupied with a can-
cerous affection (having the same cauliflower aspect of vegetation
that most of the similar cases represented in M. Serre's plates have)
throughout nearly its whole  extent, and even beyond the commis-
sure.  Instead of a semi-lunar incision, which most surgeons would
have made, and M'hich would have neatly included the diseased
part without going down to the  chin, the professor of Montpellier
preferred two long incisions, beginning just  outside of each com-
missure, and proceeding downward and inward, in a  straight line,
till the branches of the  V they formed met at the thyroid cartilage.
Tm'o lateral incisions  at the upper  extremities  of the last, and
extending  horizontally with  a slight convexity upward till they
reached to near the  anterior edge of the masseter, completed  the
outline of the flaps.   The long oblique lateral triangular flaps thus
formed, M-ere completely detached to beyond the  base  of  the jaM'
on either side.   From  a  remark rather indistinctly expressed,  we
are led to infer that the buccal lining upon which the cancer was
situated was dissected off from it, and found sound.  The flaps,
therefore, in being stretched forward and upward, and then fastened
by twisted sutures, must, at their upper vertical line of union, have
rested on this membrane, while the upper edge of that membrane
M'as brought outward and forward and turned down, and hemmed
by numerous sutures  to the cutaneous edge of the  lateral incisions,
now serving by their slight  curve to imitate  a  perfectly  natural
loM-er lip, so much so,  says M. Serre, that in a few  weeks  after-
wards the  restoration was so complete and deceptive, that no one
would have suspected that any operation had ever been performed
upon the mouth.   If there be no  error in the  date of this operation,
we think  it will  be found that the priority of the idea of  making
use of the mucous membrane in these  restorations, as well as the
application of it, must, in its totality, be wholly conceded to the
surgeon of Montpellier; and  that the application of this principle
by Dieffenbach, (see text, supra,) in the  making of new angles to
the mouth in the abnormal contractions (congenital or acquired)
of that  aperture, must have  been derived  by the Berlin professor 
824           NEW ELEMENTS OF OPERATIVE  SURGERY.

in part at least from M. Serre.  In this part also it is seen, that the
single, short, lateral, and horizontal incisions of M.  Serre,  more
neatly (in our judgment) executed this office, M'hen stretched for-
ward, than if he had dissected out a longitudinal strip of flesh, as
M. Dieffenbach does in the cases just mentioned.
  M.  Serre  dwells with emphasis upon the  important result he
obtains of avoiding, by means of his short lateral incisions, the duct
of Stenon, and, by the outline of  his vertical flaps, the wounding
of the facial nerve, both M'hich dangers, he remarks, have hitherto
been too  much overlooked.
  As  an  illustration of this  he  cites  a remark  of Mr. Charles
Phillips,  (in his M'ork  entitled La  Chirurgie de M.  Dieffenbach,
premiere  partie, p. 121,) that, until M. Dieffenbach  adopted  the
practice, in  removal of portions  of the upper jaMr, of separating
the tissues by an incision running down the back of the nose and
middle of the  upper lip, (and which practice, or at least its prin-
ciples, M. Serre contends, originated m ith the school of Montpellier,)
nothing was more  common after such operations than to meet with
paralysis of one side of the face, from the  wounding  of the facial
nerve, and also  the offensive accompaniment of a  salivary fistula
from the  wounding of the duct of Stenon.
  In  case No. v.,  (Plate vi.,) the  same  operation as the last was
performed, for one half of the lower lip, and the deception of the
vermilion border, and form of the lip, &c, was complete.   Noth-
ing could be seen  but a slight traction and elevation at the place
of insertion of the  pins in the line  of union towards the chin.  M.
Serre has found this slight inconvenience prevented by an incision
upon  the  mucous  membrane on the inner surface of the flap, to be
made perpendicular to the direction in which the displacement is
to take place.  This, however, is nothing  more than the lateral
inner scorings, as  practised  in the  ancient  methods.  (Vid.  text
of M. Velpeau, supra.)
  M.  Serre, in order to establish the priority  of his  method in due
season, took an  early opportunity to  communicate it, in a  short
official letter (dated February, 1835) to the Academy of Medicine
of Paris.  (See Bulletin de Therapeutique, tome  viii., p. 148, annee
1835.) In that letter  even, he insists  that, in a great number of
cases of cancer of  the lower lip, (its usual  locality,)  the mucous
membrane is  rarely affected,  except  on its free border.  He also
asserts that he had, therefore, as long as three  years before,  (i. e.,
1832,) used the healthy portion of the buccal  membrane of the flap for
the border of the new lip, attaching it by suture.
  M.  Serre having read, in the Journal Hebdomad., (April 4,  1835,
tome viii., p. 23,) that Prof. Sanson, a member of the Academy, had
stated, in the  sitting of March 31, that this method belonged of
right to Dieffenbach, immediately wrote to the editor of that jour-
nal.   (Ibid., tome  viii., p. 90, 1835.)
  It appears that  M. Zeiss himself, the pupil of Dieffenbach, and
who has  published his preceptor's operations  and  processes in
autoplasty, awards the honor of the above method to M Serre, but 
AMERICAN APPENDIX.
825
claims (very unjustly, M. Serre thinks) the credit of the lateral in-
cisions in cheiloplasty for M. Dieffenbach.   It would appear, how-
ever, from  the representations of M. Serre, (see his Plate  xxx.,
fig. 2,) that the surgeon of Montpellier  is equally entitled also to
originality and priority, for the singular tact and perfection he dis-
plays (as we have already shown) in his mode of procuring, cutting,
and adjusting his flaps, in cheiloplastic operations, as for his meth-
od (by far  the  most important) of calling  into service the'buccal
membrane ; for it is very clearly shown that M. Dieffenbach, in
these operations, proposes to make, from  the  extremity  of  each
lateral incision, a vertical incision to aid the approximation, and
by which  an unseemly triangular gap would be left on each side
of the cheek, and a salivary fistula perhaps produced.   (See M.
Zeiss—Handbuch der Plastichen Chirurgie, von Eduard Zeiss, pp.
425 and 426; § 376, 377, 378, 379.)  The method of M. Serre is also
briefly alluded to  by M. Velpeau, in the present work, but not in
detail, as  the former surgeon had  not  then  (1839) published his
treatise.
  We have thought it  due to M. Serre, to give the above state-
ment of the history and advantages of his method, as strikingly
exemplified in  cheiloplastic and  geno-cheiloplastic  operations, as
contrasting with  some of the more  objectionable processes which
had been  hitherto in use.  (See  M. Serre's treatise, from p. 95 to
p. 135, inclusive.)

Autoplastic  Restoration of the  Commissure of the Lips, in Cancerous
                           Affections.

  Though M.  Serre  has not yet  had but few opportunities of ap-
plying his ingenious method to these deformities, those in which
he  has done so have  been  attended with a success equally as
brilliant and  complete  as in those  we  have enumerated above.
Case vi. (Plate vii.) is a beautiful  illustration of this remark, where-
in the cancerous ulcer on the right commissure was, by means of
carrying out the surgeon's almost mathematical skill (as  we have
before remarked) in  the arrangement of his diagram of incisions,
completely embraced in  four  incisions, forming in their union, ex-
ternal  to the  commissure, and  obliquely  downward, two of the
salient angles of a perfect stellated incision.  The respective  four
sides of these  two salient angles being then ingeniously brought
into coaptation one with the other by sutures, and the buccal
membrane adjusted, the perfect  restoration surprised every one
who saw it.  Two years after, M. Serre saw the patient, and found
the parts had remained perfectly  healthy.
  In elucidation  of the superiority of this process, (which  to be
understood must be examined in the plates of the author's treatise,)
this surgeon exhibits cases where, in similar affections of the com-
missures, the deformity has been  deplorably aggravated by means
of erroneous and awkward modes of operating, hastily determined
upon  without  any preconcerted  reflectior  upon the harmonious 
826
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
combination, proportion, and adjustment of the incisions required.
M.  Serre  shows that, in some of these deformities  or distortions
upward and downward of the corners  of the  mouth, and M-hich
are frequently met with, that a simple longitudinal lateral incision,
horizontally outward from the commissure and through the cheek,
and then immediately dissecting its buccal, [above and below—T]
and hemming  it to the [cutaneous] borders  of the  incision, Mas
quite sufficient to accomplish a perfect restoration of the deformed
parts to a normal condition.
  In this (as we have  above  hinted) he has again, as  we think,
established  a  process far preferable  to that which M. Dieffenbach
claims to be the author of, viz., the removal of a horizontal narrow
strip of tissue from the commissure  outward, and dissecting down
to the buccal,  and then dividing that into  two equal halves, to be
attached to the bleeding surfaces at  the angle of the commissures
and the  edges of the wound, above and  below.  (See text of M
Velpeau, and his ingenious modification.)
  Case vii. (Plate viii.) is a fine example of both of M. Serre's pro-
cesses, the patient being an ancient officer of the guard, who, in a fit
of despair, nearly destroyed by a pistol-shot both  angles  of the
mouth, thus causing, after  cicatrization  had taken place, a distor-
tion of the right-angle downward, with a large gap exposing the
jaw, and attended with the constant flow of the saliva, while the
other angle  of the mouth was drawn upward ; the united deformi-
ties impeding  speech and mastication, and preventing closure of
the lips.   To the right commissure he applied his ingenious stellated
incision, and to the left, a single short lateral  horizontal incision,
as above described, adjusting the dissected buccal to the two bor-
ders of the latter.  The restoration of the form and functions of the
mouth was complete in every part.
  Case viii. (Plate ix.)  is certainly one of  the most adroit applica-
tions of this geometric stellated method in M. Serre's treatise.  The
patient was a young lady aged twenty-five, in whom a severe burn,
when she was a child, destroyed a portion of the left angle of the
mouth.  The  cicatrix formed from  this drew doM'n the corner of
the mouth in  a repulsive manner, the gap exposing  the teeth and
opening a constant passage to the saliva  through it.  After much
reflection, and figuring out the diagram  of the required incisions
with ink, such portions of the cicatrix were  destroyed as enabled
the surgeon to form, external to the commissure, two salient angles
of a stellar incision, one  of which, above,  pointed  outward and
slightly upward,  while the  other pointed downward on the outer
part of the chin, and reached to near the base of the jaw; secondly,
to form or 5hape, out of the left extremity of the tissues of the lower
lip, an angular flap making in its outline a third and smaller salient
angle, which  fitted exactly into  the loss  of  substance  left by the
upper or greater containing salient angle of the two just described,
and the extremity of the lower side of which smaller angle or flap
terminated  below, towards the chin, in the lower side of the con-
taining salient angle in that place. 
AMERICAN APPENDIX.                   827
   Nothing more was now to  be done than to stretch the smaller
 angle or flap upward and outward into the large containing salient
 angle above, which  movement  of course,  at the  same  moment,
 brought the two sides of the lower large angle into perfect coapta-
 tion with each other.   The mouth was thus immediately restored
 to  an almost perfectly normal shape, leaving only the slightly-
 traced outline of two acute stellar angles, one  pointing upward,
 the  other  downward, filling up also  the revolting gap, relieving
 the loathsome annoyance of the flow  of saliva, and enabling the
 patient  to  articulate  distinctly.   The  former cicatrices, however,
 from the burn, were too numerous in the  neck to prevent the head
 from being somewhat drawn  down on that side, as it had been
 before the operation.  (Serre—op. cit.,p. 135 to 150, inclusive.)
   There can, therefore, scarcely be a doubt that the method of M.
 Serre, founded as it is on geometric forms and arrangements of the
 flaps and  incisions, so natural and purely  mathematical, and the
 tractions of which, therefore, in  the process of agglutination,, can
 thus  be so accurately calculated, and, as it were, measured and
 provided for before-hand, on the mechanic laws of the composition
 of forces, (which lau's, the centripetal  and  radiating directions of
 the fibres of cicatrizating surfaces and of the growths of structures
 show to be, in part at  least, applicable to organic life and its pro-
 cesses,) there is no doubt,  we repeat, that a method so philosophi-
 cal and exact will, for the future, entirely supersede all those other
 rude processes hitherto employed, and that it will thus become the
 basis of every rational modification of autoplastic surgery.
  M. Serre especially condemns  a process  6Y M. Von  Ammon,
 (much vaunted by M. Zeiss,) of borroM'ing, for these deformities and
 losses at the commissures, a flap by transplantation from the cheek.

                  Restorations of the Upper  Lip.

  In  cases  of compound liare-lip, where there is a labial or tegu-
 mental median lobule or pedicle, and where its adjustment to the
 fissures  on  either side might, in uniting, flatten the nose, M. Serre
 proposes, with Dupuytren, and performed, in a girl aged seventeen
 years, the operation of exsecting, with the nippers, the correspond-
 ing middle incisor bone, and then fastening the lobule back at the
 upper part  of the void left by the exsection, so as to  make it serve
 as the columna to the  nose.  In addition to this, after having pared
 the two edges  of the now single fissure,  he made through the
 tissues of the lip  on either side, and near its junction with the nose,
 one of  his  lateral  horizontal  incisions, about half an inch long,
 which, with the  separation of  the  lips  from their natural attach-
 ments to the jaw, gave it great distensibility, and allowed the two
pared edges to be easily stretched over  in front, and to be brought
into exact coaptation  by means of the twisted sutures.  The resto-
ration was  perfect, and surprised all who saw her.  The cleft in
the vault of the palate remained open, as before.
  In a case of M. Gensoul, of Lyons, (alluded to by M; Serre,) and 
828            NEW ELEMENTS OF OPERATIVE SURGERY.

which that surgeon operated upon in 1830, (Journ. Clin, des Hdpit.
de Lyons, Janvier, 1830, p. 23,) he first forced back, until he had
fractured, the osseous projection which stood out three quarters of
an inch horizontally from the middle portion of a double hare-lip,
and  thus brought it into  a line M-ith the alveolar arcade.  This
was aided by  pushing back also,  but  without extracting it, the
right canine tooth, which also projected.
  In regard to  the early period of  infancy at which these opera-
tions should be performed, M. Serre says the Ephenurides Midi-
coles de  Montpellier (tom.  vi., p. 377) contains numerous  facts  to
show that they may be done with safety almost immediately after
birth; and where the fissure in the vault of the palate is excessive-
ly large, they can scarcely be performed too early.
  For a  cancer on the right side of the upper  lip, and M-hich pro-
jected into the nose,  M. Serre  happily  applied his quadrilateral
stellar principle of forming the flaps, with the preservation of the
buccal surface  of the lip which remained sound, and upon M'hich
the flap was neatly adjusted, except for a small ulceration taking
place on the border of the lip, from  using  too many pins.   (See his
Case xii., and Plate xii.)
  In a frightful case  (see his Case xiii., Plate  xiv.)  of an enor-
mous bleeding  fungus, covering the whole upper  lip, the tumor
was, after various treatment by a V (inverted) incision through its
middle, caustics, &c, finally removed by  the  ligature in  mass, so
applied as to  save  the  buccal  membrane beneath, and M-hich
greatly aided in the  adjustment of the long lateral flaps on either
side, forming altogether a tolerably decent lip, with a slight fissure,
however, in the middle.

                 Restoration of an  entire Mouth.

  A horrible case of mutilation of the face from explosion  of pow-
der came under the care of  M. Payan, of Aix, (France,) (see Gaz.
Med. de Paris,  Sept. 4, 1841,) in which a large portion of the left
cheek and the totality  of both lips M'ere destroyed, while the bones
of both jaws were  fractured in every direction.  Terrible as the
mutilations were,  M.  Payan, after the cicatrizations took place,
succeeded, by large  lateral flaps almost exclusively from the right
cheek, and by aiding their distensibility by incisions on the  mucous
membrane within, in  stretching the parts together, and with a
hem of the buccal lining  making an entire new mouth, and  lips, and
border complete, which served so well the  functions of a natural
mouth, and acquired such sensibility and  motion, that the  patient
was not only enabled to  articulate, but also to take his food and
resume his labors.
  M. Serre contends that this process of M. Payan is virtually, step
for step, that which he  adopted for the  case of fungus  just de-
scribed,  and  which  was long anterior,  in point of time, to  M.
Payan's operation, (Serre, p.  203.)
  Stomatoplasty (stomatoplastie) is the name given by German sur- 
AMERICAN APPENDIX.                    829
 geons to those reparations designed to enlarge the buccal aper
 ture, or mouth, when preternaturally contracted (then called atresia)
 Irom congenital or  accidental causes, diseases, &c.; and also to
 make an entire new mouth, or opening into the oesophagus, when
 from any cause whatever that normal communication is imperfo-
 rate, or does not exist.  The aperture, when it does exist, is hard and
 callous,  and sometimes so small that the little finger can  scarcely
 be introduced.  Rust (loc. cit. op. of Serre, p.  209) relates  cases of
 atresia, where the buccal aperture has been in  this manner so ab-
 normally contracted, and presented such difficulties to the introduc-
 tion of food, that the subjects of this deformity have died of hunger.
   Although the invention and priority of the process for enlarging
 a contracted mouth  has been  generally  assigned to Dieffenbach,
 and is also so accorded by our  author, M. Velpeau, in the text, M.
 Serre disputes  this  appropriation, and declares that it belongs to
 M. Werneck, also a  German surgeon,  (Rigaud—Thise de Concours
 sur VAnaplastic, 1841, p. 100,) who was the first to introduce into
 practice this important operation, viz., in 1817, on a person named
 Antoine Vital.  He  first enlarged the aperture at  the commissures
 by a  blunt-pointed  bistoury, and  then  keeping  the jaw firmly
 pressed downward, he made, M'ith the convex  bistoury, an elliptical
 incision  doM'n to the mucous membrane of the cicatrix, and excised
 the tissues thus circumscribed by the elliptical incision.   He noM'
 dissected the mucous  membrane to the extent of three lines, and
 then brought it forward to form the  vermilion border of  the lips,
 fastening it there  by points of tMdsted suture, using the Glover's
 suture at the angles of the commissures, (Serre, op. cit., pp. 210 et seq.)
   To  Dieffenbach,' however, unquestionably belongs the honor of
 having so modified the process  of M. Werneck, as to have made it
 one of the  most ingenious and perfect in anaplastic surgery.  M.
 Serre, however, in applauding it, finds  a serious disadvantage  from
 it in the destruction which it causes of the orbicular muscle, and
 in the difficulty and pain, and length of time, which are necessarily
 required for its  performance, (ib., p. 246.)
   M. Serre claims to have improved the process of MM. Werneck
 and Dieffenbach, in the case of a young man upon whom M. Delmas
 operated at Montpellier, in 1839, upon the plan suggested to him
 by M. Serre, and which, in reality, appears to have differed  only
 from that of Dieffenbach, in excising a narrower portion of tissues
 horizontally from each commissure than M. Dieffenbach did, (Serre,
 op. loc. cit., Case xvi., Plate xv.)  There  was, however, this shade
 of difference, and which, as  we conceive, was an important one:
 That the strip of tissue at each commissure appears to have been
 wedge-shaped,* forming thus a  long prism, as it were, the base out-
 ward,  and the apex  resting  on the  mucous membrane M'ithin, so

  * After making a horizontal incision, of four lines extent, through the tissues from
 each angle, M. Delmas, finding the tissues so thick and indurated as to interfere with
 the  approximation of the mucous membrane to the skin, « enleva fort a propos, dans
 I'epaisseur meme de chacune des levres des plaies,ju il venait de faire, une tranche de
parti's molles, qui facilita ainsi la bunion," &c, (Serre, loc. cit., pp. 219, 220.) 
830
NEW ELEMENTS OF OPERATIVE  SURGERY.
that there was no sacrifice of parts, except of the external indu-
rated tissue, and none whatever of the undegenerate  soft portion
of tissue within, covered by the internal buccal membrane ;  conse-
quently there was less painful dissection, and less time consumed.
  M. Serre, with his accustomed ingenuity in anaplastic repara-
tions, made  a felicitous  application of the great  principle  of the
reversion  of the  buccal membrane, in a case of extreme contrac-
tion of the aperture  of the mouth, complicated with cancer of the
lower lip, and in which he completely excised the cancer by two
incisions, forming together an acute triangle, whose apex reached
below the chin; after M'hich, by tM'o simple  lateral incisions, (one
at each commissure,) he brought the  parts into such perfect ar-
rangement,  as to surprise all who saw the natural mouth and lips
thus formed in a  patient whose deformity had  excited general re-
mark, (Serre, op.  cit., Case xvii., PI. xvi.)
  Werneck himself, the alleged  inventor of stomatoplasty,  also so
far anticipated the present improved modes, as to obtain a mucous
lining from the neighborhood where  that of the diseased  tissues
themselves  was  degenerated,  (Serre,  op. cit, pp. 228-230;  also
Graefe  und  V. Walther's Journal, bd. 14, p. 202.)

                          Rhinoplasty.

  In a case where a destructive ulceration  existed on the  lobule,
M. Serre circumscribed  it by a narrow triangle, the apex  resting
on  the dorsum upward ; but, finding some difficulty in bringing the
pared dissected flaps together on the  median line, from the resist-
ance of the septum and lateral cartilages, he very properly sacri-
ficed a  portion of these  last, when the  union was immediately and
perfectly accomplished, resulting in a complete restoration of the
organ,  (op. cit., Case xx., PI. xviii.)
  In regard to restorations of the entire nose, whatever be the pro-
cess  adopted, M. Serre candidly declares that  he has never been
entirely satisfied with them, neither in those  cases upon which he
himself has operated, nor M'ith those of others, (ib., p. 272.)

                           Genoplasty.

   In genoplasty, M. Serre gives the entire preference to the French
process of anaplasty.  As a striking illustration of which, he cites
the case of a woman, aged seventy-four years, who, from the age
of ten, had, in consequence of some disease of the part, lost a great
portion of the cheek on one side, so as  to expose in a frightful man-
ner the jaws, teeth, nasal fossae, &c.   MM.  Vaust and Anten, of
Liege,  (Gaz. Med. de Paris, Fev. 1, 1840,) completely succeeded in
filling up this great loss of substance,  by detaching and paring the
edges of  flaps from the cheek-bone, lower part of the cheek, and
wing of the nose, so as to give a very respectable appearance to
the face, and afford the patient infinite relief and comfort.
   M. Serre, in these operations, cautions the practitioner particu-
larly against the use of too many sutures, as interrupting a free 
                       AMERICAN APPENDIX.                   831

C-r<iillaji-0n' an(* favorinS gangrene.  For the same reasons he spe-
cially directs  the  sutured flaps to be left  naked, and uncovered
with any bandage, (ib., p. 326.)

           [Anaplasty for Immobility of the  Lower Jaw.

  M. Serre, in his twenty-ninth case, (p. 329 et seq., Atlas, PI. xxiii.,)
upon a youth with immobility of the jaws, excised, by means of two
vertical triangles united   their base  on a horizontal  incision, the
whole  of the  tissues t;    circumscribed, in order also to excise
thereby the thick cicac^os  and bridles  they included,  and by
which, it appears, the jaws were held together.  He  was obliged
to tie several vessels of some size, and the  flaps were a long time
in uniting. Finally, the separation and movement of the jaw were
not obtained over  half an inch to an  inch in width, and that could
only be maintained  by the employment of a  dilating apparatus.
This operation was performed by M.  Serre at La Pitie, Paris, 1830.
  M. Serre refers  to one case in which Dr. Mott also  felt  himself
obliged to make a long incision, from  the commissure  horizontally
and through the tissues of the cheek, in order to divide completely
the numerous inodular cicatrices it included.  But Dr. Mott has now
performed the operation for immobility of the lower jaw more than
twelve times, and with perfect success, and has in no instance found
it necessary  to resort to any anaplastic process.  The complete
and free division,  incision, and liberation of all the adhesions, cica-
trices, and bridles between the jaws, as well as of those between
the jaws and  cheek, and  in, or on the cheek  itself—by means of
the scalpel cautiously employed in the directions required, together
with the indispensable use of' the screw-wedge dilator  for a certain
period of time afterwards—has, in every  instance, achieved the
most satisfactory  results, and entirely restored the jaw to its nor-
mal functions.  These operations, therefore, which Dr. Mott claims
particularly as his own, (they constituting an entire new chapter in
surgery,) and of which he had published several  cases before the year
1830, and before Dupuytren, or  any other surgeon, even attempted
their cure, cannot properly come under anaplasty, nor even under
sub-cutaneous section of bridles,  (as that is but a part of the pro-
cess of cure ;) but will be reserved for their more appropriate head
in a subsequent part of this work, immediately following Anchylo-
sis of Joints, to which this disease seems to be more nearly allied,
though  anchylosis is rarely  complicated with it, except in cases
long neglected, and in which no relief from Dr. Mott's process can
be anticipated.—T.]

                         Blepharoplasty.

   In blepharoplastic  operations, M. Serre urges the adoption, also,
of his great and essential principle in all the forms of facial auto-
plasty, to wit: the lining the internal surface  of the flap,  or flaps,
of the new lid, or lids, with the palpebral conjunctiva;  a neglect to
attend to which, and which, we believe, no other surgeon has ever 
832
NEW ELEMENTS OF OPERATIVE  SURGERY.
before thought  to recommend, explains, in his opinion, most of the
failures in these operations.  Unfortunately, in many of these de-
formities, the results of destructive burns, wounds, &c, there is no
palpebral membrane left to obtain a supply  from.
  The adaptation of this principle was beautifully illustrated by
M. Serre, in a case in which, through mal-treatment of a malignant
pustule  at the external angle of the  eye by  caustic potash, the up-
per eyelid became firmly adherent to the globe, and the lower lid
everted by an ectropion.  An incision of about three lines length
was made transversely, (i. e., horizontally,) from the outer commis-
sure of the eye, which enabled the patient immediately to raise the
upper lid.  To  maintain this incision open,  the palpebral conjunc-
tiva was brought forM'ard and attached, by two points of interrupt-
ed suture, to each lip of the wound.   The union was perfect, and
the restoration  of the natural appearance and uses of the upper lid
so perfect that  the patient would not submit to a further operation.
(See Case xxxiv., p. 375, et  seq., and PI. xxvii., Atlas.)
  This principle M'as, if possible, still more effectually put into suc-
cessful  application by M. Ansiaux, in 1840, at Liege, in a case of
total  destruction of the lower eyelid, and part of the adjacent tegu-
ments of the cheek; in which, hoM'ever, a portion of the conjunc-
tiva remained  unaffected.   An incision was first made from each
commissure of the eye, which  incisions, meeting below, formed a
triangle whose base corresponded with the  lower lid, and thus in-
cluded  the degenerated parts.   A lateral incision was then made,
in a horizontal direction from the  outer angle of the eye, and from
the outer extremity of that incision another was  brought down-
ward and obliquely forward, so as to be parallel to the outer inci-
sion of  the triangle.  He thus obtained a quadrilateral flap, which
being rotated inward, and its inner surface brought into coaptation
with the portion of palpebral conjunctiva remaining, and fastened by
points of suture, formed a perfect restoration of the lid.  The M'ound
left by  the flap was also united by sutures.   Considerable hemor-
rhage took place during the  operation, which,  however, did not
prevent the necessity  of some leeches and cooling applications
during  the cure.  The restoration of the lid proved of  inapprecia-
ble value  to the patient in keeping the ball covered, which, with
the ectropion  in the upper lid, and loss of  the lower, had been a
source of great distress to the patient. (See  Serre, op. cit., p. 397, et
seq.; also, Annales d'Oculiste, par M. Cunier, t. v.,  3e liv., p. 130.)
   M. Serre, in claiming the above process  for the  French method,
and as anterior to and not belonging to Dieffenbach, thinks it much
inferior to that of M. Hysern y Molleras, of Madrid, (vid. Traladc
de la Blefaroplastia Temporo-Facial, 6 del Metodo de Restaurar las
Destrucciones de los Pdrpados,  pag. 103, Madrid, 1834,) and which
is called by its author the temporo-facial.   This  (to which our au-
thor, M. Velpeau, has alluded  in  the supplemental appendix, in a
communication from M. Hysern) consists in  excising the degenerate
lower lid, for example, by a triangular incision,  and making  a
quadrilateral flap external to it by an incision parallel  to the outer 
AMERICAN APPENDIX.
833
side of the triangle.  A portion of the fibres of the orbicularis mus-
cle are thereby retained, and a slight rotation enables the surgeon
readily to adjust  the flap to its place, while the lips of the fresh
wound of the flap are united with the same facility.
  According to M. Serre, (op. loc. cit., pp. 410, 411,) M. Hysern y
Molleras practised this process  as early as 1829, long before M.
Dieffenbach.
  This process is also applicable to the upper lid, and appears to
us to include that of another Spanish surgeon, M. Argumosa,  (vid.
Professor Rigaud, Thise  de Concours sur VAnaplastic des Livres,
des Joues, et des Paupiires, 1811.)
  Without doubt  the most extraordinary triumph in facial auto-
plasty, and far exceeding even the remarkable case of M. Payan
above, is that performed in 1839, at  Gand, by Prof. Burggraeve,
(vid. Annul, de la Soc. de Med. de  Gand, Juillet, 1839,) on a soldier,
who, by a gun-shot wound, had  the entire upper lip and  most of
the front part of the cheeks and upper jaw carried away,  and the
nose driven in and finally agglutinated to the vault of the palate.
It is impossible to form an idea how this hideous deformity, which
exposed the tongue and  fauces, was covered by flaps from either
side of the face, and how the nose was brought out in place, and a
new mouth made, and articulation and deglutition,  &c, restored,
without perusing the details of the operation ; and even then it ap-
pears difficult to comprehend its various steps.  Suffice it to say,
that  the patient obtained a degree of comfort  and relief which
clearly established the almost marvellous restorations which  ana-
plasty can produce in the hands of skilful surgeons, (vid. Serre, op.
cit, p. 426 to 439.)
 M.  MALGAIGNE'S MANUAL OF OPERATIVE SURGERY.

       (Manuel de Medecine Operatoire,) 4th edition, Paris, 1843.

  [The appearance of the fourth edition of this useful compendium
(a work which has been well spoken of by our author, M. Velpeau,
vid. sup.) during the time this edition has been in the press, makes
it necessary that we should avail ourselves, in this concluding  ap-
pendix, of the more important items of new matter it contains rela-
tive to subjects embraced in this volume of our translation of  M.
Velpeau's elementary work.—T]

                  The Sub-Cutaneous  Incision.

  Of all the modes adopted in this new order  of surgical incisions,
which  are now regularly described in works of operative surgery,
(see Malgaigne, pp. 9,10,) that which seems to be most preferred, 
334           NEW ELEMENTS OF OPERATIVE SURGERY.

where it is practicable, is the one M'here the teguments are drawn
tense to one side, so that when the section of the tendon, bridle, &c.
is made, the puncture of the tenotome no longer corresponds (dther
to the extremity or to the line of the incision.  Whereby M'e have
attained what is generally considered the most  important result,
and the highest perfection of the great principle of the sub-cutane-
ous method, that of an almost perfect occlusion of air.

                    Caustics  and Cauteries,

  The new caustic of M. Recamier, recently introduced into surgery
by that  practitioner as an application to cancers, is the regal water,
(Veau regale) containing in solution a certain quantity of the chloride
of pure gold, (chlorure d'or pur.)   M. Malgaigne gives it the prefer-
ence over nitrate of mercury, as we are enabled, he says, to cauter-
ize deeply with  it, while  the  eschar which  it forms separates in
three or four days, and a repetition of the application can be made
at pleasure.  If, as is asserted, it gives but  little pain, and that its
action is purely local, these qualities M'ould  give it, in the estima-
tion of that surgeon, an unquestionable superiority over all other
cauteries, (Malgaigne, Manuel, fyc, Paris, 1843, p. 15.)  [As to the
nitrate of mercury,  the remark of Dupuytren that he has seen its ab-
sorption produce violent cholics, diarrhoea, and bloody stools, is, in
our opinion, a conclusive  objection  against  it, and should  cause it
to be rejected from practice.—T]  Among solid caustics, M. Mal-
gaigne,  and also M. Mayor, very justly, as  we  think, put a high
value on the kali purum, especially in  repressing fungous growths,
as it causes, says the former surgeon, but little irritation, forms a true
saponaceous [and healthy] compound with the animal tissues, re-
sembling, he adds, hospital gangrene, [but  very different, in  our
opinion, from that disease, which is a putrescent decomposition,—T]
and  may be easily washed  off and applied also daily, (lb., p. 18.)
[It should have, we think, in every respect a decided  preference
over all mercurial caustics, for the reasons above given.—T]
  The hot-iron  cautery of  M. Mayor, M'hich he calls  the double
hatchet, (bicultellaire) has the advantage of shortening the opera-
tion by making two rays of eschars at  one stroke, (lb., p. 21.)

 The Sub-Cutaneous  Principle successfully employed in applying
            Ligatures for the extirpation of a Goitre.

  The inappreciable value of the sub-cutaneous principle could not
be more beautifully illustrated, than in its very recent application
by MM. Ballard and Rigal, of Paris, in the  adjustment of ligatures
for the complete sub-cutaneous absorption and eradication of that
most formidable and common disease,  goitre.  We shall give this
in full detail in its proper  place ; but, in the mean time, think it due
to the important and  new branch, called sub-cutaneous surgery, to
advert to this ingenious  process  in this volume, and  to  remark,
merely, that although this method of placing ligatures in the form 
AMERICAN APPENDIX.
835
 of three separate sub-cutaneous nooses around and through the base
 o a goitrous tumor, requires great tact, and seems somewhat com-
 Pleated, the complete success of the experiment in the hands of MM.
 Ballard and Rigal, while it reflects the highest honor on those sur-
 geons, and meets with the entire approbation of so  eminent a judge
 m these matters  as  M. Malgaigne, is  destined, we hope, to add
 another brilliant triumph to surgery, in a disease which had hitherto
 been deemed beyond the resources of art.  We may briefly state,
 tor the benefit of science, and to give as speedy and immediate dif-
 fusion to this discovery as it may be in our power through this pre-
 sent American edition of Velpeau's Surgery, that the surgeons men-
 tioned employed two long waxed ligatures, each armed with three
 needles, viz., one straight, and M'ith a cutting edge, at one end of
 the thread; one round and pointed, in the middle part of the liga-
 ture ; and  one curved, with cutting edge, at the other end of the
 ligature.   The skin was drawn forcibly up above the goitre, oppo-
 site to its upper third, so as to make a vertical fold.  This fold was
 pierced by the  straight cutting needle,  which was then drawn
 through. The fold of skin, now returning to its place, left, of course,
 the ligature forming a sub-cutaneous arc over this upper part of
 the tumor.  The round needle was now made to pass by the same
 puncture which was first entered, so  as to go under and directly
 through the base of the tumor, and thus bringing the median noose
 out by the other puncture, this noose was cut in two and tied there,
 by one knot only at first, so that it completely embraced  this por-
 tion  of the tumor at its base, by a sub-cutaneous  noose, and also
 left another thread under the tumor at this part.
  The same principle was now adopted with  the other long  liga-
 ture  to the  lower third of the  tumor, and the curved cutting needles
 remaining  were then passed from above downward, under the skin
 laterally, and outside the base of the tumor, and their threads  so
 tied  with the two threads  that  penetrated  under  the base of the
 goitre, as to form a complete sub-cutaneous noose around the whole
 base of the tumor, the threads forming three knots only at three
 punctures,  and  leaving the fourth puncture to be  closed up.  On
 the 20th day, the whole tumor had entirely disappeared, (vid. Mal-
 gaigne, Manuel, fyc, 1843, pp. 507, 508, 509.)   [We have had the
 gratification, in the practice of Dr. Mott, of seeing an equally inge-
 nious mode used by him in applying ligatures by continuous nooses,
 to remove carcinomatous indurations of the tongue ; which method,
 though not sub-cutaneous, he has for many years been in  the habit
 of using in those as well as other similar affections, all of which
 will  be detailed when we come to the  subject of operations upon
 the tongue.—T]   The process of MM. Ballard and Rigal cannot
 be understood without carefully perusing it in detail in  M. Mal-
 gaigne's work.
  To make Progressive Strangulation,  upon the Pedicle of a Tu-
 mor,  for  example, M. Malgaigne prefers  the Serre-nceud (or knot-
tightener) of Graefe to that of M. Mayor, improved  upon Roderic's.
Graefe's  is copied from the tourniquet  of Petit, and consists of a 
S36
NEW ELEMENTS OF OPERATIVE SURGERY.
steel shaft, (tige) or  stem, pierced at its upper extremity, through
which pass the two  ends  of the noose which  has been already
applied.   At the other extremity is a screw, (vis) which, on being
turned in one direction or the opposite, causes to ascend or de-
scend  a  moveable nut, (ecrou) to which the ends  of the  liga-
ture are  firmly attached.  A simple  turn  of the screw suffices
then to increase or diminish the constriction at pleasure.   This in-
strument  unites  great simplicity to great  force.  (Manuel,  fyc,
1843, p. 26.)

  Compression of the Arteries and Veins to arrest Hemorrhage.

  In regard to compression upon the brachial artery at the lower
third of the humerus, the place usually recommended, because the
ulnar and radial nerves  are  there separated from the artery, M.
Malgaigne says it is  of little  value, inasmuch as the artery is con-
stantly accompanied by the median nerve, (lb., p. 32.)
  M. Malgaigne  speaks with confidence of compression of the ab-
dominal aorta, as recommended in uterine hemorrhages by M Tre-
han.  He, however, thinks it impracticable except in thin subjects.
After placing the patient  in  a situation to  relax  the abdominal
muscles,  he prefers the umbilicus as the most favorable point upon
which the pressure can be  made, and advises that we should use,
for this purpose, a strong pelote, to be applied crosswise to the ab-
dominal  walls.   The continuance of this pressure for five or six
minutes has, he says, effectually arrested uterine hemorrhage  after
parturition, by giving time  for the uterus to recover itself.   It may
be used, also, in lesions of the iliac arteries.   M. Faure and others
have advised  also, in uterine hemorrhage after delivery, to  make
pressure  through the walls  of the abdomen on the uterus itself, (lb.,
p. 33.)
  The femoral artery may  be compressed crosswise upon the ilio-
pubic protuberance;  and so effectually, that it is now, in conformity
to the recommendation of M. Louis, who first introduced this mode
in amputations, very frequently preferred to and substituted for the
tourniquet.   M. Malgaigne remarks, that we should recollect that
the protuberance inclines forward and downward at a variable an-
gle ; for M'hich reason, in order that the pressure may be made per-
pendicularly, it is necessary  that it should  be directed a little ob-
liquely upon the artery, and  upward and backward, forming with
the horizon an angle of about forty-five degrees.
  Where venous  hemorrhage,  in operations, is owing to the violent
efforts of the patient in  holding  his breath, and thus obstructing
free respiration, and causing a reflux of the blood into the cavas,
M. Malgaigne says, that two or  three full inspirations will some-
times arrest a flow of venous  blood that had been thought unmanage-
able, (lb., p. 35.) 
AMERICAN APPENDIX.
837
                Cauterization with the Hot Iron.

  Certain experiments of M. Bonchacourt, on the dead body, have
thrown some new light upon  this subject.  He found that, heated
to a white heat, the cautery too rapidly carbonized the vessel, and
that, though its mouth closed, a small aperture was left in it, of
one-third the diameter of the  calibre of the  vessel;  whereas the
cautery at a dull red heat, (rouge obscur) frequently and gently ap-
plied, at short intervals, and for a few moments only at each time.
not  only carbonized  the artery slightly, and closed it more rapidly
and securely, but  caused  its  cut extremity to retract within the
calibre of the vessel, like the retracted finger of a glove, (by a
species of introsusception.) to the distance of three  to five centi-
metres, in  trunks of some size ; while the mouths of the small
collaterals that were cut near the trunk, were also dragged into
the calibre of the main artery along with its inverted extremity,
and assisted in  thus plugging it up, and effectually arresting the
hemorrhage, leaving scarcely any perceptible  aperture.  These
experiments have not yet been performed on living animals.   M.
Malgaigne  seems to attach considerable importance to them, as
establishing new rules for the application of the hot iron to arteries.
(Ibid., pp. 40, 41.)
  The valet a patin, mentioned frequently in the body of this edi-
tion of Velpeau, is a steel forceps, whose branches are kept to the
degree of approximation desired, by means of a small button gliding
along a slit which is made lengthwise in the aforesaid branches.
(Malgaigne, p. 43.)

                           Ligatures.

  M. Malgaigne gives the preference  to deer-skin ligatures, made
round  like thread, as introduced by  our countryman, Physick.  He
finds that they  cut  the inner  tunics of the  artery as M'ell as the
ordinary kind, besides having this  advantage,  which suggested
their employment, viz., that of allowing us to cut both their threads
near the knot, as the latter is readily absorbed.  Mr. Jameson also
prefers these ligatures.  (Ibid., pp. 44, 45.)

                            Torsion

  When the artery  is sound,  M. Malgaigne  prefers this  method,
according to the process of Amussat, to the ordinary ligature.   In
the smaller arteries, simple torsion, without the necessity of trac-
tion upon the artery, and breaking its tunics by the pince a ba-
guettes before twisting it, is quite sufficient. (Ibid., p. 49.)
  A new mode of securing arteries, and one  which, according to
M Malgaigne, promises, when better  established  by further  ex-
periments, to become of great importance, and to supersede  all
other methods for the large trunks, is that proposed by M. Amussat, 
838
NEM' ELEMENTS OF OPERATIVE SUROERY.
of first applying a ligature in the ordinary way, and then, Math his
vince  a baguettes, (i. e., forceps M'hose branches terminate in two
slender rounded  stems,) breaking up  by pinching, as  he  does in
torsion, (and which in this new process is called par les machures)
the tMo inner tunics of the artery in several places.  What is re-
markable, says M. Malgaigne, the clot of blood adheres solidly to
the entire circumference of the  artery, at all the points where the
internal tunics, or coats, have been cut.  It retains, however, its
conical form, and even near the collaterals  every portion of the
cone,  where the machures or pinchings  have not been made, is
found  wanting;  but  the  adhesion, nevertheless, is solid at  each
mdchure. (Ibid., p. 50.)
  In the application  of strips  of adhesive  plaster, he gives a de-
cided  preference to the method of M.  Gama  and others, (Ibid.,
pp. 51, 52,)  of commencing their application by their middle  part,
(as on a limb, for example,) and  on the  point diametrically oppo-
site to the  situation of the wound, as  they then act, he says,  m ith
the greatest force, are far more solid, and also not liable to become
loose.   The very reverse  of this  strikes us as the truth, and there-
fore we give a decided preference to the ordinary mode of attach-
ing first, in a firm and secure manner, and at a sufficient distance
from the wound, one  extremity of the  strip, at right angles to and
on the side  of  one  of the dips of the wound, and then, while the
opposite lip is approximated by pressure of the  fingers  as close
to its  corresponding  lip  as possible, fastening firmly over it the
other  extremity of the strip, and crossing the ends on the opposite
side of the  limb.  It  has  always appeared  to us, in the constant
use of these strips, that their power of  approximating the lips of
the wound is then the greatest, because its force is exercised by the
middle portion of the strip, which is unyielding, whereas it is the
ends of the  strip, which have  not this strong antagonist adhesive
power to  keep them in place, (even  w hen  crossed,) M'hich is the
reason  why they, and  not the  middle part  of the strip, are the
soonest to become detached.—21]
  In lieu of the ordinary mode of applying the twisted suture, it is
proper to recollect, as a general principle, the method  adopted by
Dieffenbach in rhinoplasty, and other  plastic operations where the
tissues are thin and many pins are to be inserted.   This is, to use
delicate insect pins, whose extremities, after their insertion, he bends
upward, so as  to  form a curve, whereby their action, by means of
this curvature, keeps the  lips of the  wound in close  coaptation,
enabling the operator thereby to dispense altogether with threads.
(Ibid., p. 56.)
  M.  Malgaigne commends very highly, from his own personal
experience,  the new  and,  as it appears, very convenient  mode  of
forcing a needle  with facility through  dense  tissues, by means  of
fixing it in a solid handle, (porte-aiguille,) as  recently introduced by
M. Rigal de Gaillac.  (Ibid., p. 56.)
  In the application of leeches, Dr. Mott has recently been much
gratified with  a method  which appears to succeed where  most 
                       AMERICAN  APPENDIX.                    839

other modes fail.   It is to introduce the leech head-foremost  into
a small glass tube, having at this extremity, where his mouth is,
a smaller aperture than  the other, and then, by means of a  rod,
which fills up like a piston the cylinder of the tube, compelling the
leech, by  forcing this piston down upon him, to take hold of the
tissues in  his own defence.  Several tubes  may thus be  used at
once; and this is certainly preferable to the delay, often vexatious
and embarrassing, both to the patient  and physician, which so
frequently attends the application of leeches by the common modes.
  On the same principle, and which is, in fact, analogous to the
mode proposed by M. Loeffler, of forcing leeches down by means
of a rod directed upon  the narrow extremity of any hollow mate-
rial, as pasteboard made into the shape of a cone, (see text, supra,
of this edition,) the use of leeches has become a most invaluable
therapeutic  resource, by being introduced through the appropriate
specula, to the mouth and neck of the womb  and the  walls of the va-
gina, and also by a speculum open in its  anterior part, as recom-
mended by M. Amussat, in abstracting blood from the prostate through
the parietes of the rectum, all of M'hich modes are noticed with ap-
probation by M. Malgaigne, who  also recommends, M'here a num-
ber are to be applied on an exposed surface, to cover them with  a
compress, and then effectually to secure their escape by means of a
glass placed over the whole. (Ibid., p. 61.)
   We confess our surprise, however, that this author should recom-
mend that leeches, after  coming  off, should be left to absorb the
blood they have abstracted, and thus be preserved for a second ap-
plication !   According to our experience, they never bite so well  a
second time, and it is a practice, moreover, that  may be attended
with danger, not only from certain changes which the blood re-
maining in them (and it is familiarly known to all how long a time
they retain  it) may have undergone, but because morbid properties
in the blood of  one person, or virtually made morbid by the mere
difference of the  blood itself in one individual from another, may
thus be transmitted to another, and occasion serious oedematous en-
gorgement,  erythema, or even acute and dangerous inflammation of
an erysipelatous character, which, in certain  habits, even the appli-
cation of fresh,  and healthy, and  unused leeches, is almost alM'ays
certain to produce, (in the flabby tissues, as the eyelids, neck,  scro-
tum, &c.)  Physicians  as well as students, which  latter should
seize occasions to become familiar and practised in these minor
operations in surgery, cannot be too cautious, therefore, (especially
in  this country,' where we have to depend on foreign supplies,)
both in the  selection and  application of this most invaluable reme-
dial resource.   The high price of leeches here may and does often
tempt to their use a second time, by druggists and apothecaries who
vend them; but, on the other hand, their extreme cheapness and ex-
cellent qualities in France, England the West Indies, &c, render a
repetition of the employment there of the same leeches almost crim-

m3To arrest the  bleeding of leeches, which, as we  have said in the 
840           NEW ELEMENTS OF OPERATrVE SURCERY.

body of this work, can most effectually be accomplished by a suture
of fine silk with a fine needle,  another and more prompt, cheap,
and readily accessible mode has also been proposed by M. Hatin,
viz., a small piece of wood split at one end, and by which, when made
to include a fold of skin, the  lips of the puncture may be firmly kept
together.   This  ingenious contrivance,  similar in principle to the
small spring-forceps used in operations for arresting hemorrhage
from small arteries M'hen expedition is  required, and we have not
time to stop to tie the vessels, might do  very well in grown per-
sons or children  who would be  alarmed at the sight of a needle.
(Vid. Malgaigne, p. 63.)
  In bleeding at the  arm, M. Malgaigne says  that, where  we are
obliged  to open the median basilic over the  brachial artery, it is
better to make the incision parallel with the axis of the artery,
inasmuch as such wounds in arteries, should a wound be unfortu-
nately made, are less dangerous than those that  are transverse  to
their calibre. (Ibid., p. 69.)  This seems to be very judicious advice.
  M. Coster relates that he has had complete success in the cure
of goitre by electro-puncture.  His mode is to use this agent as a
means of  promoting the absorption of iodine by the tumor.  To
attain this object, he rubs on one side of the tumor a small quantity
of pure iodine, and then transmits  through the tumor the galvanic
current, by placing in contact with it two poles of a voltaic pile.
(Ibid., p. 84.)
  For PREVENTING THE REUNION OF BORDERS OF WOUNDS AFTER THE RE-
MOVAL of cicatrices, the division of bridles and adhesions, as between
the arms, legs,  fingers,  &c, either  congenital or  after  burns  or
other injuries,  M.  Malgaigne  attaches  much  importance to  a
method  lately proposed  by M. Amussat, viz., the repeated division,
every twenty-four hours, and after the parts have begun to suppu-
rate, of the new inodular membrane, M'hich has  such  a  constant
tendency  to reunite the edges.   This  is  to be  performed at the
angle of junction  of the two surfaces  of the division. (Ibid., pp.
136, 137.)
  On the  authority of M. Malgaigne M-e see it stated that M. Bon-
net has  divided the masseter muscle. (Ibid., p. 139.)   The details
of this operation we have not met with.
  The same author also states  that M.  Guerin noM' divides almost
all the muscles which surround the  coxo-femoral articulation,  in
order to facilitate  the  reduction of  congenital  luxations. (Ibid.,  p.
140.)
   As M. Malgaigne has recently  made, in the Paris Academy of
Medicine, (as we  have  stated above,)  a bold attack  on M. Jules
Guerin, in relation  to his practice,  within a few years  past, of
extensive divisions of the tendons  and muscles in  cases of retrac-
tion, and  especially in reference to dorsal myotomy, as performed
by M. Guerin for lateral curvatures of the  spine, it may not be
improper, in elucidation of what  we have given  above,  to quote
from M.  Malgaigne's  late  work  on surgery a short paragraph
which he has on this subject: 
AMERICAN APPENDIX.
841
  " I confess I fear that a sort of temporary  eclat has allured sur-
geons a little further than was necessary or allowable.  In  the
first place, sections of muscles  have been made without a clearly
defined indication, or in cases in which, though there were indica-
tions, they could have  been well fulfilled without an  operation.
There remains also another question to clear up.  When a muscle
is divided, the fibrous cicatrix which reunites its two portions di-
minishes its force, but  does not  annihilate it; it is the  same with
the section of tendons  shut up in a cellular sheath, like the tendo-
Achillis.    But M-hat becomes, after these sections, of tendons that
glide in synovial sheaths ?  Are they reunited in a manner to pre-
serve the action of their muscles, or is this lost ?   However it may
be, I do not wish to meddle with tendons of this description, except
in cases of well-established necessity, and then it would be easy to
apply to each tendon the processes of  subcutaneous sections,  and
those which we are about to describe."  (Ibid., p. 140, 141.)

                 Division of the Tendo-Achillis.

  In certain cases of amputation of  the foot  by the method of Cho-
part, it is found  that the  foot is thrown backward by the pre-
ponderating power of the solei (soliaires) and gastrocnemii mus-
cles.  The  section of the  tendo-Achillis has  been recommended
for this difficulty, and M. Malgaigne states that, in a case in which
he had operated upon, M. H. Larrey made this section with com-
plete success. (Ibid., p. 144.)
  As the veins, according to M. Scouttetten, in  decided cases of
club-foot, are morbidly (pathologiquement) distended, and describe,
as well as the artery, (tibialis  postica,) flexuosities,  which oblige
them  to  occupy a larger space than in their normal  state, there
is, therefore, reason (says M. Malgaigne) to fear that we might
wound them in young subjects,  in M'hom the deformity  of club-foot
existed to any considerable extent, and so  much the  more if M'e
should divide the tendon  at its  most superior part, as the tibialis
postica artery is there covered by the tendon. Whereas, in making
the incision too low  down, we incur the  risk of wounding the
bursa mucosa, which separates the tendo-Achillis to a considerable
extent from the os calcis, immediately previous to its attachment to
that bone.
  For which reasons M. Scouttetten lays down the following rule:
" Draw a line transversely which divides  (partage) the external malle-
olus and is prolonged to the tendon, and you will have the exact height
at which the  section ought to be made;" M-hich M. Malgaigne seems
to approve of, as also the  recommendation  of M. Scouttetten, to
make the puncture at the  inside of the tendon through a fold of the
skin, and to direct the  edge of  the tenotome upon it between  the
skin and  tendon, cutting from  without  to its deep-seated surface,
while the foot is firmly kept in a state of extension (Ibid., pp. 144, 
842
NEW  ELEMENTS OF OPERATIVE SURGERY.
                       Morbid Cicatrices.

  On this subject we  confess ourselves  again somewhat surprised
to find M. Malgaigne reverting back to the now proscribed opera-
tion  of simple excision  of the cicatrix, as was  recommended by
Dupuytren.   On  the  other hand, he makes no  mention, (see his
work, pp. 134 et  seq.,) as far as we can discover, of the new and
ingenious process of our countryman, Prof. Mutter, of Philadelphia,
M'hich  was croM ned M'ith the most triumphant success, in the very
worst forms of those cicatrices, viz., those from extensive burns on
the neck, &c, (see details in the text, supra,) and which is certainly,
therefore, applicable,  we  should reasonably suppose, to those  of a
less  formidable character.  Thus where, for example, as described
by  Dupuytren, cicatrices, leaving loss of substance, have caused
adhesion, and shortening of the flexors of the fore-arm, and violent
flexion of the fingers, instead of excision of the cicatrix  and exten-
sion of the  parts, with a view to procure  a new and larger cica-
trix, as he recommends, why might not a flap of sufficient length and
breadth, on Dr. Mutter's principle, be first made  to occupy  the place
of the excised cicatrix ; and after sufficient lapse of time for perfect
agglutination of the same, what objection would  there  be  to make the
necessary sections of  the  retracted tendons and muscles ?  We are
aware of the meager and thin condition of the tissues here, and
that this modification has been attempted, as we saw in one in-
stance, by Dr. Detmold, without success; but it nevertheless seems
to us practicable  under certain circumstances, and where the  cu-
taneous tissues are sufficiently nourished, as is proved by the suc-
cess of the Tagliacotian process of rhinoplasty. (See text, above.)
  M. Malgaigne says he has seen the method of Dupuytren succeed
where the extensor tendon of the  middle finger  and the contraction
or shortening of this tendon had reversed the first phalanx of that
finger backward, and flexed the two other phalanges forward.
  M. Malgaigne  mentions also a case in M'hich  the extensor ten-
dons being divided, their extremities were  separated by the action
of the flexors, followed by the formation  of  a  cicatrix, in such
manner  as to leave too great a length  to  the  muscles, whereby a
forced degree of flexiop was produced.  M. Dutertre, he adds, in a
case of this kind, removed the  entire cicatrix, straightened  the
fingers by means  of a suitable dressing, and approximated by
suture the borders of the skin and  the  ends of the muscles them-
selves, obtaining  thereby complete success. (Ibid., p. 147.)
  The ingenious  and successful application of the  sub-cutaneous
principle, by M. Goyrand, of Aix, within  a few years past, to the
EXTRACTION OF FOREIGN BODIES  FROM THE ARTICULATIONS, particularly
from the knee, where they are most frequently met with, not having
been given in detail,  though noticed in  our text, (supra,) we insert
it in this place, from  M. Malgaigne's work, where this method, we
perceive, justly receives  his entire  approbation, and decided pre-
ference over all others. 
AMERICAN APPENDIX.
843
                     Process of M. Goyrand.

   The  patient being placed  on a  bed, the  surgeon on his left
 crowds the foreign body into the outer part of the upper cut de sac
 of the patella, where he holds it fixed, at the distance of four centi-
 metres  above this bone, continuing to press  it from below upward
 with the left fore-finger and thumb.   He then causes the assistant
 to raise up the skin upon the  thigh, above the foreign body, into a
 large transverse  fold, so as to bring to the neighborhood of the
 foreign body a portion of skin from a great distance.  Then, with
 a sharp-pointed  bistoury, whose blade has seven centimetres in
 length,  and four only in width at its base, he plunges it from above
 downward into the  base  of this fold, and directing the point toM'-
 ards the foreign body, he cuts beneath the  skin, and in a direction
 parallel to the axis of the limb, all the tissues M-hich cover this
 body.   He found it necessary [in his first operations] to repeat this
 manoeuvre  upon  the  tissues  three  times  before  he could divide
 them, after which the operator perceived the concrete body escape
 under his fingers.   It had passed out  of the  articulation.  The bis-
 toury was then withdrawn, and the assistant let go the fold of the
 skin.  Some drops of blood, mixed with bubbles of air, issued from
 the  puncture, which last mounted upward to  eight centimetres
 above the point where the synovial [membrane] had been divided.
 Some bubbles  of  air also remained  in  the  sub-cutaneous cellular
 tissue below the puncture.  The foreign body was lodged betM'een
 the middle and outer portions of the  triceps, at the distance of six
 or seven centimetres above  the incision into the synovial.  A com-
 pression was established underneath both,  to prevent its retroces-
 sion, and to keep it in contact with the sub-cutaneous incision.
 This compression was removed on the sixth day.   In the case given
 in illustration in  the above description, M. Goyrand found, a few
 days later, that two  other foreign bodies had made their appear-
 ance in the articulation.  For one of them  he repeated the  same
 operation sixteen  days  after the first, wdth  this difference, that he
 made his incision a little within the first, and incised the triceps
 and  aponeurosis  to sufficient  extent  to  allow the foreign body to
 arrive under the skin; and though he did not succeed to the extent
 he wished, he caused it to arrive under the  aponeurosis.
  Eleven days later, presuming that all communication between
 this  foreign body  and the synovial was closed, the surgeon effected
 its extraction by an ordinary incision ; but he did not feel inclined
 to try the same operation for  the body which had become lodged
 under the vastus  externus  muscle;  and he  is of opinion that it is
 better to confine ourselves  to removing them from the joint and leav-
 ing them in the  cellular tissue, where they become encysted without
 causing any inconvenience,  (ib. pp. 213, 214.)  [We should suppose
 that after a sufficient lapse of time for the reunion, or adhesions of
the synovial membrane, it would be better to remove them.—T] 
844
NEW ELEMENTS OF OPERATIVE  SURGERY.
                       Artificial Joint.

  After describing Dr. J. R. Barton's operation, M. Malgaigne sug-
gests whether in an urgent case it M'ould  not be advisable to  in-
troduce a steel chisel  through a narrow wound, and to strike upon
it with a lead mallet,  so as to break the bone Mdthout  exposing it
to the air, (ib., p. 215.)  We  should  suppose  so harsh a  process
would produce too uneven a division; in fact, a rough fractured
surface together with splinters, endangering suppuration  and de-
struction of parts, M'hich might be followed by anchylosis, and thus
defeat the great object that most surgeons aim at,  which is to
have a smooth transverse surface on the end of each fragment.
  Under the head of  the redressement of  angular deformities pro-
duced by a morbid callus, may properly be ranged a neM'  method,
which lately succeeded with M. Wasserfuhr. In a child, aged five
years,  the  ends of the bones, after a fracture of the femur four
fingers  breadth below the great trochanter, had consolidated in
such manner  upward and  outward as to form a right angle,  to-
gether with a  shortening of the limb to the extent of tM'elve fingers
breadth.  The callus was  large and  solid, and three weeks had
elapsed since the fracture.  The operator,  having stretched the skin
below with his left hand, so as to make the projecting angle of the
callus more prominent, made on this projection a transverse incision
to the extent of a fourth of the circumference of the thigh.  A second
cut divided the muscles down  to the  bone.  The retraction which
followed exposing the angle of the callus,  he proceeded M-ith a fine
saw to divide  it to the extent of one-third of its  thickness, the soft
parts not allowing  him to go any farther.  His intention then being
to break the remainder, under the impression that the rough ends of
the bone would better favor the process of consolidation, [see M. Mal-
gaigne's suggestion above, in respect to artificial joints, and probably
based on this idea,] he placed the part across a truncated pyramid of
wood, whose top was  covered with deer-skin, and base fixed firmly
upon the table.  Strong efforts on the ends of the bone, in order to
break  the  callus, not succeeding, the soft  parts were dilated  by
another incision, which enabled the  surgeon to  saw the  bone to
some  distance farther, when  another  application of force com-
pleted the fracture ;  the whole operation  consuming but a few
minutes, and causing  the loss only of thirty grammes of blood, (ib.,
pp. 233, 234.)

                          Tarsoraphy,

  This name has been  given to an  operation performed by  M.
Walther, upon the outer angle of the eye.  An individual had a
cicatrix, with loss of substance, on  the temple,  which drew out-
wardly the palpebral commissure, and gave it an irregular round
form.   The lids were bent outwardly, and the conjunctiva was in-
flamed.  The operator encompassed the  cicatrix by two incisions 
AMERICAN APPENDIX.
845
which united on the temple, and included the  outer third of the
tarsal cartilage of each lid.  Two stitches of suture brought the
wound together, and the double ectropion was  completely cured.
(ib., pp. 366, 367.)                                 v     J

                    Myotomy for Strabismus.

  In relation to the anatomy of the eye, M. Malgaigne contends
that under the conjunctiva there is a fibrous membrane, which has
been  forgotten by modern anatomists, and which, first pointed out
by Tenon, but imperfectly, has been first demonstrated and described
by him [M. Malgaigne] in his lectures, and in  his Anatomie Chi-
rur gicale.  This membrane is white  and elastic,  and lines the ocu-
lar conjunctiva in every part of it, united  at the base of the  orbit
with  the palpebral ligament and periosteum, then extending up to
the cornea, where it makes  a duplicature backward  to form  a
complete envelope to the sclerotica, until it finally reaches the  optic
nerve, with the  neurilema of which it appears to be continuous.
On the sclerotica it is very moveable, and  a layer of cellular serous
tissue separates  these two membranes.  At the points of insertion
of the tendons upon the globe of the eye  it is not perforated, but
folds itself around those tendons in such manner  as to form a  short
and fibrous sheath to them, which degenerates into cellular tissue
on their fleshy fibres.  This membrane M. Malgaigne calls the al-
buginea, (albuginee)  Some have called  it the  fibrous  capsule of
the eye ; others, the sub-conjunctival fascia.  They have called the
part which lines the conjunctiva, the first layer, (feuillet;)  that
next the sclerotica, the second.  M. Guerin has called that portion
of it the muscular toga,  where its fibrous fourreaux, reflected  upon
the muscles, leave, nevertheless, between  the tendon and  the  scle-
rotica, a small free  space, where  they do not continue upon the
tendon.   When  the  section of the tendon is  made very near the
sclerotica, we divide only the anterior portion of the sheath; but to
divide it entire we must carry the  instrument to  the fleshy body of
the muscle itself.
  M.  Malgaigne disapproves  the  horizontal incision on the  con-
junctiva, as recommended by M. Lucien Boyer, because it renders
the operation more  difficult and less secure.   He would give  a
decided preference to the sub-conjunctival method of M. Jules
Guerin, except that it has the disadvantage of being very difficult;
also that  of endangering the wounding of the sclerotica, and de-
priving  us of an opportunity of ascertaining if the whole muscle
has been divided.
  M.  Malgaigne mentions having dissected an  eye, in which the
section of the rectus internus did not allow the eye to be drawn
outward by  the erigne, so forcibly had the superior and inferior
rectus been drawn  inward, by the retraction of the internal rec-
tus.
  He therefore  determines in favor of the ordinary method,  only
that the incision should be small.  This has the immense advan 
846           NEW ELEMENTS OF OPERATIVE SURGERY.

tage, he says, of enabling the surgeon to follow his instrument with
his eye, so that he knows what he is doing.
  M. Malgaigne gives the preference to the forceps over the erigne,
to take up the fold of the conjunctiva, as unquestionably more se-
cure.  The double hook to raise the muscle has no advantage over
the single, and is more complex and quite unnecessary.
  The vertical  incision  is the preferable one, except  where the
sub-conjunctival puncture of M. Guerin can be substituted.
  The section  of the obliquus superior alone (du muscle grand ob-
lique) has never yet been undertaken  for strabismus, but only after
that  of the internal rectus.   The reason is, M. Malgaigne, himself
a distinguished anatomist, confesses, because the part this muscle
has in strabismus  is not precisely known.  JM. Bonnet, in fact, af-
firms that its section, to say the least, is uncalled for (au moins in-
utile) in that disease.   M. Gairal, hoM-ever, has suggested the sec-
tion  of the insertions of the fixed pulley  (poulie de renvoi) of this
muscle at the inner and upper angle of the orbitar edge, and M'hich
would require  only a simple puncture of the skin M'ith the teno-
tome.  This operation, however, M. Malgaigne thinks it is unne-
cessary to dwell upon,  as there is no object to be thereby ob-
tained.
  When, after  the section of the rectus internus, the  strabismus
(convergent) continues, especially if the eye is turned upM'ard and
inward, the reflected portion (la portion reflechie) of the obliquus su-
perior has been laid bare and divided.  The  object here  is not to
look for  its insertion upon the  sclerotica, M'hich is twenty-three
millimetres behind the periphery of the cornea.  But to effect our
object  we dilate upward the incision of the conjunctiva and albu-
ginea,  [i. e., the fibrous membrane (see supra) which M. Malgaigne
claims to have first accurately described.—T]  The adipose tissue
is divided directly upward, and a little backward, until the muscle
appears.   Some  then pass backM'ard  a blunt  hook  very much
curved, (fortement recourbe) directing  its concavity upM'ard; others
simply divide it with the scissors.  This operation M. Malgaigne
thinks somewhat hazardous, attended with a great deal of lacera-
tion  in the orbit, and much more loss  of blood than the mere divi-
sion  of the rectus internus, and, if the hook is not used, giving
occasion to painful traction.  Some operators, it is  said, have in-
advertently divided the muscle without laying it bare, and Mdthout
being  aware of it;  after M'hich they have uselessly endeavored,
and  at the cost of much suffering, to  find where  it Mas.  M. Mal-
gaigne apprehends that  this division  has been made without any
well-ascertained necessity ;  since  the  most correct observations
that have yet  been made  on the functions of this muscle induce
us to believe, that instead of draM-ing the eye upM'ard and imvard,
it  draws  it downward  and outward.   M. Bonnet, who  is of this
opinion, concludes, therefore, that if the section of this  muscle has
appeared to be attended with success, it is because, in order to ef-
fect  it, we have been obliged to isolate the eye to a great extent
from its fibrous capsule, and that we  have thus  destroyed all the 
AMERICAN APPENDIX.
847
fibrous connections which retained the eye in its convergent direc-
tion.  This  explanation may appear hypothetical;  but the indi-
cation of the section of the  obliquus superior  is still more uncer-
tain, and, from all  the  information we have at present, ought not,
from prudential considerations, to be attempted.
  The section of the rectus externus, clearly indicated in divergent
strabismus, which,  however, is exceedingly rare, exacts attention
to two important considerations:  1. That the muscle is inserted at
nine millimetres from  the  cornea, consequently a little farther be-
hind  than the  rectus  internus, which requires the  incision to be
made in reference to this attachment; 2. That it is found imme-
diately  above the  outer palpebral angle, and, consequently, that
we must look for it above this angle.
  The rectus superior  and the rectus inferior have been still more
rarely divided.   The first is inserted at  eight, and  the second at
seven centimetres from the  cornea. It is scarcely necessary to add,
that we must take  care not to mistake either for the corresponding
oblique muscles.
  To make the section of several of these muscles, as has been
done by several surgeons, it is necessary to make an extensive di-
latation of the incision of the conjunctiva.
  The section of the obliquus inferior (petite oblique) has been made
by means of an incision into the conjunctiva, and M. Bonnet states
that he has sometimes  found an  advantage from it, in conjunction
with the section of the rectus externus.  But, though there may be
occasion of dividing this muscle (the inferior oblique) in certain
cases of myopy, fatigue of the eyes, convulsive  trembling, and even
in certain cases of amaurosis, it is even, in such cases, much more
simple and easy to divide  the muscle by a sub-cutaneous  incision,
at its insertion at the orbit.
   The obliquus inferior is inserted at the inferior edge of the orbit,
at the distance  of from six to twelve millimetres from the outer side
of the lachrymal sac.   Around this insertion there is neither nerve
nor artery, nor any important organ, and the cutting instrument,
glided between the lower wall of the orbit and the  muscle, cannot
be brought forward without hooking it up and dividing it.

                    The process of M. Bonnet.

   The left being supposed to be the eye operated upon, the opera-
tor places himself on the right of the patient, and uses a tenotome
sufficiently pointed to perforate the eyelid, and sufficiently blunted
in its point not to catch in  gliding along the floor of the orbit   The
blade should have four centimetres in length,  and three millimetres
in breadth, and cut only to the extent of three centimetres, so that
when it has penetrated to a proper depth, the  cutting edge should
be found entirely concealed in the tissues.  The  operator places
hTs  left fore-finger on the middle of the  lower eyehd sc.that the
angle rests immediately above the orbitar edge.  With this finger
he pushes  back the eye and lid, and thus leaves  prominent (met 
848
NEW  ELEMENTS OF OPERATIVE SURGERY.
ainsi en relief) the middle of the inferior orbitar border.   In front
of the angle, and immediately behind the orbitar border, he plunges
the tenotome held in the right hand in the manner of a writing-
pen, pushes it first downward until it touches the floor of the orbit,
then pushes it inward, while it  grazes  this floor, in a direction
obliquely backward and inward, to the depth of two to three  cen-
timetres.  When the point, which should never be allowed to leave
the bony  plate, [le plancher osseux, i. e., the osseous floor of the
orbit.—T.,] has  arrived  near the ethnoid bone, the instrument,
which has been gradually made to descend horizontally, is  brought
forward, with the cutting edge in the same direction.  The point
thus reaches under the skin, a little outside the lachrymal sac.   In
this way  we must have necessarily reached the inferior  oblique,
but we may not have divided it.   To make sure of its section, we
first turn the blade downward, then against the anterior portion of
the maxillary bone, so that the muscle, if we have not yet divided
it, is placed between the  bone  and the cutting instrument,  in with-
drawing which last we cannot fail in completing its section.
  At the moment of the  section, the lower eyelid becomes gorged
with effused blood, without any pain, and which never continues
over twenty-four to forty-eight hours.  At the expiration of  this
time it  has entirely subsided, leaving only  an ecchymosis, every
trace of which ordinarily disappears by the  fifteenth or twentieth
day.  It  is unattended either with inflammation or suppuration.
In a patient, in whom M. Malgaigne performed  this operation on
one eye, for gradual loss  of vision and corresponding projection in
both eyes, the eye  operated upon became much diminished,  and
seemed to become sunken (enfonci) into the orbit.  As to the vi-
sion, it first returned to the eye M'hich had not been operated upon,
and, strange to say,  afterwards in a lesser degree to the other, but
to a degree so satisfactory  to the patient, that he would  not con-
sent to be operated upon in the other.
  M. Guerin, following out the idea of M. Dieffenbach, of snipping
or excising out, in cases of slight  convergent strabismus, a portion
of the  conjunctiva and albuginea, near the  insertion of the exter-
nal rectus, has, in a case where divergent strabismus followed the
section of the internal rectus,  and was not relieved by the section
of the external rectus, inserted into  the  external albuginea near
the outer border of the cornea, and by means of a needle, a noose
of waxed thread, which he then fastened to the dorsum of the nose, so
as to draw the eye inward, and thus effect the adhesion of the  pos-
terior end of the cut externus (previously detached from  its neM*
insertion) farther backward, by which means the eye was perfectly
restored  to its  normal position,  [ib., pp. 375 et seq.; see  also, on
this subject, the late treatise of M. Velpeau on Strabismus, incor-
porated with the  text]

    A  New Process of Cheiloplasty claimed by M. Malgaigne.

  " It appears to me (says M. Malgaigne) that we might  contrive 
AMERICAN APPENDIX.
849
 w1of^uw«Ttage8/f ?e.two methods'Viz" fil1 UP the lareest
 process wWh    •'  Tl °b/ain a moveable lip, by the following

 5533 ^LTTS^£?5ac*e) to the ancient method'Jd
 eittr'tTvi'v?^6'  *" ^ d*S™"***  parts should be removed,
 either by a V incision, as in the ancient method, or by vertical in-

 anZnitedther1^ * ?* baSe °f the Wer i™> ^sZax^l)
 and united there by a transverse incision.

 it ^ttfn /f ^M  T6 ShTld  hfVe a tria»g^ar loss of substance ;
 hv » tr«  adviSable.to Prolo"g th* angles of the mouth on each side
 bL  "    TG inciSlon'and t0 dissect in  such manner as to obtain
 two triangular flaps.  Their  vertical borders should be united on
 the median line by means of points of suture ; as to the upper bor-
 der all that  goes  beyond the extent that we wish to give the lip,
 will also be united to  the other border of the horizontal  incision.
 [1 his principle it will be seen, (vid. the text, supra,) was recently
 happily applied by Dr. Mott, in attaching the border of the semi-
 unar incision, left by the excision of the  cancerous  portion of the
 lower lip, to the upper border of the horizontal incision made at
 one angle of the mouth.—T]
   In the second case  the loss of substance is quadrilateral.  To the
 two incisions which prolong the commissures, it is necessary to add
 two other parallel ones along the base of the [lower] jaw.   We
 then have it in our power to detach, by dissection, two quadrangu-
 lar (quadrilatires) lateral flaps, which may be united to each other
 on the median line, and to the other incisions wherever it may be
 necessary.
   This is, in fact,  says M. Malgaigne,  the  process of Celsus, im-
 perfectly comprehended (mat compris) by all  his translators, show-
 ing that to translate a surgeon requires a  knowledge of the science
 of which he treats.
   It results from this process, that the cheeks alone contribute to
 form the lip, whose free border is formed by the bleeding border of
 the horizontal incision.  In this manner the new lip  contains mus-
 cular fibres belonging to the orbicular and its antagonists;  behind
 it is covered by a natural mucous [membrane,] and we may also
 cover its free border  by the mucous membrane, by making use of
 the process of M. Dieffenbach, [see text, and also M. Serre, supra.]
 This process,  says M. Malgaigne, which  I described in 1834, has
 been successfully employed by M. Bonnet, of Lyon,  with this dif-
 ference, that he is of opinion that we may  dispense with sewing on
 the mucous membrane, as it will spontaneously unite  to the skin in
 the progress of the cicatrization.
  If the dissected  portions could not be sufficiently elongated, we
might have recourse to the semilunar incision of Celsus, by means
of which the base of the flap on the side of the ear would be sepa-
rated from the posterior integuments.  M. Malgaigne does not think
that the exsection of a too salient portion of the lower jaw, which
was practised  by M. Roux, (lb., p. 453, et seq.,) [see his case in the
text, supra,] should be had recourse to but as desperate means
                             107 
850
NEW ELEMENTS OF OPERATIVE  SURGERY.
when all others  have been exhausted.   [JM. Malgaigne does  not
seem to appreciate the little danger which attends these exsections,
when implicating even the entire half of the jaW,  and which fact
had been long since  fully established by the important operations on
the lower jaw for osteo-sarcoma, which Dr. Mott (and  not Dupuytren,
as M. Malgaigne in  another part of his work asserts, nor any other
person) M'as the first surgeon to perform.   We* can discover nothing
original in the process above described by M. Malgaigne as his in-
vention,  and every part of w hich would seem, by M. Serre's elabo-
rate and accredited M'ork, to have been long  before anticipated by
either  the Professor of Montpellier or the surgeons of Germany.
Even the part of the process which M. Malgaigne  does not claim,
and which he gives to Dieffenbach, to wit, that of the buccal lining,
M. Serre asserts that he himself is as fully entitled to it as the Ber-
lin Professor, and that neither of them, in fact,  nor any other per-
son, have any claims to it but its discoverer  or  inventor, M. Wer-
neck, (vid. our abrege from M. Serre's work,  above.)—T.]

   In Bronchoplasty, M. Malgaigne, though according praise to the in-
genious process of M. Velpeau in filling up fistulous  openings in  the
trachea with a bouchon-flap of integuments in the  neighborhood, (see
text, supra,) thinks it might be superseded by that of Dupuytren; if,
instead of converting the fistula into a longitudinal [i. e.,  vertical j
wound, (as this last-mentioned surgeon did in a case  where the fistu-
la was situated between the hyoid bone and  thyroid cartilage,)  the
wound should be made transverse, and the pared edges, therefore, uni-
ted by the interrupted [and not the twisted] suture, and from above
downward rather than from one side to the other.   M. Malgaigne
says his experiments on animals had convinced him that the union
of wounds, in this part, is much more favorable when transverse than
longitudinal, which  is the reason why  he  adopts them in sub-
hyoidean laryngotomy.   It might, he thinks, be advantageous, also,
to cut the two lips with bevelled edges, the upper  at the expense
of its outer border, and the inferior at the  expense of its inner bor-
der, (lb., p. 499.)   [These opinions touching the pathology of trans-
verse wounds seem to be discordant M'ith the text of our author,
and with common belief and observation.  But this difference may
be only fallacious, and M. Malgaigne may be right, as wounds  are
properly transverse or longitudinal according to the direction of
the fibres, not the mere  position of the part, as, for example,  be-
tween the ribs, &c.—T]

                         Uretroplasty.

  In fistulous openings into the urethra, with loss of substance, M.
Malgaigne  considers the process recently proposed  by M. Alliot,
founded  on the ancient method, as one of the most ingenious and
successful.  It  consists in circumscribing and dissecting [on  one
side of the fistula] a small quadrilateral flap; then removing from
the other side a portion of the skin equal to this flap, he covers with 
AMERICAN APPENDIX.
851
this latter both the wound and the fistula, so that the principal su-
ture is found at a distance from the urine when it passes the ure-
thra.   As, however, the infiltration of urine, the great obstacle to
the cure of all these fistulas, may still present itself, it is well briefly
to notice here the new and ingenious  process recently adopted
with  the happiest success by  M. Ricord, of Paris, following out
the suggestion first made by Dieffenbach, and afterwards again
urged by M. Segalas.  This consists in making an artificial  open-
ing into the urethra beyond the fistula, and keeping therein a ca-
theter to draw off the urine  by this aperture, until the fistula is
perfectly healed.  (Ib., p. 657.)   [The process  of M. Alliot is the
same as that of M. Velpeau for certain kinds of staphyloplasty,—vid.
supra.—T]
END OF VOL. L 
 
 
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